Did Palliative Care Spend a Decade on the Wrong Problem?

I think this might be true, but I invite your commentary and reactions: The move toward “everyone with serious illness needs specialist palliative care” consumed a decade of oxygen and money while the harder, more consequential work—how to pay for specialist, team-based palliative care as defined by NQF/NCP standards—remained nonexistent.

Let’s test it. Preferably before it's too late.

What “specialist, team-based” actually means

We’re not talking about generic “comfort care.” The National Quality Forum framework and the National Consensus Project (NCP) guidelines lay out an interdisciplinary model with eight domains: structures/processes, physical, psychological, social, spiritual, cultural, care of the imminently dying, and ethical/legal. That implies physicians, APRNs/PAs, nurses, social work, chaplaincy, pharmacy, and more—delivering coordinated care across settings.

Those standards are real. They also aren’t cheap.

• NCP 4th ed. explicitly positions palliative care as interdisciplinary, person- and family-centered, across the trajectory of serious illness and settings. That is a team—not a lone consult.
• Hospital penetration rose over two decades, but comprehensive staffing remains uneven; fewer than half of programs report all core disciplines. That is a financing problem masquerading as an operations problem.

The universalist slogan vs. scarce teams

“Everyone with serious illness needs specialist palliative care” sounds inclusive. It also ignores workforce math and payment architecture.

• Workforce: In 2022 there were ~8,935 board-certified HPM physicians and NPs; >90% clustered in metro areas, with disproportional gaps in high-deprivation communities. That’s not “everyone.”
• Broader projections show U.S. physician shortages through 2037, with nonmetro areas hit harder—making specialist access even more constrained.
• Even where hospital programs exist (83.6% of 50+ bed hospitals; >96% of 300+ beds), rural and for-profit hospitals lag significantly (34.5% and 49.0% respectively). Again, not “everyone.” Structural urbanism much?

If the denominator can’t be served, the universalist promise is bad policy. It dilutes the real question: how to fund teams where they’re needed most and pay them to do team-based work per NQF/NCP.

Ten years of messaging vs. payment mechanics

While the field rallied around legitimacy, the federal payment experiments tiptoe around palliative care:

• CMS’s MA “hospice carve‑in” (VBID) attempted concurrent and transitional models but ended in 2024 citing operational challenges and low utilization of palliative/transitional benefits. After it ended, no Medicare model explicitly includes palliative care. That’s the vacuum.
• TEAM (Transforming Episode Accountability Model) will be mandatory for selected hospitals in 2026, with post‑acute coordination requirements. Useful as a model, but not a palliative care benefit (yet?); it references connecting patients appropriately, not paying for interdisciplinary palliative teams per NQF standards.
• The most serious, team‑supportive proposal—AAHPM’s PACSSI (for which I served on the development work group)—earned PTAC recommendation for limited testing…in 2018. It has not become a national benefit.

Meanwhile, real-world financing still leans on fee‑for‑service professional billing, patchwork contracts with MA/commercial plans, and philanthropy; CAPC’s own guidance focuses on optimizing coding, care management codes, and payer contracting because there’s no coherent national mechanism to pay the team.

The payment architecture we keep dodging

The NQF/NCP model assumes interdisciplinary work that fee‑for‑service undervalues. Payment needs to match the work:

• Fee‑for‑service pays individuals for discrete services, not interdisciplinary coordination; it incentivizes volume, not outcomes.
• Care management codes (e.g., PCM 99424–99427) help but primarily finance non‑face‑to‑face management for a single condition and do not fund social work, chaplaincy, or team infrastructure at scale. They are partial fixes with complex associated bureaucracy, not team funding.
• Without a per‑member‑per‑month (or episode/capitated) payment that explicitly includes non-billing team roles and quality metrics aligned to NQF domains, programs either under‑staff or cross‑subsidize disciplines. That erodes fidelity to the model. Do I have thoughts on how to do this? You bet I do. Keep reading to find a linked Technical Brief, below.

