Proceedings of a Workshop—in Brief

Convened November 6, 2025

Advancing Value-Based Payment for People with Serious Illness to Align Financing with Quality

Introduction

The U.S. health care system's evolving transition to value-based payment presents unique challenges and opportunities for individuals with a serious illness¹ who benefit from receiving coordinated care from an interdisciplinary team. To explore these challenges and opportunities, the National Academies of Sciences, Engineering, and Medicine's (the National Academies') Roundtable on Quality Care for People with Serious Illness² held a workshop on November 6, 2025.³ The purpose of the workshop was to

• Consider the evolution of the health care financing landscape over the past five years and the impacts on health care quality, costs, and patient outcomes for people with serious illness.
• Examine the rapid growth and variation among Medicare Advantage (MA) plans and the impact on the serious illness population.
• Explore experiences with Medicare's alternative payment model demonstrations as well as palliative care mandates in Medicaid programs.
• Consider potential strategies and policies to support the transition from fee-for-service to value-based care to ensure high quality care for all people living with a serious illness.

Phillip Rodgers, University of Michigan, welcomed participants to the workshop and provided background information on the topic. "Serious illness touches all of our lives," he said, whether as professionals, family members, or individuals. Advances in health care have led to people living longer, and while this has been a success, the health care system is now faced with the challenge of caring for a larger group of people with more complex illnesses. The financing of serious illness care has also evolved over the last 40 years. Major events have included the creation of the Medicare Hospice Benefit in 1983, the beginning of MA plans in 2003, and the passage of the Affordable Care Act and establishment

of the Centers for Medicare and Medicaid Innovation (CMMI) in 2010. In 2015, the Medicare Modernization and CHIP Reauthorization Act was enacted; one result was the establishment of the Quality Payment Program, which facilitates Alternative Payment Models and the Merit-Based Incentive Payment System in Medicare. Other relevant changes in Medicare have included the CMMI Medicare Care Choices model in 2016, the CMMI Value-Based Insurance Design model in 2017, and the availability of supplemental benefits through MA plans in 2019. Supplemental benefits—such as expanded home health and home care services—are critical for people with serious illness, said Rodgers. As of 2023, MA covered half of all Medicare beneficiaries, representing a "true tipping point," he said.

The first workshop session featured speakers who have lived experience with serious illness as patients, caregivers, or health care team members. The next sessions covered issues related to the Medicare Hospice Benefit, MA, and palliative and home care. The final session focused on the progress toward a value-based payment system to improve the care of people with serious illness. Terminology used by individual speakers throughout this summary will be defined if the speaker provided that information.⁴

LIVED EXPERIENCES: WHY PAYMENT MODELS MATTER

To understand the impact of payment models on real people living with serious illness, workshop participants heard from two people about their lived experiences. Katie Adams, who is living with amyotrophic lateral sclerosis (ALS), shared her perspective through a statement read by her mother. Adams was diagnosed with ALS just over three years ago, and MA was her only option for insurance coverage at the time. These plans are intended to cover anything Medicare covers, said Adams, but from her work as an occupational therapist, she knew this was "very far from the truth." She was soon denied coverage for a power wheelchair and was told she should get a standard wheelchair instead. This substitution would be inadequate given the normal progression of ALS to full paralysis, said Adams. She began a year-long process that ultimately resulted in approval, but she said, "anyone who is living with a serious illness doesn't have the time or energy" to deal with appealing a denied claim. Adams told participants about her experience testifying in front of the Senate Health Committee about the necessity of allowing people with serious illness to receive original Medicare and purchase Medigap coverage. She expected it to take years for changes to be implemented, but soon after the committee gave unanimous approval, and she was able to switch to original Medicare with Medigap. This was a significant improvement, she said, although living with a serious illness has still not been easy. Adams was recently hospitalized twice and had several bad experiences. For instance, emergency responders to her home couldn't figure out how to move her, she spent 48 hours on a gurney in a hospital hallway, and her shortness of breath made it impossible for her to advocate for her own care. After leaving the hospital, she was still unwell but refused to go back because of these experiences. She and her family tried to reach providers for advice, but they could only send non-urgent messages through the patient portal. Adams explored palliative care options in the hopes of getting help but found that she could only contact someone during normal business hours. The difficulty of getting quality care in a timely manner is a big challenge for people living with serious illnesses. ALS "has taken so much from us, and it shouldn't be this hard to access quality care," she said. The health care system is "seriously flawed," and we have to do better, she added.

Deborah Laxson, former member of the Minnesota Palliative Care Advisory Council, told workshop participants about her experiences as a caregiver to her son Christopher and her husband Bill. Christopher was diagnosed with adult-onset Ewing sarcoma in 2023 after 187 days of thinking that his pain was due to a sports injury. Christopher began receiving treatments to shrink and contain the tumor, and surgical removal was deemed not possible. His daughter was a sophomore in high school at the time of diagnosis, and Christopher set a goal of making it to her high school graduation. He was a "data guy," said Laxson, and he kept track of everything—treatments, tests, communications, and handoffs. There were numerous times when the "ball was dropped" in terms of information sharing and insurance approvals. Christopher would get on the phone and work his way up the chains of command on the provider and payer sides until he found two people who were willing to talk, and he would facilitate a conference call to figure out the issue. These issues took up time; there was a cumulative delay of about a month in getting approvals for care, and at one point, Christopher missed out on joining a clinical study because of a communication breakdown. Christopher used to say that he "shouldn't have to do this" as the patient, but he felt like it was the only way that he would receive treatment. Christopher

died on January 15, 2025, 128 days before his daughter's graduation.

Laxson's husband Bill was diagnosed in 2008 with multiple myeloma in the emergency room, going from "normal to terminal in four hours." He underwent intravenous chemo, a stem cell transplant, and oral chemo. Bill's goal in treatment was to gain more time, said Laxson, but unfortunately, the extended time was not quality time. His treatment rendered him immunocompromised, which impacted his ability to go out, attend events, or be near his new granddaughter. "Extra time is not always usable time," she said. Bill died in February 2011 after 10 days in a medically-induced coma in the Intensive Care Unit (ICU).

"Christopher and Bill don't get a do-over," said Laxson, but "today we get an opportunity to do better." What would have helped Christopher, Bill, their providers, and their family? Palliative care was not an option in 2008 when Bill was sick, said Laxson, but it would have been helpful. She explained that palliative care is specialized, team-based care that focuses on improving the quality of life of the ill person and their family. When Bill was sick, Laxson recalled that she was sitting by herself in the ICU acting as his health care agent; for the first time in her life, she couldn't talk to the person she most needed to talk to. She said she could have used someone who would have a longer conversation about treatments, procedures, and timelines—and could have used more support in general. When Christopher was sick, palliative care was helpful with some aspects of care. However, he didn't need more help with pain and symptom management. Instead, he needed help with the "pain and suffering resulting from the administrative burden." Laxson urged workshop participants to consider all aspects of payment for serious illness, including the administrative burden on patients and the missed opportunities and delays in treatment that can be caused by issues with payment.

