The Future of Palliative Care? Community-Based Models with Alan Chiu, Mindy Stewart-Coffee, and Ben Thompson

Eric 00:09

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

Alex, we got a fun filled episode going on.

Alex 00:16

We got a fun episode. We got this idea at CAPC in Philadelphia the conference when Alan came up to us and said, hey, we should do podcasts about this.

Eric 00:26

Yeah.

Alex 00:27

So I’m gonna introduce Alan first. Alan Chiu is a palliative care doctor. He’s chief of palliative care at Monogram Health. Alan, welcome to the GeriPal Podcast.

Alan 00:37

Happy to be here.

Alex 00:38

And we’re delighted to welcome Mindy Stewart-Coffee who is a palliative care leader and national vice president for palliative care at Optum Home and Community. Mindy, welcome to the GeriPal podcast.

Mindy 00:49

Thanks for having me.

Alex 00:50

And Ben Thompson, who’s a palliative care doctor and national medical director for hospice and palliative care at Gentiva. Ben, welcome to the GeriPal Podcast.

Ben 00:59

It’s a dream.

Eric 01:03

So our topic today is we’re going to be talking about community based palliative care and this, I don’t know how, I don’t even know what our title is for this podcast.

Alex 01:12

Yeah, maybe we can workshop it throughout. Maybe by the end it’ll be part of our journey for this hour.

Ben 01:17

Yeah.

Alex 01:18

Title by the end. We’ll get ideas from our guests as.

Eric 01:22

We proceed, but we got a lot to talk about. I’m really excited because there is a tremendous growth area, but it also potentially poses some, I don’t know, is it too strong to say, existential threat to palliative care. But we’ll talk about that. But before we do, Alan, do you have the song request?

Alan 01:42

Yes. So I ultimately landed on a very timely song that’s been in the media recently, Defying Gravity from the movie Wicked. The song is about breaking, expect, breaking away from expectations. The words are relatively self explanatory and it’s a good reflection, a good synopsis of how we feel for those of us who are in this community based space where we want to be working towards a different future than the limitations we’ve gotten so used to with on the fee for service side of things. It inspires me. It helps me to get through my day. And when I’m in the shower, I love singing that final belt. So.

Alex 02:27

Let’s see how so listeners sing along with me. Here’s a little bit.

Alex 02:36

(singing)

Alan 03:33

We’re going to make it a mission. We’ll make as many references to that song during our podcast as possible.

Alex 03:38

I look forward to that.

Eric 03:40

All right, well, Alan, let me ask you this. How are you feeling about pal? Are we defying gravity, continued growth, or. I don’t want to say what do you see? But how are you feeling about it?

Alan 03:52

Yeah, I overall am very optimistic about our field.

Alex 03:56

You.

Alan 03:56

You alluded to some of the worries that we’ve expressed planning for this, and I do have concerns around some of the growth. But overall, I’m very optimistic, partially because there’s a lot of acknowledgment that the status quo of the way things have been is not sustainable for very long.

Eric 04:18

Tell me what you mean by the status quo, because this is the second time you’ve mentioned that a change is needed and the status quo is not what we need.

Alan 04:32

So there’s the status quo for palliative care, and then there’s the larger status quo for the larger healthcare field, particularly around our aging senior Medicare population. You don’t need to look in the news very long to see that there’s a huge cost expense issue with the way that our healthcare spend is going on in this country.

We’ve talked really extensively about the Silver Tsunami and the increasing number of folks that are not only just entering into their senior years, but starting to develop those polymorbid, those polycrotic multiple diseases, developing cancers, developing dementia. And so that need is only going to increase greater and greater and the cost is getting more. And so that’s.

Eric 05:18

What about for palliative care?

Alan 05:19

Yeah. So palliative care. It’s been encouraging to hear that palliative care is being included in a lot of conversations around solutions for this unsustainable health system that we have. This gets a little bit to the. To the concern, though, is that there’s a lot of conversations around palliative care and their role in this, but there aren’t a lot of palliative care leaders that are part of those conversations that are happening at really high levels.

