Breaking down the payment barriers that impede access to palliative care will take building up a reimbursement structure that more narrowly defines service scope and sets specific parameters for quality.
The nation’s fragmented payment structures for palliative care reimbursement create opportunities for regulators to examine the facets of these different models across varied geographic areas and patient populations, according to Fred Bentley, managing director for Medicare innovation at ATI Advisory.
While this allows palliative care providers to explore different approaches to delivery and service capacity, it can also strain their ability to sufficiently support the full spectrum of interdisciplinary serious illness care, he stated.
“There are some core services that are pretty standard in most palliative care programs, but palliative care as a discipline is evolving,” Bentley told Palliative Care News. “A couple challenges that palliative care has been dealing with is that it is not a super well-defined set of services.”
The different shades of palliative care regulation
The U.S. Centers for Medicare & Medicaid Services (CMS) defines palliative care as health services that address physical, mental, social and spiritual well-being “as appropriate for patients in all disease stages” throughout their illness trajectory. Palliative care providers use a multi-disciplinary approach to treat a person living with a chronic condition who “may or may not be terminally ill,” CMS indicated.
Some versions of palliative care are woven into value-based models, including Medicare Advantage, Accountable Care Organization (ACO) arrangements and several state-level independent pathways that focus on primary care, oncology, kidney care and other services.
The widespread variances around these services represent the main barrier to improving palliative care access and awareness at the local level, according to Bentley. The splintered payment chassis can create care delivery challenges that potentially could be resolved through a more targeted, standardized approach, he said.
But that needle is moving at a slower pace than needed to keep up with changes in the palliative space, Bentley stated.
“It’s not a defined benefit right now and the reimbursement rates are not great,” he said. “But that would take an act of Congress, and I wouldn’t be holding my breath on anything getting through Congress right now.”
Every state across the nation has at least introduced, if not passed, at least one form of legislation focused on palliative care policy and improvements in serious illness care during the last decade, according to Yale University’s Palliative Care Law and Policy GPS database.
Maryland is among the states with the highest volume of legislation, having introduced 29 palliative care bills between October 2015 to October 2021, the most current available data on Yale’s policy tracker. Nine of these bills were passed.
Georgia came in second in terms of palliative care bills, introducing 27 legislative pieces during the same five-year time frame. However, 16 of those bills passed, marking a higher ratio compared to other states.
Keys to defining palliative care
Providers should stay abreast of government activity around palliative care in their home states.
These laws often vary in terms of their focus and care delivery models, as well as their strategies for raising public awareness, developing quality and clinical training standards, and improving access to underserved populations such as pediatric patients, among other factors.
To date, the lack of structure in regulation and payment isn’t helping to clarify the scope of palliative care services among patients, families and their clinicians, according to PalliCare Inc. CEO Jonathan Fluhart.
“Trying to understand the clinical world and the home care world and fuse them together is where the biggest challenges have been in the conversation of what is palliative care and trying to define it in a way that not just patients can understand it, but even clinicians,” Fluhart said during the Hospice News Palliative Care Conference. “Ask three different people what palliative means and you get three different answers, and that goes for patients and even for doctors, skilled care facilities. It’s really just trying to understand who we are as an identity as palliative care and how do we communicate that.”
This could continue to adversely affect equitable access, Bentley stated.
Quality and reduced costs are two keys to demonstrating the value and defining the scope of palliative care services, according to Samaritan Healthcare & Hospice Chief Medical Officer Dr. Stephen Goldfine. The New Jersey-based nonprofit offers hospice and palliative care, among other services.
Tracking this through claims and quality data can help lay the groundwork for standardized palliative care services, he indicated.
“Palliative care is interesting and is evolving,” Goldfine told Palliative Care News. “It’s helping to maintain quality to patients as well as reduce costs and put patients in the right level of care, and that’s really the important part. [It’s] expanding throughout the continuum of their care so you’re not seeing them episodically in very small moments. That will prove to be a better model for patients.”
