Viewpoint: We need to fill the palliative care gap — for the patients and the system 

After a few years of significant disruption in healthcare delivery, it’s time to think beyond crisis mode and build on what we’ve learned. We must continue to deliver the full continuum of high-quality care across physical and virtual locations — and in the patient’s preferred setting whenever feasible.

While many aspects of healthcare delivery could be significantly improved, it’s important to note we’re already doing some things well. For seriously ill patients, hospice care has a long history of providing care at home to help relieve pain, symptoms and stress, improving patients' quality of life in their final days. It's an invaluable Medicare benefit that provides essential care to patients as well as much-needed caregiving support for loved ones. Moreover, hospice has been shown to lower costs, individually and systemically. 

According to a recent cohort study published in the JAMA Health Forum, hospice use by community-dwelling Medicare beneficiaries was associated with significantly lower total healthcare costs across all payers in the last three days to last three months of life. 

Here's where we’re falling short: patients only qualify for hospice when they have a prognosis of six months of life or less, after ceasing curative care. Their serious illnesses and chronic conditions begin long before that time marker. If we’re truly delivering a full continuum of care, these patients need access to specialized care while they're still receiving curative care.

That specialized care—palliative care—can help improve outcomes, reduce hospitalizations and lower the overall cost of care. The opportunity to serve more patients is significant: The Center to Advance Palliative Care (CAPC) estimated last year that 12.4 million Americans could benefit from palliative care.

Our existing system is well positioned to provide more patients with community-based palliative care; CAPC also reported that hospices represent at least half of the nation’s in-home palliative care providers. However, many patients face a significant barrier to access. Most private insurance plans and more than 100 Medicare Advantage plans currently cover palliative care, but traditional Medicare does not. 

To get these patients the care and relief they need will require a robust and defined Medicare benefit for community-based palliative care. Not only could this improve care for seriously ill Medicare patients earlier in their disease progression, but it could help break down barriers to hospice access. Currently, 25% of hospice beneficiaries are with hospice for less than seven days—nowhere near the six months they’re entitled to have. A palliative care benefit could support an earlier and more seamless transition to hospice care when the time comes, providing value to patients and the larger healthcare system. 

Expanding community-based palliative care also is likely to reduce unnecessary hospitalizations. Preliminary results from NORC found a community-based payment model for palliative care could produce hundreds of millions of dollars in savings to the Medicare program. 

To support successful outcomes for all, the hospice community is urging the Center for Medicare and Medicaid Innovation (CMMI) to consider a few key factors in structuring a care delivery and sustainable payment model for palliative care. First, registered nurses and social workers should drive this model, as many already have the home-based clinical and social determinants of health experience necessary to care for seriously ill patients. Physician and nurse practitioner oversight can be provided using telehealth. It also will be critical to prioritize payment for care coordination between those providing palliative care and the providers delivering alternative curative care. Finally, the goals of this model must be designed to complement the hospice benefit, supporting earlier access to hospice through enhanced advance care planning and education for patients and their families.

As a community, we remain hopeful that CMMI implements a community-based palliative care benefit. Hospice care providers stand ready to serve more of our nation’s seriously ill patients, at home, helping them navigate the end of life without unnecessary, high-cost and burdensome transitions.

Nick Westfall is the President and CEO of VITAS® Healthcare, the nation’s leading provider of hospice care. 


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