Standardizing Home-Based Palliative Care: Necessary, Doable, and Fruitful

When health plans and palliative care clinicians come together about contracting, progress can be slow before things even get started. It can take months of discussion just to come to an agreement on what home-based palliative care (HBPC) is—including basic things such as what services are included. And what worked for one plan/provider agreement may not work for the next one, which means starting the negotiation cycle from scratch each time.

Six years ago, some payers and providers in California realized there had to be a better way and asked one another, “Why don’t we just agree on what the basic, minimal standards for HBPC are, so we can move more quickly to actually meet the needs in our communities?” With leadership from the Coalition for Compassionate Care of California (CCCC), that is exactly what they did.

In partnership with Blue Shield of California, CCCC convened representatives from California health plans, palliative care providers, policy advocates, researchers, and other stakeholders in 2016. Their charge was to establish minimum standards to inform contracting for HBPC, no matter the payer. The goal was to clarify for everyone—including patients and families—what could be expected when we say, “Yes, we have a home-based palliative care team.”

Multiple meetings were held in-person and virtually, and a consensus was achieved through guided discussion and compromise. Any reports of blood, sweat, or tears are (probably) exaggerations. An important aspect of the work was what the convened representatives were not doing; they were not rewriting the National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care or other clinical guidance from the field.

Rather, their goal was to specify consensus expectations for operationalizing, delivering, and reimbursing HBPC through payer-provider contracts. This work happened simultaneously with the state’s efforts to define a Medi-Cal (Medicaid) palliative care benefit; representatives from both efforts informed each other and came to many of the same conclusions.

The result was a document released publicly in 2017 that summarized consensus standards for HBPC in five domains:

• Eligibility: General and disease-specific criteria for which patients should be identified as eligible
• Services: Expectations for assessment, clinical services, care coordination, and communication
• Staffing: The disciplines that must be included in a palliative care team
• Measurement: Specific process and outcome measures of interest to payers and providers
• Payment model: Concurrent with other services, recommended value-based reimbursement and case rate payments that cover the efforts of all team members

Do you remember Abbie Hoffman’s, “Steal this Book”? Everyone is welcome to “steal” these standards and use them as a starting place for contract negotiations, or to modify them to achieve stakeholder consensus elsewhere. You might end up with a different set of standards that suits your stakeholders and partners. That’s fine with us; we would just hate to see you start with a blank slate.

With standards in hand and continued support from CHCF, our group wanted to tackle an even bigger question: What happens when payers and providers apply these standards in contracting and practice? To find out, we launched a demonstration project in 2018 with four payers and eleven providers in two regions, Los Angeles and Sacramento. This included health plan members/patients with three insurance types: Medicare Advantage, commercial, and Medicaid Managed Care.

Note that all contracts specified patient populations, minimum services, etc., which at least met the minimum requirements outlined in the standards. Everyone was welcome and encouraged to do more (broaden access, provide more services, etc.), and most did—but that was a choice, not a requirement. It’s an approach that is similar to that used in a lot of health care: all Medicare-certified home health agencies have to provide the services CMS has specified in the home health benefit, but some agencies choose to do more.

Did the standards work? The short answer is yes. (The long answer is 3 hours of presentations available for free). Generally, the payers and providers felt the standards provided a good starting place, and they appreciated the freedom to exceed those standards in contracts or care delivery. There was some variation in implementation, but the standards plus good implementation choices helped to reduce negative outcomes and unwanted variation.

Over 900 patients started HBPC in the fifteen-month window of the demonstration project, and their average enrollment was 5.8 months, which differed by insurance type: 4.7 months for Medicaid, 5.5 months for commercial, and 6.3 months for Medicare Advantage. Three-quarters had “moderate” or “severe” comorbidity scores. Three-quarters had the kinds of serious illnesses expected—cancer, heart failure, COPD, dementia, kidney disease, and liver disease.

Overall, the total costs of care for HBPC recipients were reduced, compared to those persons’ own baseline costs. For example, the total costs of care for Medicaid beneficiaries decreased by forty-nine percent, comparing four months before HBPC to four months with HBPC. Analyses comparing HBPC recipients to “usual care” beneficiaries are still being run. See the CCCC website for slides and recordings describing the full range of payer and provider experiences and feedback.

What’s next? Like you, none of us can say that our work is done. There is much that remains to be done to standardize, sustain, and scale-up delivery of HBPC across the nation. We hope that our project can help others to do this more quickly and more efficiently—without too much blood, sweat, and tears. Think of it as a starting place.