A look back at Palliative Care News’ five most-read stories this year paints a picture of trends shaping the serious illness care space.
Securing reimbursement — and the promise of value-based contracts — continues to be top of mind for many palliative care providers as they look ahead to 2024. Operators have their eyes on the ever-shifting payment landscape and the headwinds and opportunities that come with it.
Meanwhile, more providers are increasingly working to address health disparities among underserved populations in various settings, including prisons and rural areas, among others. But in the midst of this, workforce shortages and clinical capacity issues remain obstacles to palliative care access.
The following are the most-read Palliative Care News articles of 2023.
#1 State Palliative Care Laws Impact Where Patients Die (June 14)
Palliative care components in state health care regulations vary widely. Researchers earlier this year dug into the variances in palliative care laws and uncovered the ways they can impact where the nation’s seriously ill patients are dying.
State laws to promote palliative care have proliferated during the last decade. Nearly 80% of states nationwide have passed at least one or more types of palliative care legislation since 2014, according to Yale University’s Palliative Care Law and Policy GPS data tracker.
These laws have focused on categories such as payment, workforce and clinical skill-building, public awareness, telehealth utilization, quality standards and specialized pediatric palliative care.
This patchwork of palliative care laws can complicate patients’ trajectories at the end of life.
Recent data suggests that seriously ill patients in states without some form of palliative care law in place may be more likely to incur higher health care costs as they near terminal stages.
Research unveiled in June found that differences in state laws around palliative care can have reverberating effects on the place of death for patients with cancer. The JAMA Network Open study found that more than half of cancer decedents in states that require health care providers to offer palliative consultations died at home or at inpatient hospices versus a hospital setting.
Palliative laws stipulating that health care providers communicate all end-of-life care options were associated with a 12% to 18% increased likelihood of cancer patients dying at home or in hospice, according to the study.
States without palliative care laws may be seeing higher numbers of seriously ill patients who utilize more costly emergency, urgent and hospital care due to a lack of familiarity with palliative services among patients and providers alike.
#2 ‘It’s Where We’re at Right Now’: US Prison System Struggling to Keep Up with Growing Need for Palliative Care (Aug. 9)
Seriously ill individuals who are incarcerated often lack access to palliative care.
Swelling seriously ill populations are driving demand for palliative care, with providers increasingly strapped for resources to keep pace. Workforce pressures are bearing down on providers’ ability to reach patients in a variety of underserved populations, including those in prison settings.
The impacts of staffing shortages amid rising demand can be severe when it comes to quality for seniors in locations that offer poor access to palliative professionals.
The number of incarcerated seniors has grown in the United States, which is partly a product of demographic trends alongside a proliferation of lengthy prison sentences. The nation’s supply of trained palliative care professionals falls far behind the curve to meet these patients’ needs.
More incarcerated people are 55 and older now than ever before, a trend expected to continue in the coming years, data shows. The United States has seen a 280% uptick of incarcerated seniors from 1999 to 2016, with individuals 55 and older projected to represent nearly one-third of prison populations by 2030, research from the Prison Fellowship found.
These seniors often often do not receive the full interdisciplinary scope of palliative services. Prison health care staff can include various clinical disciplines, but often lack palliative-specific professionals such as nurses.
Consequently, fellow incarcerated caregivers provide much of the care and support that palliative care patients receive in prison settings. These individuals lack the training and education to provide sufficient pain and symptom management and often face difficulty communicating patient needs to palliative care teams.
These caregivers also encounter practical challenges in providing care at the bedside, such as limited time outside of their cells to spend with seriously ill individuals and policies that prohibit certain interactions among incarcerated individuals, which can hinder the type of care provided and quality received.
Additionally, these seriously ill incarcerated seniors may be in inaccessible areas, such as solitary confinement, which can impact the ability to address their physical, mental and emotional health needs.
Palliative care providers have kept an eye on evolving payment models to support their interdisciplinary services. In this environment, regulatory trends among Medicare Advantage (MA) plans may be having an impact on palliative providers’ ability to sustain and grow their scope of services.
The U.S. Centers for Medicare & Medicaid Services (CMS) in 2018 began allowing MA plans to offer supplemental benefits, including palliative care. In conjunction, the agency began giving MA plans more flexibility around the definition of “primarily health-related” services, which expanded to include adult day services, palliative care and in-home support.
The consulting firm ATI Advisory reported that 157 MA plans offered palliative care as a supplemental benefit this year, up from 147 plans in 2022, which saw a 7% increase from the prior year.
