As the demand for palliative care continues to grow, so too has the way businesses have bolstered their programs to better serve patients.

Providers are consistently looking for new methods to deliver responsive, value-based services that can generate savings and reduce high-acuity utilization.

Hospice News spoke with three palliative care providers that have risen to these challenges. In recent years, the following three companies have all gained prominence as palliative care providers through risk-based reimbursement systems, but each has moved forward on a slightly different path.

Prospero Health

Memphis, Tennessee-based Prospero Health has grown tremendously during the past three years. The health care startup currently provides interdisciplinary services in 28 states to 30,000 seniors who suffer from chronic health conditions and social determinants issues. This is up from 1,700 patients in three states in 2020.

The start and subsequent growth of the business can be attributed to a few major factors, according to Dr. Kris Smith, Prospero’s chief clinical officer.

Smith said it started with Doug Wenners, Prospero’s founding CEO, who championed palliative care and was instrumental in enlisting the investors needed to make the program what it is today.

“Doug talks very eloquently and passionately about the challenges in his family of managing care when a loved one has a serious illness. He often talks about his father, who has a longstanding serious illness,” Smith told Palliative Care News. “His desire was to build a clinical program that would help the exact type of patient his father is and to provide the best home-based serious illness care in our community.”

Wenners started building the foundation of the palliative care program by attracting investors. Enter UnitedHealth Group (NYSE: UNH). Around four or five years ago, the insurance mammoth was contemplating how they could better serve their members.

Initially, UnitedHealth Group made the decision to invest in Prospero’s home-based program instead of purchasing a company.

“At that time the interest in how you take care of patients with serious illnesses, palliative needs or end-stage diseases was really accelerating,” Smith said. “[UnitedHealth Group] provided all the seed funding, as well as the initial contract in a couple of markets to see whether the leadership team could build the business and run it effectively. They wanted to ensure it created value for patients and value for their health plans.”

Prospero did just that, by placing a new focus on responsiveness and achieving strong early financial results. The company doubled down on its rate of visits within 48 hours of hospital discharge, as well as the annual number of urgent visits per 1,000 patients. As a result, the number of ED visit cases dropped.

The UnitedHealth Group subsidiary Optum ultimately did acquire Prospero in early 2021 and is in the process of merging the company with its Landmark subsidiary.

Smith said Prospero’s global measure of success is providing more days for patients at home, rather than keeping them in hospitals, nursing homes or rehab facilities.

“The key secondary goal is to make the support and care we provide easier for caregivers of patients with serious illnesses,” Smith added. “We want to make sure that we are responsive and available to patients, so that when they have a deterioration or a worry, or they’re suffering, we are there for them in their time of need.”

Another important initiative was creating the right kind of culture at Prospero.

Smith said that having a responsive interdisciplinary team is vital. In the best-case scenario, these teams will be able to build rapport with patients and families through face-to-face interactions. Constructing a strong program required rethinking palliative care from a more personal perspective.

“Culture has been very important to us. Hiring the right clinicians has been very important to us,” Smith said. “We’ve been successful because of good early results, good culture, good hiring and a good clinical model that helps to keep patients with serious illness at home.”

Contessa Health, a subsidiary of Amedisys Inc.

Contessa Health, headquartered in Nashville, is a company looking to become a major player in palliative care.

Traditionally focused on hospital-at-home and skilled nursing facility-at-home services, Contessa has been building its program by creating joint ventures with hospitals and health systems to provide home-based services, including palliative care. Amedisys Inc. (NASDAQ: AMED) acquired the business in 2021.

Among the company’s JV partners are Baylor Scott & White Health, Memorial Hermann Health System, Mount Sinai Health System and more. Joint ventures like these have had a big impact on the way Contessa serves patients.

“We’ve been out building our palliative programs because it’s the right thing to do,” Amedisys Chairman Paul Kusserow told Palliative Care News. “We’ve got eight clients that are working with us right now. We have some that want to find a good partner and fundamentally drive better profitability for their hospitals, but we’re also working with companies that tried to do a palliative program on their own and fundamentally realized it’s way too complex to do without help.”

Kusserow said that palliative care is very much in demand, from both the home health and hospice sides, but he added that there’s been a reluctance on the part of the government to fund it appropriately.

