Blog Post | March 13, 2019

Home-Based Palliative Care Programs Follow Needs and Growth of Medicare Advantage Plans

Of the 20 million Americans enrolled in Medicare Advantage (MA) plans, well over one-third can be categorized as “high need” — meaning they have a serious or advanced illness that interferes with their ability to lead independent lives. These individuals are more likely to have limited financial means, low levels of education and social isolation, making it more important than ever for plans to identify high-need beneficiaries based on medical and social risk factors, not simply medical diagnoses, when providing supplemental benefits. What’s more, it is expected that many of these seniors prefer to maximize their independence at home.

MA plans typically provide more comprehensive coverage than Medicare parts A and B and is managed by private insurers. Over the next 10 years, the proportion of enrollees covered by MA will rise from 34 percent to 42 percent of the overall Medicare population, while the number of people on Medicare who are 80 and older will nearly triple by 2050.

A growing number of MA plans are turning to innovative models of community-based palliative care (CBPC) that provide telephonic and home-based services to meet the needs of members living with serious or advanced illness, as well as to support their caregivers.

Palliative care focuses on providing relief from the symptoms and stress of a serious illness with the goal to improve quality of life for both the patient and the family. As organi­zational leaders begin to recognize that clinicians with palliative expertise are needed to effectively address the impact on cost and quality of care for those with serious illness, community-based palliative care becomes one of the most attractive programmatic additions to MA plan offerings.

Medicare Spending at End of Life

Of the 2.6 million people who died in the U.S. in 2014, 2.1 million, or eight out of 10, were people on Medicare, making Medicare the largest insurer of medical care provided at the end of life.

Spending on Medicare beneficiaries in their last year of life accounts for about 25 percent of total Medicare spending on beneficiaries age 65 or older.

The fact that a disproportionate share of Medicare spending goes to beneficiaries at the end of life is not surprising given that many have serious illnesses or multiple chronic conditions and often use costly services, including inpatient hospitalizations, post-acute care, and hospice, in the year leading up to their death.

CMS Relieves Barriers to Adoption

In response to this significant transformation in healthcare delivery is the recent introduction of regulatory and legislative policy changes to MA that will:

1) provide plans with more flexibility and enable provision of services matched to individual member needs; and
2) expand the types of services that can be covered. These changes have direct relevance for provision of palliative care and social services for beneficiaries in MA plans.

Specifically, MA plans will be allowed to cover new supplemental benefits and providing flexibility for plans to offer different supplemental benefits, including:

  • In-Home Support Services to assist with activities of daily living, such as bathing, dressing, and toileting, as well as instrumental activities of daily living, such as shopping, cooking, and housekeeping
  • Support for Caregivers of Enrollees, such as respite services, counseling, and training; and, importantly…
  • Home-Based Palliative Care, described as “services to diminish symptoms of terminally ill members with a life expectancy of greater than six months not covered by Medicare (e.g., palliative nursing and social work services in the home not covered by Medicare Part A)”

The specific mention of home-based palliative care is critical because CMS is explicitly acknowledging how valuable palliative care is and giving MA plans permission to cover it outside of acute care settings as a formal benefit.

This change will allow non-medical palliative care to provide relief from the symptoms and stress of a serious illness, as well as MA-contracted nurses and social workers—whose time is not directly billable under traditional Medicare fee-for-service—to go into the home to provide the high-quality services that palliative care, including home-based assessments and interventions, communicating relevant information to the primary treating physician / medical home to foster better communication and to ensure that care delivery is consistent with patient goals.

In addition, The Centers for Medicare & Medicaid Innovation (CMMI) recently announced an expansion of the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model to test several wide-ranging updates to MA offerings, including a hospice carve-in set to take effect in 2021. Hospice care is currently not allowed as a benefit covered in MA plans. This expansion is designed to increase access to hospice services and improve coordination between patients’ hospice providers and their other clinicians.

A Population Health Approach to Community-Based Palliative Care

With the introduction of innovative models, it is now possible for an MA plan or a health care delivery system to partner with a company like Turn-Key Health and capitalize on its Palliative Illness Management (PIMTM) program:  a solution that identifies members earlier in their disease progression who are likely going to be overmedicalized during the last 6-12 months of life, as well as information gleaned from in-home visits to identify high need individuals and provide structured and consistent home-based palliative care that scales across broad geographies.

PIM Ensures:

While traditional approaches call upon local resources, they lack the appropriate oversight that PIM delivers, enabling payers to scale their programs for diverse geographic regions, serve larger populations, drive better outcomes. and function as a palliative medical home.

The PIM solution prioritizes the importance of care in the home, providing appropriate social services, clinical assessments and referrals, and partnering with physicians to deliver a solution that is patient-centered, data-driven and evidence-based.

Ultimately, this population health approach brings a greater focus on health and avoiding overmedicalized care, with home-based services that address health-related needs, resolve issues related to everyday living and provide a level of systemized support that may go missing from other models.  This structured, consistent approach to community-based palliative care enjoys a proven return on quality improvement and investment in resources.

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