Palliative care services and hospice care services are often provided to patients with serious illnesses, with the aim of relieving the symptoms of the disease and/or the side effects of treatment. Often, palliative care is provided as a part of hospice care. However, the two types of care are not interchangeable. Hospice care services are designed specifically for patients who have decided to forego curative treatment, whereas palliative care can be provided to patients receiving active treatment.
On March 19, 2024, the Washington legislature directed the Washington Office of the Insurance Commissioner (the “Insurance Commissioner”), in consultation with the Washington State Health Care Authority (the “Health Care Authority”), to convene a “palliative care benefit work group” (the “Work Group”) to develop recommendations for palliative care benefits for health plans.
The Role and Specifics of Pediatric Palliative Care
Palliative care is similar to hospice care in that it is not designed as curative care, but is meant to ease the burdens of a
patient’s illness. Specifically, “palliative care” is defined as:
What is Palliative Care?
Palliative care is similar to hospice care in that it is not designed as curative care, but is meant to ease the burdens of a
patient’s illness. Specifically, “palliative care” is defined as:
- Specialized care for people living with serious illness.
- Care is focused on relief from the symptoms and stress of the illness and treatment, whatever the diagnosis.
- The goal is to improve and sustain quality of life for both the patient, loved ones, and other care companions.
- It is appropriate at any age and at any stage in a serious illness and can be provided along with active treatment.
- Palliative care facilitates patient autonomy, access to information, and choice.
- The palliative care team helps patients and families understand the nature of their illness, and make timely, informed decisions about care.
As noted in this definition, palliative care “is appropriate . . . at any stage in a serious illness and can be provided along with active treatment.” Unlike hospice care, palliative care does not require certification that the patient is expected to have six months to live if the illness follows the normal course, nor does a patient have to choose between palliative care and curative treatment. Palliative care can be provided as part of a home health plan of care or a hospice plan of care.
On March 19, 2024, Substitute Senate Bill 5936 was signed into law directing the Insurance Commissioner, in consultation with the Health Care Authority, to convene the Work Group to design the parameters of a palliative care benefit for health plans. The Work Group shall consider the following elements: (i) clinical eligibility, (ii) the services to be included, (iii) appropriate staffing models and provider training, (iv) evaluation criteria and reporting requirements; and (v) evaluation models. The Work group shall report its recommendations on the palliative care benefit to the legislature by November 1, 2025.
Currently, the Health Care Authority offers a palliative care benefit. The Health Care Authority palliative care benefit includes the following services (a) an initial assessment, (b) goals of care and advance care planning, (c) assessment of cognitive impairment, (d) assessment and management of functional needs, (e) assessment and management of serious illness and/or multiple chronic conditions, (f) assessment and management of pain and symptoms, (g) ongoing care management and care coordination, and (h) caregiver support and education. Palliative care can be provided in the home, outpatient clinics, long-term care settings, and hospitals.
In order to be eligible for the palliative care benefit, the patient must have (1) at least one serious illness or a combination of three chronic conditions, (2) significant functional limitations and the need of assistance with one or more activities of daily living and rely on durable medical equipment, and (3) a recent history of unscheduled health care utilization. Qualifying “serious illnesses” include metastatic cancer (e.g., Pancreatic, gastrointestinal, lung, brain, or hematologic cancers), heart failure with class III or IV function, heart failure with a left ventricular assist device, advanced pulmonary disease, advanced dementia with stage 6 or 7, a progressive neurologic disorder, hepatic failure (cirrhosis), end stage renal disease (excluding patients on dialysis), protein-calorie malnutrition, cachexia, or a hip fracture (with functional decline). Qualifying chronic illnesses include cancer, leukemia, chronic pulmonary disease, coronary artery disease, congestive heart failure, peripheral vascular disease, severe chronic liver disease, diabetes with end-organ damage, renal failure, and dementia.
On March 19, 2024, Substitute Senate Bill 5936 was signed into law directing the Insurance Commissioner, in consultation with the Health Care Authority, to convene the Work Group to design the parameters of a palliative care benefit for health plans. The Work Group shall consider the following elements: (i) clinical eligibility, (ii) the services to be included, (iii) appropriate staffing models and provider training, (iv) evaluation criteria and reporting requirements; and (v) evaluation models. The Work group shall report its recommendations on the palliative care benefit to the legislature by November 1, 2025.
Currently, the Health Care Authority offers a palliative care benefit. The Health Care Authority palliative care benefit includes the following services (a) an initial assessment, (b) goals of care and advance care planning, (c) assessment of cognitive impairment, (d) assessment and management of functional needs, (e) assessment and management of serious illness and/or multiple chronic conditions, (f) assessment and management of pain and symptoms, (g) ongoing care management and care coordination, and (h) caregiver support and education. Palliative care can be provided in the home, outpatient clinics, long-term care settings, and hospitals.
Palliative care is similar to hospice care in that it is not designed as curative care, but is meant to ease the burdens of a
patient’s illness. Specifically, “palliative care” is defined as:
Practical Considerations
Whether the Work Group’s recommendations would be similar to the Health Care Authority’s palliative care benefit is yet to be seen. However, once the recommendation takes effect, providers will face a complex regulatory and contractual scheme to ensure that patients are eligible and that services are medically necessary and appropriately provided. Working with knowledgeable counsel to navigate the issues will be essential to ensure compliance with all legal requirements and patient contracts.
For more information, please contact Emily R. Studebaker at estudebaker@studebakernault.com or Jeremy L. Belanger at jbelanger@studebakernault.com.