Building a Sustainable Palliative Care Program (Part 1)

Podcast Episode 1


Speaker 1 (00:00)
I believe home based palliative care is not only the most cost effective in the long run, but it provides the best care. And in this case, the best care equates to fewer readmissions, to fewer deaths on palliative care and really, patients who are more pleased with the outcomes that they get.

Speaker 2 (00:29)
Welcome to Transcending Home Care. Stan Massey of Transcend Strategy Group holds vital discussions with other experts on insights and ideas to help providers succeed in the ever changing landscape of home care and senior care. For more than 20 years now, Stan has helped providers build their brands to increase referrals, admissions, staff retention and performance scores.

Speaker 3 (00:53)
This episode features a conversation with special guest Mark Hendrix, president of Intact, a company that specializes in building sustainable palliative care programs. Mark and Stan talk about overcoming obstacles to palliative care through smart billing strategies, processes and technology.

Speaker 4 (01:14)
Mark, thank you so much for being our podcast guest today and for your.

Speaker 5 (01:17)
Willingness to discuss the often puzzling world of palliative care.

Speaker 1 (01:21)
Thank you for having me. I look forward to the discussion and certainly I’m very passionate about the importance of palliative care and look forward to our talk.

Speaker 5 (01:30)

Speaker 4 (01:31)
Well, let’s tackle the elephant in the room right away. It’s no secret that Medicare reimbursement for palliative care is and has been weak, which has been a major obstacle for.

Speaker 5 (01:41)
Providers to offer this valuable service.

Speaker 4 (01:43)
What are other big barriers, in your opinion?

Speaker 1 (01:46)
Well, first I’d like to say that I think we’re making great progress. Over the last few years. We’ve seen many changes that have been encouraging to the palliative care community. The Medicare grant, the CMMI grant really started that change and I think payers are now beginning. Other payers besides Medicare are beginning to recognize its importance. But I think that one of the key things that’s a barrier now is data. I think Medicare having more awareness that palliative care saves Medicare money by reducing readmissions and unnecessary procedures. They’ve learned that they can collect more money from patients by spending a little bit more on palliative care. So we really must collect more data that supports our case.

Speaker 4 (02:37)
That makes a whole lot of sense.

Speaker 5 (02:39)
What are ways that providers can make.

Speaker 4 (02:41)
Palliative care financially viable? With the current situation, I think the.

Speaker 1 (02:46)
First thing they have to do is we have to focus on efficient processes and models. There are many models out there, some are more efficient than others, but I think they have to focus on processes and becoming very efficient at everything that they do. The other thing is the billing codes. Use the billing codes more efficiently. There are still many palliative care programs that do not effectively use the CPT codes that are already out there. So that’s really a shame. And I think that they really should focus on educating themselves as well as their team on how they can use the billing codes more effectively. So those are two of the key things. And I think beyond that, the use of technology such as telehealth, remote patient monitoring, all of those things can be used and many more to increase the coverage areas and to monitor patients more efficiently. And monitoring patients is the key to palliative care. It’s the most difficult thing, but it’s really the key to keeping patients out of the hospital and keeping them at home under the care of palliative care. Another thing is really tracking the key performance indicators and communicating with our community partners.

Speaker 1 (04:06)
But all of those things are part of building a very successful and financially viable palliative care program.

Speaker 4 (04:15)
Yeah, very good points. You mentioned the use of telehealth and technology, and I think in a future episode we might get into that more deeply. But in general, COVID ushered in a greater acceptance among Medicare and other payers for allowing telehealth to be billed where in the past it wasn’t allowed. Are you seeing more loosening of those regulations coming down the path so that telehealth will be a viable method and users will be able to get reimbursed?

Speaker 1 (04:47)
Yes, I do. As a matter of fact, in the 2023 CPT codes, we’re still evaluating what the true impact on them is. And there’s certainly some changes that we would perceive as being.

Speaker 1 (10:00)
Positive and some not so positive. But telehealth is one of those that I think is going to be around. COVID really proved that it’s an essential part of palliative care and caring for patients at home. And more and more people have used it and by using it, they’ve communicated that back to Medicare and to other payers. So I think that telehealth is going to grow as well as remote patient monitoring is going to grow and I think Medicare and other payers are going to begin to see the importance of that in providing good lower cost palliative care and home palliative care.

Speaker 2 (10:41)
I hope that is the case because it would be helpful all the way around. We’ve been working with clients and just watching the industry for more than 20 years now. And I know that when Palliative Care was initially chosen as a separate service line from Hospice Care for a lot of providers, I heard a lot of our clients using a retail term, and they said that they were going to consider palliative care as a loss leader because with the weak reimbursement, they felt certain that they were going to lose money providing palliative care, especially at the patient’s home. Their concept was that they would form a relationship with those patients and families and convert them to hospice care earlier than they were currently doing to increase length of stay. And I think for the most part that has not worked out with that game plan. So there are providers that are still losing money on palliative care and they still are fulfilling their mission to provide the best quality care they can because of situations like that. I’ve seen a lot of providers attempt to put guardrails on their palliative care program to limit its scope and perhaps contain the costs or at least their losses from it.

