Palliative care coverage: Connecting the dots

With its new palliative care program, Cambia Health Solutions and its Regence Blue Cross Blue Shield plans created a comprehensive, person-focused approach to address and pay for end-of-life care services. In the first installment of this two-part series, Cambia CEO Mark Ganz explained the drivers behind focusing on palliative care and what goals the insurance company wants to attain with its new program.

In part two, FierceHealthPayer spoke with Torrie Fields (pictured), Cambia's program director for serious illness and palliative care. She describes the specifics behind Cambia's palliative care program, which began July 1 and is available to its more than 2 million members, and how it helps members have the difficult conversations around end-of-life care.

FierceHealthPayer: How have you structured the health plan benefits to cover palliative care?

Torrie Fields: It was initially a conundrum to us as a fee-for-service plan about how to structure the benefits and still make it person-centered. There's a number of ways we're addressing that. The first thing is that this isn't just a benefit that we're offering or something that will just be in our products [because] the benefits structure for fee-for-service is somewhat limited. So we're actually expanding our benefits to include coverage of home health aids and in-home counseling for folks who are palliative care-eligible.

We know we want to include the behavioral health piece in addition to the medical piece, because this is a very difficult time in the life of patients and their families. We're also reimbursing for some softer services and skills like advanced care planning, care plan oversight and medical team conferences so that providers are actually incentivized to have an interdisciplinary team and discussion.

We're also including enhanced reimbursement for social workers to be part of this process because we know that they are really the great conveners of palliative care. They're able to connect the dots between medical services and behavioral and social services. When I was speaking with providers, they often said they're only one piece of the puzzle. They're able to provide medical services if they're educated in providing palliative care, but there are other social needs that are necessary.

FierceHealthPayer: Have you made any changes internally at Cambia to help address and cover palliative care?

Torrie Fields: This program is really all about meeting members where they live or where they are in their mindset about their disease progression. It's often very difficult for patients to think about having an advance directive or working on goals of care because it's an emotional issue. It's very difficult for them to think about death. So we have our internal care management team that's very skilled in working with patients and their families.

We have hired internally at Regence a nurse care manager and a social worker with more than 30 years of combined clinical experience in palliative care in the Pacific Northwest. They're connecting our members with the medical, behavioral and social supports they need in their locations.

What they also can do is speak with patients, families and physicians about what services might be necessary for their specific situation or condition. For example, a family wanted to have their child stay in the hospital because they were uncomfortable bringing him home for care. We were able to reimburse for those services to keep the child in the children's hospital at an inpatient hospice rate to help the family and the patient feel comfortable.

FHP: What role do your providers play in ensuring the palliative care program succeeds?

Fields: The next and largest piece of the program is provider partnerships. We're working on developing a medical home model for serious illness and palliative care that will transition patients from the outpatient ambulatory setting to the home. That would make the transition seamless for the patient and provide an infrastructure for health systems to set up an outpatient palliative care program. This is getting at the need to not only reduce the rate of readmissions for people who have palliative care needs but also eliminate the admission at all for people who really don't need or want to be in the hospital for their serious illness.

We sent communications out to many of our providers, especially those who we have accountable care contracts with and I've been receiving calls from chief medical officers of those organizations saying they're very excited to partner with us and would like to see how they can get more involved.

FierceHealthPayer: How does advance care planning factor into the program?

Torrie Fields: We want to change the mindset of palliative care being an illness activity to instead something that affects everyone. So we're starting with advance care planning as a wellness activity or a preparation activity. Really building that critical mass is important, so we know that it's our responsibility to educate our members about what their options are and how they can think about and prepare for a serious illness, because we know it doesn't always come at the most opportune time.

Advance care planning can happen at any time. It's having the conversation with yourself and your family about what matters most to you and if something were to happen where you weren't able to make decisions for yourself. What person would make those decisions for you and what things  would you want to communicate to that person and to your physicians about your needs if you have a serious illness?

If you're starting to talk about it early before a diagnosis of a terminal condition, your family and friends who matter most to you already are on the same page about what your wishes and needs are during that difficult time. And it will allow you to prepare accordingly.

Beginning with advance care planning then starting with palliative care at the point of diagnosis is a seamless transition for members and their families.

FHP: These are some tricky topics to navigate. How are you trying to motivate your members into having these conversations?

Fields: Yes, they are tricky things to talk about. We're developing a large community engagement exercise in our four states as a partnership between the health plans and the Cambia Health Foundation. So the foundation is really interested in moving into the community and fostering these conversations.

We have a partnership with the Conversation Project, which is a really great tool to use in beginning these family conversations. So the foundation has started to support interface work and community initiatives that focus on advanced care planning so that the information can be received from multiple angles and not just from the health plans.

On the health plan side we're working with each state to develop coalitions at the state level to disseminate health education about advanced care planning. We will start developing channels from the state health department all the way down to specialist provider offices. It's really about making this conversation a little bit more comfortable for people, and the way to do that is to bring it to them from people they feel the most comfortable with, whoever that may be.

Editor's Note: This interview has been edited and condensed for clarity.