Health care’s hunt for treatment and cure can leave comfort overlooked. But if it is to meet growing demand for high quality palliative care, the United States needs interdisciplinary teams that can attend to patients’ complex clinical, social and emotional needs.
Challenge enough, but these teams must also choreograph their work within Medicare’s fee-for-service coding system, which limits billing to a single provider. The rigidity of reimbursement can leave patients companionless at life’s most difficult stations, but it can also put companies trying to scale and orchestrate their care in a precarious position.
Over the last decade or so a young crop of independent providers has begun to negotiate niches in this space. They are doing so with a compelling argument: that by combining clinical, technological or commercial innovation, they can keep the seriously ill out of the hospital — giving them more quality time with their loved ones and lowering total costs for payers.
“We’re very much like a vehicle that runs on a home health chassis,” Jonathan Fluhart, CEO of Texas-based PalliCare, told Palliative Care News. “It has an interior that feels like hospice, but the engine under the hood is a physician-based billing and collecting mechanism.”
The ascension of value-based care — which requires providers to quantify improved outcomes and lower costs — provides resonance for the business case of standalone providers. By demonstrating value, they can fuel themselves with a mix of fee-for-service and larger contracts.
“It starts with sufficient reimbursement and aligned incentives and the work we do with our health plan partners — the efficiency with which we provide our care — and then ultimately, it’s the outcomes we provide,” Darren Schulte, CEO of Vynca, based in California’s Bay Area, told Palliative Care News. “If we don’t demonstrate positive patient outcomes, cost and utilization outcomes, then we won’t make for a sustainable practice.”
Maximizing operational efficiency in interdisciplinary teams means keeping specialist work in specialist hands, according to palliative care providers.
For PalliCare, which sees a lot of fee-for-service work, that means having a strong billing team that can deal with the “monotonous” but “gymnastic” work of sending and answering claims, leaving clinicians to focus on care, said Fluhart.
For Schulte, it’s about ensuring clinicians “operate at the top of their license”, with in-house developed administrative software coordinating teams and automating tasks where possible.
Per-member-per-month contracts with Accountable Care Organizations (ACOs) can temper the financial uncertainties of fee-for-service, Fluhart said. However, determining an appropriate rate is “crucial.” He has seen providers overheated by the rapid scaling such contacts can demand.
“One of the things we tried to do early on was just focus on learning how to establish a good profit margin for sustainability. Then, once we had that equation in place, building a scalable operational team around that concept,” Fluhart said.
For Jessie Israel, CEO of Colorado-based Journey of Care, the secret to sustainability is an even split between fee-for-service and other payment models. A focus solely on per-member-per-month contracts with ACOs is self-limiting, according to Israel.
“I really think that we’re underestimating the amount of partnerships that we could have in palliative care,” she told Palliative Care News, citing oncology, kidney and guided dementia care models as examples. “There is a blue ocean of opportunity as anyone managing a large number of people will benefit from adding palliative care into the mix.”
Taking an expansive view on partnership opportunities also means looking beyond traditional payers, Israel indicated.
“Anyone who is delegated to care for that Medicare Advantage plan’s patients — throughout that entire pool you’re going to have more opportunity than going directly to the Medicare Advantage plan themselves,” she said.
An enduring challenge for the palliative care sector is the lack of awareness among patients and families of the services that are out there.
“Often these individuals don’t know their choices and aren’t given the types of advanced care-planning discussions that are required to ensure they’re getting what we call goal-concordant care,” Schulte said.
The potential for broader partnership and unmet demand for palliative care means sustainability can take a back seat, according to Israel
“I personally don’t have any concerns about sustainability and growth, because if we’re looking at things in a new way and building something that’s different than it has been built in the past, we can only win,” Israel said.
