Reimbursement News

Medicare Reimbursement Add-On to Boost Palliative Care Revenue

Providers can improve palliative care quality and increase revenue by about $202 per patient by leveraging the Medicare reimbursement add-on for in-home visits, a study showed.

Providers can use a Medicare reimbursement add-on to enhance palliative care, a study shows

Source: Thinkstock

By Jacqueline LaPointe

- A recent study in the Journal of Palliative Medicine showed that providers should be leveraging a supplemental Medicare reimbursement to enhance palliative care in the last seven days of life.

CMS pays providers for furnishing routine home care as part of a palliative care plan using an all-inclusive daily rate based on the average visit patterns of hospice providers updated each year. But the Medicare reimbursement structure does not require in-person visits with routine home care and hospice providers are left to decide if the visits are necessary during the period.

To improve palliative care, CMS established the Service Intensity Add-On (SIA) payment in 2016. The supplemental reimbursement pays registered nurses and social workers for making in-person routine home care visits during the patient’s last seven days of life.

An analysis of 42 hospice programs from across the country treating over 250,000 patients between 2005 and 2010 showed that 86.3 percent of hospice decedents who experienced routine home care days in their last week received one or more visits that would qualify for SIA Medicare reimbursement.

The average total add-on payment would have been about $202 per decedent, representing a 21.6 percent increase over the usual routine home care reimbursements per qualifying patient.

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“Our results point toward a potentially sizable increase in additional in-person direct patient care visits by RNs [registered nurses] and SWs [social workers] and a reduction in existing disparities of such visits that can significantly improve the quality of care received by hospice beneficiaries at their end of life,” wrote researchers. “It provides an important benchmark to put in perspective the importance of the SIA incentive.”

Improving palliative care is key to reducing healthcare costs and improving care quality for patients who are terminally ill. Recent research has shown that early palliative care lowered hospital admissions by one-third, emergency department visits by 20 percentage points, and intensive care utilization by 15 percentage points.

As a result, direct inpatient costs in the last six months of life decreased from $25,754 to $19,067.

Extending the same high-quality palliative care to patients in the last seven days of life can similarly prevent costly healthcare utilization and improve a patient’s quality of life.

The recent study showed that while 80 percent of decedents received routine home care at least one day in the last seven days of life, about one-third experienced general inpatient care in the same timeframe.

READ MORE: How a Palliative Care Focus Eases Healthcare’s Cost Burdens

Researchers also reported that in close to one-third of the routine home care days studied the patients had no direct contact or no care activity at all in their last days.

Hospice decedents that were the most vulnerable to not receiving SIA-eligible visits were:

• 41.7 percent of those over 65 years old received an eligible visit versus 45.3 percent of those younger than 65 years old

• Only 39.2 percent of African Americans received an eligible visit compared to 44.1 percent of white patients and 42.3 percent of patients from other racial groups

• African Americans were also more likely to see higher rates of days with only indirect or no contact (34.6 percent versus 30 percent for white patients and 31 percent for other racial groups)

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• Hispanics experienced lower rates of SIA-eligible visits (43.5 percent versus 49.2 percent for non-Hispanics) and higher rates of visits by staff other than registered nurses and social workers (15.7 percent versus 11.8 percent for non-Hispanics)

• By principal diagnosis, dementia patients had the lowest rate of eligible days with just 41.3 percent of visits

Patients with cancer and kidney disease had the highest rate of eligible routine home care days with nearly 45 percent of visits qualifying.

Those who lived at home versus a nursing home also witnessed more visits eligible for the supplemental Medicare reimbursement. About 45.6 percent of visits for patients living at home qualified for the payment, whereas 42.1 percent of visits to those living in nursing homes and 43.7 percent of visits to those at assisted living facilities qualified.

Patients living at home also saw less routine home care days with indirect or no patient care days.

For palliative care visits not qualifying for the supplemental Medicare reimbursement, researchers found that most (60.1 percent) were performed by home health aides, followed by licensed nurse practitioners (15.4 percent) and by chaplains (13.8 percent).

While the study revealed potential palliative care improvements for certain patient groups, it also showed the economic benefit of leveraging the in-person visit reimbursement.

If the SIA Medicare reimbursement was available to providers, the average add-on payments would have been $74.30 per SIA-eligible day, with the total reimbursement amount for palliative care in the last seven days of life averaging $202.50.

Non-profit hospice programs would have seen slightly more Medicare reimbursement with an average payment of $234 compared to $201 for non-profit programs.

“The size of the SIA payment incentive, together with the large disparity in SIA-eligible hours observed across hospice programs, has the important implication that while the SIA will incentivize all providers to increase the number of RN/SW visits during the last week of life, the incentive will be particularly strong for programs currently delivering at the low end of SIA-eligible minutes,” the study stated.

Researchers added that hospice programs should also increase their SIA-eligible visits to maximize revenue and improve palliative care.

“More people will get the expert assistance they need in the last days of life because of this research,” stated Charles F. von Gunten, MD, PhD, Editor-in-Chief of Journal of Palliative Medicine and OhioHealth system’s Vice President of Medical Affairs and Hospice and Palliative Medicine.