The senior care company agilon health (NYSE: AGL) will more than double the size of its palliative care program this year, with plans to leverage its robust suite of data to optimize care.
The company is a value-based organization that partners with primary care physicians nationwide to jointly take on the total cost and quality of care for their senior patients through Medicare Advantage or the the U.S. Centers for Medicare & Medicaid Services’ (CMS) Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) model. It currently operates in 35 markets in 15 states.
Through agilon’s partnership model, it can arm community-based physicians with the technology, data capabilities, human resources and insights that are often necessary to improve patient outcomes at scale along with reducing costs.
A recent study published in the Journal of Pain and Symptom Management found that the primary care-led, integrated approach to palliative care espoused by agilon were two-thirds less likely to die in a hospital and on average spent five more days at home near the end of life.
Hospice News spoke with Dr. Benjamin Kornitzer, agilon’s chief medical officer and a co-author of the study about the workings of their palliative care model, the results it achieved and the company’s plans to grow the program in 2024.
Could you elaborate on the specific role of agilon relative to the physician practices you work with?
Our role there is as a partner. We bring technology. We bring insights. We can bring powerful data and care pathways. We can co-invest in resources, whether they’re nurses, care managers, social workers. We also can help them create risk sharing contracts with palliative care organizations. But as agilon, we don’t provide the care ourselves. We do it through our partners.
There’s one very important distinction: A vendor would approach this by saying, “We’ve got a bunch of tools that we could sell you.” Our approach has been, “We’re in this together. Whatever we do, we agree upon it together, and we do it at cost.” That way, we’re very aligned. The only thing that matters to us as an organization is that patients are getting better outcomes.
How would you characterize your patient population?
We take on the total cost of care for the entire senior panel of our primary care piece. Essentially, this is a real-world, community-based view of patients. So it’s in urban environments and rural environments where there isn’t a single street sign in town. We’re in the Northeast, where three feet of snow isn’t unusual, and we’re down in Texarkana, Texas.
These are very real world community-based practices that are taken care of by MDs, by DOs, by nurse practitioners. We work with primary care-only groups. We work with multi-specialty groups. We work with independent physician organizations, and we even have started working with a few health systems.
One of the things that for me is an important takeaway is that, really, it’s the value-based care construct that allows you to reorganize care delivery. That’s so impactful, not necessarily the specific attributes of one of our position partner groups.
Do your partners use a standardized palliative care model across the board, or are there customized models based on your agreements with your provider partner?
It’s a hybrid approach. We have a standardized toolkit that we bring to all of them that includes the data elements. We have an algorithm that can help identify which patients are at risk of having adverse events and which are approaching end of life. We have a whole toolkit that can help train them.
Because one of the things we hear from our [primary care providers (PCPs)] is they don’t know how to have conversations with their patients about end of life. This wasn’t something that they were trained in medical school how to do effectively.
We find the best way to do that is really roleplay. We go to each of these markets and do one-on-one training with our physicians. We have a series of metrics that we can use that help us understand our patients getting goal-concordant care, and we track it the same way you would track any other intervention.
Finally, we have a construct to manage how we’re actually providing that palliative care whether it’s through our partner themselves — some of whom have palliative care nurses and physicians or whether they partner with an external group — and we create a joint operating committee. Once that patient is referred to palliative care, the PCP doesn’t step away. They stay involved.
That involvement may be on a regular basis. It may be just checking in once a month with the palliative care agency.
One anecdote, just to demonstrate how it functions a little bit differently, one of our providers historically had worked with a palliative care agency. In the past, they would refer patients to palliative care, and that palliative care provider would go and call the patients. Sometimes the patients picked up the phone; sometimes they were too infirm to pick up the phone. But because it was a traditional referral, no one was actually going and making sure that that patient gets seen. If no one picked up the phone, they fell through the cracks.
When all of a sudden you’re responsible for the outcome of an entire panel. It doesn’t matter whether that patient picks up the phone or not, you’re responsible for their outcomes. All of a sudden, you start working the phones. You call their daughter. You call their son-in-law. Maybe you even send someone to their home.
But you would look at any time a patient isn’t seen as a failure. You would do a root cause analysis. This is very different from a fee-for-service mentality where all you think about is, “I got a referral. I saw the patient. I dropped the billing code.” You also have the ability to look at metrics.
