Payer-Provider Partnerships for Palliative Care

Summary

A school of colorful tropical fish swim together in a large group.
Despite evidence of the benefits of community-based palliative care (CBPC) and data indicating that our current capacity is insufficient to meet the need, growth of these services has likely been slowed by the lack of adequate, defined funding streams. To address these challenges, from 2014 to 2017, CHCF supported a planning and implementation process for six teams of payer and provider organizations committed to strengthening and spreading CBPC services in California. Participating providers included large academic medical centers, hospices, and a specialty palliative care practice, while the payers included national insurers, regional insurers, and a Medicaid managed care plan.

Payer-provider teams participated in a six-month planning process during which they developed operational and financial plans for delivering palliative care services in community settings (clinics, patient homes, and tele-visits), followed by a 24-month implementation phase where contracts were executed and services were launched. This kind of collaboration between payers and providers is an emerging trend in CPBC, and our grantees were among the first to participate in such efforts.

Growth of community-based palliative care services has likely been slowed by the lack of adequate, defined funding streams.

This series, Lessons Learned from Payer-Provider Partnerships for Community-Based Palliative Care, explores lessons about the process of developing and enacting agreements to deliver CBPC:

Explore each lesson below. Download the full report, or read the Quick Tips sheet for a brief overview.

Next: Initial Engagement

Initial Engagement

As a first step in building a successful partnership, payers and providers should take the time upfront to communicate openly and share information about organizational characteristics, goals, and priorities.

Invest in the beginning
Be open about goals, pressures, and priorities
Discuss resources, expectations, and past experiences
Expect complexity and to revisit plans over time

Next: Defining Population

Defining the Eligible Population

The clinical, operational, and social criteria used to define the target population will influence the number of potentially eligible patients, the number that are referred, and the types of supports that need to be delivered.

Be intentional in defining the target population
Understand the needs of the target population
Appreciate how eligibility will be assessed and by whom
Anticipate how eligibility criteria will impact volume, costs, and outcomes

Next: Promoting Referrals

Promoting Appropriate Referrals

Both payer and provider share responsibility for getting the right patients to the service.

Use all your assets — data resources and human resources
Plans and palliative care providers should engage with referring providers
Expect significant time investment
Initial referral volume may be low and may increase slowly

Next: Service Design, Ops Issues

Service Design and Operational Issues

The clinical model and operational processes adopted by the partnership will impact care quality, patient and family satisfaction, care team satisfaction, and costs, so thoughtful attention to detail is essential.

Align care model, patient needs, and desired outcomes
Specify expectations and boundaries
Consider approaches to increase efficiency
Look for and address operational challenges

Next: Payment Issues

Payment Issues

Determining the right payment mechanisms and amounts requires that both payer and provider have a solid understanding of care delivery costs.

Understand costs and cost drivers
Anticipate negotiation and renegotiation
Consider layering payment mechanisms
Financial negotiations can be difficult

Next: Metrics, Assessing Impact

Metrics and Assessing Impact

The right metrics are the ones that are feasible to implement and that meet the information needs of both the plan and the provider organization.

There is no standard set of metrics for community-based palliative care
The right metrics are the ones that work for both parties
Consider data access and collection burden
Plans and providers can share the burden

Next: Monitoring, Modifications

Monitoring and Modifications

Achieving and sustaining balance across three critical areas — provider effort/cost of care delivery, payment amount, and desired outcomes — requires ongoing attention to program functioning and a willingness to revisit multiple aspects of program design and operations.

Successful contracts have balance across effort, payment, and outcomes
Set yourself up to recognize and address imbalances
Expect changes when transitioning from pilot to sustained program
Not every pilot will be sustained

Next: Relationship Issues

Relationship Issues

Creating a mutually beneficial contract can be really hard. A good payer-provider relationship makes it a lot easier.

Empathy, transparency, and collaborative problem-solving are valued highly
Recognize that things won’t necessarily go as expected
Organizational culture influences relationships
It takes time to build relationships

View the Report