Serious Illness Care Team Perspectives

After hearing the perspective of patients and families, workshop participants heard from health care professionals who work directly with patients with serious illness. Kesha Wall Graham, an outpatient clinical social worker at the Medical University of South Carolina, spoke about the benefits and drawbacks of MA plans. MA plans vary, she said, but in general they offer Medicare A and B coverage, drug coverage, low premiums, and out-of-pocket caps, as well as dental, vision, and hearing coverage. MA plans may also include perks, such as gym memberships, cards for groceries, help with transportation, and post-hospitalization meal delivery plans. These plans "sound really good to people when they're doing well," said Graham. However, there are several disadvantages to some MA plans, she noted. For instance, for sub-acute rehab services, patients need medical necessity approvals and often face in-network restrictions. For home health care, there are prior authorization requirements, in-network stipulations, and co-pays. Patients enrolled in MA are not eligible for hospice care or programs such as Guiding an Improved Dementia Experience (GUIDE). Even some of the perks don't stretch as far as they previously did; a patient with serious illness recently told Graham, "Yes, I receive a meal card, but $85 is like $45 these days." Drug coverage under MA can also be problematic, said Graham. Some plans cover medications only if they are prescribed by a doctor, not by a nurse practitioner or physician assistant. Some plans require prior authorization for medication coverage, which can be a particular problem when patients have Friday appointments, leaving people to suffer on the weekends while waiting for pain medications. MA plans can vary widely in terms of benefits, and it can be difficult for patients to know what is covered. Coverage may even change during the course of the year. One patient told Graham, "There was a mid-year formulary change that affected my inhalers…and now I can't afford them. My primary doctor gave me some samples to keep from going to the hospital this past weekend." People on MA are often on a fixed income and don't have the ability to deal with changes in cost, said Graham. In general, she noted, MA plans appeal to younger patients with disabilities who are unable to obtain a Medigap plan. Based on her experiences helping patients with serious illness, Graham observed that MA plans are often not beneficial for individuals who deal with frequent hospitalizations, require many specialists, have high drug costs, or need to travel for out-of-network tertiary care.

Corita Grudzen, an emergency medicine physician at Memorial Sloan Kettering Cancer Center, spoke about emergency care for patients with serious illness. The emergency department (ED), she said, is the one place where there are no barriers to access. Under federal law, anyone can walk in and receive treatment until medically stable. However, said Grudzen, the ED approach to care can also be problematic because patients may not be seen as individuals

with individual needs and goals. There is a default pathway for patients in the ED toward life-sustaining therapy—or, as Grudzen put it, "pedal to the metal, resuscitate, don't ask questions." She shared an example from her work in which a patient with advanced ovarian cancer came to the ED with shortness of breath and hypoxia. She expressed that she did not want to be resuscitated or intubated, but as her conditioned worsened, her family was distressed and begged for intubation. She was intubated and admitted to the ICU but did not receive morphine or other treatment for her symptoms. This outcome was not reflective of quality care, said Grudzen.

Quality in emergency care is measured in a few different ways, said Grudzen. Patient mortality—measured either at 30 days from admission or at discharge—is a key metric for many hospitals. At the same time, there are ways to avoid having a patient's death count toward this measure, including when a patient is under observation status or if they are moved to hospice status. A team at Brigham and Women's Hospital developed a pathway for this approach, which Grudzen said was a "win-win": patients can receive the care they need to manage their symptoms, providers feel like they are doing the "right thing," and the hospital's quality metrics are not impacted negatively. ED providers often want to admit patients because they know they will be safer in the hospital when compared to the "great unknown" of sending them home. However, said Grudzen, there are ways to send patients home from the ED and keep them safe, but with lower costs compared to hospitalization. Examples of such programs include a community paramedic-led transition intervention, which provides 30 days of coaching intervention for patients and caregivers and nurse-led telephonic care, which provides training and structured assessments and care plans for patients and caregivers. Unfortunately, said Grudzen, regulatory barriers and reimbursement issues prevent programs like these from being widely implemented. There is "lots of work to do," she said, to improve the quality of care for patients with serious illness while lowering costs.

Panel Discussion

Following the presentations, Rodgers asked panelists questions about their priorities and suggestions for stakeholders. Key messages included the following:

• Improving understanding among patients and their families of what palliative care is, how it can benefit patients across the care continuum for serious illness, and how it differs from hospice care, which incorporates palliative care at the end of life. (Laxson).
• Including a case manager in the palliative care team to help patients and families navigate health insurance payments and to advocate on their behalf (Laxson).
• Promoting patient-oriented approaches rather than insurance motivated (Adams).
• Removing barriers that prevent family and health care team members from helping patients navigate systems (e.g., Social Security, insurance companies) (Graham).
• Improving provider and system understanding of the actual costs of various care models (Grudzen).
• Tracking the timing and success of handoffs among providers and payers as a metric of quality care (Laxson).
• Developing standards and best practices for emergency treatment of patients with serious illness, similar to the movement in geriatric emergency medicine (Grudzen).

MEDICARE HOSPICE BENEFIT⁵

The Medicare hospice benefit is the most durable payment for serious illness care in the United States, said Rodgers. Over half of all Medicare beneficiaries will receive hospice care at some point, and the hospice benefit is how most people receive palliative care, even though palliative care can be beneficial to patients throughout the continuum of serious illness care. In this session, speakers explored the evidence, history, and current regulatory context of the Medicare hospice benefit, including its impact on palliative care and care at home. In addition, speakers discussed alternative payment model demonstrations, such as the Medicare Care Choices model and Value-Based Insurance Design (VBID). Joseph Shega, American Geriatrics Society and VITAS Healthcare, moderated the session and provided opening remarks.

"Hospice is about living," said Shega. The Medicare hospice benefit allows patients, their families, and their providers to individualize the care plan to focus on what matters most. Death will always be hard, he said, but hospice is a unique model of care that aims to make this transition "as good as it can be." Every patient's needs are different; hospice generally includes an interdisciplinary team of hospice professionals, continuous care either at home or another setting, home

medical equipment, medication, and bereavement support. Caregivers might be able to take advantage of respite care, which allows them to take a break while someone else cares for the patient. Shega said that hospice care has positive benefits for patients, family members, and caregivers. For instance, patients have reported better pain control and less physical and emotional distress, families have said that patients' end-of-life wishes were respected and care was excellent, and caregivers experienced lowered risk of post-traumatic stress disorder and of prolonged grief when the patient died at home rather than in a hospital.

