Palliative care providers are taking varied routes to address the most disruptive forces they are encountering this year, rising to challenges that have been persistent across the sector.
Mounting workforce pressures mark the most significant of concerns for palliative care providers, according to Dr. Martha Twaddle, The Waud Family Medical Directorship’s palliative medicine and supportive care clinical professor of medicine at Northwestern Medicine.
The nation lacks a sufficient supply of palliative care professionals amid a swelling population of seriously ill patients, driving up demand. Current reimbursement streams are challenging the staffing issues even further, Twaddle stated.
“We need to educate and raise all boats to improve clinical capacity,” Twaddle told Palliative Care News. “It’s scaling up the support for staff [but] payment mechanisms in our country still can be barriers to really creating the fullness of the team. We’ve got to support these caregivers, the patients and their families more effectively, but then there’s a cost curve. In order to do all these things, you must have a full interdisciplinary team. If you parse it out and try to ‘play it cheap’ with palliative care, you’re not going to get those positive outcomes.”
Largest challenges in palliative care delivery
Workforce shortages and lack of sustainable reimbursement are indeed the largest obstacles to palliative care growth, according to Center to Advance Palliative Care (CAPC) CEO Brynn Bowman.
Insufficient staffing resources have created gaps of palliative care access in rural regions and in community-based care settings. Leaders of many palliative care programs nationwide have indicated that they are unable to find qualified clinicians in their service regions, Bowman stated.
Palliative care providers have innovated and expanded evidence-based, efficient care models that have helped to address these staffing concerns. More palliative care programs have taken flight across the health continuum, but financial headwinds are preventing greater access and utilization, Bowman said. While some health care organizations have made moves to expand their palliative care programs, this often requires significant operational considerations.
“Despite changing winds in U.S. health care, palliative care is here to stay, because it is high-value care for patients with complex needs who require an added layer of support,” Bowman told Palliative Care News in an email. “Financial volatility across the health system presents a substantial risk to palliative care teams, because there are no requirements that health systems or plans provide palliative care (with some specific exceptions).”
Another hurdle to growth in the palliative care landscape is the current status of telehealth regulations. Temporarily expanded telehealth flexibilities set forth during the pandemic are set to expire March 31, 2025. Congress extended the expiration date, initially set for Dec. 31, 2024. The flexibilities have allowed palliative care providers to reach patients in rural areas and hard-to-reach locations.
The unknowns of potential for changes in telehealth regulations are among the leading concerns among palliative care providers, according to Shelby Moore, CEO, Heartlinks. The Washington-based organization provides adult and pediatric hospice, palliative care, grief support and senior living services.
Telehealth has become an important part of palliative care delivery, with providers navigating a complicated outlook of evolving regulations, Moore stated. Narrowing the scope of telehealth utilization would have significant impacts on patient access and workforce capacity, she said.
“One of the greatest opportunities in palliative care today is leveraging telehealth to improve access, particularly for those who struggle with transportation or mobility due to illness,” Moore told Palliative Care News in an email. “Proposed restrictions on prescribing controlled substances via telehealth could further limit the effectiveness of palliative care programs. Telehealth has proven to be an invaluable tool in delivering quality care, and its continued adoption holds enormous potential.”
Palliative care opportunities taking shape
A beacon amid the workforce challenges is that more palliative care education initiatives are taking place in pockets across the United States. These programs have increasingly focused on providing clinicians in other health care settings with greater exposure to palliative care skills, such as training in goals-of-care communication.
“Palliative care clinical education for non-palliative care specialists is gaining in momentum, with a particular focus on the communication skills needed to navigate difficult conversations with patients and families, and on expert pain and symptom management,” Bowman said.
Alongside the expanding educational efforts has come the opportunity for wider palliative care awareness and utilization. Collaborative care partnerships have helped pave the way for pivotal turning points in the palliative care space, according to Twaddle.
Northwestern Medicine has rolled out an initiative that more deeply integrates its palliative care program across the continuum of its health services. The collaborations have led to an extra layer of support for patients and their families and strengthened staff’s ability to deliver goal concordant care, she stated.
“At Northwestern there’s this enormous initiative across the whole system to really scale up palliative care in its fullness,” Twaddle said. “These are cultural shifts, as well as business and process shifts. What happens in the process is a very positive change and a sense of satisfaction that they’ve helped that person in deep ways. You can’t put a price tag on that. It’s really expanded what we can do for our patient population. It’s a win-win to better allocate these resources and we’re seeing more favorable outcomes.”
Palliative care has been gaining momentum in terms of these services’ potential to reduce unnecessary and expensive health care spending among seriously ill patient populations, according to Twaddle. Palliative care utilization has led to decreased hospitalizations and emergency department services, avoiding some of the common “waste patterns” in a fragmented health care delivery system, she stated.
Growing recognition around palliative care’s value proposition has in part sparked new payment pathways for these services.
Palliative care providers have more reimbursement opportunities now than they ever had historically, according to Bowman.
Among the most promising avenues for palliative care providers is the new Guiding an Improved Dementia Experience (GUIDE) payment demonstration. Roughly 40 hospice and palliative care organizations are currently participating in the GUIDE model, which is designed to improve quality of life for dementia patients and their caregivers by addressing care coordination, behavioral health and functional needs.
State-level palliative care payment activity has also been building in recent years, Bowman indicated.
Case in point, California’s Medicaid program Medi-Cal recently expanded its palliative care programs to cover more patient diagnoses such as cancer, congestive heart failure, chronic obstructive pulmonary disease and end-stage liver disease. The growth has sparked some palliative providers in the state to pilot new programs dedicated to enhancing patient outcomes and reducing costs.
Medicaid palliative care coverage also grew in Hawaii last year when the U.S. Centers for Medicare and Medicaid Services (CMS) approved a State Plan Amendment (SPA). Hawaii became the first state to request SPA approval, part of Medicaid’s process for adding new benefits. The SPA defines palliative care as a preventive service, establishes a payment methodology and sets quality reporting standards in the state.
“New billing opportunities for palliative care teams have emerged in recent years, providing funding for caregiver education, navigation, time spent with high-complexity patients, and other services for which palliative care teams previously had no reimbursement opportunities under traditional Medicare,” Bowman told Palliative Care News. “The needs of caregivers in general are increasingly being recognized at the advocacy, policy and payment levels, bringing some new resources to bear.”
