As services evolve in the palliative care field, providers may be facing tough questions around quality.

Quality can be difficult to both define and measure among the varied forms of palliative business and care models currently in use.

Currently, no standardized quality measures are in place for palliative care. One of the toughest questions percolating in the space is how providers can assess their performance, according to Dr. Christopher Comfort, president and CEO of Calvary Hospital. The New York-based acute care hospital focuses almost exclusively on palliative and hospice care.

In the varied and dynamic climate of palliative care, transparently outlining the scope of what is and is not included in an organization’s services is a crucial step towards setting standardized quality expectations, he said at the Hospice News Palliative Care Conference in Washington D.C.

“If we believe this is an industry, palliative care, that can go beyond what it is now, then it will have to mature into a business model that is much different than how most of us are running it now,” Comfort told Palliative Care News. “That’s a challenge, and it’s also the reason transparency is good, because it puts us all on the same playing field to understand what are the opportunities we have as we move forward. All of us have to look at that in terms of understanding for quality, as well as for a business model itself.”

The palliative care field emerged in the United States during the 1980s, shortly after the Medicare Hospice Benefit came into being, according to research from Johns Hopkins Medical.

Since then it has taken a winding course across the health care spectrum, for better or worse.

Some providers have “cherry-picked strategies” to care delivery, piecing together ways to address palliative patients’ needs, according to Chapters Health System CMO Dr. Tara Friedman.

Some palliative care programs only offer physician consulting services or advance care planning, while others limit services to certain types of support for pain management, she said. This broad brush can be confusing for referral sources, patients and families when seeking the full scope of quality in interdisciplinary serious illness care, Friedman indicated.

“I fear that we’ve gone from a day where we defined palliative care very specifically as an interdisciplinary comprehensive approach to patients, to this being a picked-apart, unbundled service line,” Friedman said.

This piece-meal approach also poses challenges for providers in their ability to define valuable, high-quality care, she added.

“We have to continue to grow out the skill structure across normative palliative care, and maintain the subspecialty level infrastructure that we have that defines what pure palliative care is as a medical subspecialty,” Friedman said. “I do worry about sort of the ‘co-opting’ of the term palliative care, and the diminishing value that we might see from that if we don’t hold on to it a little bit more.”

Payment models are partly at the crux of these questions in palliative care, as quality standards tend to accompany detailed reimbursement models.

Currently, palliative care providers can find reimbursement through Medicare Part B for physician services, and also through supplemental benefits included in Medicare Advantage. Other reimbursement options exist in payment arrangements with Accountable Care Organizations (ACOs) and Managed Services Organizations (MSOs).

About a dozen states have integrated some form of specialized palliative care service benefits into their Medicaid programs, according to a 2022 report from the Texas Health and Human Services Department.

Monitoring and addressing quality is unlikely to get any easier for providers as reimbursement trails behind the cost of care and its multifaceted delivery systems, Comfort indicated.

“As the industry matures, especially in the palliative industry, these are going to be the hard questions that we’re going to have to ask each other in terms of what is good for the industry,” he said. “The costs of these programs ends up being so high that it is important that we start thinking about some of the novel [care] models that we have.