Advantages and Challenges of the Hospice Benefit

Steven Landers, National Alliance for Care at Home, spoke about hospice care from the perspective of the National Alliance for Care at Home, a diverse coalition of hospice, palliative care, home health, and community-based care organizations. Hospice care is a "national treasure," said Landers, and is central to meeting Medicare's founding mission of mitigating unintended suffering. In contrast to standard health care in the United States, which is often fragmented and siloed, hospice care is interdisciplinary, team-based care focused on people's individual needs. Hospice is beloved by families, he said, and research demonstrates that it lowers the incidence of death in inpatient and intensive care settings, improves quality of life, and reduces symptom burden. Spending for Medicare hospice has grown in recent years, but it remains a small percentage of overall Medicare spending; Landers said hospice care is "by no means a runaway cost center" in the health system. Landers offered his ideas for improving the Medicare hospice benefit. There is a need to confront fraud, waste, and abuse, he said, particularly in non-hospice spending for people receiving hospice care. There are challenges involving access to hospice and lack of coverage for concurrent care; Landers said he has worked on an initiative to shift people into palliative and hospice care earlier, which improves outcomes and lowers overall costs. Other potential areas for reform, he said, include improving access for patients who need dialysis during end-of-life care, developing a home-based respite model, and implementing innovative payment models.

Ethan McChesney, National Partnership for Healthcare and Hospice Innovation, agreed with Landers that there is a need to address fraud and abuse in the Medicare hospice benefit. The benefit structure has remained essentially unchanged since it was created in the 1980s, said McChesney, and there is a risk that hospice will be left behind as health care shifts from fee-for-service to value-based payment. The current payment structure—in which a provider receives an approximately $180 per diem regardless of the needs of the patient or what care was provided—has led to bad actors taking advantage of the program. Reported fraud and abuse in this area has cast a "negative veil" over the entire community, he said, and there is growing competition from organizations that provide "hospice-lite" or engage in fraudulent behavior. As Landers noted, there are concerns about non-hospice care being billed to Parts B and D; hospice is a holistic model of care and thus there shouldn't be many non-hospice expenditures. At the same time, he noted, there are misdirected and misguided audits of responsible and well-meaning providers. Another issue with the Medicare hospice benefit is that there is no link between the quality of care provided and the payment received. While hospice reduces end-of-life cost, providers do not receive a share of the cost savings. There are tools available to measure quality (e.g., the Hospice Care Index), but there is no tie-in between these metrics and reimbursement. With Medicare facing solvency pressures, the hospice benefit could be on the chopping block despite its demonstrated benefits to both health outcomes and costs, said McChesney. Given these issues, he suggested that the core parts of the hospice benefit—holistic care, person-centered values, patient and family autonomy, and wraparound supports—ought to be preserved, while changes are made to enhance and improve the structure of the benefit. Potential targeted improvements suggested by McChesney include

• Payment models that cover upstream palliative care to enable a true continuum of serious illness care,
• Seamless patient experience that provides continuity from aggressive treatment through end-of-life,
• Diversified revenue to provide stability for non-profit providers,
• Greater ability for hospices to manage whole-patient total cost of care, and
• Reducing the number of individuals discharged from hospice alive, given the intention of the program to provide end-of-life care, and avoiding late or burdensome transitions to hospice.

Innovations in Medicare Hospice Benefit

As other speakers have noted, there are several challenges related to the current Medicare hospice benefit, said Bethany

Snider, Everent Health; she shared a few other challenges. The reimbursement structure does not match the diversity of patients served; for example, care in rural areas can be more expensive to provide but is reimbursed at a lower rate. This creates a system in which some people in rural settings do not have access to hospice care. Another challenge, she said, is that choosing hospice care requires a patient to turn down aggressive treatments, and there is no defined concurrent care benefit available to Medicare beneficiaries who wish to continue disease-oriented therapies. There are several existing models that could be used by Medicare to provide concurrent care; many commercial plans, pediatric plans, and veterans plans pay for 12 months of hospice plus concurrent care. Due in part to these types of restrictions, half of Medicare beneficiaries who are eligible for hospice do not elect to use the benefit. These patients who decline hospice thus do not have access to palliative care, leaving serious gaps and poor-quality care. Finally, said Snider, the benefit is underutilized—the hospice benefit is designed for 180 days, but the median length of stay (MLOS) in the hospice program is around 18 days and trending down.

Innovative programs have been developed and piloted to address some of these challenges; Snider spoke about the Medicare Caring Choices model and the VBID model.

Caring Choices was developed in 2016 as an alternative payment model that allowed eligible patients to enroll in hospice while continuing with curative or aggressive interventions. Participating hospices received around 5 to 10 percent of the normal hospice reimbursement rate and were required to provide routine home care hospice services to patients. Hospice participation in the program was low, said Snider, but the outcomes for patients were positive. There were higher rates of hospice utilization, longer length of stay in the program, decreased hospitalizations and costs, and high patient and family satisfaction. Unfortunately, despite these benefits, the Caring Choices program has not been continued; Snider said policy makers ought to consider bringing it back.

The VBID model was launched in 2017 to test the integration of hospice into MA, with the goals of improving transitions of care, expanding access to palliative and concurrent care, and testing supplemental benefits. There was limited participation in VBID, and the program was challenging for health systems to implement, said Snider. One issue was that they were required to provide a palliative care benefit with an interdisciplinary team and 24/7 care, which was funded through cuts to the hospice daily rate. In theory, the earlier access to palliative care should have driven earlier transitions to hospice care because palliative care programs provide high-quality advance care planning discussions early in the disease process and drive goal concordant care, easing the earlier transition to hospice. Unfortunately, uptake of palliative care was low; at Everent Health, volume was less than 10 percent of what was projected due to a patient handoff process between the payer or care provider and the palliative care organization that failed to ensure patients were prepared for a phone call from the trusted palliative care organization. Another challenge, she said, was that palliative care varied by plan and was often an episodic and limited benefit. If a patient was not yet ready for hospice at six months, the palliative care supports and resources were taken away. "People with serious illness don't get better after six months," said Snider. VBID also offered concurrent care as an option, but utilization was low due to barriers such as prior authorization requirements and time limits. The administrative burden of VBID was enormous, said Snider, and contracting with hundreds of MA plans in one market was impractical.