There are some, but not nearly as much as I personally would like. And so when we started talking about this idea of Pali Light. I think that’s a bit of a precursor or a bit of early signs of some of that concern where there’s work that’s being put under the label of palliative care is being put out there because they see it as a potential solution for a lot of the problems in our healthcare system, but it may not necessarily have the full involvement, the full power of the larger palliative care world really guiding what that growth looks like.

Eric 06:25

So we’ll talk about that. We’re going to get into that. I want to hear from our other two guests. Ben, I’m going to start with you. How are you feeling?

Ben 06:34

I love what Alan just said, which is they see it as a potential solution. And I hope that resonates with a lot of people. In any practice of palliative care is there’s this other set of people who have ideas about what it is that we do and how it is that we can, you know, we can fix a problem. I recall in my previous life as a division chief being, you know, brought into a room and they said sepsis mortality is terrible on the weekends and palliative care is going to fix that. Right.

Eric 07:09

So I think that I’m guessing they weren’t talking about palliative care increasing the amount of antibiotics being given.

Ben 07:16

Exactly. Palliative vancomycin. Love it. You know, to Alan’s point, I’m excited for the growth and also excited to have more palliative care clinicians in the they suite. You know, in the conversations that shape the way that our field progresses. You may even say that we’re through with playing by the rules of someone else’s game. There it is.

Alex 07:42

There’s number one. That’s the first one I called.

Eric 07:44

Is that a lyric?

Alan 07:45

Yeah.

Alex 07:45

Yeah.

Eric 07:47

I think I gotta watch Wicked now. Mindy, what are you thinking about this? How do you think about the growth, Mindy?

Mindy 07:53

Yeah, I’m excited by it. You know, I think our healthcare system’s really underprepared to meet the needs of people living with serious illness. And I think palliative care is really uniquely positioned to drive innovation in this space. You know, I. I do think we risk isolating palliative care to sort of only the specialty realm in acute and clinic settings. And like Alan and Ben both said, sort of that would result in others kind of stepping in to lead innovation in areas where our expertise should really guide the way.

You know, I. I also think that we should be careful to not war with ourselves, though, as well, over who gets to sort of use the term palliative, is there a place for many of the models that have been built? Yes. You know, they were built to address a need, whether it’s a program, you know, bridging home health patients to hospice or point solutions to support people with advance care planning. I think this is all good and necessary stuff. You know, the rub is really just that these programs are characterizing what they’re doing as providing palliative care. And are they wrong? I would say not really. They’re providing components of palliative care.

Eric 09:13

But it’s a tension, right? Like a tension between just labeling, you know, having a, you know, administrative staff call somebody up and ask about their symptoms. Is that palliative care? If you label it as a palliative care, it. It addresses one component, symptoms.

Alex 09:29

Yeah. On the other hand, like, we, we can’t say this. We can’t make this argument when it seems convenient or appealing and then not make it in. When we’re talking about, like, research studies that are palliative care informed.

Alan 09:44

Yeah.

Alex 09:45

You know, like, like Enable, for example, you know, where you have like trained nurses calling people or even lay health workers. We have a podcast that we’re gonna record coming amazing results, assessing patients symptoms and then connecting them with advanced practice providers. Is that palliative care light? Are we. Why isn’t that. Why are we using this palliative care light label?

Alan 10:09

I wanna, I wanna, I wanna ground this conversation in a couple of. In two specific things that come to mind.

Eric 10:15

Ground us, Alan.

Alan 10:17

We need grounding as we are talking about population health. How do we deploy resources? We have to be grounded in, like, what are the core things that are North Star. So one thing, and this is piggybacking off of conversations that AIRA started a few weeks back talking about access. Right. We as a field, I don’t think anyone here disagrees that expanding access to palliative care is a good thing and that there’s tons, millions of patients who would benefit from palliative care that aren’t receiving it.

And there’s about five or six kind of categories of access that I could think of, whether it’s, you know, downstream versus upstream access, geographic access, disease profile access. You know, we’ve historically really anchored on on oncology for very understandable reasons, and we’ve great. Done great work there and with more work, you know, in the last few years around advanced heart failure and neurologic disorders, dementia.

But there’s still a lot of areas where palliative care doesn’t really know exactly what best practice looks like for our polychronic patients, our 70 year old with dementia, diabetes and COPD, you know, what does it look like for palliative care to deliver a high quality palliative care there? So the disease profile, all of those are parts of access. Right. And if we want to be able to talk about this, we have to be able to balance what does it look like to increase access to something that is under the umbrella of palliative care and helpful.

