I recently went down to the neighborhood I grew up in on the South Side of Chicago. It’s really not the best area to say the least, but it does boast the best pizza I have ever had — Palermo’s on 63rd Street. So, I made the drive with my oldest daughter, Katelyn, my partner, Allison, and a group of friends.
While we were enjoying our dinner, the restaurant’s owner came out and talked with us for a while. He showed us various photographs that line the restaurant’s walls and told us stories about them, including some past customers like Barack Obama and the current pope.
Given my work, I love hearing and telling stories, so it was a great night. I love places that have a history.
Speaking of potential stories, let’s dig into some recent developments around palliative care. A series of references in four proposed rules from the U.S. Centers for Medicare and Medicaid Services (CMS) indicate that the agency has palliative care on the brain and may be mulling new pathways to access.
First, CMS in its 2027 home health proposed rule clarified that palliative care is currently available through that benefit for patients who meet its eligibility requirements. I have written about that on Hospice News as well as here on Inside Hospice. I won’t repeat all the details here, but you can check out those stories for more info.
The agency emphasized that palliative care under the home health benefit would be separate from hospice care and could support patients earlier in the course of serious illness. CMS plans to issue further sub-regulatory guidance on palliative care via home health.
CMS is also asking questions about palliative care in other areas. The agency included Requests for Information (RFI) in its 2027 proposed rules for hospice, end-stage renal disease (ESRD) and its physician fee schedule proposal.
This quartet of clarifications and inquiries could signal that CMS is considering greater access and investment in palliative care. That can only be a good thing, even if looking at it within these specific programs comes with some limitations. For example, to receive palliative care via home health, patients must be homebound.
In the proposed hospice rule, CMS looked for input on how to better support and expand palliative care services in community settings for patients with serious illnesses who may not yet be eligible for or ready to elect hospice.
The RFI also explored how to optimize palliative care delivery under existing Medicare structures versus identifying gaps that might require future policy or legislative action.
In the physician fee schedule, CMS is seeking stakeholder feedback on patient eligibility criteria and essential service elements for community-based palliative care, including how to support adequate payment for interdisciplinary services and between-visit care coordination. The agency also had questions about protecting palliative care services from fraud, waste and abuse.
The word “interdisciplinary” is encouraging. Currently, Medicare only reimburses for physician and licensed independent practitioner services when it comes to palliative care. This RFI could indicate that CMS may be open to expanding payment to cover the full range of services that effective palliative care requires, such as nurses, chaplains and social workers.
In the ESRD proposal, CMS posed questions about palliative dialysis. For ESRD, Medicare pays a single bundled amount for dialysis treatments furnished in facilities or at home. This payment is intended to cover all renal dialysis services as defined in the statute.
“Dialysis is life-sustaining but not curative,” CMS indicated in the ESRD RFI. “While it may be furnished consistent with palliative goals of care, current Medicare policy does not distinguish between maintenance dialysis and dialysis furnished in a comfort-focused context. As a result, payment policy does not explicitly account for palliative care objectives within ESRD treatment.”
The RFI also cited low rates of hospice utilization among ESRD patients, in which fears over losing access to dialysis are often a contributing factor.
CMS asked questions related to what patient eligibility should look like, as well as care delivery and settings, payment policy and program integrity safeguards.
The agency presented an extensive list of queries. Here are a handful of examples:
What objective and auditable criteria should be used to identify beneficiaries who are appropriate for palliative dialysis?
Should eligibility be limited based on indicators such as serious illness, frailty, functional impairment or limited prognosis?
What are the primary barriers to delivering palliative dialysis in home- or community-based settings?
Could access to staff-assisted home dialysis improve the experience for those receiving palliative dialysis?
What services are necessary to support safe and effective home-based dialysis (for example, equipment setup, cannulation assistance and monitoring)?
What factors affect the feasibility of integrating hospice and dialysis services, including care planning, payment and provider roles?
To what extent are palliative renal dialysis services currently encompassed within the ESRD Prospective Payment System bundled payment?
Are there services or supports that are not adequately reflected in current payment?
What safeguards are necessary to ensure appropriate targeting and prevent overutilization?
What this actually means for palliative care in the United States remains to be seen. After all, CMS has yet to take any real action here. It clarified existing avenues to palliative care via home health and asked some questions that could inform future policy.
Nevertheless, these developments are significant. They signal that CMS is thinking about ways to ease and expand access to palliative care for patients in need, specifically using an interdisciplinary, community-based model. I, for one, am excited to see what happens next.
How about you? How do you think CMS should handle palliative care policy in the long term?