Home health and hospice providers see a pressing need for more palliative care in the United States but struggle to find financially feasible ways to offer it. Hosparus Health is investing about $1 million annually in a palliative care program, building a case for why government and private insurers should start reimbursing these services.

Louisville-based Hosparus Health was founded in 1978 and is primarily known as a hospice provider, serving about 7,800 patients and their families across 37 counties in Kentucky and Indiana. Since 1980, the company has been providing pediatric palliative care through its Kourageous Kids program. In 2015, it expanded into adult palliative care.

That year, it ran an adult advanced illness/palliative care pilot with a local commercial insurance provider. Results were promising—for the 22 patients involved, 30 emergency room visits were prevented, for an estimated $36,000 cost savings to the health care system as a whole. Patient and family satisfaction was 4.9 on a 5-point scale.

With these findings in hand, Hosparus decided to continue the program after the 16-month pilot concluded, despite some challenging math.

Currently, there is no insurance-based payment source for palliative care—that is, for supporting people with chronic or degenerative illnesses or conditions, managing symptoms and enhancing quality of life while often easing them into hospice care or, in some cases, maintaining their level of wellness or helping them improve. Such services are left out while Medicare, Medicaid and private insurers cover acute care in hospitals as well as skilled home health and hospice.

At the same time, people in need of palliative care are often cash-strapped, considering that they usually can’t work and have sometimes staggering medical expenses. So, Hosparus Health has created a sliding scale for payment, based on what palliative care patients can afford. Most people are paying very little or nothing.

To keep the program running, Hosparus is relying on contributions from donors and is re-investing some of its own profits, to the tune of about $1 million annually.

The nonprofit is approaching about $70 million in annual revenue and operates at a 3% margin on its core hospice Medicare reimbursements, so that leaves about $2.1 million, Hosparus Health President and CEO Phil Marshall told Home Health Care News. Considering that tight labor markets mean wages and benefits need to be more competitive than ever, it’s tough to put money into innovative programming.

Still, the company is making a commitment to palliative care for a few reasons. One is that it fits into the organization’s long-standing mission. Another is that Marshall and his leadership team want to prove out how palliative care can help keep costs down for the health care system as a whole while improving outcomes and patient satisfaction, to help convince payors to add palliative care benefits. And then, they want to be in a good position to tap into these revenue streams.

Already, Hosparus is in talks with private payors and a hospital system, discussing potential demonstration models for palliative care. It is also advocating at the state and federal levels for palliative care benefits. And the company is optimistic, given what is hearing in its own negotiations and in the progress that is being made in legislation and public policy. For instance, the company supported the move to add a personal care benefit to Medicare Advantage, and its leaders were pleased to see that finalized.

“We just keep talking about it and trying to reach whoever will listen, at the state level, federal level, payors, partners,” Hosparus Health Executive Director of Palliative Care Denise Gloede told HHCN. “We can help these folks, but there needs to be some sort of reimbursement model.”

Beyond dollars and cents

In 2017, the palliative care program served 87 adults and 150 kids, Gloede said. That number could more than double in 2018.

The model involves an interdisciplinary team, with a nurse and social worker doing monthly patient visits. Certified nursing assistants (CNAs) and volunteers do more frequent home visits depending on patient and family needs.

Care coordination is a focus, to prevent the fragmentation of care that can lead to exacerbations and hospital admissions. Sometimes, additional services such as skilled home health are brought in if a patient qualifies. Many palliative care patients have multiple conditions, and some of the common diagnoses are chronic obstructive pulmonary disease (COPD), heart failure, cancer, and Parkinson’s and other neurodegenerative diseases.

Pain, anxiety and fatigue are the three most common symptoms that these patients report, based on a quality-of-life index that Hosparus Health uses, Gloede said.

“Fatigue is interesting, [that it’s] not a more serious physical symptom,” she said. But when even brushing your hair can be physically draining, it’s no wonder that fatigue is a serious concern, she added. These three symptoms are also interrelated.

Consider that a person might be on dozens of prescription medications that get re-filled at different times. After going to the pharmacy three times in a week, a patient might feel too tired to go again, despite needing more medication to prevent shortness of breath. This situation causes anxiety, which can escalate to the point where a person is calling 911 in a panic and unable to breathe, resulting in an emergency department visit.

The palliative care team can help get medications all re-filled simultaneously, preventing this situation, Gloede said.

The program is also focused on patient goals. One example of what this means: The program worked with man in his 50s who was morbidly obese, diabetic and had high blood pressure, and experienced numerous complications after gastric bypass surgery. His first goals involved working with home health to treat and heal a chronic wound, and then he set a goal of becoming more mobile. At first, he was barely able to walk down his driveway, but he was working out at a gym when he was discharged from palliative care after a year-and-a-half.

Not every patient is able to improve, but palliative care workers can help all patients work toward their own goals—and often, these are straightforward objectives that do not require expensive medical interventions. So, even though Hosparus is making a big financial commitment to palliative care, the return on investment is well worth it not only from a dollars-and-cents perspective, but in terms of patient satisfaction.

“It’s such a simple, low-cost, low-tech, highly engaged kind of program,” Gloede said.

Written by Tim Mullaney