But then at the same time we have a workforce shortage where the growth of work from palliative care workers is slowing down. Right. And so how do we do both at the same time? At the same time that the health system is trying to pour money into.

Eric 12:04

And I’m going to add another component. So we had Ira Biock come on and talk to Christine Newport, talk about quality palliative care.

Ben 12:14

And then.

Eric 12:14

Yeah, I’m Bryn. Cause quality is the other, the big thing. Cause I remember. So there was a time we have satellite clinics here at the place that we work and we heard that somebody was opening up. So I run our palliative care service. I heard that somebody not in our palliative care services opening up a palliative care clinic. I’m all, huh, that’s interesting. I don’t know anything about this. And I found out that they were, what they were calling palliative care clinic is they were going to send out squeeze stress balls to people and some packet of stuff. And really that was about it. So it’s truly palliative care life.

Alan 12:51

Palliative care. Yeah.

Eric 12:52

And man, like I had to put the kibosh on that because like a. I don’t want people thinking, oh, this is what palliative care does.

Alex 13:00

It’s the squeeze ball.

Eric 13:01

It’s the squeeze ball like. And that’s all we do.

Alex 13:04

Right. And you may all have examples of. Concerning practices and I don’t feel free to share.

Eric 13:09

Nobody would have started a cardiology clinic or a cardiology service, labeled it cardiology and just sent out squeeze balls. I don’t know. What do you think?

Mindy 13:22

I mean, I think what people are poking at when they say, you know, that there are a lot of programs that are sort of palliative in name only, is that many of these programs all are sort of solving for just one piece of the puzzle and they’re not providing comprehensive support to patients. So, you know, the potential harm there is that someone referring to palliative care. So a referring provider or even patients or their families that believe they’re accessing a service that would address their needs holistically.

That’s not what they’re getting. You know, they may get some narrow version of that, which likely leaves their needs unaddressed and unmet. And, you know, you mentioned this sort of existential threat to palliative care earlier. I think that’s where that starts to harm this field because it harms the perception of palliative care and it dilutes its perceived value.

Alan 14:17

Actually, what is the other side of that coin where it’s not just if the patient is expecting something else, if the patient receives. Because we know a ton, you know, the vast majority of people don’t know a good definition of palliative care. And so if the version of palliative care received is a stress ball and the person going through an ACP document, then when things progress or when someone advises no, you actually need more robust versions of palliative care.

This happens in our daily practice all the time, where patients will decline. Our board certified physician leading an IDT team with a chaplain and a nurse because they think they were receiving palliative care because someone comes to their home once a month and does a home health assessment and maybe an ACP review. Right. And it’s causing brain confusion in that way as well. And that’s part of this existential crisis that I’ve been alluding to.

Ben 15:12

We need to take control of the narrative around what services palliative care provides. Right. And that’s part of the reason that you asked us to come on the podcast is, you know, what is the threshold for a palliative care program to exist? I was having a conversation with someone yesterday about a pre health student home health companionship service. Right. That sends a student who’s trying to get access to patients and to have experiences caring for someone.

And I know that when I refer to that service, I’m referring to a lay support service. But if someone looks them up on the Internet, they may think they’re getting a home health service at a significantly reduced price. So we need to make sure that when it comes to the brand of palliative care, that we’re giving people sufficient access to palliative care resources.

Eric 16:14

Yeah, can I go back for one second too? Because maybe it would be helpful if we put this in scope. I’m going to go back to you, Alan, because one of the things we talked about was this difference between this older model and. You were alluding to this at the start older model of fee for service. You have a consult team. Really, the only people who can bill for that consult are the licensed independent practitioners and a newer model from these community based palliative care. Which of those are, are you seeing growth in both? Like where, where is your excitement coming from, your optimism coming from?

Alan 16:56

And, and I want Mindy to also be able to weigh in on this as well. Yeah, I, my optimism is coming. So, so the growth that we’re seeing is as far as defining some things, fee for service, you guys are all pretty used to this. It’s, it’s basically you get paid for the amount of work that your team does according to whatever rules of the game that CMS or the health plans put in. This other general category of value based care, it’s a spectrum. Some can just be fee for service with some additional incentives for certain behaviors that you’ll get extra revenue for, but it can all the way.

