Serious illness management requires coordination across providers, caregivers, and care settings in ways traditional fee-for-service healthcare was never designed to support. 

By Alicia Bloom, Empassion COO 

Modern healthcare was largely built around specialties, procedures, and episodes of care. 

That model works reasonably well for many conditions. A patient sees a cardiologist for heart disease, an orthopedist repairs a knee, or an oncologist manages a cancer treatment plan. Responsibility is relatively clear, reimbursement pathways are established, and outcomes are often tied to a defined course of treatment. 

But serious illness care rarely works that way. 

Patients living with serious illness often experience multiple interacting conditions simultaneously. Congestive heart failure may exist alongside COPD, diabetes, renal failure, cognitive impairment, mobility limitations, depression, and caregiver exhaustion. Clinical complexity is frequently compounded by social isolation, functional decline, transportation barriers, and repeated emergency department visits or hospitalizations. 

Needs evolve quickly. Goals of care change over time. The care journey spans specialists, hospitals, primary care providers, home health agencies, palliative care teams, hospice organizations, caregivers, and community resources — all at once. 

In many cases, no single provider or organization truly “owns” the patient experience. 

That fragmentation creates one of the greatest operational challenges in healthcare today, particularly for the small population of medically complex patients who account for a disproportionate share of spending. 

Health plans understand this population well. The sickest patients often represent approximately 5% of members while accounting for nearly 25% of Medicare spending. These are exactly the populations healthcare organizations should focus on improving outcomes for. 

Yet one of the greatest misconceptions about serious illness care is that the problem is simply poor coordination. Coordination matters. But it is ultimately a symptom of a deeper issue: modern healthcare was not designed to meet many of the needs that drive suffering, crises, and avoidable utilization for seriously ill patients.

Serious Illness Exposes the Gaps Between Healthcare Encounters

Traditional healthcare excels at treating acute conditions and delivering specialized interventions. 

But serious illness exposes the gaps between those encounters. 

Patients often leave appointments without fully understanding their prognosis or treatment options. Symptoms escalate at home without support. Caregivers become overwhelmed. Depression, isolation, functional decline, and psychosocial distress quietly compound until they trigger emergency department visits or hospitalizations. 

These are not failures of individual clinicians or organizations. 

They are care gaps that exist because the healthcare system was built around diagnoses, procedures, and billable events — not around the longitudinal realities of living with serious illness. 

Patients experience illness holistically. But much of the healthcare system still manages care through individual specialties, episodic encounters, and reimbursement silos. 

That creates a structural mismatch precisely where patients and families need integration most. 

Why Fee-for-Service Healthcare Struggles With Serious Illness

Traditional fee-for-service healthcare is built around billable encounters. 

A procedure is performed. 

A specialist visit occurs. 

A diagnosis is treated. 

A claim is submitted. 

But the most impactful interventions in serious illness care are often the least reimbursed. 

Helping patients and families navigate complex medical decisions. 

Managing symptoms proactively before they become crises. 

Supporting caregivers experiencing burnout. 

Addressing psychosocial distress and social determinants of health. 

Helping patients clarify goals and align treatment plans accordingly.

These interventions are time intensive, highly individualized, and often best delivered outside traditional clinical settings — sitting at the kitchen table with patients and families navigating extraordinarily difficult moments. 

They are foundational to quality care, yet they frequently fall outside the scope, time constraints, and reimbursement structures of traditional healthcare delivery. 

This is where serious illness and palliative care models fill a critical gap.

Palliative Care Addresses Needs Traditional Healthcare Often Overlooks

Palliative care is frequently misunderstood. 

It is not simply an additional layer of coordination, nor is it limited to end-of-life care. 

Palliative care is a specialized clinical model designed specifically to address the unmet needs that traditional healthcare models often overlook. It focuses on symptom management, psychosocial support, caregiver support, advance care planning, and helping patients navigate serious illness in ways that align medical care with quality of life and patient goals. 

Importantly, palliative care is delivered alongside curative or disease-directed treatment — not instead of it. 

The work extends beyond the patient alone to support the entire family unit through an interdisciplinary team that may include nurses, social workers, chaplains, and community health workers. 

That complexity makes serious illness management difficult to operationalize at scale and helps explain why building these programs internally can be challenging even for sophisticated healthcare organizations. 

Success requires more than a provider network. 

It requires infrastructure intentionally designed around the realities of serious illness.

Why Health Plans Increasingly Partner Instead of Build

For health plans, the challenge is not recognizing the importance of these members. 

The challenge is building infrastructure capable of systematically identifying and addressing unmet needs at scale across fragmented local markets, provider ecosystems, and care settings. 

That is why many organizations increasingly partner with specialized serious illness care providers.

The expertise required is not simply operational coordination. It is the ability to identify and close the care gaps that traditional healthcare models were never designed to solve. 

Patients with serious illness require: 

• longitudinal engagement 
• proactive symptom management 
• caregiver support 
• psychosocial intervention 
• transitions-of-care management 
• alignment around goals of care 
• coordination across multiple providers and settings 

Those capabilities are difficult to standardize quickly and consistently across large populations. 

Partnership models allow health plans to remain focused on their core competencies while working alongside organizations purpose-built to support medically complex patients and their families. 

Importantly, this is not about replacing providers or health plans. 

It is about building systems capable of addressing the realities of serious illness more effectively. 

The Future of Serious Illness Care

As Medicare Advantage enrollment grows and healthcare continues shifting toward value-based care, serious illness management will become increasingly important. 

The future of healthcare will not be defined solely by access to services. 

It will increasingly be defined by the ability to identify unmet needs, connect fragmented systems, support caregivers, manage symptoms proactively, and help patients navigate serious illness with dignity and clarity. 

For patients and families, that support can mean the difference between crisis and quality of life. 

For health plans, partnering with specialized serious illness organizations may be the most effective way to close the gaps traditional healthcare was never designed to address. 

Alicia Bloom is Chief Operating Officer of Empassion Health, a national leader in serious illness and hospice care.