Payers are supporting palliative care through value-based contacts.
Highmark is a regional payer organization that serves members throughout Pennsylvania, Delaware and West Virginia. It offers unique palliative care services to its Medicare Advantage members and supports hospital palliative care through value-based contracts.
Value-Based Contract Example
Highmark utilizes value-based contracts to support palliative care. Highmark’s Quality Blue incentive program supports hospital palliative care by providing incentive payments to hospitals based on these key metrics:
- The percentage of patients receiving a palliative care consult in the hospital (per 100 admissions).
- Patients who have documentation of resuscitation status on or before day one.
- Patients who have documentation of ICU efforts to identify the medical decision maker on or before day one of the ICU admission.
- An interdisciplinary family meeting conducted on or before day five of the ICU admission.
“The program includes a lifetime limit of 10 visits by a palliative care–trained social worker or registered nurse, who comes to the home as needed to provide patient and family education, consult about goal setting and care planning, and connect patients and families with community resources.”
Highmark’s Advanced Illness Services program reimburses hospice agencies to provide interdisciplinary (non-hospice) palliative care home visits for its members at a special fee-for-service reimbursement rate that accounts for the additional time required. The palliative care visits from the hospice agency are reimbursed via procedure codes that permit providers to bill for eligible services.
The program includes a lifetime limit of 10 visits by a palliative care–trained social worker or registered nurse, who comes to the home as needed to provide patient and family education, consult about goal setting and care planning, and connect patients and families with community resources. The program provides 24/7 telephonic or in-home access to a palliative care team in case of unmanageable pain and symptoms. The type of outreach chosen is at the discretion of agency staff. Palliative home visits allow for early intervention, ongoing coordination of care with providers, and timely access to information to assist members and families with:
- Communication and complex decision making related to goals of care.
- Advance care planning.
- Control of pain and other symptoms.
- Psychological and practical support for patients and family caregivers.
- Referrals to community services.
Lisa Remington is president of the Remington Health Strategy Group and publisher of the Remington Report magazine and has worked with more than 6,000 organizations in both a consultancy role and educator. Lisa monitors the complex key trends and forces of change to develop a correct strategic approach to de-risk decision-making and create sustainable futures across the healthcare continuum.