Uncertainty around Medicaid cuts and other health care policies could slow or stymy palliative care growth, according to Brynn Bowman, CEO of the Center to Advance Palliative Care (CAPC).
Bowman recently crafted an open letter to her colleagues in the palliative care field in which she discussed the looming questions in the health care space and offered recommendations for a path forward.
Palliative Care News spoke with Bowman about the risks billowing up in the current political environment, new partnerships available to palliative care providers and strengthening referral relationships.
You mentioned in your letter that palliative care providers are struggling for resources. Can you expound on that?
Our specialties, quality standards, the National Consensus Project guidelines articulate that a high quality palliative care team should be an interprofessional team. So that means not just billing providers, physicians, advanced practice nurses, but it means dedicated social work time, spiritual care time.
In a fee-for-service world, it becomes harder to sustain that interdisciplinary team made up of some key team members who support their patients’ social and psychological spiritual needs when they can’t bill for the time that they spend with patients. So that’s sort of a baseline resource concern for palliative care.
Under value-based payment arrangements, there’s a very strong value proposition for palliative care. Patients have better outcomes, avoid crises that indicate poor quality care and that are costly health care episodes when they have the benefit of seeing a specialty palliative care team. But at the same time, uptake of payment contracts has been slower in the field, across the board, than we’d like to see. As you know, there is no Medicare benefit for palliative care services, so there’s not a dedicated stream for palliative care teams. Really, it does come down to negotiated payment contracts or billing for professional services in the inpatient and outpatient settings.
The fact that there are so many palliative care programs, that those programs have grown so much over the last 20 years, really is a testament to the strength of the evidence base demonstrating the value of palliative care for patients, for health care organizations. It’s a testament to the strength of palliative care leaders who are making that case to their organizations’ leadership. It’s a testament to patient perceptions of that care and what a positive experience they have with it.
So in this moment of time where, because of the change of administration, there’s just a lot of uncertainty in health care across the board. Palliative care programs are in a funny position. Programs have been scraping together the resources for those services already. There is no requirement for palliative care services that could change or be taken off the books. That’s never been the case.
As a field, we are watching and waiting like the rest of the U.S. public to see what changes may occur in Washington that could affect the care that patients receive. There is not a direct link to the way that palliative care programs get paid today. Now there are indirect things, the thinking about palliative care programs inside of a health system or inside of a hospital or a physician group.
There’s an environment of uncertainty that we could expect would cause decision-making paralysis or would mean that the leaders of those organizations are less likely than under business as usual to invest in new services or to make big strategic moves until they understand the lay of the land. And so if a palliative care program has been on a growth trajectory, the concern is that this is a time when that growth may halt while organizations are not not making those investment decisions.
In what ways is the health care landscape unstable and unpredictable? What are some of the contributing factors?
The thing that’s top of mind for so many of us right now is the potential to cut Medicaid funding or changes to eligibility requirements for Medicaid. There’s sort of the general impact when you think about the number of Americans receiving Medicaid benefits who are managing a serious illness, and that includes children. So many patients are critically dependent on Medicaid funding to get the treatment that they need for those conditions, and especially to achieve best outcomes and avoid emergency care dealing with serious illnesses for families, for households with a child with a serious medical illness.
The science for treating so many conditions in that pediatric patient population has really advanced by leaps and bounds. But that is expensive, long-term care in and out of hospitals for years. That comes with high out-of-pocket costs for families, and the Children’s Health Insurance Program really is the lifeline for so many of those families, because those are not costs that households who are not wealthy can bear. So that’s a really big concern across the board.
I mentioned the sort of the chilling effect on decision making for new programs. So for example, you can imagine the palliative care program working in a hospital that’s been planning for outpatient expansion, maybe going to start a new home-based service. In a time of uncertainty, they may be less likely to get that service expansion approved. And that’s not specific to palliative care. Other services may experience the same thing. It’s a concern because so much progress is really put at risk in a moment like this.