On the other side of the spectrum is what we would consider to be full risk, where basically the org, the practice is going to share in the, the profits and the potential loss if the outcomes of the patient ultimately aren’t the expected outcomes or desirable outcomes. So it’s really a focus on outcomes and it could be almost completely removed from the amount of work it takes to get that outcome that’s in its most like, simplistic way.

Eric 18:01

And so, so this is the value based carrier. You’re paying for whatever we’re terming as value, right?

Alan 18:08

Yeah. And so it’s essentially a population health version of palliative care is where there’s a lot of growth that’s happening and the other area where there’s a lot of growth is in practices that are trying to do some version of home based care or value based care. And it oftentimes is associated with something resembling complex care management where they may be the PCPs, they may work alongside the PCPs and they’re being asked to deploy palliative care esque interventions alongside of it when necessary.

But in both of those scenarios, in order to do any of that stuff, well, it becomes less about how does palliative care respond to the needs that are being given to them. It’s more as, okay, we have a population, then how do we figure out what the palliative care needs of this population are and then how do we deploy the right amount, the right intensity at the right time, in the right location, what, what we think these patients will benefit from?

Eric 19:06

Is that how you’re thinking about it too, Mandy?

Mindy 19:09

Yeah, I, I have to say I don’t think I’ve ever met anybody that is excited about the fee for service component of this. So I, I think the like excitement and optimism that I hear and see is more in, you know, the value based space and, and what is sort of possible more broadly in the field of, you know, population health and chronic care management.

Eric 19:34

And I gotta say, you know, CAPC had a hiatus because of COVID Before COVID I gotta say I did not see a lot of value based organizations, community based palliative care, at the CAPC meetings this time around. Alex and I were like shocked. Like the difference, I’m not sure if you felt that difference too. If any one there is, is that a lot of the people we met, including folks like Alan for the first time, are working for these organizations. Were you feeling the same thing? Like this is the, this is the big growth?

Mindy 20:10

Yeah, yeah, I think it is. And you know, I think that’s sort of the rub too, right, is it’s a little bit of the wild west. And I think when, you know, risk bearing entities, payers, you know, folks that are in that value based space are looking at their population and trying to determine where do you invest your resources, who is sort of the sickest portion of your population. It tends to be your palliative population. And so I do think that that’s where a lot of the opportunity and excitement is coming from. It’s also what’s creating a lot of these, I think sort of like concerns from the field.

And you know, I, I guess the way I think about it a little bit too is we can agree on standards for what is community based palliative care. What is palliative care outside of, you know, this specialty focus or outside of an acute setting. But you know, the, the thing that I wonder about too is even if we can agree on standards, which I think that like the national clinical practice guidelines are a good starting point for that. I think we’ve actually got a good foundation for what standards should be. How are they going to be enforced? And I, I think this is another reason there’s a little bit of a rub here I think too with, you know, fee for service does largely only reimburse for provider visits.

But I think the foundation of palliative care is more interdisciplinary. And so, you know, the way that you would design sort of an ideal palliative practice doesn’t really align with the way that it’s reimbursed. And so, you know, one of the things that I think we should also be talking about is a palliative care benefit. And that would really allow you to have standards for what Community based palliative looks like what really high quality, you know, palliative programs look like. Because without that, without a formal benefit, with defined standards and monitoring, program integrity and program design really relies on kind of voluntary adherence to best practices and consensus based definitions. So we’re all really just in kind of a handshake agreement with one another on what we think palliative care is or what quality palliative care is.

Eric 22:31

Yeah, that was aira’s big focus, is having standards for palliative care. So we know what we’re saying. But as it comes at the caveat is it takes, you know, innovation also comes from a space where maybe we’re pushing those standards, we’re changing what. And a lot of the innovation is happening in these programs. I’m wondering, like is there coalescence in this wild west about like who is staffing these programs?

Mindy 22:58

Like what disciplines?

Eric 23:00

Yeah, like what does it look like out there? Maybe for your own individual ones or ones that you’ve heard of. If you don’t want to talk about.

