Week 7: 2/22-2/28-The Influence of Public Sector Institutions

Public institutions play a significant role in the success or detriment of both inpatient and outpatient palliative care programs.   Because the vast majority of individuals dying in the United States fall into the Medicare age group, Medicare is the largest insurer for end of life health care (KFF, 2015). This becomes problematic when considering the costs accrued in the last months/years of an individual’s life. Approximately 20% of Medicare beneficiaries are living with at least 5 chronic medical conditions (S. Winn-McCorkle, personal communication, February 22, 2016 ). This number is especially astounding when considered in the context that 2/3 of Medicare expenditure goes to this specific cohort (S. Winn-McCorkle, personal communication, February 22, 2016 ). Furthermore, 25% of Medicare spending is utilized for individuals in the last year of life (KFF).

   2010    ◦ 171 new referrals    ◦ 415 established patient visits      An LCSW was added, split between hospice and pal...
Palliative care serves as an important aspect of the health care team (2)

So how do these statistics relate back to palliative care and the significance of H.R. 3119? To put it simply, all of the groups mentioned above tend to be the best candidates for palliative care (S. Winn-McCorkle, personal communication, February 22, 2016 ). Not only does the addition of palliative care improve quality of life and longevity, but it has been to shown to decrease time spent in intensive care units and hospital readmissions (S. Winn-McCorkle, personal communication, February 22, 2016 ). Furthermore, because palliative care focuses on symptom management that is guided by the needs and wants of the individual, unnecessary tests, medications, and overall costs are often reduced (S. Winn-McCorkle, personal communication, February 22, 2016 ).

Palliative care focuses on symptom management that is guided by the needs and wants of the individual


While it is clear that palliative care benefits the Medicare and Medicaid budget, it is essential to examine how these public sectors can maximize the functioning of palliative care. While hospice care has been funded by the Medicare Hospice benefit for many years, palliative care has traditionally had a more difficult time being covered by the public sectors (NIH, 2010). Traditionally, Medicare does not have specific billing in place for palliative care. That being said, some aspects of palliative medicine (i.e. hospital care, treatments, medications, specialists, and social workers), can be billed to Medicare (NIH). However, Medicare beneficiaries are still often responsible for copays and fees which contrasts to the coverage for hospice care (NIH). Medicaid tends to follow suite and reflects the same potential coverage of palliative care services with its own Hospice Benefit (CMS, 2016). This however is even more problematic as the coverage varies from state to state (NIH). Patient access to palliative care varies drastically from region to region building upon existing health disparities as well as the availability of palliative care programs (Giovanni, 2012). Consequently, rural areas and states with smaller hospitals tend to not have established palliative care programs (Giovanni).

The percentage of hospitals with palliative care programs varies from state to state (3)

The Medicare Care Choices Model, introduced in 2014, does play a role in this as well (CMS, 2014). This model allows Medicare beneficiaries who would otherwise qualify for hospice to choose palliative care treatment in conjunction with curative treatments (CMS, 2014). The purpose of this model is to study whether or not this improves the rates of individuals using the Medicare Hospice Benefit as well as the quality of care and satisfaction experienced by patient and caregivers (CMS, 2014).

With the advent of the Affordable Care Act in 2009, the weight of public sectors has become even more prevalent. While hospice care and reimbursement were acknowledged by the act, palliative care reimbursement was not addressed. An executive summary of the Affordable Care Act and end of life care recognizes that while the Affordable Care Act did not specifically acknowledge palliative care, it does identify the need to have “Federal agencies develop a research agenda on palliative care to address issues such as the development of practice guidelines and methods of quality improvement, as well as the exploration of reimbursement options” (GWU, N.D.).

The aging population will need palliative care access (4)

As the trend for repayment systems are navigating towards quality assurance, the patient and cost outcomes related to palliative care have an optimistic chance of receiving improved reimbursement specific for the care provided. Moreover, the general consensus from the literature continues to reinforce the need to prioritize federal and state funding for palliative care training and research. Connecting back to H.R. 3119, the bill seeks to not only improve training and research, but additionally seeks to generally improve the awareness of palliative care in the community which also has the potential to contribute to improved reimbursement.

Photo Credits

1. Header photo: https://www.mdanderson.org/education-and-research/departments-programs-and-labs/departments-and-divisions/palliative-care-and-rehabilitation-medicine/index.html

2. http://www.slideshare.net/Kindredhealth/palliative-care-across-the-continuum

3. http://www.slideshare.net/ctsinclair/hospice-palliative-care-missouri-health-net-aug-2009

4. https://publichealthwatch.wordpress.com/2014/03/15/how-the-affordable-care-act-opens-the-door-for-two-vulnerable-populations/


Centers for Medicare and Medicaid Services (CMS). (2014). Medicare care choices model. Retrieved from https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-03-18.html

Centers for Medicare and Medicaid Services (CMS). (2016). Hospice benefits. Retrieved from https://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/hospice-benefits.html

George Washington University (GWU). (N.D.). The affordable care act and end of life care: Executive Summary. Retrieved from https://smhs.gwu.edu/gwci/sites/gwci/files/EndofLifeExecSummary.pdf

Giovanni, L. A. (2012). End-of-life care in the United States: Current reality and future promise-A policy review. Nursing Economics, 30 (3), 127-134. Retrieved from https://www.nursingeconomics.net/ce/2014/article3003127134.pdf

Kaiser Family Foundation (KFF). (2015). 10 FAQs: Medicare’s role in end-of-life care. Retrieved from http://kff.org/medicare/fact-sheet/10-faqs-medicares-role-in-end-of-life-care/

National Institutes of Health (NIH). (2010). End of life. Retrieved from http://nihseniorhealth.gov/endoflife/payingforcare/01.html