Measuring Hospice Care Quality

Hospice is a unique model of care, said T.J. Christian, Abt Global, the contractor supporting the Centers for Medicare and Medicaid Services (CMS) Hospice Quality Reporting Program, so the approach to measuring hospice quality is also unique. Traditional metrics of quality care, such as patient mortality rate, do not work in hospice because the goals and objectives of care are different. The Hospice Quality Reporting Program (HQRP) at CMS uses a variety of data sources and currently reports four quality measures:

• Comprehensive Assessment at Admission: Measures whether all seven core processes were conducted at admission (e.g., patient's beliefs and values addressed, pain screenings and assessments conducted);
• Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey: Survey of recent hospice caregivers to measure their experience of care on a 1-10 scale (e.g., whether caregiver would recommend the hospice, whether timely help was received);

• Hospice Visits in the Last Days of Life: Whether a registered nurse or social worker provided care in the last few days of the patient's life; and
• Hospice Care Index: Array of 10 claims-based indicators of various aspects of hospice care (e.g., gaps in nursing visits, burdensome transitions, minutes of care per day).

There have been criticisms that not all the measures are focused on quality of care from the patient's perspective, said Christian. CMS convened a group of experts in 2024 to provide input and recommendations on what should be included in quality measures, and in October 2025, launched a new patient assessment tool called the Hospice Outcome and Patient Evaluation (HOPE). Concepts that have been discussed as important for inclusion in quality measures include timely follow-up for symptoms, relief of symptoms, medication management, chaplain visits, addressing family distress and caregiver well-being, psychosocial assessment, wound care, and attainment of patient preferences and goals. CMS began collecting HOPE information recently, said Christian, presenting a new opportunity to better understand the stories and experiences that people have in hospice and how to ensure better quality care for patients and families.

Melissa Aldridge, Icahn School of Medicine at Mount Sinai, talked about two specific challenges related to the quality of Medicare hospice care: hospice aggregate caps and per diem reimbursement. The hospice aggregate cap is Medicare's primary means of cost containment, said Aldridge. Broadly speaking, a hospice's aggregate cap is calculated by taking a fixed amount (about $34,000 in 2025) and multiplying it by the number of hospice patients cared for by that hospice during that year; this number is compared to the total reimbursements Medicare has paid the hospice in that year. If the total reimbursements from Medicare are greater than the hospice's aggregate cap value, the hospice must pay back to Medicare the difference. This negatively impacts hospices with long lengths of stay, said Aldridge. While the median length of stay has remained steady around 18 days, there is an increasing proportion of people with long stays. The patients with the longest average length of time in hospice are those with neurological conditions; this is primarily driven by people with dementia who are accessing hospice care in increasing numbers. The percentage of hospices exceeding the cap is increasing every year, said Aldridge, from 16.3 percent in 2018 to 22.6 percent in 2022. To avoid hitting the cap, hospices may choose to disenroll patients who have been receiving hospice for long periods of time. Disenrollment is "very concerning," she said, because people who are disenrolled have higher health care utilization, more ED visits, more hospitalizations, and more burdensome transitions. This is concerning from the perspective of both quality and finances; the major cost savings of hospice come in the final weeks of life, but these savings are not realized if patients are disenrolled in order to avoid the cap. Research suggests that hospices approaching the cap are only about 6 percent more likely to disenroll patients, but Aldridge said this may become a bigger issue over time as more hospices hit the cap each year and financial incentives become stronger.

The second challenge related to the hospice benefit is the per diem payment structure. As McChesney noted, hospices get paid by the day regardless of the care they provide. This incentivizes fewer visits, particularly fewer visits by skilled staff, fewer visits to rural areas, and fewer visits by chaplains, therapists, and other ancillary caregivers. As some patients are staying in hospice for increasingly long periods of time, said Aldridge, it is important to look at the care they are receiving throughout their care trajectory. There is a need to better understand the patterns of care and hospice visits to identify outliers and how deviations impact patients. The Medicare Hospice Benefit and its regulations were put in place when hospice users were a more homogenous population, said Aldridge. As the U.S. population has become more diverse—across types of patients, settings, and providers—there is a need to assess the quality of care being provided and consider reforms that could improve quality.

Panel Discussion

Shega asked panelists for their suggestions for policy changes that could improve the Medicare hospice benefit. Responses included the following:

• Creating a benefit that would serve more patients with serious illness and allow the benefit to flex to meet the needs of patients with both higher and lower acuity (severity of illness and intensity of care needs) (Snider).
• Avoiding making reforms that destroy the hospice benefit in the name of value; end-of-life care is a necessary, vital, and required part of our health care system (Snider).
• Allowing hospice patients to access concurrent care when appropriate (Landers, McChesney, Christian).

• Ensuring that payment system reforms are tested on a smaller scale before implementing them on a national scale (Landers).
• Utilizing a metrics-based approach that looks at attributes such as acuity and frailty for eligibility determinations, transitioning away from an arbitrary time-based prognosis (i.e., six months to live approach (McChesney).
• Developing a payment structure for the hospice benefit to ensure that any patient who wants to access Medicare hospice benefits can do so, regardless of location or other characteristics (Christian).
• Adapting the hospice benefit and eligibility criteria to meet the needs of patients with dementia, a fast-growing group for whom hospice has real value (Aldridge, Shega).

MEDICARE ADVANTAGE

With more than half of Medicare beneficiaries using a MA plan, said Rodgers, it is critical to understand how MA plans work and to identify opportunities to improve experiences and outcomes for individuals with serious illness through MA. Claire Ankuda, Icahn School of Medicine at Mount Sinai, began the session with data about the growth in MA plans. In 2007, 19 percent of Medicare beneficiaries were enrolled in MA plans; by 2025, this number had steadily grown to 54 percent (KFF, 2025). The variation in MA plans can be challenging to navigate, said Ankuda, but it also presents an opportunity to learn what works and what does not. MA plans differ in many ways, including the number and type of clinicians and facilities available, costs of care, and access to palliative care. For palliative care, MA providers might facilitate access to palliative care providers through their networks of hospitals and physicians, develop their own palliative care programs, or contract with existing providers. MA plans also may provide supplemental benefits such as transportation and meals. Ankuda said the workshop session would focus on the challenges and opportunities of MA programs for patients with serious illness. Speakers discussed their experiences with MA, lessons learned, and suggestions for change.

The U.S. health care system is "fragmented, broken, and letting many Americans down," said Wyatt Decker, UnitedHealth Group. The United States has the best doctors, nurses, and medical care centers, he said, but the system is designed to reward volume of care rather than quality of care. Decker noted that most stakeholders in the system are acting rationally to optimize their piece of the pie—health organizations try to maintain their modest margins, while payers try to ensure that patients get the right care at the right time but not "too much" care. Despite these efforts, the incentives in the system are misaligned and result in excess costs, excess ED visits and hospitalizations, and excess morbidity and mortality. What is needed, said Decker, are policy changes to align incentives to reward stakeholders for providing coordinated, quality care. The best example of an existing system that is aligned toward quality care, he said, is MA. Although MA has "warts and challenges," it is designed to ensure coordinated and holistic care, with payers and providers working together.