But this year federal regulators began to zero in on private insurers that administer MA plans. CMS in February released its proposed payment rule for MA that included a plan to yield an expected average revenue change of 1.03% for MA plans.
Medicare Advantage stakeholders pushed back against the proposal, arguing it would actually turn into a cut of about 2.27% across the board. CMS’ finalized rule ultimately included an increase to MA payment of 3.32% for 2024.
A large concern in the industry is that MA plans may reduce payments to providers for some services due to the potential financial pressures.
Some have referred to the current environment of palliative care in the United States as the Wild West in the health continuum. Widespread variation in palliative care delivery is a much-debated topic as it relates to the challenges and opportunities around quality and access.
The nation lacks a dedicated reimbursement system for palliative care. No established palliative care benefit exists, with reimbursement avenues largely living in state, regional and private insurance programs, Medicare Advantage and some Accountable Care Organization (ACO) arrangements. Though several federal payment models have expanded to include palliative care components, fee-for-service remains the dominant reimbursement pathway, though it does not cover the full scope of interdisciplinary care.
The lack of a standardized reimbursement system leaves palliative care providers without clarity around what these services should include. Some palliative programs focus on consultative services such as advance care planning, while others attend to nonmedical, psychosocial needs and social determinants of health. Palliative programs also typically include various medical components aimed at pain and symptom management.
The reimbursement maze has resulted in wide variations in patients’ and families’ palliative care experiences, as well as uncertainty about sustainable growth.
Demonstrating how palliative care can reduce rehospitalizations at the end of life is one measure that could make the case for an dedicated palliative care payment model. Palliative care patients tend to have lower utilization of hospital and other high-acuity care services compared to others, which generates cost savings.
Though some industry groups have proposed a dedicated Medicare benefit, some providers have voiced concern that this could come with limitations on reimbursement and access. A structured payment model would be limited to beneficiaries in Medicare and Medicaid reimbursement systems, for instance, and would leave out seriously ill individuals covered by private insurers.
Another challenge would be defining the eligibility parameters for palliative care services, such as when these could start and stop for patients with various conditions and needs across the care continuum. Currently, the patients who are most likely to be eligible for palliative care are those who suffer from dementia-related illnesses, cancer, diabetes, heart or kidney disease, Parkinson’s disease or stroke.
Some maintain that the diverse range of care models allows providers to tailor programs around the complex needs of seriously ill populations, including coverage around caregiver and respite services and social determinants of health.
#5 CMMI Deputy Director Ellen Lukens: CMS to Take Multifaceted Approach to Palliative Care (April 21)
Forthcoming payment model demonstrations will reflect the heterogeneity of seriously ill patients’ needs and will be fashioned using inclusive, yet measurable tools, Ellen Lukens, deputy director of the Center for Medicare & Medicaid Innovation (CMMI), said at the Hospice News Palliative Care Conference in Washington, D.C.
In the near term, CMMI will likely integrate palliative care components into a range of disease- or setting-specific models, Lukens told Palliative Care News at the conference.
Accountable care and primary care models currently hold the greatest flexibility for providers to diversify their palliative services, she stated. These allow providers to test out different palliative care delivery models and determine which services best meet patient needs in a cost-effective way.
Coming down the payment pipeline are models that place incentives and requirements around health equity, quality outcomes and cost savings, Lukens indicated. Ultimately, a main goal of current payment models is to ensure a health system that achieves more equitable outcomes and higher quality of care, according to Lukens.
Current palliative reimbursement can be found in predominantly risk-based arrangements. Palliative care, for example, is an element of the hospice component of the value-based insurance design (VBID) model. Palliative providers also enter payment arrangements with ACOs and Managed Services Organizations (MSOs). They can also bill for physician services under Medicare Part B.
Future payment models will also include a greater focus on the role of family caregiver in supporting seriously ill seniors. Caregiver needs will be a key focus of future CMMI demonstrations.
Addressing unpaid caregiver needs and increasing financial support for respite services are two “very significant innovations” for CMMI, according to Purva Rawal, the center’s chief strategy officer. Payment models are testing ways to provide more respite options and practical and educational resources for caregivers, she said at the Coalition to Transform Advanced Care (C-TAC)–Center to Advance Palliative Care (CAPC) Leadership Summit in Washington D.C.
One such model is the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) program, which includes requirements for providers to develop services that address health disparities among their patient populations. The ACO REACH model includes incentives for providers that address unpaid caregiver needs, including respite and training support.
Providing greater caregiver support can help improve quality outcomes among seriously ill patients, data that regulators and policymakers take into account when forming reimbursement models.