So if you think about a deeper service environment, even the best palliative care providers, do they really have the resources to aggressively track every single patient phone call, every time a patient’s medication changes, every time a patient goes to the emergency room or to the hospital? We’re able to look at those metrics and create dashboards. So you can say to yourself, “Are we rising to our promise of delivering better care to these vulnerable patients?”
You really need an economic model that can support that, and that’s really what’s been so transformative about the work that we’ve been doing.
When did agilon first start to get involved in palliative care? Was that from the outset of the company or was that a service that kind of got added on as you proceeded?
Like many great innovations in health care, it really bubbled up from our community.
Our first partner started in 2018. They already had a small palliative care resource. Some of our partners did have palliative care partnerships working in their community, but those were very, very individualized. They didn’t have many of the standard elements that we spoke to before.
But we were able to leverage learnings from those groups to say, “What does ‘good’ look like if you could create a new model from scratch that would change how seniors are experiencing their final months of life? What would it take to do that?
So we’ve really been building that starting in 2018, but it was really around 2020 and 2021, when we began to ramp that up much more significantly. In the study you saw eight communities. By the end of 2024, we will be in 25, all with a similar construct.
How do you secure reimbursement for the palliative care services?
It depends whether the palliative care provider is embedded within that practice or if they work with an external group.
In all cases, what makes this possible is that the primary care physician is responsible for the patient outcomes, including the total quality and cost of care. They can use those dollars to pay fees beyond what the Medicare fees would be for palliative visits. In fact, we see improvements in things like 24/7 access to palliative care, the ability to send doctors and nurses into patients’ homes, and we recognize the fact that that may involve investments that go beyond what a traditional Medicare approach would allow.
We’re able to make those investments. We can do that either through our own employed palliative care specialist or working with external partners in the community. We always see that if there are aligned incentives — meaning that if the group that’s providing the specialty care is able to get better outcomes for those patients — then the dollars and the economics reward that.
We’ve been very creative in making sure that the partners that we work with, whether it’s our primary care partner or palliative care, we want them to have the resources to be able to really improve care for seniors.
What’s coming next for agilon’s palliative care program in 2024? What’s your outlook? What kind of growth do you expect?
We’re really very excited by the data that we’ve seen that shows that primary care physicians, when they work with a high-quality palliative care program can make a big difference.
If you think about it, those patients are getting more than five more days of home during their last months of life. They are two-thirds less likely to die in a hospital. They have 50% fewer ICU days, and the total cost of care is decreased by a third. It’s over $10,000. That’s a dramatic endorsement of our ability to really make a difference on this most vulnerable population.
We’re working with community doctors. We don’t employ them. We don’t tell them what to do. We partner with them, and they decide what their priorities are. Every single one of our physician partners has enthusiastically embraced palliative care. They feel that this is something that just resonates with them, as a caregiver and as human beings.
There’s a study that shows that doctors are far less likely than others to die in a hospital. I think it’s because we know intrinsically that there are many aggressive interventions at the end of life that just cause more suffering and don’t benefit patients. This work, part of the reason it’s been so successful is not just because it’s a good model, but that our physicians embrace it.
So, expanding this program has been very, very easy. It’s like walking through an open door. As I said before, we’re going to go from the eight markets that were in the study to over 25 communities. That’s essentially all of our partners that have been with agilon for greater than a year.
We are significantly updating our technological capabilities. Our ability to identify patients using advanced modeling and algorithms is going to create even greater signal strength.
Finally, we are delighted to see the impact we’ve had on patients. We actually feel that there’s room to continue to improve, and so we’re going to continue to measure every single interaction. We have to understand where we can get better patient care and where we see signals. Is it getting to patients’ homes more quickly? Is it 24-7 care? Is it embedding resources within a hospital so that patients who have a new acute exacerbation can get more quickly integrated into a palliative care program?
We’re essentially going to be taking all the things that we have right now and continue to measure them very rigorously, because you can’t improve what you can’t measure. We’re very enthusiastic that this is not just going to be a year where we’re going to continue to expand an existing program. We have very strong conviction about identifying the elements that would make this program even more beneficial to the patients that receive it.