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While recent actions by CMS could incrementally move the needle on home health palliative care access, they could also come with many limitations. CMS in its proposed 2027 home health rule clarified that home health providers can use certain billing codes to provide community-based palliative care to eligible patients, emphasizing that this care would be distinct from hospice.
Hospice Stakeholders Respond to the Home Health Palliative Care Clarification
Stakeholders in the hospice community were quick to applaud the proposal. “We are pleased to see CMS recognize the value of palliative care and the important role it plays in improving quality of life for people living with serious illness both before hospice election and during it,” National Partnership for Healthcare and Hospice Innovation Founder and CEO Tom Koutsoumpas told Hospice News in an email. “NPHI has long advocated for greater access to, and sustainable payment for, palliative care services much earlier and throughout the course of serious illness, and we welcome CMS’s openness to advancing this work.”
Not a New Policy, But a Clarification
The clarification in the proposed rule does not represent new policy or practices by CMS. The agency indicated that it would release further sub-regulatory guidance later this year on how home health agencies can provide home health palliative care.
Eligibility Gaps Limiting Home Health Palliative Care
However, what CMS has done falls short of a community-based palliative care benefit. For one, patients must meet the eligibility requirements for home health. This means that, among other requirements, patients must be homebound to receive this care, according to Katy Barnett, director of hospice and home health operations and policy for LeadingAge. This excludes many patients who may benefit from palliative care.
A Barrier for Community-Based Hospice Programs
This also means that hospices with community-based palliative care programs cannot bill using those codes unless they have a Medicare-certified home health service, further narrowing which organizations can actually deliver home health palliative care under the new clarification.
Why the Home Health Palliative Care Model Falls Short of Hospice
The palliative care model that exists within home health is also somewhat less robust than the services provided by hospices, Barnett indicated. “We do believe that home health is a good place for palliative care patients. I think one of the things that we’re struggling with is that, if we push palliative care into home health, the benefit really doesn’t support the same intensity of care as the hospice program,” Barnett told Hospice News. “It’s a really tight payment, and that’s why you see so few new home health agencies. It’s a really tough industry to be in right now, especially with the last four years of payment cuts.”
Quality Measures Not Built for Palliative Patients
Existing quality measures for home health also do not incentivize the provision of home health palliative care. CMS evaluates home health largely on improvement measures that show a patient’s progression toward recovery, which are not built for maintenance or comfort care, according to Katie Wehri, vice president for regulatory affairs, quality and compliance at the National Alliance for Care at Home.
Calls for Payment and Quality Structure Reform
“[Quality measurement] is an area where there needs to be some more work. The payment structure needs to be revised, but the quality structure does as well,” Wehri told Hospice News. “Those quality measures aren’t really aligned to the typical patient who’s going to be receiving palliative care services, or even the typical patient who is more of a maintenance patient rather than a patient who’s there for skilled rehab services.”
Missing Interdisciplinary Support
Wehri posits that the home health payment model does not cover the full range of interdisciplinary care that a hospice might provide, including chaplain services and more frequent social worker visits. She also said the payment model needs to be updated to reflect the more acute level of care that palliative patients often need.
A Call for Formal Medical Collaboration in Home Health Palliative Care
Also, the home health benefit does not require collaboration with a medical or advanced practice provider, according to Brynn Bowman, CEO of the Center to Advance Palliative Care, and Allison Silvers, chief healthcare transformation officer at CAPC. “The home health team should have a formal collaboration with a qualified palliative care medical or advanced practice professional,” Bowman and Silvers told Hospice News in a joint email. “This is aligned with palliative care quality guidelines and CMS should clarify that the medical provider can bill Part B while the home health is billing Part A.”
A Step in the Right Direction, But Not the Full Solution
All in all, stakeholders recognize this move by CMS as a positive step, but many also feel that further reforms or additional access points are necessary to truly meet the needs of patients who could benefit from home health palliative care. “I definitely think that acknowledging that palliative care services are part of home health is a step in the right direction,” Wehri said. “It is not where we need to be fully. We’ve got to take some steps to look at serious illness throughout the continuum of care, not just for those homebound patients.”
