America’s Care of Serious Illness

ESTABLISH or expand loan forgiveness programs for clinicians who work as palliative care specialists.

Federal and state governments can support growth in the palliative care workforce by helping cover the costs of training. For instance, Maryland maintains the Maryland Loan Assistance Repayment Program (MLARP). This program provides financial support that can be applied toward higher-education loans to certain physicians, physician assistants, and medical residents who work in eligible care sites.

PAY for services beneficial to people with a serious illness by using existing codes, such as advance care planning, interdisciplinary team consults, and respite for family caregivers.

States can support palliative care through traditional Medicaid by adding specific billing codes to their Medicaid benefits. For instance, both Delaware and Virginia added codes that pay for advance care planning services, interdisciplinary care team consults, and respite services.

INCLUDE home-based palliative care as a benefit under Medicaid Managed Care (MMC) and/or Managed Long-Term Services and Supports (MLTSS).

CREATE opportunities to support pediatric palliative care, including embedding within existing programs and structures, such as Medicaid Health Homes or Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).

REVISE state exchange requirements to allow palliative care to be included as a benefit in any on-exchange plan.

INCLUDE functional and cognitive status as a distinct element in premium risk adjustments in Medicaid Managed Care (MMC).

INCENTIVIZE provision of palliative care services to beneficiaries with serious illness under MMC and Managed Long-Term Services and Supports (MLTSS) through improved risk adjustment and quality incentives.

MMC plans provide a significant opportunity to expand palliative care to states’ most vulnerable residents. In 2014, California passed SB 1004, which required that all Medi-Cal plans cover palliative care for members with a serious illness.

INSERT licensure requirements that hospitals and skilled nursing facilities with fifty or more beds provide access to specialty palliative care teams, as well as staff training on palliative care, communication, and symptom management.

Maryland, informed by findings from a legislatively mandated pilot study on hospital palliative care, updated its regulations to require that hospitals with fifty or more beds establish an active, hospital-wide palliative care program that provides consultation services to patients living with a serious illness.

INSERT a definition of and minimum standards for palliative care in the state code and relevant regulations, outside of hospice regulations.

Formalizing a clear definition and standards for palliative care can ensure quality and consistency. Colorado has a detailed definition in its health facility licensure, which provides clarity on the settings in which palliative care can be offered and establishes a foundation for palliative care activity in the state and a future framework for accountability.

ESTABLISH separate licensure for home-based palliative care and modify existing licensure for hospices and home health agencies based on existing practice standards.

To clarify that licensed hospices can provide non-hospice palliative care services to people with a serious illness, California passed SB 294. The state will monitor and evaluate the effects of hospice providers offering palliative care services and review findings by 2021.

REQUIRE providers, accountable care organizations, and managed care plans to report on relevant metrics or include palliative care in performance improvement projects to relevant oversight bodies.

Texas included palliative care as one of the projects in its Delivery System Reform Incentive Payment (DSRIP) program. By the program’s end, twenty projects were reporting on one or more outcomes related to palliative care, including pain management and treatment preferences, with most reporting improvement over their baseline.

ENSURE that any policies designed to address the opioid epidemic do not restrict necessary access to these medications for people with a serious illness and those receiving palliative care.

While a majority of states are passing new laws and regulations to reduce the harm caused by the opioid epidemic, several states have simultaneously recognized the need to balance policy proposals and preserve access to necessary medications for people living with a serious illness. Maine, Vermont, and Indiana are examples of states that have included such exemptions.

CREATE a grant program to fund targeted clinical training in the care of people with a serious illness. This can include the implementation of state cancer control plans.

Nebraska established a separate 501(c)(3) to implement its cancer control plan, which includes palliative care in the survivorship section. It has used Comprehensive Cancer Control Program funding to provide palliative care training to targeted cancer programs and clinicians and has leveraged national surveys to capture palliative care availability in the state.

REVISE state health professional licensure and continuing education requirements to include a minimum number of hours of instruction in both communication skills and symptom management skills.

