A Payer-Provider Pilot of a Financial Model for PC Delivery

Topic: Impact of Program Financing

Providing comprehensive multidisciplinary community-based palliative care (PC) delivery is challenging from a provider perspective using fee-for-service reimbursement. As part of a California Health Care Foundation (CHCF) payer-provider partnership grant, UCLA Health and Anthem piloted a contract modeled after the Oncology Care Model (OCM) for advanced cancer patients beginning in January 2015 to support NP-based PC embedded within oncology clinics. PC in this pilot clinical model was provided to appropriate patients with advanced cancer in the clinics of 5 oncologists. Patients who had Anthem PPO insurance and were “fully insured” qualified for payment under the pilot contract. Other Anthem PPO patients, e.g., those for which Anthem provided Administrative Services Only (ASO) for employer-based insurance, did not qualify for payment under the contract. We evaluated the number of Anthem PPO patients with advanced cancer who received PC under the pilot clinical model and the percentage of those patients who qualified for additional payment under the pilot financial model. We also compared key process and outcome measures for Anthem PPO patients with advanced cancer who received care through the palliative program compared to Anthem PPO patients with advanced cancer who did not.

Forty-five Anthem PPO patients with advanced cancer received PC in one of the 5 oncologists’ clinics from January 2016 through May 2017; 16 (36%) qualified for the innovative payment structure under the contract because they were fully insured. Patients with advanced cancer who were enrolled in the PC program were more likely to have documented goals of care conversations (76.2% v. 8.3%, p<0.05), to have a completed POLST (19% v. 4.1%, p<0.05), and to be referred to our multidisciplinary integrative psychosocial support care center (47.6% v. 30.6%, p=1). There was no difference in advance directive completion. Among decedents, patients enrolled in the PC program were more likely to be referred to hospice (50% v. 30.2%, p<0.05) with a trend towards less hospital (2.3 v. 5.0 days) and ICU (0.8 v. 1.2 days) use during the last 30 days of life. We plan to explore how enrollment in the PC program affects healthcare costs. Expansion of innovative financial models by payers and employer organizations are likely to be an important step toward increasing access to community-based PC.

Author

  • Anne M. Walling, MD
  • University of California, Los Angeles
  • 911 Broxton Ave
  • Los Angeles, CA 90024
  • 310-794-2284

Co-authors

  • Anne Coscarelli
  • Ann Zisser
  • Christopher Pietras
  • Jennie W. Kung
  • Neil Wenger
  • Samuel Skootskly
  • Sarah D'Ambruoso

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