MA has been "tremendous" for serious illness innovation, said Kristofer Smith, Ruby Health and the Coalition to Transform Advanced Care. Over the past decade, MA grew significantly along with programs for serious illness; without MA, there would be far fewer patients receiving serious illness care. Smith offered his observations about what can be learned from these experiences from a business perspective. One major challenge, he said, is identifying who falls into the category of "patients with serious illness." Different organizations define it differently, in part because they are optimizing for different outcomes. For example, a business that aims for near-term cost of care savings might define the patient population narrowly in order to demonstrate savings. There is a need to better define the population; Smith suggested that "serious illness" should be defined through a combination of an advanced illness diagnosis with claims-based data focused on characteristics such as impairment and frailty. Smith suggested this would likely include patients who have a life expectancy of two to three years and whose care is persistently expensive. Smith noted that an algorithm to identify patients with serious illness must be tailored to identify those who really need serious illness care—including everybody means "taking care of nobody." Another challenge in serious illness programs, he said, is a lack of clarity in program requirements. For example, most serious illness programs require that patients have 24/7 access to care. However, he asked, what does this mean specifically—access to a provider within five minutes, ten minutes, two hours? Clearly defining these requirements is essential for all parties involved, including payers, providers, patients, and families. Smith's final observation was that serious illness programs need to be treated as the lifeline that they are for

patients. These programs are not care management or care coordination programs; they are programs that become part of the patient's care environment and cannot be easily withdrawn. Insurance companies need to understand this when making decisions about what vendors and programs to partner with; the company cannot make a "quick decision to get rid of a vendor" when the vendor is an essential part of the life of a patient with serious illness.

Snider continued the conversation by adding her perspective on challenges in the system and innovations that have worked. Everent Health has contracted with MA plans to provide a serious illness program, she said, and there have been successes and failures over the years. There were some plans that they partnered with that did not share their "North Star" value of doing what is best for patients and families; they ended these contracts despite the financial incentives. The most successful partnerships have been three-way agreements with MA and at-risk provider groups, said Snider. Their longest running program has been a three-way agreement focused on interdisciplinary palliative care that deploys resources after hours and on weekends to keep people out of the hospital. One reason why the three-way agreements have worked so well, she said, is that they use "warm handoffs." In a "cold handoff," the payer identifies patients eligible for a program and has the program do the outreach; most patients won't even answer the phone, said Snider, and uptake into the program is low. In a "warm handoff," providers with established patient relationships tell patients about the program and how it works, and patients are much more likely to enroll. Smith added that another successful method for enrolling patients is to pay them for initial visits; getting patients in the door with the promise of a $75 gift card makes it more likely that they will enroll once they have learned about the benefits of the program.

Snider agreed with Smith's earlier comment that a major challenge in this field is the difficulty in defining the population of patients with serious illness. The definition must focus on those who need high-intensity, community-based palliative care, said Snider, because the costs of caring for lower acuity patients will outpace the return on investment. Snider noted, however, that lower acuity patients should still have access to some kind of palliative care. Another challenge includes the use of financing models that treat palliative care as short term or episodic. Serious illnesses get worse over time, but the quality of life for patients and families can get better with high-quality palliative care. Once the right patient population is defined, she said, these patients need consistent and intensive care that is not "ripped out from under them" after a few months. Another challenge that needs to be addressed, said Snider, is the administrative burden for providers. Access to care is already challenging, and local community-based providers are critical for ensuring that patients have access across different geographic regions. However, the administrative requirements for participating in MA serious illness programs may be too burdensome for some providers. For example, Snider noted that her organization had to start a data analytics department because every contract required different data and different reporting. The administrative burdens of MA programs may further exacerbate the barriers to accessing high-quality care for serious illness, she said.

Palliative care for patients with serious diseases is a medical specialty that people should be entitled to when eligible, said Snider. Health professionals spend years training to be experts in the field and to receive advanced training and certifications, but palliative care is not valued in the same way as other specialties. There is a need for stakeholders to advocate for palliative care as the best practice and standard of care for its intended population—and to advocate for a payment structure that supports it. Smith agreed with Snider that "we need a payment model to support what we know works because what we know works is expensive." Until palliative care receives the recognition and investment that it merits, said Snider, people with serious illness will experience care that does not meet their needs.

Institutional Special Needs Plans

Gabriel Waterman, SCAN Health Plan, spoke with workshop participants about a specific type of MA plan—the Institutional Special Needs Plan (I-SNP). I-SNPs are designed for individuals who require long-term care in a skilled nursing facility. A related type of plan is the Institutional Equivalent Special Needs Plan (IE-SNP); these are designed for individuals who live in the community but require an institutional level of care. Many people who live in senior living communities have moved there because they have difficulty taking care of themselves, said Waterman. They have a high prevalence of chronic diseases and polypharmacy, need assistance with activities of daily living, and have mobility

issues. The traditional ambulatory health care system is not designed for this population, and the staff in senior living communities are not equipped to handle their needs. Senior living communities are "glorified hotels" in many regards, said Waterman, rather than health care providers. When a health care problem arises for a resident, the easiest solution is to call 911, which results in significant over-utilization of health care services and poor-quality health care for seniors.

SCAN Health Plan is a non-profit health plan that provides care to seniors living in senior living communities and nursing homes through I-SNPs and IE-SNPs. It is an integrated payer-provider model that employs physicians, nurse practitioners, pharmacists, therapists, and other health professionals to provide holistic, comprehensive, and aligned primary care to members. Care is closely coordinated with other providers, caregivers, and staff, and SCAN contracts with a network of specialists when necessary. Waterman noted that this model removes many of the barriers to care that have been discussed at the workshop, such as navigating systems or getting prior authorization. If a member needs a specialist appointment, he said, the SCAN team creates and approves the authorization, arranges the appointment and transportation, transmits medical records, and follows up after the appointment to close the loop. If a member ends up in the ED, SCAN is notified and the case management team contacts the ED to share information and discuss the care plan (e.g., relevant medical history or a do-not-resuscitate order). Waterman said that SCAN uses the age-friendly health systems approach of the four Ms; in every visit with a patient, the provider asks about mind, mobility, medications, and what matters most. In addition, they ask questions about metabolism (such as urination, bowel movements, and blood sugar) and patient satisfaction. This hospitality mindset is "endemic to the DNA" of SCAN, said Waterman.

