Billing and Payment Models for Palliative Care

Transcription

1 Billing and Payment Models for Palliative Care Liz Fowler, MPH President and CEO Bluegrass Care Navigators October 15, 2017 Tom Gualtieri-Reed, MBA Partner, Spragens & Associates Consultant, Center to Advance Palliative Care 1

2 Session objectives Review billing and payment models for home care and palliative care services Discuss contracting opportunities and coordination with all types of providers across the continuum Identify financial issues and common pitfalls for organizations 3 Session agenda National trends in palliative care and payment Payment and partnership models Case example: Bluegrass Care Navigators Lessons learned & group discussion 4 2

3 About the Center to Advance Palliative Care (CAPC) CAPC provides hospitals, health systems, hospices, payers, and other health care organizations with the tools, training, technical assistance, and metrics needed to support the successful implementation of palliative care. 5 About Bluegrass Care Navigators Formerly known as Hospice of the Bluegrass In 1999 established the first physician practice exclusively dedicated to the practice of palliative medicine Palliative Payment Models/Strategy include: Fee for service (FFS) Partner subsidies Case rates Per member per month (PMPM) 3

4 The Payer-Provider Opportunity: Finding Common Ground Individual/retail Commercial or private payers Self-funded employers Federal and state agencies And providers working in shared risk arrangements Financers of health care Patient & family caregivers Better quality of life and care for those with serious illness Providers of health care The Opportunity: Partner to achieve a common outcome 7 Growing Attention on Serious Illness Who Are the Costliest 5% of Patients? Source: IOM Dying in America Appendix E The American Cancer Society s 2015 Cancer Facts & Figures report estimates: 14.5 million survivors now; this will jump to 18 million by 2022 Most will experience persisting pain, symptoms and stress that affect quality of life (QOL) 8 8 4

5 Increasingly, Health Plans are Advancing Palliative Care Strategies 9 New Payment Models and the Shifting of Risk are Changing Payer-Provider Relationships ACO Models: ACO Assigned Beneficiaries by County Payment for Cancer Care: Oncology Care Model Centers for Medicare & Medicaid Services (CMS) 190 practices and 16 payers Testing payment and care delivery models focused on chemotherapy

6 Value based payment provides the best opportunity to match care provided to the actual needs of patients with serious illness. This is an opportunity for palliative care to be integrated as part of standard care for those with serious illness. Diane E. Meier, MD, FACP, FAAHPM What is the Impact of Palliative Care? Quality: Relieves pain and symptoms Patients live longer Better family support Crisis prevention Cost: Setting & treatment aligned with patient goals Reduces 911 calls, ED visits, and hospitalizations Reduces unnecessary tests, procedures 12 6

7 Lesson Learned: Your Data Matters! Academic Results vs. Your Results Peer reviewed journals: Lustbader Dana, Mudra Mitchell, Romano Carole, Lukoski Ed, Chang Andy, Mittelberger James, Scherr Terry, and Cooper David. The Impact of a Home-Based Palliative Care Program in an Accountable Care Organization Journal of Palliative Medicine. January 2017, 20(1): We will reduce readmissions We will reduce ED visits We will reduce hospital LOS

8 Community-based Palliative Care Programs are Emerging Out of a Range of Organizations Lehigh Valley Health Network Meridian Health System NorthWell Health System Trinity Health Hospitals & Health Systems BlueGrass Four Seasons The Denver Hospice Hospices Emerging New National Entrants Aspire Landmark Turn-Key ProHEALTH Interim Health Care Hill Physicians Group Practices Home Office LTC Others Home health agencies Advanced illness orgs Studies Reinforce that Palliative Care Delivered in the Home Improves Cost and Quality Study ProHEALTH Lustbader D, Mudra M, Romano C, et al., The impact of a home-based palliative care program in an Accountable Care Organization, Journal of Palliative Medicine, September Key Findings Medicare shared savings program Cost per patient during the final three months of life was $12,000 lower with home-based palliative care than with usual care ($20,420 vs. $32,420; p = ). Lehigh Valley Lukas L, Foltz C, Paxton H. Hospital outcomes for a home-based palliative medicine consulting service. J Palliat Med. 2013; 16(2): Fee for service model Total hospitalizations, total hospital days, total and variable costs, and probability of a 30-day readmission were significantly reduced (30%) in the 18-month period following program enrollment. Variable hospital costs < $3,400/case

