The opportunities are endless when it comes to clinical innovation in palliative care delivery. This is according to Amy Scheu, associate vice president hospice and palliative care at Advocate Health Care.
However, providers are also battling severe headwinds, including reimbursement pressures and workforce shortages.
Palliative Care News recently sat down with Scheu to discuss the largest obstacles preventing greater access and utilization of palliative care; inconsistent reimbursement and regulation.
How would you describe the current state of community-based palliative care delivery in the United States?
What I see is inconsistent access to services depending on the community that people live in. There is not a real standard definition of the services that palliative care provides because it’s not a [federally] established benefit for payers. That’s confusing to patients and families, because there is not a set of standardized benefits and services that have to be provided like there is in hospice.
Palliative doesn’t have that sort of definition for things. So, some people define palliative care as nursing care, some are advanced practice physicians and have board certified people in their programs and interdisciplinary care teams.
Some organizations like [the Center to Advance Palliative Care (CAPC)] have really tried to help put some standards out there and have done some analysis and surveying on what programs are out there. What’s been found is that more suburban and rural areas have more palliative program offerings than the urban areas do sometimes. But organizations providing these services were a little bit more heavily weighted in the hospice space, with then some hospitals, medical groups and freestanding health systems providing a lot less of those services. That still kind of continues to hold true from a market perspective.
The services being provided aren’t going deep from a community perspective into the community-based space.
What are the largest factors driving the future outlook of community-based palliative care?
When I think of the largest factors driving right now and the future outlook, it is not necessarily opportunities. The opportunities are that we have growth in the aging patient population who would be eligible for the services. There are more and more patients who become eligible every single day for palliative care services. So, it’s a growing market.
In one way, that growth is a positive piece. The flip side of that is the workforce shortages that are a challenge to some programs being able to expand and being able to see more eligible patients. So, it’s really figuring out some of that workforce piece as one of the driving factors for the future. This is why we need to have some of those innovations for telehealth.
I also think the expansion of evidence-based and integrated care models is an opportunity. There is more and more information coming out about organizations that are taking an integrated care delivery model approach and embedding palliative care into a continuum of other services. That is where palliative care has a great opportunity to thrive.
Advocate Health actually just received a $460,000 research grant from The Donaghue Foundation to study our palliative care services in a continual manner. We’re looking at things like cost and quality outcomes with patients having access to a continuum of palliative care, including hospice.
What does clinical innovation look like in the realm of community-based palliative care delivery?
It’s having more of a personalized and predictive care approach and really tailoring interventions to intervene in potential patient admissions. It’s utilizing all your tools and technology to be able to get ahead of where the patient is at from a reporting perspective. That is a huge opportunity for delivering care in the future.
It’s also focusing on upscaling clinical home teams to manage more complex patients in the home. It’s also connecting patients with other services to continue to support them in the home. Technology can add another layer of sophistication there.
We also really need to focus on medical student education. We try to do palliative care rounds for medical students no matter where they’re at in our organization, so they get exposure to it. We also have our own fellowship programs across Advocate Health where we’re trying to grow our own palliative physicians to train, educate and get a lot of rounds in the field. We expose more clinicians to those services to expand primary palliative care skill sets and awareness across the board.
What are some of the significant trends that palliative care providers need to be aware of when it comes to the community-based setting? How can providers understand these trends to inform and shape their care delivery approaches?
The first thing that I would mention is really expanding telehealth services to either get into more rural communities and provide service, or use it for extending staff in the community without having to travel. I see telehealth as a big opportunity to get more people into some disease-specific programming. It’s really tailoring services to some of the chronic, long-term illnesses, and doing some disease-specific offerings tailored to that is an area that’s kind of up and coming.
Technology plays a bigger and bigger role every day. Remote patient monitoring, wearable technologies and other types of things help keep clinicians connected with the patient and family on their medical journey.
Another big area that is huge for us in the board-certified provider space is addressing workforce challenges. There’s a small pool of these provider fellowships required for palliative physicians, so it’s a competitive market for recruiting and especially with retention.
What are the largest obstacles preventing wider opportunities for community-based palliative care growth? How can providers navigate these challenges?
I’d say it’s reimbursement, reimbursement, reimbursement. That is the biggest challenge right smack in the face of providers, because there is no defined Medicare benefit to provide a continuum of palliative care. That is a challenge to try and figure out how you’re supporting a program just on the professional fees. Unless you have an Accountable Care Organization (ACO) connection, a Medicare Advantage plan or partnership with private insurance companies, it becomes difficult. Even with these, coverage is offered in an unstandardized way, with multiple paying sources for palliative care services all having different requirements for reporting.
All the different standards providers have to follow makes it more difficult and more burdensome to implement. If there was that standardization there, it would be much easier to do. A lot of the reimbursement structures require the palliative providers to take on risk. That can be very overwhelming for some organizations to work through and figure out.
We try to find multiple sources to fund our palliative services. You can’t just be a single-payer entity at this point. You have to find dollars from multiple places. For our organization, we utilize our Medicare Advantage plan and we utilize our ACO, which then helps us cover our costs. You have to find multiple venues and multiple avenues for revenue streams to help make sure that you’re covered for your total cost of the program. It’s got to be a multi-pronged strategy.
Geography-wise, your location matters. The majority of the states do not pay for it. It’s not a one-size fits all across the country from a payer perspective. Value-based care is the only place that you are really able to provide an entire interdisciplinary team. In fee-for-service most payers are only paying for professional services of the physician, the nurse or social worker, if requirements are met from a billing perspective.
It’s much more challenging, and you need to have a lot more patient volume in fee-for-service to be more successful. Whereas in value-based reimbursement you have more opportunity to pay per month per patient and spread those costs over different services and disciplines.
What is important to keep in mind as the landscape of palliative care evolves?
It’s trying to continue to capitalize on the payment systems that are there and help shape where it needs to go in the future.
A palliative care benefit is going to be a game changer. That’s part of why Advocate Health has been doing some of these research pieces to be able to tell our story. There is nothing like good, hard data to articulate that story of why these services are a benefit, and what those services have been to try and help shape some more innovation and potentially policy. That’s kind of a long-term view of things.
It’s also just continuing to utilize the tools that are available, continuing to redefine the programs and always looking forward to that next step in every palliative care program’s journey. You cannot stay stagnant in this environment.
