Referral Management the Biggest Obstacle to Palliative Care Growth

Hospices that provide palliative care have found that issues surrounding referral management were the most significant hindrance to the financial stability of their programs, according to research conducted by the National Hospice & Palliative Care Organization.

Close to 50% of a statistically significant sample of 328 providers indicated in a survey that referral management was their biggest concern, citing issues such as a lack of understanding of palliative care among clinicians in other settings as well as among patients and families. Both of these issues contribute to troubles maintaining adequate referral volumes.

Providers and other stakeholders have their work cut out for them when it comes to raising awareness and understanding of palliative care. A Journal of Palliative Medicine study found that as many as 71% of people in the United States have little to no understanding of what palliative care is, including many clinicians in a position to refer patients to palliative care or hospice.


“Palliative care services have grown rapidly in the hospital setting,” according to the report. “As the seriously ill population grows exponentially, so does the need for community-based palliative care services. Hospice providers are ideally positioned to meet this need, and many are already engaged in providing palliative care services.”

Roughly half of community-based palliative care providers in the United States are hospices, according to the Center to Advance Palliative Care (CAPC). While a growing number of hospices are diversifying their service lines to include palliative care, many struggle to maintain financial sustainability in the current payment environment, which most prevalently relies on Medicare fee-for-service models.

While no standardized definition exists for “palliative care,” the U.S. Centers for Medicare & Medicaid Services (CMS) defines the term as “patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.”


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 2019 report.

Some hospices have gotten creative in developing avenues for payment that go beyond Medicare fee-for-service. Some have contracted with private payers, forged partnerships with hospitals or other providers, leveraged philanthropic funds or arrangements with Accountable Care Organizations or Medicare Shared Savings Plans, according to NHPCO.

CMS as of 2019 has allowed Medicare Advantage plans to offer palliative care as a supplemental benefit. According to an analysis by ATI Advisory, 61 health plans nationwide are offering in-home palliative care as a benefit this year. This is up from 29 in 2019. More than 455,000 beneficiaries are enrolled in these plans.

For 2020 however, the plans that are offering in-home palliative care are concentrated in relatively small geographic areas, mostly in Ohio, Pennsylvania, and parts of Minnesota, Washington state and Oregon, according to the ATI analysis.

Coming in 2021 are the direct contracting and Serious Illness Population payment models under the Primary Cares Initiative at the Center for Medicare & Medicaid Innovation (CMMI), through which opportunities will exist for hospices to expand their palliative care programs. However, none of these initiatives rise to the level of a Medicare community-based palliative care benefit. Calls for the establishment of such a benefit have grown louder during 2020 as the COVID-19 pandemic rages on.

“The growth seen in our second report on palliative care needs of providers adds to the growing evidence base to support the need for a CMMI supported community-based palliative care demonstration under CMMI,” said NHPCO President and CEO Edo Banach. “Such a demonstration would not only help establish clear criteria for community-based palliative care services in the U.S. but would lead to improved quality and cost outcomes for Medicare beneficiaries experiencing serious illness.”

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