Interest has mounted in the palliative care arena, but building and sustaining these services requires stronger reimbursement and workforce resources.
The palliative care space is gaining momentum, despite large challenges tied to staffing and reimbursement strains, according to Mark Kulik, senior managing director of the advisory firm The Braff Group.
Palliative care is becoming an increasingly prevalent part of the care continuum, with payers, providers and investors recognizing the potential for these services to improve quality outcomes and reduce costs, he stated. But insufficient payment pathways represent a large hurdle for palliative care’s growth potential, Kulik said.
“If palliative care is a common provision of services in the marketplace, then the investor world is definitely looking at that,” Kulik told Palliative Care News. “No investor goes into buying something hoping that it stays flat. They’re going to try to spur growth. If palliative care is prevalent in an area, then they’ll take that into account as part of their investment thesis. There’s a domino effect that unless you can carefully and progressively come up with a reimbursement plan to support palliative care, you killed the ability to grow and support it.”
Obstacles in palliative care’s path
More physicians offices, primary care providers, hospitals, oncology centers and other facility-based health care providers are stepping into the community-based palliative care space. Hospices have historically represented the biggest cohort of the palliative care provider mix since the field emerged in the United States during the 1980s.
Though reimbursement for palliative care has been building in recent years, much room for improvement exists to fuel future interest, according to Conlee Fisher Clark, director of growth at AMOREM.
“I see the outlook as strengthening the presence of palliative medicine in the health care field,” Fisher said during the Hospice News Sales & Marketing webinar series. “A lot of hospitals and doctors offices are becoming full-risk [Accountable Care Organizations (ACOs)], and that means they get X amount of money trying to manage those patients the best they can. That makes palliative care’s outlook good. The only problem we have is reimbursement, which is low for this type of service.”
A large challenge in the palliative space is that reimbursement models are not keeping pace with rising demand, according to Stephanie Adair, vice president of hospice services at Liberty HomeCare & Hospice Services. The North Carolina-based company provides home health, hospice and palliative care services across its home state and in South Carolina and Virginia.
Fee-for-service reimbursement that doesn’t sufficiently cover the full interdisciplinary scope of palliative care has complicated providers’ ability to improve quality and develop innovative care delivery approaches, Adair stated. But the reimbursement pendulum may be swinging toward stronger palliative payment support, particularly as more value-based arrangements take shape, along with ACOs, she added.
“Trying to improve the quality of care by providing additional resources for palliative care patients is challenging,” Adair told Palliative Care News in an email. “This can cause a financial strain for an organization [but] demand can also be a positive opportunity. The increase in ACOs and other integrated care models can provide opportunities for organizations to reduce cost while providing high quality care.”
Staffing resources are also lacking in the palliative space, Adair added. Medical students often don’t receive exposure to palliative or hospice care throughout their education. Misconceptions about palliative care proliferate among the public and other health care providers across the continuum, often conflating these services with hospice.
Workforce shortages that have long-plagued the health care industry are hitting palliative care with a particularly detrimental force, according to Adair. Sustainability in the palliative care space will in part hinge on more education and training, she said.
“There is a global shortage of health care professionals. Most palliative programs are primarily run by nurse practitioners and there is a shortage of NPs as well,” Adair said. “The greater the emphasis on palliative care the more education and training that will be required among health care providers and the communities.”
Palliative care’s service, payment propositions
Palliative care programs vary widely across the nation, Susan Ponder-Stansel, president and CEO of Florida-based Alivia Care Inc., said at the National Association for Home Care & Hospice’s (NAHC) Financial Management Conference in Las Vegas. The association has since completed its affiliation with the National Hospice and Palliative Care Organization (NHPCO), forming the newly named National Alliance for Care at Home (NACH).
The diversity and wide breadth of services can be beneficial to patient-centered care, she said. Palliative providers can offer consultative services, care coordination assistance, pain and symptom management, different therapies, respite for caregivers and spiritual and emotional support.
The service delivery variations can also represent a challenge in the defining palliative quality, eligibility and scope of interdisciplinary services, according to Ponder-Stansel. These are areas that hospices could help narrow and define, she added.
“There’s a huge opportunity with palliative and transitional care,” Ponder-Stansel told Palliative Care News at the conference. “We do need to recognize that things that we didn’t understand were palliative care could be. Many hospice providers are already doing it, but it’s hard to make them run when you’re eating costs and losing money on roughly 80% of your patients.”
Palliative care’s largest value proposition is its cost-savings potential, said Kristen Yntema, president and CEO of AuthoraCare Collective. The North Carolina-based nonprofit provides hospice and advanced illness care, grief support and caregiver resources.
Palliative care utilization can reduce rehospitalizations and emergency department visits and help ensure goal-concordant care as a patient’s serious or terminal illness progresses. Alleviating financial burdens of high health care costs is among the levers that are widening value-based palliative reimbursement pathways.
Palliative providers can help support patients in whatever setting they call home, which can lead to less burdensome care transitions and improved outcomes, said Yntema.
Providers need stronger payment structures in place to sustain palliative care delivery and ensure earlier access, she added. Many of these palliative payment methodologies are unfolding in the value-based care landscape, to which hospices have a limited window into without the Medicare Advantage carve-in, according to Yntema. That may change in the near future.
The U.S. Centers for Medicare & Medicaid Services (CMS) has increasingly moved toward value-based payment models, and hospices may need to adapt to navigate reimbursement arrangements successfully, Yntema explained.
“CMS clearly stated in 2030 that we’re going to be paid differently,” Yntema told Palliative Care News at the NAHC conference. “Hospices are going to have to figure out how to be ready to adapt and be successful in multiple payment models, whether it’s with an ACO, Medicare Advantage payer or some different kind of structured payment based on insurance providers’ rates. We’re going to have to be nimble, agile and willing to make changes that could require us to bill differently.”
