The palliative care space is at an inflection point at which unprecedented awareness and demand are fueling growth that could be hampered by limited reimbursement and staffing shortages.
Palliative Care News spoke with a group of industry leaders about the most impactful forces that will shape the space in the coming year. Some of the common themes include the growth potential of these services, the need to adapt to changing payment models and the persistence of headwinds like the workforce issue and widespread misconceptions about palliative care.
Palliative care’s continued expansion
Palliative care leaders expect continued growth in 2024, driven by the proliferation of value-based payment models, greater recognition of these services’ quality improvement and cost savings potential.
In addition to the expansion of existing programs, more are cropping up. Close to 60% of nearly 330 hospice professionals indicated that their organizations planned to launch palliative care programs for the first time during 2023, according to Hospice News’ Industry Outlook Survey, prepared in collaboration with Homecare Homebase. This marks a climb from 52% last year.
However, providers may be challenged to sustain and manage that growth in light of labor shortages and the lack of nationally scaled reimbursement models.
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One of our priorities for the coming year is continuing to meet or exceed our goals for sustainable growth. While we remain committed to our mission, impact and reach, we need to do so in a sustainable way where services are sufficiently reimbursed, and team efficiencies are maximized.
—Skelly Wingard, CEO, By the Bay Health
In 2024 we’ll see continued expansion of palliative care services beyond traditional settings, with more focus on providing support in patients’ homes and within their communities, as well as continued efforts to advance research in palliative care, along with increased educational incentives and initiatives for health care professionals to enhance their skills in delivering high-quality palliative care.
—Nikki Davis, vice president, palliative care programs, Contessa Health, an Amedisys (NASDAQ: AMED) company
We’re growing pretty significantly. This year, we doubled the amount of patients that we had on our service and anticipate that next year we’ll do better than that. Managing that growth is a priority, because growth can also be a burden, especially when we get to the point of service when we have to pay our nurses, but we don’t get reimbursed for that visit, depending on the payer. So the challenge is going to be being able to take advantage of all the opportunities that are out there for palliative and being able to manage that growth.
—Jonathan Fluhart, CEO, PalliCare Inc.
Palliative care has traditionally been focused more on end-of-life care and transition to hospice care. However, relief of suffering – the true focus of palliative care – is applicable from the time of diagnosis onward. Since suffering is present throughout a person’s illness, palliative care must evolve throughout the disease journey.
—Catherine Campbell, CEO, Aspire and Caremore
Evolving payment models, system integration
Most palliative care in the United States is reimbursed through fee-for-service programs that cover physician services and do not fully support the entire scope of interdisciplinary care.
Currently, providers’ best bets for more robust payment are Medicare Advantage and Accountable Care Organization (ACO) relationships, as well as a growing number of disease-specific model demonstrations that incorporate elements of palliative care. Examples include the Kidney Care Choices Model, the Guiding an Improved Dementia Experience (GUIDE) Model and the Enhancing Oncology Model.
The emergence of these payment systems represent an opportunity for providers, but many will have to adapt to new ways of doing business, including greater reliance on performance data, different billing methodologies and cost control.
In addition to diverse payment models, providers are seeing greater integration of palliative care into other types of services, including primary care.
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With the movement towards value-based insurance design (VBID), I see many more players entering the palliative care space, recognizing the ability of these specialty areas to both improve outcomes and drive costs down.
These organizational providers will continue to come from both the for-profit and nonprofit arenas, with organizations that have geographic reach and high capacity able to benefit from experimentation with the full range of payment models, including shared-risk and full-risk models. This is still a space where we haven’t seen a dominant model/structure in terms of innovation, and also leaves a lot of gray area around reimbursement.
There will be increased participation in value-based and shared savings/risk-based financial models, and an increase in the number of states that implement Medicaid waivers to test and apply innovative payment and service delivery models for palliative care.
The success that we’ve really started to see with palliative care was working with physician groups primarily, which may or may not be an ACO, but any kind of value-based system. They’re starting to see the value in palliative care, that it is truly a way to save that money in that value-based system that they weren’t able to get their arms around before. Where I see palliative going, is really becoming a very valuable tool set to mitigate increasing costs in value-based care systems.