Mindy 23:06

Your individual ones, go ahead, go ahead.

Ben 23:10

I think the financial implications have forced a coalescence, right. That it’s barely financially sustainable to have nurse practitioners in the field. It’s not sustainable to have physicians doing home based palliative care visits. So I think the overall model in my organization and many other organizations I’ve spoken with is a nurse practitioner led. You have excellent training, comprehensive year long trainings with ride alongs, with access to Cap C. You have trained nurses and the nurses the nurse practitioners may do in home visits, they may do telehealth visits.

I know that at Gentiva we also have access with our home based care programs to chaplains and social workers. If we’ve identified that that may be a benefit to the patient. So I think that there’s a feeling there’s an agreement that palliative care by nature is an interdisciplinary specialty. But we have to think about how to innovate the delivery of that interdisciplinary care.

Eric 24:28

And even nurse practitioners are expensive.

Alan 24:30

Yeah.

Eric 24:31

So I don’t know. What were you going to say?

Alan 24:33

Alan? I want to add an adage that everyone in this space says is you’ve seen one value based org, you’ve seen one, right? It’s hard to extrapolate. There are going to be things that once there’s been time for all these models to play out where we will learn some degree of best practice. Not to get into the weeds of stuff, but sometimes a model could work great, but the way that a certain contract is written can Tank it. So there’s a lot of nuance that there’s a lot of factors that we have to take into account with that being said, some truisms that I think are relevant in this space.

Back to one of your original questions around fee for service versus value based care. One thing that is unique about this space is in fee for service. If we were going to lean into our non specialty partners to be delivering the foundational steps to be able to make our work as a specialty docs, as a specialty teams more effective, they were essentially doing that against their own interest. Right. It would take, it would make their visits longer. It would be more. It’s if they’re, they’re out of their typical weehawks.

If you’re asking a cardiologist to be engaging in kind of preliminary goals of care conversations, they’re doing that because they think it’s the right thing to do, not because that’s what the system is incentivizing them to do. In the value based care world where there’s much more focus on outcomes, a lot of these orgs are actually putting accountability on non specialists to be driving quality, whatever you want to call it, if you want to call it palliative care, if you want to call it the beginnings of a serious illness conversation. And so that behavioral motivation, those dynamics are actually in our favor in this space where we were actually working against us. We were trying to work in spite of them. And fee for service.

Eric 26:16

Can I push back on that for a second?

Alex 26:18

But before you push back, just a clarifying question for our longtime listeners who probably heard our podcast about Medicare Advantage with Claire and Kuda and Don Berwick and we talked about special needs plans. I’m hearing a lot of value based plans and fee for service. Is value based plans synonymous with Medicare Advantage or is that something else?

Alan 26:40

Yeah, Mindy, actually, do you want to, do you want to tackle that?

Mindy 26:43

Yeah, I think they typically are so either dual eligible or. Yeah, Med Advantage plans. So I would say any, any sort of risk bearing entity which tends to be in the part C space.

Alan 26:56

Okay, thanks. And a lot of. Here’s my question, are contracting with these risk bearing entities to deliver care.

Eric 27:03

So you have these risk bearing entities. Obviously people want to deliver good high quality care. But part of this is also cost containment is you’re accepting risk and for any board member you have fiduciary duty to the stockholders for a lot of these organizations. So you do want to do cost containment and fee for service. There is no cost containment push. Right. It’s about bringing money in and hopefully delivering high quality care. In these organizations, these value based organizations, certainly high quality care is just like fee for service, everybody wants to deliver.

But there is this other motivation which is opposite for fee for service, which is cost containment and potentially trying to do like, if, if you were just focused on cost containment, it would be delivering the bare minimum needed to achieve that cost containment outcome. Not saying anybody is doing that, but like I think that is this tension between fee for service and these value based organizations. How do you think about that and does that sound right? Mindy, you know, we’re pushing you a little bit on this one.

Mindy 28:17

Yeah, I guess the way I think about it in value based arrangements, I mean, you know, I, I, I would say a lot of people could view them as cost saving strategies. I would also argue though that if palliative care is done really well, cost savings becomes the byproduct, it’s not the purpose. So I, I think, you know, both can be true. I don’t think we can ignore the.

