Minnesota-based Livio Health launched in 2015 as a mobile urgent care company and began offering home-based palliative care services about two years ago. The company initially served the Minneapolis metropolitan area but during 2021 expanded to cover the entire state, covering about 1,100 patients.
The for-profit company is backed by parent company Stella Health, which also operates the nonprofit BlueCross BlueShield of Minnesota, the principal payer that Livio currently partners with for its palliative care business.
Hospice News recently sat down with Livio’s Chief Clinical Officer Sumair Akhtar, M.D., to talk about the growth trajectory of the company’s palliative care model and what the future holds for value-based payment for these services.
You’re working with Blue Cross Blue Shield of Minnesota. Do you have relationships with any other payers for palliative care?
Primarily it is Blue Cross currently. We are able to take care of patients across their Medicare Advantage, their Minnesota Senior Health Options (MSHO) and their commercial, fully insured service lines. We have a strong desire and a lot of optimism that we’ll be able to expand to some new partnerships in the coming year or two.
How would you characterize your patient population?
Our services are ultimately aligned to the top 5% to 7% sickest members of the population overall. Certainly cancer makes up a chunk of that, but we also provide palliative services to other patients with other serious illnesses as well. This includes advanced and end-stage [chronic obstructive pulmonary disease (COPD)], congestive heart failure, kidney disease, and often a combination of more than one or two of the above.
These patients will also often have some significant issues in behavioral health, as well as quite a significant burden of unmet social needs, along with the other physical manifestations of having all of these at once, which includes, you know, malnutrition, and other issues as well. When you really look at these patients a lot of them are really, really ill, because of a combination of all of these factors hitting their health at the same time.
A big chunk of our patients ultimately are in Medicare. So you’re talking about the 65+ population. The average age of our population skews into the 70s. If you paint the picture, you’ve got a generally older population with multiple serious illnesses and the overlying behavioral health and unmet social issues that really creates a tough, tough population of patients to be able to take care of.
Can you tell me about your patient palliative care model and what distinguishes your program?
I’m super proud of the model that we’ve developed and the team that we have developed. Our care model consists of nurse practitioners and physicians that have a strong background in palliative and often hospice care as well to take care of the medical side of the equation. We also have a really robust presence of social workers, [licensed practical nurses], care coordinators, registered nurses, and chaplains, as well as a few other members of the team that help round out the team to address the non-medical needs.
We talked about the behavioral health aspect, so the rest of the team is really able to help focus on those aspects of the patient’s care as well. You get this really strong partnership between prescribing providers and other clinical team members that I think is really powerful.
I think one thing that’s really a differentiator for us at the end of the day is that we spend so much energy on that nonclinical side of the equation as well. You often see social workers and other members of the team as part of palliative care, complex care models, but you don’t always see the ratio that we have established which really puts the other non-prescribing team members in the front seat. They’re not playing second fiddle. They’re just equal partners in the care for these patients.
Our care model is both able to provide in-person care as well as tele-palliative care. Obviously, it’s no secret that the pandemic has taught us a lot about how to provide effective care through the phone and video visits as well. A big chunk of our visits actually ended up being virtual, which allows us to flex and provide care not just to patients in the metro area, but also to greater Minnesota and some of those more rural communities as well.
I think the piece that I love the most at the end of the day is, whenever clinicians write notes on top of patient records, the first thing that goes on the note is something called the “chief complaint.” This is basically the chief reason that you’re talking to the patient that day. We have something similar to that, but we call it “the patient’s most important thing.”
It’s a term that we use to describe what matters most to the patient at the end of the day, and to make sure that the tailored care that we’re providing to them ultimately helps the patient achieve their most important thing, and not just what the clinical team feels is that chief complaint of the day.
Livio got started as a mobile urgent care provider. When did you begin to offer palliative care and what factors contributed to the decision to launch that business?
Our palliative care program has been around just for about two years. That was a bit of a pivot from the work we started out doing. There was just a big gap that needed to be addressed. When you think about palliative care, there’s not a lot of high quality outpatient palliative care available in health care these days. Livio is really trying to fill that gap.
I think a lot of people believe that palliative care happens when the patient is in the hospital, in the ICU, connected to a ventilator, and they’re a few days, weeks, maybe a couple of months away from potentially passing. I think that’s a tragedy because palliative care is really all about maximizing quality of life and managing symptoms and providing support to caregivers, all of which can happen substantially sooner, before the patient ends up in that situation.
