More payors and policymakers than ever before are working to implement policies and benefits to increase and sustain access to services that improve care for people with serious illness and their caregivers. At the state level, increased federal requirements and access to funding has accelerated adoption of benefits supporting people with serious illness, such as palliative care and caregiver services. This is particularly true in the Medicaid and Medicare populations where managed care organizations (MCO), including health plans and health systems, are required to track and document advance care planning for quality measurement documentation and to assess people for social risk factors to meet their needs.
Managed care payment models also base reimbursement on the quality of care that is delivered to patients and families. That means that payors are increasing access to and education about the services that serve to improve quality measures they are required to report. This includes measurement programs like the Medicare Star Ratings, HEDIS, and the Medicare Quality Payment Program (MPP). These federal requirements for Medicare and Medicaid beneficiaries have increased access to programs and services addressing the following needs, among others:
- Falls Risks
- Emergency Room Visits
- Caregiver Support
- Diet-Specific Meal Delivery
- Transportation Services
- Risk Assessments and Screening for Social Determinants of Health (SDOH)
- Advance Care Planning
- Outreach and Engagement to Underserved and Marginalized
To support these measurement requirements, state health information exchanges such as Michigan’s Health Information Network (MiHIN) have begun engaging community stakeholders to begin to standardize data collection and reporting activities.
In addition to updated measurement requirements, funding from the American Rescue Plan Act (ARPA) has been distributed to states to increase the capacity of home and community-based services and other necessary infrastructure to states. This funding has accelerated state agencies into action, working to file waivers and applications to expand services supporting social determinants of health and serious illness. The ARPA funding awarded to states can go to addressing unmet gaps in the community that can ensure more home and community-based services are available for people when they need them.
The pandemic also identified the considerable need for better coordinated palliative care services that can be delivered outside of the hospital to manage a person’s pain and symptoms and address holistic needs of a person and their loved ones when serious ill. Palliative care serves to improve quality of life and reduce pain and other issues people with serious illness face and reduce unnecessary emergency department visits, hospitalizations, and nursing home stays.
California’s SB1004 has also demonstrated that access to palliative care services improves access to outpatient and home-based services while reducing the overall cost of care for those being served. Outcomes also demonstrated that high provider and patient satisfaction rates when receiving palliative care services. This model is serving as a framework for numerous other states working to create more sustainable access to palliative care services and to replicate results from California. State agencies across the country are considering several ways to ensure access to palliative care services, including:
- Requiring MCO and other payors to deliver palliative care to their beneficiaries that meet state requirements
- Incorporating palliative care services into Master Plan on Aging (MPA) requirements
- Incorporating palliative care services as an additional level of care within their health home or patient centered medical home models
- Including palliative care services as part of updates to dual eligible (Medicaid-Medicare) alignment plans
- Developing standalone palliative care benefits through amendments to their state plan or waiver
Efforts are only being accelerated further through initiatives like SCAN Foundation’s Advancing States and NASHP’s Serious Illness Institute. In addition to the new benefits being accelerated, Medicaid MCO’s are now required to develop community partnerships and invest in initiatives supporting the populations they serve. These community benefit dollars can serve to create inroads for community-based organizations to begin partnering with health systems and healthcare payors to address needs more holistically.
