Perennial growth in managed care enrollment, changes in health policy and payment incentivizes innovative approaches.

By Turner West

It is widely recognized that the U.S. healthcare delivery system has been maladaptive in meeting the needs of seriously ill adults and their families. The consequences of our system deficiencies are seen in myriad ways.

Seriously ill patients often experience intractable pain, inadequately managed symptoms, burdensome and unnecessary transitions between care settings, inattentiveness to emotional and spiritual concerns, dissatisfaction with healthcare services and medical care discordant with preferences and values.

Growth of Palliative Care

Thankfully the past decade has shown marked improvements in serious illness care and these improvements are in large part attributable to the growth of palliative care programs. Palliative care is specialized medical care that focuses on improving the quality of life for people living with serious illness and their families.

The expansion of palliative care services has been driven by hospitals as hospital leaders have recognized the ability of palliative care teams to improve clinical and satisfaction outcomes while also reducing non-beneficial utilization of services. Consequently, as of 2016, over 75 percent of hospitals with greater than 50 beds have a palliative care team.

Although the growth in hospital-based palliative care is laudable, there is a broad consensus that ameliorating serious illness care and spurring innovation requires ensuring access to palliative care services in community settings.

The adoption and proliferation of community-based palliative care has been limited by a predominately fee-for service payment structure but changes in health policy and payment create significant opportunities for improvement.

Accelerating the Adoption of Palliative Care

The perennial growth of Medicare Advantage enrollment, expansion of Medicaid managed care and healthcare delivery system reform efforts that reward value over volume create the conditions for innovative approaches to improving serious illness care. Managed care plans are increasingly interested in ensuring access to palliative care for their members as palliative care teams deliver on the value equation.

Repeatedly palliative care has been shown to improve clinical outcomes, enhance member satisfaction, and reduce non-beneficial healthcare utilization. Moreover, policy and payment changes are aligning financial and clinical incentives in ways that is accelerating interest in palliative care.

In April, CMS released their annual call letter which included a reinterpretation of “primarily health-related” supplemental benefits and the “uniformity requirement” for health plans. Through guidance memos, CMS elaborated on the expanded definition of primarily health related.

Plans will be able to cover services used to “diagnose, compensate for physical impairments, acts to ameliorate the functional/psychological impact of injuries or health conditions, or reduces avoidable emergency and healthcare utilization.” CMS provides home-based palliative care as an example of a service that plans now have the flexibility to cover.

Additionally, plans can now cover adult day health services, in home supports and services, non-emergent transportation, home and bathroom safety modifications and respite care for caregivers. This reinterpretation provides plans with the incentives to innovate and offer a needs-driven approach to seriously ill members.

Legislators Take Notice

At the state level, legislators are noticing that not only does palliative care serve seriously ill patients and families well but paying for palliative care is an efficient use of the public dollars. In California, legislation was passed that requires access to palliative care services for all beneficiaries in a Medicaid managed care plan.

Beginning this year, all seriously ill individuals enrolled in a Medicaid managed care plan have access to palliative care services. This policy is spurring innovation and new collaborations to improve serious illness care.

Palliative Care Leadership Center

Bluegrass Care Navigators was an early adopter of palliative care and began providing access to specialist level palliative care in 1999. Because of a commitment to improving the quality of life of the seriously ill, Bluegrass Care Navigators is designated a Palliative Care Leadership Center, one of nine centers of excellence through the Center to Advance Palliative Care.

Bluegrass Care Navigators has trained over 330 organizations, representing 40 states, in the development of high-quality palliative care programs. As palliative care garners interest from patients, caregivers, payers, and policy makers in Kentucky, Bluegrass Care Navigators is here to support initiatives and partnerships that improve serious illness care.

-Turner West is associate vice president for Health Policy and director of the Palliative Care Leadership Center at Bluegrass Care Navigators.

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