Ben 28:40

Need to deliver meaningful value program like.

Eric 28:45

Honestly, really care about, are they caring, are they doing these contracts because they really care about delivering high quality palliative care or are they doing these contracts because they think hey, this is a good cost containment strategy?

Mindy 28:58

Yeah, I, I don’t know. Honestly I can’t speak to their motivation necessarily, but I, I guess I would view it whatever their motivation is. I think in, in the value based realm it has opened up access. So, so even if that is the motivation of a med advantage plan or you know, a risk bearing entity is they think oh, there’s potentially some cost savings to focus on this population. The byproduct of that motivation is that they have been invested in palliative care which has expanded access to people. And I think that’s inherently positive. And so then I think it’s, it’s really up to, to us to then make sure that the, that programs are constructed and delivered in a way that they create good clinical value for the people that are receiving that care.

Alan 29:52

Yeah, yeah. And part of the onus falls on us as the palliative care community, the palliative care leaders in this space is to actually help show that value beyond cost containment. And that’s a big challenge and struggle for us to be able to do so. We don’t have to kind of, we don’t have to talk too much about all the nuances of the way financing works in this space, but there are a lot of ways that we can show that value other than Cost containment, other than getting patients onto hospice. But it’s not. There’s no manual per se. CAPC has given a lot of resources to assist with that, but there’s no playbook on exactly how to best do that within your org. Ben, I think you. Yeah.

Ben 30:35

What is the hospital’s motivation for having a palliative care team? What has CAP C told us about the benefits of having inpatient palliative care and outpatient palliative care?

Alan 30:45

Right.

Ben 30:45

Decreased length of stay, decreased ICU admissions. Right. These are all cost containment strategies that, you know, for the last decade we’ve used to ask for more resources for inpatient palliative care. Right. And palliative care should be so excited about value based care because it’s what we’ve been delivering even in the inpatient setting as we’re asking for more resources. Hey, listen, you know, I would like to have another full time palliative care doctor, another full time palliative care chaplain.

Because we have saved X number of ICU days, which translates into this cost savings, we’ve been able to transition patients appropriately into hospice so they haven’t died on the hospital census, which has helped with our metrics. Right. We’ve always presented a value argument when talking about the benefits of having a palliative care team when you’re talking to hospital leadership. So I think that it’s just, you know, you throw in this big, scary Medicare Advantage, you throw in the scary for profit or private equity funding, and the conversation can get blown out of proportion. But I think at the end of the day, you know, every palliative care leader has approached someone when arguing for resources and talked about cost savings. Right?

Eric 32:09

Yeah. It’s the tension in the field. It’s always been a tension in the field is that, you know, everybody cares about quality and delivering high quality palliative care, and we think that’s the primary focus of palliative care. But happy happenstance is that it may actually reduce overall costs for the healthcare system, which has led to palliative care growth. It’s been a big driver, probably the primary driver in palliative care growth. And is this like evolution? You know, that was Palliative Care 1.0, and is this Palliative Care 3.0, where we’re pushing that growth based on more and more focus on, you know, benefits to the system?

Mindy 32:54

I think that’s one of the things I think of, you know, when I get excited about where we’re at is people actually want to invest in this space, which again, opens Access. It provides such an amazing service for more people. I can certainly understand why as a field, you know, people get nervous about the motivations for that investment. But, you know, at the end of the day I, I think it’s a better position to be in that people see value in the work and, you know, they want to invest money to increase, you know, the, the scope and span of, of this work and these programs versus the opposite, which is, you know, I think if, if we say, eh, I don’t know, as a field, we’re nervous about this. We don’t really trust you make us so precious.

Yeah, like we’re, you know. Yeah, we don’t really trust what’s going on here. So. No, thank you. You can keep your funding and let’s just, we’ll go over, we’ll go over here in the corner. Then I think we, we just isolate ourselves and somebody. We talked about this at the beginning of the podcast. Somebody will fill this space. If it’s not palliative, the, this gap in care delivery, this gap in care management, this gap for, for patients and their families still exists. Somebody will fill it. If it’s not palliative care, it’ll be something else. You know, it’ll be home health, it’ll be whatever. So I think let’s like not look a gift horse in the mouth, I suppose is maybe a way of saying it. Like people want to invest in this. Fantastic. You know, let’s just make sure that we’re doing it in a way that is quality.