We’ve started to really develop the collaboration between the patient’s primary care physician and our Aspire clinician which helps foster that true whole health continuum – making sure that when we have serious illness, there isn’t a gap in care. We build that bridge for those patients, and it’s a natural fit with our business model having both the Advanced Primary Care and Palliative Care health professionals under the Carelon Health brand.
Investments in data and technology
As more palliative care providers start working with value-based payers, they will need a robust set of data that demonstrates their value in terms of quality outcomes, cost savings and a demonstrated track record of prevention of hospitalizations and emergency department visits.
This will likely mean further investment in data collection and analysis systems, including predictive analytics and machine learning.
Systems like telehealth, process automation and remote patient monitoring will also become more prevalent as providers seek to maximize touchpoints with patients while reducing the burden on their stretched workforce.
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In an environment where payers have mixed opinions about what the true value of palliative care might be in a dollars and cents perspective, it’s an ongoing challenge to capture that value from a data perspective and share it with payors (as they are often the parties with the most robust data).
There will be continued integration of technology for improved symptom management, caregiver support and enhanced communication between health care providers and patients, increased use of telehealth technologies to provide consultations, monitor symptoms and offer support remotely — especially considering the importance of accessibility and convenience for patients.
What we’re doing to help these value-based programs are starting to really come out in the data. We’re starting to see data where we are making an impact. But we’re not really getting the financial benefit of that. It’s very difficult to get into the risk-sharing with these ACOs.
Virtual care in the palliative space is on the rise. It became more widely used during COVID, but we’re leveraging it to help broaden access/availability to palliative care — which is especially important in care deserts/rural areas. People living in rural areas are at greater risk of poor health conditions and face significant barriers to accessing care. As a result, rural residents live close to two years less than those living in urban areas.
Awareness, workforce headwinds persist
As providers seek to reach more patients and capitalize on palliative care’s growth potential, they will have to navigate around a few obstacles.
Chief among these will likely be continued workforce pressures and the difficulty associated with establishing sustainable, let alone profitable, payer relationships.
However, they also face the continued need to educate and raise awareness among patients, families and clinicians in other health care fields, especially those in a position to make referrals.
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The biggest challenge remains the active engagement of patients once they are identified and referred to our program by their health plan or primary care providers. Our program is focusing on how well we can make contact with patients, and then effectively communicate how our program can support them through their care journey. We have the greatest impact when our palliative care patients welcome our support and are active participants in planning their care.
Many individuals still lack awareness of palliative care and there is a need for increased awareness among both the public and health care professionals about the benefits and availability of palliative care services. There is a stigma and misconception surrounding palliative care that contributes to late adoption or underutilization of these services, preventing patients from benefiting earlier in their illness trajectories.
There is a shortage of trained palliative care professionals — including physicians, nurse practitioners and physician assistants, nurses, social workers, chaplains and community health workers. This shortage can limit the capacity to provide comprehensive care to those in need.
Inconsistent or inadequate reimbursement for palliative care services can create financial challenges for health care providers and organizations, impacting the sustainability of palliative care programs.
[Reimbursement structures] make it very difficult to make sure that we are sustainable, which I’m proud to say that PalliCare is fully sustainable. We are making money, which I think we’re one of the few independent palliative companies to ever do that. But we’re doing it on a very slim margin. And so I think a big challenge for us is always gonna be being able to match our scale, because we’re growing so fast and being able to pay for that that growth. That’s very big challenge for us.
Medicaid redeterminations have reduced/eliminated palliative care coverage for some patients.
We also feel its important to continuously address self-care for our palliative care clinicians, so that they are emotionally and physically able to continue providing these important services for our patients. A lot of our focus has been on the trauma that our palliative care specialists go through when caring for seriously ill patients. It takes a lot to support the patient, their caregivers and family members during a really vulnerable time. If we continue to take great care of our providers, they will continue to take great care of our patients.