9 There are a Range of Alternative Payment Models Quality Cost Emerging Payment Models that Integrate Palliative Care PAYMENT MODEL Enhanced fee schedule FFS with shared savings /losses Add on fee Case rate (PMPM) (Partial capitation) Lump sum payment Bundled /episode based payment Description Paid a higher % of Medicare. Some commercial health plans pay for clinical social workers and others. Shared savings (or losses) based on meeting specific cost, quality, or experience targets. Additional payment per patient for services such as case management. Monthly payment per enrolled member/patient per month. Contracted payment for specific clinical coverage period (e.g. $X per 4 hour clinical block of time). Payment for a set of services for a period of time. 18 9

10 Bluegrass Care Navigators Case Study Episode Based Payment: 6-week hospital to home nursing transition case rate that includes: Initial hospital visit and assessments Home visits for 4 weeks Telephonic support in week 5 and home visits in week 6 Detailed assessment of patient s ability to conduct activities of daily living Provide medication management Coach patient for follow-up primary care visit Accompany to the primary care visit Conduct phone calls for each week there is not a home visit Payment for Palliative Care has Several Sources Traditional Medicare Traditional Medicaid Health Plan (including Medicare Advantage and Medicaid Managed Care) Other Health Care Providers Home health episode Eligible clinician fee-for-service Varies according to state, but can include: Home health episode Eligible clinician fee-for-service Home health contract Eligible clinician fee-for-service Negotiated alternative payment for home-based palliative care services Direct contract or Subcontract Session payment Salary support Gainsharing 20 10

11 Bluegrass Care Navigators Case Study Palliative Care Clinic within a Medical Group BCN provides HPM physician, Nurse, SW Medical Group provides Administration Chaplain Subsidy Enhancing Palliative Care Skills of Care Team Traditional Medicare Integrating palliative care improves home health agency performance under Medicare value-based purchasing Home Health Quality Measure Unplanned hospitalizations Emergency Department Use without Hospitalization Improvement in Pain Interfering with Activity HHCAHPS Ratings Palliative Care Positively Impacts 22 11

12 Bluegrass Care Navigators Case Study Partner experienced: Improved employee engagement survey results Increased retention (partially attributed to employee satisfaction with palliative care partnership for care of complex patients) Enhanced Services can be Billed Under Part B, for Eligible Clinicians Traditional Medicare Advance care planning codes Advance care planning via Telehealth Chronic care management codes Complex chronic care management codes (for non-billable clinicians) Prolonged face-to-face services code Prolonged non-face-to-face services code 24 12

13 Health Plan Payment Models Vary Health Plans Health Plans use a variety of payment models, with more flexibility to cover the program s costs Enhanced fee schedule Fee-for-service with shared savings Add on fee (aka care management fee ) Case rate or PMPM Lump sum payment Episode payment 25 Bluegrass Care Navigators Case Study Exceptional Patient Needs/Plan Flexibility Private Duty LPN/Trach Care/Dialysis Food Subsidy Medication Refrigerator Longer term intervention 13

14 Health Plan Case Rate Examples Health Plans Health plan pays a fixed monthly payment for each member enrolled in the program Services specified in the contract. Often include: Clinician visits - Home nursing Personal care - 24/7 monitoring/response Contract also specifies enrollment and disenrollment criteria Often, patients eligible regardless of homebound status Some national home-based palliative care organizations are also paid shared savings 27 Health Plan Lump Sum Payment Example Health Plans Program receives a fixed annual payment for nurse coordinator and social worker team. Team is available telephonically to health plan members who are referred by the plan s case managers

15 Health Plan Bundled Payment Examples Health Plans Three-month bundled payment for home-based services Patient eligibility reviewed and renewed as needed after three months Fixed payment for a six-week structured program focused on symptom stabilization, caregiver education, and advance care planning 29 Contracting with Other providers Other Providers There are opportunities to contract with or through other provider who are at-risk for cost and outcomes Accountable Care Organizations Build or sub-contract for home-based palliative care Oncology Practices under bundled payments and OCM Subsidize office-based palliative care programs 30 15

16 New Medicare Payment is Emerging Independence at Home CMMI demonstration as permanent benefit under Medicare congress/senate bill/464 Physician Focused Payment Models for Serious Illness Under MACRA have been submitted and are in process 31 Preparing to Contract: 5 Steps

17 Get Started! Relationships Matter! Persevere! Communicate! Practical Advice Questions? Contact Us: Tom Gualtieri-Reed Liz Fowler