Alex 34:32

Oh, go ahead, Ben.

Ben 34:34

Those investments drive the innovation. Right. You can innovate very slowly in a fee for service space, but when someone says, here is this bundle of money, I want you to create, create the best service that you can provide for these patients with this amount of money. You know, some are going to do well, some are going to fail, but that’s the quick evolution that can happen in this space.

Eric 34:59

Yeah.

Alex 35:00

Can I ask a question? I think all three of you work for for profit companies that write Monogram, Optum and Gentiva. I see everybody nodding and I don’t know if all three of you were at CAPC. I know Alan and Ben, you were there. Mindy, I don’t know if. Were you there?

Mindy 35:18

I was not.

Alan 35:18

No.

Alex 35:19

In the opening plenary, Diane Meyer came down pretty hard on for the rise of for profit palliative care and hospice. And I wonder what you think about that. And the major concern is that for profit, hospice and to some extent palliative care has been associated with worse outcomes for seriously ill patients. And then I think the guest that Diane Meyer was talking with said I don’t think it’s about tax status. This is true of plenty of, you know, nonprofit organizations as well.

And there was a lot of clapping from the audience. I’m interested in your thoughts on this. Like what concerning practices have you seen that might validate, you know, Diane Meyer’s concern? And also like what would you say in response to somebody who’s like really concerned about the growth of for profit and like private equity investment in palliative care?

Ben 36:16

You know, before I ran into the two of you Cap C, I actually was able to talk with Diane Meyer and, and what I told her was that, you know, I hope that by being in this space, by being a board certified, fellowship trained, hospice and palliative care ph in this space, you know, over my career I can change your mind about the importance of tax status and that, that it truly is just tax status. But as you know, right. We’ve seen all of these issues with fraud and with Medicare fraud and abuse happening with hospice companies in the great state of California and other places.

So you know, there are stories that make people nervous about the idea of a for profit company going in and being predatory towards patients. You know, I think having more players in the field who have the training, who potentially have worked at not for profits or in the hospital space and ensuring that the care that our companies provide keeps the patient first and focuses on the patient. And I think if you do a good job of that, regardless of tax status, your program’s gonna grow and you’re gonna be able to iterate exceptionally high quality care.

Eric 37:37

Yeah, I’m go back. It sounds like as long as the people at the table who are making those decisions are people who care about that. I think that was the first argument is being at the table. Yeah. Other thoughts on Alex’s argument or Alex’s question?

Mindy 37:55

I agree with Ben. I guess personally that’s, that’s the way I’ve always felt about it is in the country that we live in, health care. I don’t want to say healthcare is a, is a business, but like it, you know, it is, it is the way it is. You know, it’s. We don’t have a sort of universal healthcare national health system. It is like perfectly fine and legal and encouraged for, you know, for profit companies to, to exist within this space. And, and I, I think it was mentioned earlier that also has driven a lot of innovation.

And so I think, I guess for me personally, I’ve always felt like you have to sort of belly up to the table and be a part of the conversation and not just be, you know, I, I think too hardline or I don’t know, just, just take the position that well, I don’t exactly feel right about the profit motivation and healthcare and so I’m just going to sort of opt out. I don’t think that’s the right way to go because I, I’ve always felt like, well, if you opt out of the discussion and you don’t engage and you know, you don’t work within this framework or, or you know, within the for profit space, then there are 20 people behind you that are happy to take your seat.

Eric 39:09

So certainly looks like somebody in academics. Academic medical centers are certainly looking more and more like for profit entities where bot matters. Alan, I got a question for you though is that there is like this for profit versus like private equity where your goal is very short term gains over a span of like 2 to 5 years.

Alex 39:31

You mean in private equity?

Eric 39:32

Private equity. Like is there a difference there? And how are you thinking about this distinction between nonprofit and for profit?

Alan 39:40

That’s a great question. As far as the motivation, I will say for for profit versus nonprofit settings, ultimately the conversations sound very similar. There’s not a huge difference as far as the ultimate goals of what you’re trying to achieve. So tax status is somewhat irrelevant in that standpoint. In that way. To your question though, it is true that when you are working in particularly in this value based care space, a lot of times the outcomes that we’re looking to impact may be on a shorter timeline than what we would normally like.