Reimbursement for palliative care in fee-for-service Medicare currently only covers physician or nurse practitioner services. The lack of reimbursement opportunities can often hamper progress on developing sustaining palliative care programs.

“When we would try to do palliative care before, we’d lose money,” Kusserow said. “I think the government should understand that the right thing to do is to pay for palliative care appropriately. That will lead to better hospice care, which will lead to lower end-of-life costs.”

The U.S. Centers for Medicare & Medicaid Services (CMS) does allow Medicare Advantage plans to cover home-based palliative care as a supplemental benefit.

CMS has also included palliative care elements in the hospice component of the four-year value-based insurance design demonstration (VBID).

To help fund its palliative programs, Contessa decided to embrace “at-risk” payment models, like Medicare Advantage, as its main revenue stream.

“Medicare Advantage plans recognize the value of palliative care, of paying for palliative care,” Kusserow said.

Kusserow said a key component of delivering palliative care is financial planning, specifically, partnering with new clients who can help make the business profitable.

Currently, Amedisys has many new partnerships in the works.

“Our emphasis is on building out our palliative programs so that we get people into hospice at the right time,” Kusserow said. “That’s one of the reasons why we bought Contessa and why we’re very excited to announce palliative deals and talk about at-risk palliative care.”

Delivering palliative care to patients via an at-risk payment model isn’t without pitfalls, but Kusserow said success and expansion often come by working through some of the kinks.

“I think the key is to go deeper with our clients. We want to continue to prove out the model with some of the folks that we have now. We’re doing the traditional home health and hospice partnerships and we’re also doing palliative,” Kusserow said. “I’ve been really pleased with what I’ve seen in Contessa.”

Lightways Hospice and Serious Illness Care

Lightways, an Illinois-based nonprofit, made monumental strides in pediatric palliative care in 2022.

In January of last year, they took on the former pediatric patients of JourneyCare Hospice, which was acquired by Addus HomeCare (NYSE: ADUS) in an $85 million deal. Consequently, Lightways saw its average pediatric census nearly triple to 120 patients.

They have since expanded the program to the City of Chicago and other areas further north and northwest.

Before Lightways took on JourneyCare’s former patients, no other programs would take in the children. This isn’t surprising. Palliative care programs are notoriously difficult to launch, grow and manage because few clinicians have training or experience in that specialty and payment is often insufficient.

Given these risks, deciding to take on that many new patients simultaneously is a difficult choice for any company, but fortunately, Lightways CEO Mary Kay Sheehan and her company felt differently.

“My board and I just couldn’t say no to all those kids,” she told Palliative Care News. “We’re a big company, so we knew we could cover losses by raising money.”

A wide range of hospice providers rely on philanthropy to support palliative care services for both children and adults. To help finance the expansion, Lightways received a grant from the Addus Foundation, the company’s charitable arm. They also conducted a fundraising campaign for additional support.

The remaining costs are covered by revenue from Lightways’ hospice operations.

Sheehan said they worked out a way to hire and transfer all the staff from JourneyCare’s pediatric business within 60 days.

“A change like this is never easy, but because the staff came with the transfer we were blessed. The whole team of nurses, social workers and chaplains were so committed to their patients,” Sheehan said. “They had to come into a brand-new place and navigate a new system, but they did a tremendous job.”

Sheehan said the child life specialists are prepared to work with children to help them understand their feelings in a variety of ways, such as drawing, playing music or other activities that allow them to be comfortable with expressing themselves.

“For us it’s about quality of life,” Sheehan said. “We don’t want them to think they have to stop everything in their lives and die. Palliative care doesn’t mean death; it means comfort.”

Lightways plans to continue developing its services by hiring a full-time pediatric medical director to foster a culture that truly understands palliative care for children.

“We’re challenged by the lack of education about palliative care among physicians and nurses,” Sheehan said. “We’re hoping that a director will help to ensure that interns and fellows learn what palliative care really is as part of their training.”

Sheehan said she also plans to start a speaker series and implement website upgrades like TikTok videos focused on palliative care that patients and their families will find informative and fun.

“We want to help patients come to peace,” Sheehan said. “And we hope to provide them a measure of companionship along their journey.”