How a Full-Risk Payment Model Powers an Illinois Home-Based Palliative Care Program

How would you respond if I asked you, “What’s holding your health care organization back from being able to provide the exact kind of palliative care that you want to provide?”

I suspect that many of you would say that it’s all the hoops that you have to jump through for reimbursement. The fee-for-service (FFS) model has long been a poor fit for the type of interdisciplinary, person-centered care that is palliative care.

My organization, Aurora Advocate Health (in Illinois), has chosen an approach that empowers our palliative care team to be more responsive and creative when it comes to providing care. Aurora Advocate Health has been moving toward a full-risk payment model for many of our Medicare Advantage patients. As a result, we manage all of their care and take on the full cost, too. That includes palliative care, which we provide in the home.

Our leadership has recognized the value added by strong home-based palliative care, and this becomes especially important under risk-based payment. It’s working out nicely for everyone—and it does actually result in important cost savings, too.

Our program may be a little different from what you’re accustomed to. We launched a home-based palliative care program in 2010. But a few years later, the leaders of my organization decided to merge the home-based palliative care program with our home-based primary care program. They believed the move would greatly benefit our patients by streamlining the process of navigating the various options of care.

After coping with the onset of the COVID-19 pandemic, we officially merged the two programs—including all the staff—into one program in May 2021. Today, we have a group of approximately fifty people who make sure that our homebound patients receive the care they need. For some, that’s a blend of primary and palliative care, but for others, it’s just palliative care. This really helps us meet every single patient exactly where they are.

For our total risk population of patients, we provide all the home-based care that they need. For palliative care, we send one of our nurse practitioners, registered nurses, or social workers to each patient’s home. It takes time to make those home visits, but we believe in value, not volume. We want to be able to spend enough time with every single person. As a result, we don’t cram dozens of visits into each day; our palliative care team may only make four or five home visits per day.

A key difference in our approach is the ease at which our clinicians can tailor care for individuals in our total risk population, especially when compared with fee-for-service (FFS) patients and traditional Medicare patients. The clinician can decide the most appropriate type of care (within the patient’s covered benefits) to provide—and then just do it, without having to get additional authorization for the full-risk contract patients.

For example, say that one of our palliative care clinicians decides that a homebound patient really needs an IV to provide hydration therapy. If the patient is enrolled in the Medicare Advantage program, the nurse can set up the IV right there in the home and begin the therapy or can admit them to a skilled nursing facility for infusion therapy. But if your patient has traditional Medicare, you would have to take additional steps before you can begin this type of infusion therapy. With our approach, it is just a seamless part of their overall care without any interruptions—and with the same care team.

But don’t forget: we have patients with other types of insurance, too. Depending on the particular policy and coverage they have, they may have to wait while one of our care coordinators navigates the time-consuming process of obtaining prior authorization. Depending on their insurance, that might take several days, or it might not happen at all.

As you might expect, our palliative care clinicians really appreciate the freedom afforded to them by the total risk contract.

Since not all of our patients are covered by a risk contract, they do still have to jump through hoops for those other patients. That creates quite a contrast from the more straightforward experience of providing care for the patients covered under the full-risk contract.

• Our patients benefit because they receive the care they need without having to wait for it
• Our palliative care clinicians benefit because they get to provide care for their patients without having to agonize over what’s covered and how
• Our colleagues in our system’s office-based practices no longer have to manage their complex cases in 15-minute office appointments

And Aurora Advocate benefits, too. Caring for these patients in the home actually saves money in the long run. Providing palliative care in the home reduces the likelihood that those patients will need to be admitted or readmitted to the hospital, which can result in substantial cost savings. In fact, we have reduced hospital admissions by 50%, which reduces the net total cost of care by an average of 36%.

Right now, Aurora Advocate has about 1,200 patients in Illinois who participate in our home-based care program. About one-third of them are full-risk patients, but we would like to provide this kind of care for even more patients. Luckily, our organization recognizes the aligned incentives in accountable care programs such as the Medicare Shared Savings Program (MSSP), and is tapping into their waivers to provide this same care for those patients. Palliative care leaders may want to encourage their own organizations to participate in programs such as the MSSP or the new ACO REACH model, or the new Enhancing Oncology Model for those who see opportunities to improve value in cancer care. There are many ways to integrate palliative care into population management through these payment models.

Eventually, we hope that Medicare will improve its coverage of palliative care services so that everyone can benefit. But in the meantime, we will do our absolute best to manage our patients as well as possible and enable them to stay in their own homes—and out of the hospital.

Edited by Melissa Baron. Clinical review by Andrew Esch, MD, MBA.