Table 1.
Examples of Existing and Proposed Payment Models
| Existing payment models | Elements covered | How elements are/would be paid | Advantages/disadvantages for palliative care |
|---|---|---|---|
| FFS | Payments based on volume, for example, procedures, hospitalization. | Based on current procedural terminology (CPT) or diagnosis-related group (DRG) codes, payment directly to hospital or provider | Disadvantage—no link to quality or value. Unbillable interdisciplinary team services |
| Medicare Access and CHIP Reauthorization Act (MACRA) | Payment based on value and provider incentive programs. | Reimburses Medicare B providers based on domains of quality, spending, performance improvement, and health IT. | Advantage—focuses on improving quality-of-care delivery and reducing costs (proven outcomes of palliative care.) |
| Medicare advantage plans | Part A and B + dental, hearing aid coverage, drugs discounts, care management programs. | Plans receive monthly payment from CMS, may incur loss if total cost exceeds the total premium. | Advantage—covers items and plans promoting health and wellness. |
| Disadvantage—access to a narrower network of providers/hospitals in network. May exclude specific palliative care providers. | |||
| Care Coordination Fee | Activities supporting information sharing and patient decision making. | Practices/providers receive additional fixed fees to create and coordinate care plans. | Advantage—funds time for assessment and discussions with patients and family. Disadvantage—all nonbillable expenses may not be covered. |
| CMS Conditions of Participation | Specific conditions healthcare organizations must meet to receive reimbursement from CMS. | Facilities, for example, hospices, dialysis centers, nursing homes are reimbursed for care by CMS if standards of care are met. | Advantage—improves quality, protects health, and safety of patients. Potential for reproducible in-home palliative care programs or for specific serious illnesses, for example, advance care planning (ACP) before high-risk surgery for frail elderly patients |
| Proposed models | |||
| CMMI—Oncology Care Model | Focuses on patient and family communication and outcomes. | In addition to usual services, practices receive a performance-based monthly enhanced fee for the duration of treatment. | Advantage—incentivizes partnership with palliative care. Processes may help avoid unnecessary emergency department (ED) visits and hospital admissions. Potential to be replicated in other subspecialties. For example, pulmonary clinics |
| Chronic Care Act 2017 Passed by Senate Finance Committee, May 2017. | Long-term supportive services and management of patients with 2≥ chronic care. | If passed CMS would devise incentives and standards for documenting treatment preferences and goals. | Advantage—aligns with palliative care domains. |
| Care Planning Act 2017 | Promotes advanced illness planning and coordination. | If passed CMS would identify high-quality measures and revise requirements for advanced directives and portable treatment orders. | Advantage—tests innovative payment and service delivery models for the uptake of palliative care services. |
| PCHETA | Graduate Medical and Nursing education. | If passed provides grant funding for palliative care training programs for physicians, nurses and other professionals | Advantage—increases workforce and enables research agenda to be accomplished by training clinicians on palliative care topics. |
CMMI, Center for Medicare and Medicaid Innovation; CMS, Center for Medicare and Medicaid; FFS, fee for service; MACRA, Medicare Access and CHIP Reauthorization Act; PCHETA, Palliative Care and Hospice Education and Training Act.