Speaker 2 (11:59)
Some offer palliative care only for certain disease states. Others I’ve seen have care only at clinics and not the patient’s home. What are the parameters you’ve seen that make the most sense to limit the scope and scale because of the financial reimbursement situation?

Speaker 1 (12:17)
Wow, there’s a lot in what you just said. And of course, I have some pretty strong opinions about palliative care and we talked earlier about barriers to palliative care and I think one of the key barriers to palliative care is mindset. We have a mindset that’s a loss leader, many people do, that is unsustainable. And we spend so much time talking about how it’s unsustainable or how it’s a loss leader that we forget to really track our performance, to collect our data, to really run it like a business. And we have to run it like a business that’s in the business of caring for patients. So guardrails, I think, can really be too strong, if you will. In other words, we get so focused on it being a loss leader that we really don’t put the emphasis on it that it really needs to have so far as restricting it. Especially, I see some people restricting it just to clinics or whatever. And clinics are an important part of palliative care. However, just like all settings, clinics at first can appear to be the least expensive care model. But maybe it doesn’t always provide the kind of care that the patients need, especially for those patients whose disease has progressed to the point to where it’s very difficult for them to make a visit to the clinic.

Speaker 1 (13:46)
I’d really love to see a study, and maybe this is something we can initiate stan is to see a study that compares, really, the readmissions to the hospital for patients in clinics and the length of stay in hospice of patients who were prior clinic patients compared to those patients who really were home based palliative care patients. I believe home based palliative care is not only the most cost effective in the long run, but it provides the best care. And in this case, the best care equates to fewer readmissions, to fewer deaths on palliative care, and really patients who are more pleased with the outcomes that they get.

Speaker 2 (14:40)
Those are definitely all benefits of an effective palliative care program. You mentioned earlier about really running palliative care as a true business and not expecting it to be a loss leader. Are there certain guidelines that are just smart business practices that you recommend for palliative care, such as starting small, I mean, either geographically or what’s the minimum staff an agency needs to run a palliative care program efficiently?

Speaker 1 (15:09)
Great question. If you’re a hospice agency, or any agency for that matter, that’s looking at starting a palliative care business, I’d like for you to think of it not in terms of starting a palliative care business, but building a palliative care business. I compare it to building a fire versus starting a fire. When you build a fire, you start small with a spark, and then from there you give it exactly what it needs at each step of the way, all the way until you have a huge fire. But you do that by starting with a good foundation, starting with a good plan, and you build it and you give it what it needs. In reality, palliative care programs become financially viable. When you’re looking at about four nurse practitioners with a caseload of about 70 to 80 patients per provider per nurse practitioner, at that point in time, you’ve got sufficient billing to begin supporting staff such as an admissions team, nurses, those type things. So at that point is when you really begin to see the benefits of the program, not only from the standpoint of financial viability, but you begin to see your program begin to transition patients at a much higher level.

Speaker 1 (16:39)
And you can only do that with a direct focus that really supports the hospice team and supports your entire team.

Speaker 2 (16:49)
Wow, that’s really good advice. And that’s some interesting guidelines as far as staffing that I think our listeners will really benefit from. You were talking also earlier, Mark, about the need to collect data. And I know that there have been multiple studies that have proven clearly about the financial impact on the total cost of care that palliative care has. I know of one study in particular, and I wanted to cite a couple of data points from this study that took place in western New York. It involved a really good combination, a collaboration between a provider, a major health system in the area, and an insurance payer. And I’m quoting from the synopsis of that study, and these figures are pretty staggering. It said, and I quote, cost savings were apparent in the last three months of life, $6,804 per member per month for palliative care participants versus $10,712 for usual care. So that’s a difference of $4,000 per member per month. The study goes on to say that during the last two weeks of life, the total allowed was $6,674 per member versus 13,000 846 for usual care. So again, that is a difference of $7,000 per member with such clear data.

Speaker 2 (18:16)
And there have been other studies in California, other parts of the country, that have very similar results. And with that data, palliative care obviously benefits payers tremendously. So why is it taking so long for payers to really get behind palliative care?

Speaker 1 (18:37)
That’s a great question. It seems so obvious. It really seems so obvious. But I think that we have to look at it from the standpoint of for so long. We’ve seen healthcare costs increase, and this is across the board, not just for palliative care. And insurance companies, I don’t think really saw their role at that point in time as being to reduce cost. It was more to cover cost. But as healthcare costs have increased, I think that that’s one of the key drivers to where they’re now seeing the importance of reducing their cost. I believe that CMMI grant for palliative care highlighted this, and I think it highlighted it for palliative. But across the board, that really the best place, not only from a care standpoint, but from a cost standpoint, to care for patients is in the home and not in emergency rooms and not in hospitals. The best and the least expensive place to care for the patients is in the home. Hospitals weren’t really designed to care for patients who had the type of illnesses that we’re seeing, and they are great at what they do. But palliative care is not one of the things that really focused on, nor should they be focused on.