Especially if we’re thinking about doing good palliative care and seeing the natural byproduct of good palliative care and not having the. What was it the tail? Was it the wagging tail? I forgot the tail. Wagging the dog, you know, like you’re actually motivated by the right thing. And that timeline is a little bit shorter than I think what a lot of us would ideally want to have. And this alludes to some of the other stuff that we talked about where okay, what are the other things that tie back to the core tenets of palliative care like maximizing quality of life, reducing avoidable suffering in the face of serious illness?

A lot of the stuff that specialty palliative care folks like myself, before I started entering into more the geriatric space didn’t think too much about things like re hospitalization reduction for a polypharmacy, being really Careful about polypharmacy, being thoughtful about falls preventions, fractures preventions.

Eric 41:02

Lot of geriatrics there, a lot of Geri.

Alan 41:05

A lot of the Geri. Right. And that stuff, also from a cost containment label, falls under that bucket. But that’s also core to what quality of life looks like for these frail geriatric patients that we are being asked to take care of. And so that’s another existential, I don’t want to say crisis, but thing that I want to encourage our palliative care leaders, palliative care community, to be thinking about what it looks like to start incorporating a lot of those things that we’ve often siloed into the geriatric space, because that stuff matters to our patients and it matters to Will never and.

Eric 41:37

Even into our training like that. The amount of training we do in palliative care on deep prescribing falls, cognitive impairment is minimal. I wonder. Last question for all of you. Lightning round. Because initially we were going to trim this palliative care light. I think you’ve con. You’ve changed my mind to say maybe that’s a pejorative title and we shouldn’t be using palliative care light.

But like, when we think about Palliative Care 3.0, like if you had a magic wand, you can make Palliative Care 3.0, what would that look like for you right now? Especially as we talk about these, these areas of growth in these community based palliative care organizations. I’m gonna start with Mindy. What’s your magic wand? What does palliative care 3.0 look like?

Mindy 42:23

Oh, gosh, you know, I, I think that it is programs that are really specific to the populations that they’re serving and where the model matches intensity to patient need and also, you know, conforms to minimum necessary requirements that ensure comprehensive palliative care.

Eric 42:46

Wonderful. Ben.

Ben 42:48

I would want every patient with a life limiting illness and, you know, on a certain timeframe, if we had a perfect prognostication tool, and I could say that two years before the end of someone’s life, after they’ve had their serious illness, that they could have a real advanced care planning conversation. Hey, you’ve been down this road with heart failure. You’ve had an exacerbation. Now what’s important to you? If we could get that piece right and then have specialty services from there, either home based palliative care with some frequency, hospice when appropriate, I think that would be, that would be perfect. But really letting everyone make advanced care planning decisions contextually, in the context of their serious lms.

Eric 43:36

Wonderful. Thank you Ben. Okay Alan, bring us home.

Alan 43:40

I think it’s important to build a ecosystem around a patient where we are thinking about what upstream less clinically complex kinds of interventions we can we be providing for patients as they’re further upstream in their serious illness journey and we give tools to non specialists to be able to deploy that and then that we have thoughtful monitoring of those patients as they continue on and then we can layer on more specialty level care as the patient needs and that we track it thoughtfully as part of one coherent, one continuous program. Kind of.

I may be tooting my own horn. That’s what I’m trying to build at my pro at at our org. But I feel like that is going to be really key to doing this work at scale knowing that there’s not a thousand pally docs that are going to build. We have limited scale resources.

Eric 44:32

So yeah, we’re not unlimited, but maybe together we are unlimited. Together we’ll be the greatest team that’s ever been.

Alex 44:48

(singing)

Eric 45:41

I actually had to look up the lyrics.

Alex 45:42

Yeah, I saw that. You haven’t seen the movie. You gotta watch the movie. Song is great. Amazing.

Eric 45:50

Well, I want to thank all of you for being on this podcast. Mindy, Ben Alan, that was amazing. And thanks for the great work that you’re doing and really leading innovation. So thank you.

Mindy 46:00

Thank you you.

Alan 46:02

Yes.

Eric 46:03

And thank you to all of our listeners for your continued support.

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