How Health Plans Can Help Reduce ED, Inpatient, and ICU Utilization with Earlier Palliative Care

For health plan chief medical officers, medical directors, and clinical executives, serious illness is one of the most important tests of whether a care model is truly proactive. Members with advanced COPD, heart failure, cancer, renal disease, dementia, and other progressive conditions often move through a fragmented system of specialists, medication changes, symptom flares, caregiver stress, and transitions across settings. When support arrives only after a crisis, the emergency department, inpatient unit, ICU, or late hospice transition can become the default path.

The opportunity for health plans is not to avoid appropriate acute care. Some ED visits, admissions, and ICU stays are clinically necessary. The opportunity is to reduce the escalation that occurs because symptoms were unmanaged, medications were not optimized, caregivers did not know whom to call, or no clear plan existed when the member’s condition changed.

That is why earlier serious-illness intervention should be viewed as an acute-care reduction lever, a quality-of-life imperative, and a core component of a more connected population health model.
 

Palliative care is not synonymous with end-of-life care

One of the most persistent barriers is the belief that palliative care belongs only at the end of life. Michael Gabriel, MD, Chief Medical Officer of Carelon Palliative Care, explains the distinction clearly: “Palliative care is frequently associated with end-of-life because it has historically been introduced late, but clinically it is broader than hospice. Palliative care is an added layer of support for patients with serious illness at any stage — delivered alongside disease-directed treatment.”

That reframing matters. Earlier palliative care does not replace a member’s treating physicians or disease-directed care. It adds clinical support around the issues that commonly drive crisis-based use: pain, dyspnea, nausea, anxiety, medication complexity, caregiver strain, unclear goals, and poor coordination between settings.

For plans, the question becomes: how early can members with advanced serious illness be identified, assessed, supported, and connected to reliable clinical guidance before the next escalation?
 

The path from better support to lower acute use

The connection between palliative care and lower acute utilization is clinically intuitive. As Dr. Gabriel says, “Utilization often decreases when members have proactive symptom management, clear care plans, and reliable access to clinical guidance before a situation becomes a crisis.”

In practice, that means members and caregivers are not left to interpret worsening symptoms alone. They have an action plan. They understand medication steps. They know when to call. Clinicians can assess for red flags, intervene earlier, coordinate follow-up, and escalate appropriately when risk increases.

Carelon’s Palliative Care model includes symptom management, medication support, advance care planning, caregiver resources, in-home services, virtual care, and 24/7 support for patients and families with serious illness. Those capabilities are directly relevant to health plan goals because they address the operational gaps that often lead to ED visits and admissions.

Dr. Gabriel offers a practical example: a member with advanced COPD and recurrent admissions developed symptoms after hours. Because the care team had already established early warning signs, medication steps, and escalation criteria, the member called the 24/7 line early. The team assessed for red flags, initiated a clinician-directed rescue plan, arranged close follow-up, and maintained clear thresholds for ED referral. The member improved safely at home.
 

Better experience and lower cost can come from the same interventions

Health plans often treat member experience and cost reduction as competing priorities. Serious-illness care challenges that assumption. High cost in this population is frequently driven by fragmentation: ED visits, repeat admissions, late ICU escalations, and delayed goals-of-care conversations.

Dr. Gabriel puts it this way: “Improving member experience through predictable engagement, symptom control, caregiver support, and goal-aligned care reduces those events. In that sense, better experience and lower cost are frequently achieved through the same interventions.”

The interventions that make care feel more humane are also the interventions that can make care more efficient. A caregiver who has education and a reliable point of contact is less likely to rely on the ED as the only available source of guidance. A member whose symptoms are managed early is less likely to deteriorate into a crisis. A provider who understands the member’s goals and care plan is better positioned to avoid last-minute, fragmented escalation.
 

Proof points for health plan leaders

The evidence base and Carelon’s reported results point to the same conclusion: earlier, coordinated serious-illness support can reduce acute utilization while improving the care experience.

Carelon’s internal data shows a 56% reduction in hospital admissions for a Medicare Advantage end-of-life group during a January 2021 through December 2022 study period, using 2019 as the baseline. Results varied across implementations and may not be representative of every plan population, but the finding is directionally important for executives evaluating serious-illness programs.

Carelon case studies also tie savings to lower inpatient and ED use. In one case study, the palliative care team delivered a 4:1 ROI, $2,203 per member per month in savings, 34% fewer hospital admissions, and 29% fewer noncritical emergency room visits. In another integrated post-acute and palliative care model, Carelon reported a 27% reduction in acute inpatient admissions, 31% incremental savings driven by higher engagement, and 42% attribution of savings to inpatient and ER reduction.

These outcomes are not accidental. They are the result of earlier identification, comprehensive assessment, 24/7 access, medication optimization, symptom control, caregiver support, and coordination across care teams.
 

What health plans should stop doing—and start doing sooner

Health plans should stop relying primarily on late triggers, such as multiple admissions, as the point of engagement. By then, the member and family may already have experienced distress, the care team may be operating without shared goals, and the system may have missed opportunities to stabilize the trajectory earlier.

Instead, plans should identify members with advanced serious illness sooner using signals such as high symptom burden, functional decline, complex transitions of care, caregiver strain, polypharmacy, recurrent ED use, or a recent hospitalization that suggests rising instability. The goal should be timely access to a comprehensive palliative care assessment that clarifies needs, preferences, risks, and next steps.

When earlier serious-illness support works as intended, members experience better symptom control and fewer crises. Families gain education and a reliable point of contact. Providers benefit from clearer care coordination. Health plans see more stable care trajectories and reduced ED and inpatient utilization.

Earlier serious-illness support is not simply a compassionate add-on. It is a practical way to deliver the right care, in the right setting, at the right time. As Dr. Gabriel explains, “Earlier serious-illness support improves outcomes and experience while reducing utilization. When members receive proactive symptom management, caregiver support, and clear care coordination before a crisis, they experience better quality of life and the system avoids preventable high-cost episodes.”

Discover how earlier serious-illness support can reduce acute utilization in your member population.