States Explore Strategies to Advance Palliative Care at #NASHPCONF18

States, as regulators, payers, and innovators of health care, are uniquely positioned to improve the lives of Americans with serious illnesses by promoting access to palliative care. The National Academy for State Health Policy (NASHP) is working with state leaders to expand and improve palliative care, explore how these services align with other initiatives (e.g., value-based purchasing and delivery system reform), and identify what states need to effectively advance palliative care services.

What is palliative care?
Palliative care is interdisciplinary, patient- and family-centered health care that addresses the physical, mental, social, and spiritual well-being of seriously ill individuals.

It can be provided in hospital, community, or home settings. While often confused with hospice care, which typically focuses on the last months of life, palliative care can be offered alongside curative care at any time.

Palliative care services can improve care and the quality of life of individuals with serious illness by better managing symptoms and stressors. They can also reduce costs, especially for complex populations with serious illnesses. A 2016 study that examined home-based palliative care found these services generated a 4.2 to 6.6 percent return on investment, primarily by reducing unnecessary hospitalizations.

At NASHP’s recent 2018 State Health Policy Conference, a group of state leaders explored these issues from a policymaker perspective and discussed what it would take to advance palliative care services in their states. Below are some of the key themes and opportunities raised during the session:

  • States need palliative care definitions and standards: State officials identified the need for tools and resources to help states license, reimburse, monitor, and measure high-quality palliative care. Definitions and standards tailored to state regulatory needs can help jumpstart state efforts. California, Maryland, and Colorado have all implemented regulations defining palliative care, which can serve as starting points for other states.

This work is supported by a grant from
The John A. Hartford Foundation
, a national philanthropy based in New York City dedicated to improving the care of older adults.
  • Workforce shortage is a potential barrier: States report that trained professionals — able to address palliative care needs in primary care and as members of specialized palliative care teams — are in short supply. To address this issue, Rhode Island supports provider education on palliative care as part of its cancer control program, and recently expanded the training to providers who treat other serious illnesses. As part of its State Innovation Model test grant, Rhode Island is also developing patient tools for advanced care planning and is offering education to providers to help them feel better equipped to hold these difficult discussions.
  • Monitoring utilization and quality can be challenging: State Medicaid agencies can support reimbursement for palliative care in a number of ways, including:
    • Through managed care contracting;
    • As a distinct state plan option; and
    • By leveraging existing physician billing codes.

While these payment mechanisms are readily available, participants noted limitations persist. Even with enhanced reimbursement rates for palliative care, one state official reported that provider uptake was low and that the enhanced payment was underutilized. Other officials from states that had activated specialized billing codes for palliative care expressed concern about the quality of care delivered and adherence to best practice standards. States without specialty codes or a specific benefit noted that it was impossible to gauge utilization or quality given the lack of claims data.

California, which requires its Medicaid managed care plans to cover palliative care services as a package of benefits, is an example of a state that has developed a comprehensive regulatory framework to address some of these issues. Its notice to plans outlines eligibility criteria, describes service components (including advance care planning, palliative care assessment and consultation, access to a palliative care team, and mental health services) and requires plans to monitor and report palliative care utilization and provider data to California’s Department of Healthcare Services.

  • Stakeholder engagement can help when defining and developing palliative care services. State officials reported that engaging a broad range of agencies and stakeholders to develop palliative care initiatives was helpful. At least 27 states have multi-stakeholder taskforces or councils established specifically to advise on palliative care, and those groups provide a readymade forum for state policymakers.

State policymakers are working hard to move state systems toward more comprehensive and value-driven care, often with a special focus on populations that have chronic, complex, and high-cost care needs. Over the next two years, NASHP will convene a Leadership Council of state officials to identify promising policies and develop state recommendations and an implementation roadmap to increase access to and quality of palliative care.

NASHP will also be providing technical support to 10 states to assist them in advancing palliative care through resources, such as development of model legislation or Medicaid managed care contract language, and review of state regulations of palliative care providers and facilities. Look for announcements about publically-available palliative care resources and the technical assistance opportunities at NASHP’s website.

If your state has implemented or is exploring innovative strategies to support palliative care in Medicaid, please share your state’s experience with NASHP, contact Hannah Dorr.