I mentioned Medicaid, and that’s not just in terms of direct services to patients, but also the impact on health care organizations. If the nursing staff shortages already across the country are exacerbated by nursing budget cuts because of the impact of the loss of Medicaid dollars to health care organizations, it’s a really scary prospect.
Patients with serious illness are really vulnerable, among the most vulnerable to those loss of services or loss of facilities. So it’s a scary time. The [Trump] administration has talked a lot about an agenda that has a focus on prevention, a focus on chronic conditions for Americans. We just don’t know yet what that will translate to in terms of health policy. There could be elements of that that really could address important priorities for patients with serious illness. But the fact is, we just don’t know. It’s hard to have that crystal ball.
What is the potential impact of Medicaid cuts on palliative care patients?
If we’d had this conversation a year ago, I would have said one of the most exciting places in the landscape to look at growth in palliative care and momentum in patients having access to palliative care was at the state level. The state of California a number of years ago established requirements for access to palliative care for Medicaid beneficiaries. The State of Hawaii had a Medicaid waiver approved to establish a community-based palliative care benefit for residents of Hawaii. There are a number of states who have passed legislation that starts ahead in that direction for payment for palliative care, or that are actively working and using Hawaii as a model to establish payment for palliative care services in those states.
What happens if Medicaid dollars shrink in those states? We can’t know. Palliative care services would still be really beneficial for the Medicaid beneficiaries in those states, but states are going to be making hard decisions and hard trade offs at that point about what services to cover and who to cover them for. So I think that puts some of that momentum at risk.
What types of relationships or partnerships should palliative care providers be prioritizing?
One of the optimistic trends that really particularly started to notice in the last couple of years is momentum in sort of clinical collaboration, collaboration between palliative care teams and clinicians from other specialties.
CAPC right now has a joint program that we’ve partnered up with the American Cancer Society around. It’s a learning community of 20 cancer cancer practices from around the country that are thinking about how to operationalize specialty palliative care for their patients. They are also interested in training oncology professionals in basic palliative care skills so that they are equipped to address the sort of first line palliative care needs of their cancer patients. They know how to operationalize specialty palliative care in terms of when and who to refer, and what those collaborations look like.
Similarly, we’re working with the American Thoracic Society, who has a special interest group dedicated to palliative care. It has published a position statement about the value of palliative care for patients with serious respiratory diseases. It has published a position statement on what are the basic palliative care skills that anybody in the pulmonary and critical care space would benefit from having when they’re caring for patients with serious respiratory disease.
There’s been this conversation growing more and more active in the specialty societies and associations outside of the palliative care field, recognizing our patients may not always be getting goal-aligned care. Our patients too often have symptoms that aren’t adequately addressed. Our patients may be going back to the hospital because we haven’t established a stable plan of care for them in the home. We could really benefit from adopting palliative care practices or for a stronger collaboration with palliative care teams to provide that added layer of support for patients.
I’m very optimistic about that, again, because it doesn’t depend upon a particular policy or a particular payment model. It’s a culture shift.
One idea that was in your open letter, you talked about making your referral partners your advocates. What are some ways that a palliative care provider can help make that happen?
We started seeing this more and more actually during the pandemic, where if a particular service became accustomed to asking the palliative care team or referrals for their patients because things were so hectic, because patients were so high need, because palliative care teams were expert at managing shortness of breath or navigating really tough conversations about goals of care. You could characterize it as palliative care teams really gained new fans and trusted collaborators during that period of time.
That’s always been the case, but it was accelerated during the pandemic. And so if you have a head of cardiology in a hospital who says, “Well, I need access to palliative care for all of my patients that need such and such clinical threshold of complexity or of seriousness,” the hospital is very invested in making sure that their cardiology service is productive and is meeting their quality measures. That’s an equation in which, if cardiology says, “Well, palliative care is helping me meet those measures and helping me meet my both productivity and quality measures,” that’s an added incentive for that organization to make sure that the palliative care team is adequately staffed to do that work with cardiology.
That’s another point in the value case inside of a given health care organization to make sure that the palliative care team is staffed and is supported adequately to achieve those outcomes.