Georgia requires that physicians working in pain management clinics demonstrate coursework in palliative care. Other states with pain management or palliative care continuing education requirements include New Jersey, Oregon, and Rhode Island.

ESTABLISH, in states that have not already done so, a multidisciplinary palliative care advisory board and task force.

Palliative Care Advisory Councils or similar bodies have been established in twenty-eight states, including Kansas, Ohio, Oklahoma, South Carolina, and Texas.

INCLUDE access to patient-centered services such as palliative care in state patients’ bills of rights.

A patient’s bill of rights can be a consequential tool for empowering patients to demand high-quality care. Recognizing this, Vermont inserted a section on palliative care and pain management in its Bill of Rights for Hospital Patients in 2009.

INCREASE the role of state public health agencies in promoting palliative care, developing referral resources and educational materials, and possibly delivering these services directly.

IDENTIFY clinicians in the existing network who are certified in palliative care to understand network capacity, and to classify them as high-value providers. Because palliative care is a subspecialty, additional research through professional societies is needed to identify these clinicians.

REDUCE or eliminate cost sharing for all encounters with members of a specialty palliative care team, as well as for all advance care planning conversations.

One pioneering health plan has been covering unlimited advance care planning conversations during any provider appointment.

COVER interdisciplinary team care in home and office settings, with 24/7 clinical response to crises, for eligible individuals. Consider changing the hospice policy to allow concurrent disease treatment while enrolled in hospice.

The Bipartisan Budget Act of 2018 enables Medicare Advantage (MA) plans to offer supplemental benefits to subsets of their members, based on member characteristics such as diagnosis. Centers for Medicare and Medicaid Services (CMS) guidance specifically highlighted home-based palliative care services as an example of the type of supplemental benefit that can be offered.

BUILD and operate programs of in-home interdisciplinary team care, with 24/7 clinical response to crises.

The impact on avoidable utilization by a New York–based ACO that provides home-based palliative care was recently published in the Journal of Palliative Medicine.

DEVELOP and implement standing processes to screen for unmet palliative care needs by leveraging data analytics to proactively identify people living with a serious illness, functional impairment, and/or memory loss.

REQUIRE or incentivize network hospitals, home health agencies, and skilled nursing facilities to demonstrate the availability of specialty palliative care teams who meet national guidelines. Consider requiring or incentivizing advanced certification in palliative care from an available accrediting body.

One national payer incorporated palliative care as a measure in its hospital quality incentive program; hospitals earn credit by achieving Advanced Certification for Palliative Care, or by meeting four core standards that include access to a specialty team, along with an all-staff training program.

REQUIRE plans and ACOs to demonstrate sufficient specialty palliative care capacity in their provider network facilities and services.

Tools and templates to help purchasers evaluate the abilities of their health plans and ACOs to adequately care for people with serious illness are available in Catalyst for Payment Reform’s Purchaser Toolkit for Serious Illness Care Strategies.

ENSURE that case managers working with people with a serious illness or complex needs are trained in key areas such as communication skills and conducting comprehensive family needs assessments.

One national payer offers specially trained complex care management to members with serious illness. Nurses and social workers support members and their family caregivers, providing needs assessment, education, shared decision making, and goals-of-care discussions, as well as psychosocial care, resulting in reductions in inpatient days and emergency department visits, as published in 2009 in the Journal of Palliative Medicine.

PROVIDE financial incentives for selected network clinicians to acquire communication and symptom management skills. Consider targeting oncology, cardiology, neurology, nephrology, and pulmonology departments.

EDUCATE all network providers about palliative care, including instruction on when to refer to a palliative care specialty team for consultation.

One California payer helps its network serve seriously ill patients by offering training, tools, and resources on palliative care.

PROMOTE information on the benefits of palliative care to all populations.

ESTABLISH, in areas where these do not yet exist, a multi-stakeholder coalition to continuously identify and advance opportunities that improve quality of life for people living with a serious illness, and their families.

The Massachusetts Coalition for Serious Illness Care gathers plans, providers, patient advocates, professional associations, and others to strategize on the implementation of statewide campaigns that improve advance care planning, clinician skills, and more.