SCAN has about 4,000 members in California and Arizona, and data demonstrate the value of the model; the program has reduced hospitalization rates by 35 percent, and the hospital readmission rate is less than half of the Medicare average, noted Waterman. SCAN is working to gather data to demonstrate financial savings, but Waterman expressed confidence that this model is significantly less expensive than traditional Medicare while improving quality outcomes. At the patient level, I-SNPs can be much more affordable than traditional Medicare and/or supplemental plans. Studies have found that a senior in Southern California may spend $10,000 per year on health care premiums and other costs; I-SNPs generally have a $0 premium and extremely generous supplemental benefits. These are "real savings back into the pockets of our seniors," he said. About 4.5 million people live in nursing homes or senior living communities, including memory care and assisted living, and I-SNPs and IE-SNPs present an opportunity to greatly improve the care for this population. However, current penetration of these programs is extremely low—only 118,000 individuals are currently enrolled in I-SNPs across the country. There is a lot of work to do to increase awareness and uptake of I-SNPs, but doing this work will meaningfully move the needle on improved patient outcomes and reduced costs, he said.

In response to a question from the moderator, Waterman discussed the issue of quality. MA typically uses metrics like HEDIS (Healthcare Effectiveness Data and Information Set) and Star Ratings to measure quality. While these are important, said Waterman, they are inadequate and sometimes irrelevant in the context of serious illness and end-of-life care. For example, in the case of an elderly patient with advanced Alzheimer's disease and diabetes, adherence to statin medication (SUPD, or Statin Use in Persons with Diabetes) is a key quality indicator in HEDIS, but likely not the top priority for the patient's overall well-being. SCAN defines quality by what matters most to the patient, said Waterman; in the population they serve, this often means receiving care that is concordant with their wishes and maximizing quality of life. CMS requires I-SNPs to conduct Health Risk Assessments (HRAs) to screen for health and social needs; Waterman said that instead of using this as a "box-checking exercise," they treat it as a meaningful evaluation of the quality of a patient's care. Other measures of quality used by SCAN include patient fall rate and the frequency of provider visits. Waterman emphasized that quality home-based care is expensive; clinicians may spend half of their time in the car rather than treating patients. In a fee-for-service system, the value can be difficult to see. However, home-based care is always financially viable in a value-based care system. Spending a few thousand dollars for services such as provider home visits, mobile labs, or mobile radiology will always be less expensive than an unnecessary hospitalization, he said.

SUPPORTIVE PALLIATIVE CARE AND CARE AT HOME

People with serious illness "want to receive their care where they live," said Rodgers. In this session, Matthew Gonzales, Institute for Human Caring at Providence St. Joseph Health, moderated a discussion among a diverse panel of stakeholders about challenges and innovations in palliative and home care, access to care, and financial models to support these types of care.

The Value of Supportive Care

Les Biller, The Sheri and Les Biller Family Foundation, began the discussion by describing supportive care. Supportive care, he explained, can be thought of as a "wrapper" around clinical care; it can help patients manage symptoms, provide access to information, and assist with navigating systems, peer groups, and/or support for caregivers. Supportive care is intended to deal with the whole person, said Biller. Studies demonstrate the value of supportive care for patients with cancer; it reduces ED visits, hospital admissions, readmissions, and end-of-life admissions. Biller noted that these benefits save money; for every $1 spent on supportive care, $3 are saved in lower claims costs. Unlike other cost-savings measures that restrict care, these savings are the result of expanding access to care. With value for patients and payers, asked Biller, "Why isn't supportive care more widely offered?"

In 2024, the Biller Family Foundation gathered key stakeholders to discuss and identify the obstacles to supportive cancer care; stakeholders included payers, insurers, pharmaceutical companies, employers, patient advocacy organizations, and policy makers. The group made two observations. First, they had never all been in the same room together to discuss the problem. Second, they wanted to continue to work together; a few months later the Together for Supportive Cancer Care coalition was launched with the goal of moving the needle on supportive care. One major obstacle to increasing the utilization of supportive care, said Biller, is a lack of knowledge and communication. A survey found that 90+ percent of clinicians said they offered supportive care to patients, but 61 percent of patients said they had never heard of it or didn't think they had. This communication gap is something that can be fixed, he said. The survey also found that about 15 percent of patients were currently utilizing supportive care. Biller and his colleagues analyzed the cost savings of the current scenario and the cost benefit of increasing utilization. At 15 percent of patients, the annual savings were $6.7 billion; if the proportion of people using supportive cancer care moved up to 25 percent, an additional $4.6 billion would be saved. At 50 percent, the annual savings would be over $22 billion (Together for Supportive Cancer Care, 2026).

Employers are in a unique position to advocate for supportive care, said Biller. Many employers can decide what benefits they will pay for, especially large employers who are self-insured, and employers have an interest in their employees being healthy, productive, and able to come to work. Supportive care is useful for both employees who need care and those who are caregiving for loved ones. There is a lot of opportunity here, said Biller, so the coalition is currently focusing on employers to move the needle on supportive care.

Pediatric Palliative Care

"Children need to be part of the conversation" said Stockton Beveridge, Imagine Pediatrics. As many as one in five children in the United States had a special health care need in 2019–2020 (HRSA, 2022); these children are disproportionally covered by Medicaid and CHIP, have higher medical costs, and have a greater likelihood of having unmet medical needs. Pediatric palliative care (PPC) should be available for these children, said Stockton. Research demonstrates that PPC can lead to improved quality of life, decreased symptom burden, improved caregiver satisfaction with care, reduced caregiver distress, and greater likelihood to receive care at home. Unfortunately, said Beveridge, PPC is under-resourced and too scarcely available. Due to misaligned incentives in fee-for-service payment models, there is little incentive for investment in PPC. PPC programs that do exist are often understaffed, unable to meet clinical demand, and offer either minimal or no outpatient services. As a result, children are taken care of in the hospital, stabilized, and discharged "into the ether," he said. Soon, these children end up back in the hospital with uncontrolled symptoms. Value-based care models may offer an opportunity to align financial and clinical incentives for PPC, said Beveridge. A financial system based on accountability for outcomes—including quality, utilization, and patient experience—is more likely to justify investment in PPC and lead to better pediatric outcomes.

