California’s Palliative Care Rule a Potential Foundation for National Model

As stakeholders call for a dedicated Medicare benefit for the growing field of community-based palliative care, one government-led payment model is going strong in California through Medi-Cal, the state’s Medicaid program.

Effective Jan. 2018, the state’s Senate Bill 1004 (SB 1004), requires Medi-Cal managed care plans to cover palliative care for patients suffering from cancer, end-stage liver disease, chronic obstructive pulmonary disease, or congestive heart failure. Patients may continue curative treatments while receiving palliative care.

In early 2020, the state’s Department of Health Care Services will release a clarified palliative care policy for both fee-for-service and managed care delivery system, agency spokesperson Katherine Weir said. The policy will broaden the disease-specific eligibility criteria from the above four diseases to include beneficiaries with any serious or life-limiting illnesses, as determined and documented by their health care provider.

“I was very glad to see that happen with routinized palliative care recognized as a foundation of basic care, and ostensibly push back on this idea that palliative care is only for people who know enough to ask for it or who have good private insurance,” B.J. Miller, M.D., palliative care physician at the University of California Helen Diller Family Comprehensive Cancer Center. “[Palliative care payment models] have to be all inclusive. You can’t leave anybody out otherwise you completely undermine the goal, and we will not learn anything from that.”  

The benefit covers seven specific palliative services, including advance care planning, care coordination, pain and symptom management, palliative care assessments and consultations, access to an interdisciplinary care team, as well as mental health and medical social services.

California is the first state in the nation to require Medicaid plans to provide palliative care coverage. Some leaders in the field have heralded the program as a success in expanding access to palliative care for patients with serious illness.

Other states have passed legislation designed to spur public and clinician awareness of palliative care and to promote utilization, but have stopped short of requiring Medicaid or other programs to cover it. 

As of Dec. 2018, 27 states have laws on their books designed to promote palliative care, according to the National Academy of State Health Policy (NASHP). Though details of the legislation vary among the states, they each serve the goal of bringing palliative care to more patients with serious, chronic, or life-limiting conditions. A number of states have enacted similar laws during 2019 and several states are considering comparable bills.

“My hope is that other states will follow in the footsteps of California, because it has transformed California. The fact that there’s a law that says Medicaid patients in California with serious illness must have access to palliative care brought all the players out of the woodwork,” Diane Meier, executive director of the Center to Advance Palliative Care (CAPC) told Hospice News. “All the health insurance companies that manage Medicaid had to figure out how to develop a network, how to find the clinicians that do this, how to contract with them to take care of patients. We don’t have those laws in the other 49 states, and we don’t have a federal law requiring that either, but what we learned from [California] is that it’s very effective.”

Hospices provide most of the community-based palliative care in the United States. In addition to bringing comfort for patients and families, expansion of community-based palliative care can yield considerable health care cost savings, research indicates.  

Home-based palliative care could reduce societal health care costs by $103 billion within the next 20 years, the nonprofit economic research group Florida TaxWatch said in a report. It can also reduce the frequency of 911 calls, emergency department visits, and unnecessary hospitalizations.

“[SB 1004] and the program’s implementation stemmed from significant and longstanding clinical evidence, in California and other states, of improved quality of life and reduced hospitalizations and emergency department visits among adults and children participating in palliative care programs,” Weir said.

Some have considered the possibility that California’s Medicaid requirement could be adapted for a nationwide program or serve as a foundation for a Medicare benefit, removing obstacles such as the lack of a standardized definition for the term palliative care. 

“[The U.S. Centers for Medicare & Medicaid Services (CMS)] should be in the business of defining community-based palliative care, because right now nationally where you do have coverage of community-based palliative care it’s just ad hoc, undefined and all over the place. It mostly occurs within Medicare Advantage,” Edo Banach, president and CEO of the National Hospice & Palliative Care Organization said. “Medicaid has already defined in some places a community-based palliative care benefit. That’s a really good place to look. With Medicaid, you have strong coverage of community-based and non-medical support services, so stretching that out and providing that earlier through a community-based palliative care benefit makes a whole lot of sense.”