Speaker 1 (19:52)
So I’m excited actually, that so many payers are now starting to realize the benefits of palliative care. I’m just hoping that the agencies out there, the hospice agencies and the other agencies that are caring for seriously old patients, really see this as an opportunity to begin thinking about the way they run business or their business more along the lines of palliative care and reducing cost. And I think we also need more studies that educate the healthcare community of all the benefits of it. It seems so obvious. You’re right. Those numbers actually, I would say that what I see those numbers are low. I think there’s even more savings than we’ve seen in those numbers. There’s even more savings potential than we see. But I think it’s going to take time, continued time and continued focus and continued education of our community and our legislators to really see palliative be where it needs to be.

Speaker 2 (20:58)
That sounds about right to me, Mark. I think that the legislative side is something that we know that the hospice and palliative care associations and other nonprofit entities are especially working, trying to get legislative change. You’ve mentioned some of the grants that are in process, but what else is currently going on at the legislative level to improve Medicare reimbursement for palliative care? And how close do you think we are to seeing significant change? And I know you don’t have a crystal ball, I won’t hold you to your answer, but what’s your opinion on how close we are to significant change for the palliative care reimbursement model?

Speaker 1 (21:40)
Well, I think in 2023, we’re still evaluating the CPT codes, the changes that went into effect in January 1. Telehealth codes are certainly something they see. Legislators seem to see the importance of the non face to face billing codes. It seems like those are being restricted some, but I think some payers are still honoring those codes. So from the standpoint of progress, I just think we’ve got a long way to go. I think that we really have to educate our community, and I think we have to pull together as a group and a collaborative effort to really promote palliative care and to really let our legislators know what we’re doing in the community. I think we’re a long way from really seeing the full benefits. But I do want to emphasize I see progress. I see a lot of progress. I see a lot of payers taking their own initiatives to have their own programs and to reach out to hospice agencies and other agencies for palliative care. There’s a huge change underway right now, and it’s good change, but I think that we’re going to have to change ourselves before the legislators really get on the bandwagon with us.

Speaker 1 (22:56)
I think it’s up to us to educate them and us to do the right thing for our patients. I think that’s the best thing we can do at this point.

Speaker 2 (23:04)
I hear you. I know that some of our clients that have actually made margin on palliative care have mostly done so by contracting directly with hospitals and health systems. They might be an arm of sorts for that provider, and even the hospitals might say they have palliative care, but they’re really just providing an inpatient consult, which Medicare obviously reimburses for. Do you see that private contracting among community based providers working with hospital systems to be one of the most direct routes to making margin on palliative care?

Speaker 1 (23:43)
I absolutely do, and I’m glad you brought that up because I think the hospital setting, that’s a natural place to screen patients for the need for palliative care. I think most hospitals see that as an opportunity to take better care of patients. The challenge that the hospitals have is after they leave the hospital, those patients don’t receive the kind of care they need in order to keep them from being readmitted to get the kind of care they need. So I think most hospitals, if you’ve got the data and if your program is proven that you can reduce cost and you have a proven model, and I think that’s the first part of building a program is proving your model, then I think hospitals are very open and very willing to work with you. And it can be done any number of ways from the hospital providing inpatient palliative care and then letting the agency be a referral source to a hospice agency, putting resources within the hospital to work directly with those patients. But the key is once they leave the hospital, they’ve got to get care or you never really complete the circle. So they really have to have a way to care for them after they leave the hospital.

Speaker 1 (25:04)

Speaker 2 (25:04)
We’ve seen the models that you just mentioned, different cities across the country using those with success. Are there any other aspects of palliative care finances we should discuss in this episode that we haven’t yet?

Speaker 1 (25:19)
I want to just mention one other thing as it relates I don’t know if it relates to finances or not, but I think it’s important. I don’t think we talk enough about the importance of social workers in the palliative care area. I’ve worked with several programs that use social workers and I think they use them for different roles within their program, everything from the intake process to the follow up and monitoring process to going out and seeing patients in their home. And I think that they bring a completely different dynamic to the program. And I just like to see more people really investigate it and look at the potential of using social workers in their program. In today’s world, there’s a need for people to look at their social health as well as their physical health, if you will. And I think that social workers can provide that and they can bring a completely different dynamic to the program. So just consider that and we could have a conversation about social workers in palliative care. That could be an entire 30 minutes podcast.

Speaker 2 (26:26)
Right, that’s a very good point. I think everyone that participates in palliative care hopefully will see it as holistically as they perceive hospice care already doing, and social workers can play a key role in that. I’m glad you mentioned future episodes too, Mark, because I want our listeners to know that we will be continuing these important discussions with you on ways to make palliative care viable. So I encourage our listeners to keep an eye out for upcoming episodes when we explore other aspects of successful palliative care programs. So, Mark, I want to thank you so much for your wise insights during this session and I really look forward to continuing our conversation.

Speaker 1 (27:08)
Thank you, Stan. It was great talking with you and I look forward to discussing it in future podcast.

Speaker 2 (27:14)
Very good. Thanks again, Mark.

Speaker 1 (27:15)
Thank you.

Speaker 3 (27:18)
Thanks for listening. Watch for future episodes of Transcending Home Care on itunes, Spotify, Stitcher and I Heart Radio. For more content, visit

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