4 thoughts on “Week 7: 2/22-2/28-The Influence of Public Sector Institutions”

  1. Sarah, thank you for a very informing post. End of life care is incredibly important, yet I’m always surprised how palpably uncomfortable many providers become when these imperative discussions are taking place. I noticed this in my bedside nursing job as well as in my personal life. When a patient and/or family member starts asking questions about a grim prognosis, many providers start fidgeting, stuttering, and telling incomplete truths just to get out of the situation – let me be clear, this is not all providers, just some I have come across in my experiences. It is a stark contrast to compare those experiences with my observance and interaction with palliative care specialists. Those providers who have palliative care experience have a different approach to patients and the creative solutions they can offer. Knowing how comforting these specialists can be, I would advocate for everyone to have access to this care. However, I know realistically, it just doesn’t happen if it equates to high costs or minimal reimbursement.

    You may have touched on this in previous posts, but I think making a clear distinction between what palliative care offers in comparison to hospice is imperative in “advertising” palliative care services to patients, providers, and policy makers. I know that I ignorantly viewed palliative and hospice to be basically the same for years and I was a nurse. Many patients view those services the same way I did and are then reluctant to accept palliative care (they don’t want to feel like they are being given up on). Perhaps policymakers are making the same misjudgment, which causes a lack of support when trying to progress palliative care. Thank you for a great post!


  2. The Medicare Care Choices Model has opened doors for certain patient populations. The merging of specialties may be very beneficial to patients and it will be very interesting to see how this study unfolds over the next couple of years. While looking into the model, I was pleasantly surprised to see the interest it has generated among hospice providers. Orginally, CMS predicted enrolling around 30 providers, but due to the interest generated, there are currently over 140 providers enrolled CMS, 2015). To be eligible patients must have one of four diagnoses, which include advanced cancer, COPD, CHF, and HIV/AIDS. Because these illnesses are progressive, I believe patients may receive significant benefits from the utilization of palliative care services. The one thing that may be a drawback is that the model seems to focus on social services, care coordination and education (CMS, 2015). I think these services are great…but it seems that palliation in the way of symptom management would be still left up to the referring provider. I think that symptom management under the guidance of a palliative care advanced practitioner (who would be the “experts”) would benefit a patient more significantly.

    Centers for Medicare and Medicaid Services (CMS). (2015). Medicare care choices model. Retrieved from https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-03-18.html

    Centers for Medicare and Medicaid Services (CMS). (2015). Medicare care choices model- Frequently asked questions. Retrieved from: https://innovation.cms.gov/initiatives/Medicare-Care-Choices/faq.html


  3. “In four New York State hospitals with mature, interdisciplinary palliative care consultation teams, hospital costs among patients enrolled in Medicaid were significantly lower when they had consultations with the palliative care team that resulted in care planning guidance, pain and symptom management, and appropriate discharge planning transition management. These findings are consistent with previous work demonstrating a similar effect of palliative care teams on hospital costs among Medicare beneficiaries at eight diverse hospitals in a range of states and health care markets. Policy makers employing payment, regulatory, and quality levers could markedly strengthen access to palliative care for those Americans most in need, thereby benefiting patients, families, and payers alike.”(1)
    For the second time today I have employed a fiscal argument to support a human dilemma when, as far as I’m concerned, the argument that should move us is respect for a person’s autonomy and their wishes at the end of their life. I suppose for purposes of public policy I need to grow up and stop wishing the world made decisions based on love and kindness. This was reinforced for me today when I spoke with my congressman at the state capital. He happens to be a physician and in his heart supports my quest to provide education to young people about infant brain development and their psychosocial needs. He did not dwell too long on his personal feelings but talked instead of appealing to fellow legislators, confronting opposition, refuting ideas as mandates, and coalescing endorsement. Even though all I want to do is treat patients, I am seeing how I cannot escape the business end of affecting change for the patient population I serve and care about. Thank you for your blog and your kind effort to move this position forward.

    1. Morrison, R.S., Dietrich, J., Ladwig, S., Quill, T., Sacco, J., Tangeman, J., Meier, D.E. (2011). Palliative care consultation teams cut hospital costs for medicaid beneficiaries. Health Affairs, 30, 3, 454-463, doi: 10.1377/hlthaff.2010.0929


  4. Thank you for your commentary on this topic. Palliative Medicine is something that I am passionate about and hope to work in. The coverage of Palliative Care by Medicare and Medicaid is critical to ensuring patient’s quality of life but also reducing overall health care costs. What I have noticed locally, is that palliative medicine programs are being started by many of the companies offering hospice programs. For example, Hospice of the Valley and Sage Palliative Medicine program have recently started programs and they seem to be successful and reimbursed. Furthermore, a quick google search shows that Palliative medicine is offered at all of the major hospitals in the area. I have rounded in several of the programs and they seem to be growing. These facts give me hope that the pendulum has shifted towards to the recognition and value of end of life care needs and these services are being paid for.
    Palliative medicine addresses the gap of fragmented care at the end of life, and as you said, it is guided by the needs and wants of the individual. This means an individual, may recognize that they are nearing their end of life and would like to continue with blood transfusions for as long as possible. Under the hospice model, this choice may not be an option. Palliative medicine gives them that option. The Institute of Medicine’s recent report on “Dying in America” gives an excellent overview of the current situation in the U.S. with recommendations on how the health care system can fix it. Although we are advancing slowly, there is still much more work to be done. Thanks for taking on the task!

    Institute of Medicine of the National Academies. (2014). Dying in America: Improving quality and honoring individual preferences near the end of life. Retrieved from http://iom.nationalacademies.org/Reports/2014/Dying-In-America-Improving-Quality-and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx


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