Beveridge told workshop participants about his work with Imagine Pediatrics, a pediatrician-led group that provides integrated and personalized medical, behavioral, and social

care for children with special health care needs and their caregivers. Imagine does not replace a child's provider, but instead fills the gaps in the system, such as acute care services, engagement with pediatricians, or care coordination. Beveridge joined Imagine to develop and grow the PPC program. The first step was to quantify the need; he used the Pediatric Palliative Care Referral Criteria created by the Center to Advance Palliative Care to identify children in the Imagine cohort who could benefit from PPC. Out of around 20,000 enrolled children, almost 4,000 had a diagnosis that indicated a need for PPC (e.g., metastatic cancer, malignant genetic disease). This group also had higher health care costs and were more likely to have visited the ED or been admitted to the hospital in the past six months. The PPC program at Imagine is called PATH (Pain Management, Advocacy, Trust, and Hope), and it operates under an understanding of PPC as care that runs alongside curative therapies, rather than as end-of-life care. The PATH team currently consists of a doctor, a nurse practitioner, a registered nurse, and a pharmacist, and calls on behavioral health support, nutritionists, and other specialists as needed. They have served 131 patients since November 2023, providing both virtual and in-home support, such as symptom management, blood work, wound care, medications, and more. Although Beveridge is based in Nashville, he has patients in Texas, Florida, and D.C.; local paramedics and nurses provide in-person care to patients and send data to Beveridge as needed.

Beveridge shared a story about his patient J.P., an 8-year-old boy born with hypoplastic left heart syndrome. J.P. had three surgeries to repair his heart but eventually was determined not to be a candidate for transplant. He wanted to be at home for the end of his life, with his mother and four siblings, but there was no pediatric hospice in the area. Imagine Pediatrics worked with an adult hospice agency to take J.P. on as a patient, while Imagine offered 24/7 supplementary support. J.P. has since been discharged from hospice and has received home-based palliative care. In the 16 months since he returned home, said Beveridge, his symptoms have been well-controlled, and he has been making memories with his family.

State Level Programs

Kandyce Powell, Maine Hospice Council, told workshop participants about her experiences developing hospice and palliative care programming "from scratch" in the rural state of Maine. She and her colleagues did it with few resources but a lot of innovation, collaboration, and creativity. "We did it because it needed to be done," she said. The most important ingredients in the effort included listening, developing trust, and collaborating. Powell urged stakeholders to work across sectors and with non-traditional partners; in Maine, for example, palliative care was framed as an issue of consumer protection and the attorney general was involved in the work. Powell said community members are the most important partners in the work, so going into the community, listening to people's needs, and collaborating with them are key components of developing successful and sustainable programs. Powell encouraged stakeholders to think about how they can meet people's needs regardless of the obstacles. "We are bound by an insurance structure in our country," she said, but each of us can do what we know is the right thing to do for other people. For example, Powell began a hospice program at the Maine State Prison; the program was run through volunteer time and grant funds and was not beholden to the state Department of Corrections.

The collaborative efforts in palliative care were formalized in 2015, when Maine launched the Palliative Care and Quality of Life Interdisciplinary Advisory Council. This council, along with other partners, has been responsible for significant progress in Maine, including the passage of legislation in 2021 that required the state Medicaid program to reimburse for palliative care services provided by interdisciplinary teams across settings.

As another example, Daniel Fischberg, John A. Burns School of Medicine of the University of Hawaii, moved to Hawaii over 20 years ago to start the first hospital-based palliative care program in the state. At the time, home-based non-hospice palliative care was non-existent. Hawaii, like Maine, has a robust coalition of stakeholders, said Fischberg. An organization called Kōkua Mau ("continuous care") is a non-profit coalition that brings together stakeholders to create a system of quality palliative and hospice care. In 2011, a local health plan, University Health Alliance, authorized a concurrent care benefit, allowing patients with serious illness to access the benefits of home hospice without foregoing disease treatment. This was a message that told patients they did not have to choose between "living longer or feeling better," said Fischberg. With this benefit as a model, Kōkua Mau convened a group to approach the Hawaii

Medical Service Association (HMSA), which insures half of the state. With their advocacy, HMSA developed a similarly robust community palliative care benefit. Other progress on palliative care included the University of Hawaii medical school's required palliative care clerkship and incorporation of palliative care content across the curriculum, an effort led by HMSA to teach palliative care to hospice providers across the state, and hospice agencies adding palliative care services. At this point, about half of the state had access to some type of community-based palliative care.

Fischberg said that these years of experience and capacity building eventually led to a Medicaid benefit for palliative care, which launched in 2025. The benefit offers a per-member per-month payment to credentialed providers, and the inclusion criteria are broad and look at palliative care as preventive care. Although not the traditional definition, Fischberg argued that palliative care is preventive care because it seeks to prevent avoidable health crises, unnecessary pain and suffering, and low-value or unneeded health care. The benefit requires 24/7 access to an interdisciplinary team; providers have noted that the team-based approach allows patients to individualize their care and to connect with the type of provider that they need most. Although there have been administrative challenges in the implementation of the benefit, there are already stories of people whose health has improved significantly as a direct result of the interdisciplinary palliative care team. One local leader, said Fischberg, described the benefit as "transformative." A rapid-cycle quality improvement process is in place to collect data and facilitate reforms when necessary.

Panel Discussion

Gonzales asked panelists to share their lessons learned, policy ideas, and other key messages. Responses included the following:

• Creating successful programs to take care of patients and families requires listening to their stories and including their voices (Powell).
• Partnering with caregivers—particularly parents—as the experts in their loved one's care in palliative and at-home care programs (Beveridge).
• Building trust among diverse stakeholders and forming relationships with leaders and decision-makers to make progress on palliative care (Fischberg).
• Intentionality among palliative care providers about creating relationships with primary care providers and giving them respect and space to do their jobs (Beveridge).
• Paying for whole-person, interdisciplinary team care through Medicare and Medicaid (Powell).
• Educating and training all health care professional students in palliative care (Powell).
• Producing data and stories of success from local or state pilot programs that can be used to push change more broadly, including the federal level (Biller).
• Avoiding the temptation to "build the wheel from scratch" when innovating in health care; recognizing that others have faced the same problems and have experiences and insights that can be built upon (Biller).

A FORWARD LOOK ON MEASURING QUALITY AND ADVANCING VALUE-BASED CARE

The final session focused on bringing together the main themes and key messages of the workshop, said Jessica Hausauer, National Coalition for Hospice and Palliative Care. How do we define quality care, how can we measure quality, and how do we take these metrics and turn them into quality improvement? One of the challenges, she said, is that stakeholders may not be aligned on all these topics. One thing that most agree on, however, is that the patient should be at the center. With that in mind, the final speaker of the workshop was a patient with lived experience with a serious illness. Susan O'Conner-Von, nursing professor at the University of Minnesota, was diagnosed with lung cancer in late 2019. Earlier in the year, she had been experiencing lower back pain after lifting weights, and ibuprofen and physical therapy were not helping. In early November, O'Conner-Von went to her primary care provider and said there was "something drastically wrong." After an unremarkable chest X-ray, she was sent home and told to be more patient. A few weeks later, O'Conner-Von took herself to the ED and presented her symptoms. The intake nurse asked if she was there for narcotics; O'Conner-Von "took a deep breath" and calmly replied that she was there for an answer. After an MRI and a bone biopsy, she learned she had lung cancer, although she couldn't quite believe it and wondered if they had the wrong patient. In January 2020, she underwent radiation treatments for three weeks and began a regimen of therapy targeted at her specific mutation. During her illness and treatment, O'Conner-Von only spent one night in the hospital; she said this is because she knew about the value of palliative

care. As a nurse who had taught palliative and hospice care for decades, she knew the importance of getting her team together, connecting with spiritual care and social workers, and using both pharmacologic and non-pharmacologic tools to manage her illness.