There are state‑level glimmers (Medicaid palliative benefits or managed care mandates in some states), and payers experimenting with incentives tied to hospital palliative care quality. But this is patchwork and geography‑dependent; it does not constitute a national standard.

Equity and environmental justice: the costs of getting the architecture wrong

Here’s the even more uncomfortable part:

1. Access inequity: Specialist teams cluster in metro and high‑SES areas. Patients in low‑SES and rural regions—who bear disproportionate serious illness burdens—are least likely to get specialty teams. Payment inattention perpetuates this.
2. Ecological impact: Health care is 4.4–5% of global GHG emissions; U.S. health care has the largest footprint. Fragmented, episodic care and avoidable hospital utilization (the outcome of weak palliative architecture) increases emissions—travel, energy, supply chain. Better financed, proactive, home‑based palliative care could reduce avoidable high‑emissions utilization.
3. Justice: Communities already burdened by environmental exposures also face under‑resourced specialty palliative services. When payment fails to support teams that address symptom management, caregiver support, and social needs, we amplify inequities and ecological costs. Payment reform is a justice intervention.

Providence’s system‑level decarbonization scorecard shows health systems can reduce footprints with targeted metrics; aligning payment to palliative teams that prevent unnecessary acute care is a complementary lever.

What an informed skeptic will say—and how I’d respond

• “Universalist framing built legitimacy and demand.” True; it moved palliative care into guidelines for cancer, heart failure, dementia, etc. But legitimacy without financing yields brittle programs dependent on heroic staff and unstable subsidy. Show me a payment pathway that pays the team to meet those guidelines at scale.
• “Workforce is the binding constraint, not payment.” They’re linked. If the model pays only billable clinicians, teams shed social work/chaplaincy, burn out grows, pipeline shrinks, and rural coverage collapses. Payment that funds full teams and recognizes coordination time is workforce policy.
• “CMS is moving toward value; patience.” Value models that don’t explicitly include palliative care or fund interdisciplinary services produce lukewarm uptake. VBID’s hospice component ending with “low utilization of palliative care” is a cautionary tale: absent clear benefits design and funding flows, serious‑illness services don’t materialize. Health systems appear to be scaling back VBC commitments, citing policy instability—including ACA-derived funding delays, removal of incentives, and model shutdowns—as key barriers.
• "Come on, Kyle, this is all a straw person argument, we never meant that everyone should see specialists." Fair.

A short timeline of the detour

• 2006: NQF framework and preferred practices for palliative/hospice care established—clear interdisciplinary standards. Financing left for “later.”
• 2018: NCP 4th ed. reaffirms interdisciplinary, across settings; still no federal payment that funds the full team.
• 2018: AAHPM’s PACSSI earns PTAC recommendation for limited testing; no broad implementation.
• 2021–2024: MA hospice carve‑in (VBID) pilots; ends in 2024 with uneven participation and low palliative utilization.
• 2025: CMS creates TEAM—episode accountability after surgery; not a palliative benefit. Still no national payment mechanism for interdisciplinary palliative care teams.

If the last decade prioritized “everyone” messaging over payment mechanics, this is what the landscape looks like.

Re‑centering the work: pay for teams, measure what matters

Here’s the pivot I’d argue for:

1. Create a national serious‑illness care management benefit paying a risk‑adjusted, per‑member‑per‑month rate to interdisciplinary teams (APP, pharmacist, physician, RN, social work, chaplaincy) that meet NQF/NCP structural standards. Tie payment to a parsimonious set of patient‑reported measures (Feeling Heard/Understood; Getting Help Wanted for Pain) and equity metrics.
2. Permit concurrent hospice across models with technical assistance to drive uptake. Use clear eligibility pathways and standardized identification processes to avoid the low utilization failure mode and operational barriers seen in VBID.
3. Incentivize home‑based, proactive care through model design—explicitly pay for caregiver support, social needs navigation, and after‑hours coverage—because those services reduce high‑emissions acute utilization and improve equity.
4. Fund workforce where the need is: rural/low‑SES geographies via add‑on payments and training grants, recognizing the documented maldistribution of specialists.
5. Align hospital incentives so palliative program staffing meets NQF/NCP domains; plans are already experimenting with palliative‑specific quality incentives—scale this in public programs.
6. Learn from PACSSI's roadblocks to chart the way forward.

