Barriers to Care
State lawmakers address palliative care in state statute 765.102 of Title XLIV (Civil Rights). Florida state statute 765.102 defines palliative care as “ ... the comprehensive management of the physical, psychological, social, spiritual, and existential needs of patients.” The law also establishes a list of 11 requirements of what palliative care must provide.
In statue 765.102, the state recognizes, “the need for all health care professionals to rapidly increase their understanding of end-of-life and palliative care." The legislature falls short in monetary support of palliative care programs or establishing state-funding for institutions teaching palliative care.
In March of 2017, the Palliative Care and Hospice Education and Training Act (PCHETA) was introduced on the floor of the United States House of Representatives. PCHETA is an amendment to the Public Health Service Act. PCHETA as currently written would, “ ... require the Department of Health and Human Services (HHS) to provide support for Palliative Care and Hospice Education Centers.”
The bill also provides HHS with four directives, “HHS must: (1) provide Palliative Medicine and Hospice Academic Career Awards to individuals to promote their career development; (2) support entities that operate a Palliative Care and Hospice Education Center; (3) support advanced practice nurses, social workers, physician assistants, pharmacists, chaplains, or students of psychology pursuing an advanced degree in palliative care or related fields; and (4) award grants to schools of nursing, health care facilities, or programs leading to certification as a nurse assistant to train individuals in providing palliative care."
On July 23rd, 2018 the House passed PCHETA, and the bill was moved to Senate a day later. In the United States Senate, PCHETA was introduced as bill S.693. The two bills are identical in language. S.693 remains under revision by the Senate Committee on Health, Education, Labor, and Pensions, nearly a year following the House’s passage of the bill.
To complicate matters, the Association of American Physicians and Surgeons (AASP) wrote a letter to Senators asking them to vote no on PCHETA, as the AASP saw the bill as, “ ... improper to dedicate $100 million in additional taxpayer dollars to persuade patients to forgo treatment that might prolong life.” As well as providing advice as to what Congress should do instead, “... Congress should consider rolling back existing policies that perpetuate a culture of hastening death at the expense of increasing patient access to life-saving or potentially curative treatment.”
This cavalier attitude towards prolonging life at all costs attributes to all the things palliative care is attempting to prevent. It also attempts to propagate the lie that palliative care is giving up on patients.
Logo for the bill
Infographic from the CAPC
Lack of a payment model
Traditional healthcare models in the United States function much the same as any other business. If one needs to see a doctor, most often one will be able to see one as long as one can pay for services rendered. Private Medical Insurence companies, Medicare, and Medicaid help those they cover to pay for healthcare services and tests. State legislatures manage Medicare and Medicaid and create the rules on who qualifies for what and when are different depending on the state.
The issue here is how palliative care services are billed and paid for when healthcare providers take no medical tests or actions. Currently, healthcare providers are limited in the number of hours they charge insurance companies for their consultation services. Since palliative care is consultation driven healthcare providers find themselves in funding or payment deficit even if they have billed for the maximum number of hours possible.
How could this change? Most likely, state legislatures. In Florida, restructuring the current insurance payment model is needed. The new model could establish a new billing system that would adequately fund palliative care teams. State lawmakers have the opportunity to act as arbitrators in this situation and make a compromise that benefits all parties.