O'Conner-Von offered a few thoughts based on her experiences. First, there is a need for more education about palliative care, both among health care professionals and the public. Health care professionals need interprofessional education and training to prepare to work together as providers for patients with serious illness, she said. The public needs to know the difference between palliative care and hospice care, and to understand the value of palliative care in improving quality of life. Second, everyone with a serious illness should have access to palliative care, and there is a particular need to improve access for rural and underserved populations. Telehealth demonstrated its ability to improve access during the pandemic, but there is a need to continue and expand this approach. Finally, said O'Conner-Von, patients with serious illness need administrative support to navigate the system. Even as a Ph.D.-prepared nurse, O'Conner-Von said she still had difficulty knowing who she needed to call or what she needed to request. She said that she tells her nursing students that they need to be a voice for their patients and help them advocate for the quality care they deserve. O'Conner-Von closed by expressing her gratitude for the bench scientists, researchers, academics, educators, palliative care teams, and people working in hospice: "You are the reason I'm still here."

Hausauer asked O'Conner-Von to reflect on quality care and whether her definition of quality has changed over the course of her illness. The most important aspect of care, replied O'Conner-Von, was that her health care team listened to her and believed her. Other providers had dismissed her concerns because she was a generally healthy person with no risk factors. She felt seen and heard when she was finally diagnosed and a specialist was fully present with her. The other critical piece of quality care, she said, is one of the 4Ms: "what matters most." Echoing Waterman's earlier remarks, O'Conner-Von said that patients with serious illness often care most about the aspects of their life that give them meaning and purpose. In both her professional work and her experiences as a patient, she has heard numerous people identify relationships, spirituality, and family as the areas they want to focus on in the days and months they have left in life. They might want to go to their granddaughter's wedding, see their grandson graduate from college, or re-connect with their religion. Conversations about these personal topics can be intimidating for health professionals, said O'Conner-Von, but they can start with a simple question: "What is really important to you?"

FINAL REFLECTIONS

Before adjourning the workshop, Rodgers asked workshop planning committee members to share what they had heard throughout the day and to identify key themes and opportunities to advance serious illness care. Responses included the following:

• Shifting to a value-based financing system is the best opportunity to expand access to palliative care, particularly in community-based settings (Brynn Bowman, Center to Advance Palliative Care).
• Explaining the benefits of palliative care and successfully advocating for a move toward value-based care, using standardized, strong definitions, and a common language in the field (Gonzales).
• Continuing to work at the state level to grow capacity and to test innovations in order to strengthen the ability to push for change at the federal level (Hausauer).
• Exercising every individual's capacity to help alleviate the administrative burdens of health care for patients, even without changes to the broader system (Kashelle Lockman, Society of Pain and Palliative Care Pharmacists).
• Learning the lessons from community-based palliative care 1.0 to accelerate progress in developing version 2.0 (Shega).
• Working together toward a better system, rather than pitting separate components against each other (e.g., hospice care vs. palliative care) to improve care for people with serious illness (Snider).

Rodgers closed the workshop with a reminder to stakeholders to center the patient in all that they do. Instead of focusing on what services should be provided or what team members are trained to do, the focus should be on how to meet the needs of the individual patient in front of you.

References

HRSA (Health Resources and Services Administration). 2022. Children and Youth with Special Health Care Needs: NSCH Data Brief. https://mchb.hrsa.gov/sites/default/files/mchb/programs-impact/nsch-data-brief-children-youth-special-health-care-needs.pdf (accessed February 24, 2026).

Kelley, A. S., and E. Bollens-Lund. 2018. Identifying the Population with Serious Illness: The "Denominator" Challenge. Journal of Palliative Medicine 21(S2):S7-S16.

KFF. 2025. Medicare Advantage in 2025: Enrollment Update and Key Trends. https://www.kff.org/medicare/medicare-advantage-enrollment-update-and-key-trends/ (accessed February 17, 2026).

Together for Supportive Cancer Care. 2026. Reducing Costs of Care Through Supportive Cancer Care. https://supportivecancercare.org/value-of-supportive-care/ (accessed February 5, 2026).

Disclaimer: This Proceedings of a Workshop—in Brief was prepared by Rebecca English and Erin Hammers Forstag as a factual summary of what occurred at the workshop. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

Planning Committee:Phillip Rodgers (Chair), University of Michigan; Claire Ankuda, Icahn School of Medicine at Mount Sinai; Brynn Bowman, Center to Advance Palliative Care; Matthew Gonzales, Institute for Human Caring at Providence St. Joseph Health; Corita Grudzen, Memorial Sloan Kettering Cancer Center; Jessica Hausauer, National Coalition for Hospice and Palliative Care; Kashelle Lockman, Society of Pain and Palliative Care Pharmacists; Thomas Priselac, Cedars-Sinai Health System; Joseph W. Shega, American Geriatrics Society and VITAS Healthcare; Bethany Cox Snider, Everent Health. The National Academies' planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.

Reviewers: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Peter Hollmann, Brown Medicine; Thomas Priselac, Cedars Sinai Health System; Robyn I. Stone, LeadingAge LTSS Center @UMass Boston. Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review monitor.

Sponsors: This project was supported by the pooled funds of the National Academies Roundtable on Quality Care for People with Serious Illness, which includes support from The Sheri and Les Biller Family Foundation and the American Cancer Society among other sponsors listed on the roundtable website: https://www.nationalacademies.org/units/IOM-HSP-15-13#organizers.. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

Staff:Rebecca English, Abian Hailu, Joseph Goodman, Victoria Brown, Lori Brenig, and Julie Wiltshire, Health Care and Public Health Program Area, Center for Health, People, and Places.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2026. Advancing Value-Based Payment for People with Serious Illness to Align Financing with Quality: Proceedings of a Workshop—in Brief. Washington, DC: National Academies Press. https://doi.org/10.17226/29412.

For additional information regarding the workshop, visit https://www.nationalacademies.org/projects/HMD-HCS-24-12.

Copyright 2026 by the National Academy of Sciences. All rights reserved.