The channels for palliative care payment may be widening as more state legislators recognize growing demand for these services and start to weave them into Medicaid reimbursement.
More than 15 states have rolled out bills to direct Medicaid agencies and other state authorities to research the ability to implement a dedicated palliative care benefit or pay for community-based versions of these services, according to Torrie Fields, strategy advisor at the Coalition to Transform Advanced Care (C-TAC).
“Medicaid agencies and state policymakers are identifying the need to standardize and sustain palliative care services for people with serious illnesses, especially for those who are on Medicaid, who are more often less able to access care,” she said during the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice & Palliative Nurses Association (HPNA) Annual Assembly.
Case in point, New Jersey legislators are currently mulling a bill that would create a community-based palliative care benefit within the state’s Medicaid program.
California, Colorado, Hawaii, Maine and Oregon each have established Medicaid reimbursement for community-based palliative care. A common thread among these Medicaid programs is an interdisciplinary scope of services that addresses physical, mental and other types of care for seriously ill populations, according to a report from the National Academy for State Health Policy (NASHP).
“This is a great opportunity to start to work together to address the needs and the gaps in care for people with serious illness on Medicaid,” Fields said. “We want to be much more flexible in terms of being able to triage people to the right level of care, and not just accessing palliative care to fill a gap for a short period of time.”
About a dozen states across the nation incorporate adult or pediatric specialized palliative care service benefits into their Medicaid programs, according to a 2022 report from the Texas Health and Human Services Department. These are often offered as part of specialized managed care programs.
This is a great opportunity to start to work together to address the needs and the gaps in care for people with serious illness on Medicaid.— Torrie Fields, strategy advisor, Coalition to Transform Advanced Care
However, differences exist in how these programs are defined and structured.
Five states — Minnesota, North Carolina, North Dakota, Washington and Virginia — define palliative care eligibility within their Medicaid hospice programs. Therefore, those services are available only to individuals with a terminal or life-limiting condition.
Colorado, Maryland and New York include palliative care as part of their health care facility licensing.
Though services covered by these Medicaid programs vary from state to state, they often include interdisciplinary services, care coordination, case management, advance care planning and psychosocial care.
Patient eligibility criteria also fluctuate across state Medicaid lines. The patients most likely to be eligible for palliative care include those who suffer from dementia-related illnesses, cancer, diabetes, heart or kidney disease, Parkinson’s disease or stroke.
“Note that, similar to hospice care, [palliative] beneficiaries would both need to qualify for services and consent to services through this process in order to be enrolled,” Fields stated. “And that’s something that was very important to stakeholders, as well as to primary care providers — to ensure that everybody is on the same page as to when a palliative care team becomes part of that plan of care.”
Within Medicaid payment eligibility parameters, the health trajectory and needs of palliative care patients can look very different compared to other populations, according to Allison Silvers, chief health care transformation officer at the Center to Advance Palliative Care (CAPC).
These populations represent a wide range of different life stages and often have challenging financial situations, she explained. This means that varied palliative populations needs should have multifaceted avenues of support within Medicaid care models, Silvers added.
“Because of the poverty requirement, Medicaid beneficiaries present with a much more complicated picture of needs,” Silvers said. “And it’s not only the social needs, there’s a stage of life difference, at least between Medicare patients and Medicaid patients. Very often, they’re balancing raising children while caring for their own parents and their own health and serious illness. It’s a lot of complex needs.”
Because of the poverty requirement, Medicaid beneficiaries present with a much more complicated picture of needs”— Allison Silvers, chief health care transformation officer, Center to Advance Palliative Care