California is Developing a New Palliative Care Benefit: What You Need to Know

By Stacie Sinclair, CAPC Policy Associate 

California may be on the cusp of greatly enhancing access to palliative care for its Medicaid beneficiaries. The California Department of Health Care Services (DHCS), along with several local palliative care champions (notably the Coalition for Compassionate Care of California (CCCC) and the California HealthCare Foundation (CHCF)) are several months into the process of developing guidance for certain Medi-Cal (California’s Medicaid program) contracted providers on the implementation of SB 1004. So what do you need to know about SB 1004?

It Establishes a Palliative Care Benefit for Medi-Cal Managed Care Plans Across the State

Enacted in 2014, SB 1004 requires Medi-Cal managed care plans to include a palliative care benefit.  The providers of these palliative care services shall include licensed hospice and home health agencies who are licensed to provide hospice care. Eligible beneficiaries will be able to access these services concurrently with disease-directed treatment, regardless of their prognosis. The legislation also gives the DHCS latitude to determine whether additional services will be covered under this benefit.

The Implementation Process Is Designed to Include Stakeholder Input

Per the law, the DHCS is required to: (1) Establish standards regarding palliative care services; (2) Determine the eligibility criteria for beneficiaries; and (3) Develop and provide technical assistance to the Medi-Cal managed care plans to ensure the delivery of palliative care services. The law also specifies that the DHCS should consult with interested stakeholders as it moves forward with implementation. Since February 2015, the DHCS has held two public meetings (one in person, one virtual) and posted all the materials from these meetings on its Palliative Care and SB 1004 website. In addition to CCCC and CHCF, key stakeholders have included the state health plans, the University of California San Francisco and individual representatives from a variety of health organizations around the state. The DHCS also created a dedicated email address for interested individuals to submit their comments or questions at any time (SB1004@dhcs.ca.gov).

Progress to Date

Over the past several months, the DHCS has conducted background research to refine its understanding of palliative care and begin developing the standards for this benefit. Along with its stakeholders, the Department identified the following primary considerations for the implementation of SB 1004:

  1. Beneficiary eligibility
  2. Composition of the benefit package
  3. Type of payment model/payment options and the degree of flexibility the DHCS will allow
  4. Outcome measures

On May 8, 2015, CCCC, in collaboration with expert providers, submitted to the DHCS a series of recommendations for the implementation of SB 1004 that address these key considerations. Guiding the recommendations were three overarching themes, developed in recognition of factors in the state that might serve as a barrier to successful implementation: (1) The system must be flexible; (2) Workforce shortages must be addressed; and (3) Quality outcomes must be defined and tracked.

Next Steps

The DHCS will hold the next public stakeholder meeting on June 5, 2015. Interested parties can either attend in person or telephonically (visit the DHCS Palliative Care website for more information). Currently there is no formal timetable for the introduction of the benefit, although the contracted health insurance plans are making preparations so that they will be able to implement any changes as soon as possible. In its recommendations, the CCCC suggested a multi-year rollout – particularly for plans which have not provided palliative care services in the past – which might allow for a smoother transition and the opportunity to address any challenges through a pilot and assessment phase.

As implementation proceeds, how the DHCS responds to the four key considerations will have implications for whether this benefit could be a game-changer in the availability of palliative care at the state level. The DHCS is responsible for ensuring that the delivery of palliative care services remains cost neutral to the state’s General Fund, so this will certainly be a factor as the Department determines how it will identify the right beneficiaries and match them to the most appropriate services. To learn more about the implementation of SB 1004 and other palliative care activities in California, visit the DHCS Palliative Care and SB 1004 website, or the Coalition for Compassionate Care of California website.

 

Comments

  1. Proud to be in California. We are starting with the population in our state with the greatest unmet need by committing to community based palliative care. Hoping to replace volume based payment models to align payer and providers around person-centered definitions with value based payment models. Investing in the future of incentives that deliver well being and improved experience for people with serious illness and their families. Oh yeah…great palliative care can actually extend survival as well as preventing enormous waste.

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