As soon as they become seriously ill and develop all of the things that come with coping with serious illness, that’s when palliative care can be effective. That really should be happening more frequently in the outpatient setting. The absence of that is a big gap, and Livio certainly noticed that gap needed to be addressed.
We have a lot of team members that are truly passionate about being able to provide that type of care sooner to patients and not just in an institutional setting, but in the outpatient world. Certainly our health plan partner, BlueCross BlueShield of Minnesota, has seen the need for providing that type of care for their patients as well. There was a mutual understanding that this is the type of work we need to do.
How do you secure reimbursement for palliative care? You mentioned Medicare Advantage and Medicaid, is there any other kind of reimbursement that you receive?
We don’t provide any clinical services in traditional fee-for-service arrangements. We 100% structure our contracts on value-based agreements. Generally, our approach involved capitated arrangements for palliative care with the ability to potentially get paid more for achieving excellent clinical outcomes.
Our DNA is rooted in providing care through value-based arrangements, we tend to structure all of our reimbursement models in the same way.
How do you connect with palliative care patients? Is it strictly through physician referrals?
There’s a few different ways but what we have found most effective is we essentially have the ability to look into which patients would best benefit from our services through data that gives us information about their clinical conditions. With that information, we are actually able to directly contact patients that we feel would benefit. We can have a conversation with them about whether or not they are interested in our model of care. There’s a major approach for us in actually directly outreaching to eligible patients.
Sometimes health plans can also directly refer to us as they engage patients through various means, including their own care management team that is able to refer to us. Finally, provider groups that are taking care of Blue Cross patients are able to recommend patients for our service as well. It’s a multipronged approach that includes direct outreach, health plan referrals, and community partnerships.
Can you tell me about some of the ways that you market yourself to secure those referrals?
We’re certainly not doing a massive amount of advertising on TV or anything like that. Our approach to getting our name out there involves actually meeting with provider groups and teaching them about what we do, and forming more robust, sort of warm relationships with providers that we know are taking care of complex members in the community.
We certainly send information out to patients who might be interested in our services and are eligible for them through mailers and things like that. Most of this is actually grassroots efforts to build relationships with communities and providers.
What are you seeing happening in terms of demand for palliative care? Do you see interest growing?
I feel like, despite palliative care and having been around for decades, there’s still a misconception that palliative care is for patients who are about to pass away imminently or very soon. We have a tall task of trying to convince the world that palliative care can provide major benefits to patients at a much earlier stage of their illness.
There’s plenty of data that’s been published, particularly on cancer patients, that shows that involving palliative care earlier actually helps patients live longer. What we care about is giving patients more quality of life and helping maximize the lifetime that they have. Palliative care can actually play a real role there.
The overall need for palliative care is growing as our population continues to age and patients become more and more complex. I think therefore the demand will follow. But it’s going to take continuous education for us to show people that palliative care can have that impact much sooner in patients’ trajectories.
My hope is that as we continue to educate and palliative care continues to become more prominent in the system, that providers or the families and caregivers themselves realize that there’s more that can be done to to take care of these patients.
There’s a palliative care portion of the hospice component of the value-based insurance design model that the U.S. Centers for Medicare & Medicaid Services (CMS) is currently testing. Do you expect that program to impact your business?
I think it very well could. I would say that really any policies that ultimately are geared towards allowing for more flexibility for hospice and palliative care and expanding that approach to more patients will be beneficial for us in the future. I definitely see that potential. We’ll see whether or not ultimately that results in more plans and health systems taking advantage of that. But I definitely see it as being a potential boon for us in the future.
Can you provide some details on your overall growth strategy for Livio?
Our growth ultimately is predicated on a couple of things. We are maximizing our partnership with our current payer partner. We are looking forward to using the early outcomes that we have shown to be beneficial to these patient populations, like reductions in ER visits, hospital admissions or readmissions, to establish new relationships with more health plans. Now that we have more of those data, we feel more confident that we’re actually providing a reduction in total cost of care, reducing utilization, and doing it with really good patient satisfaction metrics.
Our growth strategy is predicated on striking new partnerships, and we’re very confident in our ability to do that in the next year to two years.
The other big thing we need to really figure it out as an organization is how we provide even more care to the rural population. That’s something that we are really interested in. It’s a lot easier to say we’re going to provide care mostly to patients in the metro population. But at some point, we need to get out there and be even more robust with our portion of the rural population. Another aspect of growth for us is just being able to continuously expand our geographic presence, in addition to striking up new partnerships. Those are the things that we really are looking forward to in the next year.
Companies featured in this article:
