The ability to sustain and grow a palliative care program hinges on successful retention and reimbursement strategies alongside a deep understanding of patient and family needs.

This is according to Amy Lung, national senior general manager of palliative care at Carelon. The health care services brand is part of the insurance company Elevance Health (NYSE: ELV). Previously known as CareMore, a segment of Elevance Health subsidiary formerly known as Anthem, the home-based care company rebranded and launched as Carelon in 2022.

Palliative Care News recently sat down with Lung to discuss how palliative care providers are navigating a wide range of challenges and opportunities on the near horizon. Carelon offers palliative care, behavioral health and care navigation services. The company also operates a pharmacy benefits manager (PBM) program, CarelonRx, and provides other services.

Photo courtesy of Carelon Health Photo courtesy of Carelon Health

Can you walk me through the evolution of Carelon Health’s palliative care services and how these have taken since you first began to offer them?

We are one of the largest palliative care providers in the nation. We don’t own any hospices. Our palliative care business was formed as a Nashville-based company called Aspire in 2013. The program was later placed under Carelon’s health care services in 2018 after it was acquired by Elevance Health [subsidiary] Anthem.

There’s been an enormous amount of really neat change as we think about how we utilize a palliative program like this with our other Carelon service offerings. We really take and scale palliative care in a number of different directions.

Our whole-person care model is truly rooted in empathy, with a deep understanding of the patients who we serve living with serious and life-limiting diseases. Our model connects the physical, behavioral, social and pharmaceutical areas that someone needs to integrate care that works in tandem with their existing health care team, meaning their primary care providers and other specialists. We’re available 24/7 to personalized support to meet the changing needs of patients and their caregivers.

We shifted our focus to engage patients at the right time, gain trust, avoid hospitalizations when necessary and help their caregivers understand how to work within their community to support a loved one.

We provide care across all 50 states and we’re a physician-based model, which means we have physician oversight aligned with all the state requirements to serve people. We have people on the road providing care in 40 of those states, and we offer virtual care where we don’t have people on the ground. The majority of our concentration is in 25 states across the nation.

What are the important keys to palliative care program sustainability?

We have an agility and ability to scale what we offer in the home, in local communities and virtually. The patient voice really comes through in all that we incorporate into our business model. It really connects us to a quadruple aim of provider and patient satisfaction, improved quality and improved financial outcomes.

We’ve been able to venture into alternate payment models because of our size and scale. When you think about how populations transfer care and care responsibilities through these payment arrangements, they’re working with complex patients all the time. But with our model, we’re able to hit the top 1% of the top 1% who are providing the most value to a person while connecting with their primary care physician. Our palliative care visits are much longer as a result, so the time we get to spend is additive in these alternate payment models and makes a big difference.

The other thing with palliative care value demonstration is the human oversight and bedside stratification and having patient and provider satisfaction. It’s making sure the care plans meet the needs of the patient, that outcomes lead to reduced hospitalization, shorter lengths of stay and more extensive support in transitions of care. These are the most critical things we see in palliative care as people’s conditions change.

What makes our model sustainable is our interdisciplinary care team approach. Our 24/7 phone line received more than 30,000 calls last year, with only 2% of [individuals] ending up in a hospital. The ability to treat people at all hours of the day is critical, so it’s really important to have staff trained in managing serious illness and all the things that come along with it. That model has seen the greatest evolution in the past few years and has really grown.

Also, retention is everything. This work is emotionally taxing, and we promote agility and well-being to prevent burnout. We ensure that we have ongoing business and professional development opportunities. We have also made significant investments in utilizing technology to integrate workflows and have the best tools available to clinicians.

What do you see as the significant challenges facing today’s palliative care providers? How is Carelon Health navigating these issues?

One of the biggest challenges is the misunderstanding of palliative care as a specialty. That happens a lot when you’re a palliative care organization that is embedded in the full longitudinal care all the way to hospice. Palliative care becomes an added step for someone living with a life-limiting disease, and that’s a pretty big challenge. We spend a lot of time communicating what and who we are. We’ve shifted so much of our marketing away from frailty to the real value of what palliative care brings to a person at any stage of their serious illness treatment. Being able to have the support and infrastructure that we do is a significant advantage to us.

The other challenge I see is that a lot of fee-for-service models aren’t taking an interdisciplinary care approach. They are based on provider visits. A key is navigating what could be a significant challenge in the world of provider visits and fee-for-service when it comes to the cost of the care team, which is high. You have to have scale, otherwise the frequently high windshield time results in the inability to serve patients with the high cost of providers. You don’t want them to experience burnout, and it’s having the agility to take care of patients through all kinds of models, even those that mix virtual and in-person services.

What are the opportunities in palliative care, as well as other health care areas like hospice?

We’ve done a lot of learning with new infrastructure like our electronic medical record (EMR) system. We are getting the best insight out of the deep data review of our patient population and have a line of sight into things we never were able to see before. We have an analytics team not just reporting on our outcomes, but also feedback with our palliative care populations. It’s using technology to figure out how to align care to people. I think technology will evolve and we need to keep a pulse on it. It’s really exciting to see how it will couple with our patient engagement strategies.

Also, it’s our people and caregiving strategies. We can be embedded in many of the risk-bearing programs and alternate payment models. We have the biggest opportunity to participate in end-stage renal disease or oncology programs and help that top 1% of complex patient populations who need more time and care. We can help closely monitor them and be part of the full risk pool that helps show the true financial value of what palliative care services provide. It’s aligning with the ever-changing needs of the health care system and being really good at what we do.

What are some of the innovations your organization is focusing on now, and why are these areas of focus?

We are making a huge investment into a predictive modeling approach where we can look at the people behind the numbers from both a population and individual view. We’re looking at things like why people decline a service, whether it’s because they have too many specialists or don’t understand palliative care. That’s a really exciting opportunity to know what peoples’ needs might be and where they might be going as they receive treatment. We can also make palliative care more personalized to their needs.

Our roadmap is to have our full value proposition pulled together through process outcomes, behavioral assessments and patient satisfaction in a full picture of populations. We have the intention to be able to continue to be better, faster, smarter and more educated to accomplish that mission.

How do you think the Medicaid cuts could impact palliative care access?

We have to really understand how we’re serving such a complex patient population that comes with very high costs. We see opportunity in some states that have been adopting palliative care into their Medicaid benefits. This is an opportunity to really further understand how these changes are going to materialize as we continue to serve more Medicaid beneficiaries. We operate in 18 states with Medicaid services right now, and these [beneficiaries] are our highest engaged population.

People are still going to need care. If care shifts to state accountability, the way we bill needs to be agile enough to plug into any risk-bearing arrangement that values high quality care.