Featured Health Business Daily Story, May 11, 2016

Expanded CMS Reimbursement Prompts Some Blues to Enhance Palliative Care

Reprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS, a hard-hitting independent monthly newsletter on new products, market share, management strategies, profitability, strategic alliances and executive compensation of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.) Sign up for a $72 two-month trial subscription today.

By ,
May 2016Volume 15Issue 5

Since Jan. 1, Medicare has been reimbursing physicians and other providers $86 to discuss end-of-life care with their patients during office visits. Topics include hospice, living wills and do-not-resuscitate orders. In response, several Blues plans have expanded their palliative care coverage to include such conversations.

Blue Cross Blue Shield of Massachusetts, for example, already paid medical providers for palliative care services, but in December added payment for behavioral health providers. The insurer also increased educational support for enrollees and their family members and caregivers, and encourages earlier and expanded use of hospice care.

While a whopping 95% of recently surveyed physicians — and about 80% of Medicare members — are in favor of CMS’s expanded coverage for advance care planning services, just 14% have actually billed Medicare for it, according to a survey of 736 doctors conducted by the John A. Hartford Foundation, the California Health Care Foundation and Cambia Health Foundation, the philanthropic arm of Cambia Health Solutions, Inc., which operates Regence Blue Cross and Blue Shield plans. Many providers say they are uncomfortable discussing death with patients. Nearly half of them report that they frequently or sometimes feel unsure of what to say, according to the study, which was released April 18.

The AIS Report on Blue Cross and Blue Shield Plans

Regence BlueShield has been requesting end-of-life discussion claims since November 2014. Early this year, Regence BlueShield Executive Medical Director Bruce Smith, M.D., told Health Plan Week that few doctors bill for palliative services, but said he was optimistic the new CMS code will help turn the tide in terms of utilization. (See story, p. 3, for details of Regence’s palliative care program.) HPW is a sister publication of The AIS Report.

The philosophy of palliative care is to enhance quality of life by creating a coordinated care path for patients — and family members — immediately after a life-threatening accident or diagnosis of a potentially fatal disease. Palliative care could be in place for years after a diagnosis. But too often, it is an afterthought that is considered only after doctors determine curative care isn’t going to keep the patient’s condition from deteriorating.

During their last two years of life, patients with chronic illness account for nearly one-third of total Medicare spending, much of it going toward physician and hospital fees associated with repeated hospitalizations, according to the Dartmouth Atlas of Health Care. Palliative care programs can help cut hospital readmissions and reduce overall care costs, says Judith Skretny, director of palliative care at the National Hospice and Palliative Care Organization.

“It fulfills all the needs of health care, which is to provide quality care at lower costs,” she explains.

Highmark Partners With Aspire Health

Pittsburgh-based Highmark, Inc. partnered with Aspire Health to provide an extra layer of support for members facing advanced illness, their families and the physicians caring for them. Through Aspire, Highmark offers free, around the clock support, including home visits, to in-home members in the last years of life. Mary Lou Buyse, M.D., senior medical director at Highmark, said the new program builds upon a successful palliative care pilot with Medicare Advantage (MA) members between 2011 and 2015. The Advanced Illness Services (AIS) program was seen by company leaders as effective and worthwhile. To expand it, the company turned to Aspire Health, a Nashville-based palliative care provider that operates in 12 states and 22 cities.

About 2,200 Highmark MA members are now enrolled in that program throughout Pennsylvania.

“We saw there was a lot of value in improving people’s lives at the end of their life,” she explains.

Program Helps Keep Members Home

Potential candidates are identified through internal case managers or by a member’s primary care doctor or home health provider.

“Our program is meant to go beyond what the hospitals do and help people stay at home as much as possible.” Each month, about 300 new MA members enroll in the program. Statistics from Highmark’s earlier advanced illness program indicate the extent to which the program fills a need. About 70% of AIS members who passed away died while in hospice. That compares to about 20% of MA members who enter hospice before death. Moreover, Buyse says the average length of time in hospice is about 34 day for AIS members — about double the typical 15 days of hospice care for MA members. People who go into hospice are in less pain during the final days. The goal of palliative care is to relieve suffering and provide the best quality care to people and family members who are facing the pain and stress of a serious illness, Buyse explains.

And almost 79% of people enrolled in the AIS program complete their advance care plan.

See CMS’s final rule updating payment policies, payment rates and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-i....

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