Modeling of an Alternative Reimbursement Method for Palliative Care

OBJECTIVES: Patient and Caregiver Support for Serious Illness (PACSSI), a per-member per-month (PMPM) alternative reimbursement structure for palliative care (PC) services, has been described as overly generous by HHS. We developed a modified version, PACSSI-Flexible (PACSSI-F), by modeling reimbursement for PC based on the changes in patient functional status. We estimated reimbursement for the first year that an organization might implement the PACSSI-F for PC services. STUDY DESIGN: Secondary analysis using data from the Statin Discontinuation in Advanced Illness Trial. METHODS: We evaluated the PACSSI vs the PACSSI-F in 3 phases. In the first phase, we calculated variable appropriate frequencies/relative frequencies or means/ SDs for the study population's available demographics and comorbidities, focusing on age, Charlson Comorbidity Index score, race and ethnicity, gender, and continued statin use. Exploratory analyses specific to reimbursement were conducted in a second phase. For each payment structure, we calculated the (1) mean (SD) total reimbursement and (2) number of weeks that a health care system would receive reimbursement, with both weekly and PMPM (4-week) averages. The third phase was designed to quantify any within-person (paired) differences in reimbursement between the original PACSSI and the PACSSI-F. RESULTS: PACSSI-F provides reimbursement for sustainable PC services and was cost-advantageous over PACSSI by $69.92 PMPM for 28.6% of the seriously ill population. CONCLUSIONS: Modeling of the PACSSI-F using secondary data provides a novel example of economic forecasting for alternative reimbursement structures in PC. Alternative reimbursement payment policies are necessary to expand PC for the seriously ill population.

Automated summary

This study developed a new reimbursement structure for palliative care (PC) services based on changes in patient functional status and estimated the reimbursement for the first year of implementation. The results showed that the new structure provides reimbursement for sustainable PC services and is cost-advantageous compared to the previous structure.