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How Palliative Care Can Maximize Value-Based Reimbursement

Integrating palliative care into cancer treatment can improve value-based reimbursement success in MIPS, the Oncology Care Model, and MSSP, a new study shows.

By Jacqueline Belliveau

- Providers can boost value-based reimbursement success by incorporating early palliative care into routine cancer care delivery, a new study in the American Journal of Managed Care indicated.

Palliative care incorporation into cancer care delivery can boost value-based reimbursement in some alternative payment models

Researchers at the Center to Advance Palliative Care explored how palliative care can boost success in MACRA’s Merit-Based Payment Incentive Program (MIPS), Medicare’s Oncology Care Model, and the Medicare Shared Savings Program (MSSP).

“This commentary provides examples from four significant value-based programs demonstrating how palliative care can simultaneously improve performance on quality measures while reducing costs,” wrote study authors. “These examples suggest that oncologists can benefit under value-based payment by integrating core principles of palliative care into their standard practice and/or establishing formal relationships with palliative care specialists.”

Incorporating palliative care early in a cancer patient’s treatment can boost value-based reimbursement because of care quality improvements, lower healthcare costs, and more appropriate resource use.

For example, a 2010 study in The New England Journal of Medicine found that cancer patients who received early and concurrent palliative care experienced less major depression (16 percent compared to 38 percent) and a three-month increase in survival.

READ MORE: AAFP: Drop MIPS APM Pathway to Simplify MACRA Implementation

Another recent study in the Journal of Palliative Medicine also showed that early palliative care generated lower healthcare costs because of the following inpatient care reductions:

• Hospital admissions decreased from 66 percent to 33 percent

• Emergency department visits lowered from 54 percent to 34 percent

• Intensive care unit utilization dropped from 20 percent to 5 percent

• Direct inpatient costs in the last six months of life decreased from $25,754 to $19,067

READ MORE: CMS Expects to Release MIPS Participation Status By May 2017

Based on results from various studies, the American Society of Clinical Oncology suggested in 2012 that “combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.”

However, Center to Advance Palliative Care researchers determined that palliative care barriers still exist despite the oncology group’s recommendations. The barriers included provider confusion between palliative care and hospice, lack of clinician training, and limited understanding of how palliative care adds value.

To help providers overcome the challenges, the study examined how integrating palliative care into delivery routines can maximize value-based reimbursement in several alternative payment models, including MIPS, the Oncology Care Model, and MSSP.

Boosting MIPS quality and cost scores using palliative care

Under MIPS, eligible clinicians will be evaluated on four performance categories: quality, cost, advancing care information, and improvement activities. Participants with higher performance scores will earn greater value-based incentive payments.

READ MORE: Industry Orgs Back 2018 MACRA Implementation Flexibilities

Researchers stated that providers can improve quality and cost category scores by including palliative care specialists to care teams treating seriously ill patients.

Palliative care specialists can boost quality scores by improving patient experience and satisfaction. A 2013 Journal of Palliative Medicine study showed that palliative care improved patient satisfaction scores.

Results from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) may influence MIPS scores because it is a cross-cutting measure in the quality category.

Incorporating palliative care may also improve performance on other MIPS measures, such as advance care planning, pain assessment and follow-up, and medication reconciliation, the study added.

In terms of cost, increased palliative care should result in more appropriate resource use because of lower emergency department, hospital admission, and intensive care unit utilization rates. Resource use will be a major factor in determining Medicare reimbursement adjustments in MIPS as well as the other MACRA payment track, Advanced Alternative Payment Models.

Improving Oncology Care Model quality performance with palliative care

Medicare’s Oncology Care Model incentivizes providers through monthly and performance-based payments to improve cancer care quality and furnish enhanced services. But the study showed that palliative care can improve quality performance in the alternative payment model.

Palliative care and related specialists can boost performance on the following model measures:

• Pain assessment and management

• Patient experience of care

• Emergency department visits and hospital admissions

• Proportion of Medicare beneficiaries undergoing chemotherapy in the last 14 days of life

• Percentage of patients admitted to hospice for less than 3 days in the last 30 days of life

To achieve better performance, researchers recommended that healthcare organizations educate oncologists and other clinicians on core palliative care skills or place palliative care specialists in oncology practices.

Model participants should allocate part of their monthly enhanced oncology services and performance-based payments to boosting palliative care training and staff.

Improving performance scores in the Oncology Care Model may also help some providers succeed in MACRA’s Advanced Alternative Payment Model track. Participants in the downside financial risk track of the Oncology Care Model qualify to earn greater value-based incentive payments depending on performance.

Maximizing MSSP shared savings payments by adding palliative care

Palliative care can improve a MSSP accountable care organization’s (ACO) chances of earning shared savings payments because of quality performance and readmission rates improvements.

Researchers found that palliative care incorporation is likely to increase performance on several MSSP quality measures, including all-cause unplanned admissions, ambulatory-sensitive admissions, skilled nursing facility 30-day all-cause admissions, and depression remission at 12 months.

Readmission rates should also drop as ACOs integrate palliative care in cancer treatments. CMS reported in September that national hospital readmissions rates dropped to below 18 percent in 2015.

However, 2015 National Palliative Care Registry data showed that average readmission rates were only 13.8 percent for patients discharged alive who received palliative care consultation services.

MSSP ACOs have added palliative care either at home for high-risk patients or into oncology care models.

Some MSSP ACOs linked their highest-risk patients with home-based palliative care services. The home-based care included “an interdisciplinary team providing continuous comprehensive assessment, pain and symptom management, and expert conversations in the patients’ homes, adjunctive to the care delivered by their treating providers.”

Other MSSP ACOs integrated palliative care into oncology practices. For these ACOs, clinicians underwent extensive training on advance care planning, including how to properly document care plans in the EHR.

Palliative care specialists also joined oncology practices at other MSSP ACOs to help meet the health needs of the most complex cancer patients.

Additionally, researchers found that palliative care can generate significant savings for Medicare Advantage plans by reducing inpatient utilization, boosting member satisfaction, and improving CMS star ratings.

“Plans that perform better on their measures receive more stars, leading to higher premium payments and a greater ability to attract and retain members,” wrote study authors. “Consumers consider the Medicare Star Ratings during the open enrollment period for MA and 5-Star plans have the advantage of being able to enroll members switching from other MA plans at any time during the year.”

Dig Deeper:

Understanding the Value-Based Reimbursement Model Landscape

How a Palliative Care Focus Eases Healthcare’s Cost Burdens

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