What would change if we did this?

• Programs would hire to the model (nursing, pharmacists, spiritual care, social work), not just billable prescribers.
• Rural and marginalized communities would stop being afterthoughts.
• Hospitals would see fewer avoidable admissions and ED revisits; health systems would shrink their climate footprint via reduced high‑emissions utilization.
• Clinician burnout would fall when teams have the roles and time to do the work, stabilizing the pipeline.

Operationalizing Palliative Aspirations—Payment First, Equity by Design

Palliative Care has been challenged to raise its game: publish clear standards, make meaningful data accessible, foster quality-based competition, and embrace our authentic brand. Those aspirations remain essential so let’s bring this back to the heart of the rant: payment. For ten years, we chased the idea that “everyone with serious illness needs specialist palliative care” while tinkering on the harder question—how do we actually pay for the teams that deliver NQF/NCP-level care? Here’s how we fix that, and yes, equity and antiracism belong in the payment rules, not as window dressing.

Standards → Make payment the gatekeeper

If you want enhanced dollars, you meet the standard. That means the full interdisciplinary team—nurses, pharmacists, physicians, spiritual care, and social workers—plus cultural and structural competence baked in. Interpreter services? Check. Community partnerships? Check. Antiracism training? Mandatory. No shortcuts, no “consult-only” programs skating by.

Data → Measures that matter and move money

Forget process fluff. Tie payment to a Core Set: Feeling Heard & Understood, Getting Help Wanted for Pain, and Hospice ≥3 days before death. Report by race, language, rural/urban, and SDI quintile. If gaps are bigger than 15%, payment gets held until you fix it. Publish it all on a Scorecard so no one can hide.

The benefit we could have built a decade ago

Call it the Serious Illness Care Management Benefit (SICMB). Risk-adjusted PMPMs for certified teams. Pharmacists, social work, and chaplaincy funded—not begged for. Concurrent hospice allowed by default. Standardized eligibility triggers so plans can’t cherry-pick. VBID and PACSSI taught us what happens when we don’t do this. Let’s learn the lesson.

Equity-forward adjustments (still about money)

Want to serve high-SDI ZIPs? Close subgroup gaps? You get bonus PMPMs. Equity isn’t a tagline—it’s a payment lever. And yes, publish those results so communities can see who’s walking the talk.

Governance that keeps us honest

Create an Equity Advisory Panel—community voices, social work, antiracism experts—to set thresholds and review corrective actions. Equity stays in the payment DNA, not bolted on after the fact.

We spent a decade polishing the message while leaving the financing skeleton bare. VBID’s collapse, PACSSI’s stall, and the missing national benefit prove it. If we want real NQF/NCP care where it’s needed most, we have to pay for it—and pay for it right. That’s the work. Everything else is noise.

Your turn: pressure‑testing the hypothesis

• If you disagree: Where do you see evidence that the “everyone” push produced sustainable financing for NQF/NCP‑defined teams?
• If you agree: Which levers (CMS demo, state Medicaid, MA benefit design, large commercial payer pilots) can move fastest?
• What would you add to the core measure set to prevent gaming and ensure fidelity to team‑based care?
• Where are the environmental and equity co‑benefits most compelling—and how should we quantify them in model design?

I’m ready for disagreement. But if this hypothesis is even partly right, we have to stop promising “everyone” something we refuse to pay for—and build the architecture that funds the teams serious illness care requires.

P.S. Want to see the nitty-gritty before you answer my questions? Here you go!