Palliative Care: Regulation, Oversight, and Reimbursement

Edo Banach, Partner, Manatt Phelps & Phillips LLP, and Keith Lagnese, Chief Medical Officer, Sutter Care at Home, discuss the structure and delivery of palliative care. They cover issues related to regulation, oversight, and reimbursement. Edo and Keith spoke about this topic at AHLA’s 2024 Long Term and Post-Acute Care Law and Compliance in San Diego, CA.

To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.

Transcript

Speaker 1: 0:00

<silence>

Speaker 2: 0:07

This episode of A HLA speaking of health law is brought to you by a HLA members and donors like you. For more information, visit american health law.org.

Speaker 3: 0:22

This is Ido Banick . I'm with Manat Phelps and Phillips , and I'm really happy today to have the opportunity to sit down and have a conversation with Keith Linz , Dr. Keith Ye from Sutter Health. Um, we're each gonna introduce ourselves, and then , uh, we're gonna get into a conversation that really , uh, goes into a little more detail than we went into at the A HLA long-Term Care Conference , uh, a few months ago. And , uh, it's really my privilege to , uh, to go deeper with Dr. Linnie again. Uh, Edo Bock . I'm with Manat Phelps and Phillips and Manat Health . Uh, prior to that, I led the National Hospice and Palliative Care Organization , uh, and before that was , uh, with the Centers for Medicare and Medicaid Services. A reminder that the views that we express today are our views, not necessarily those of our , uh, employers. Keith,

Speaker 4: 1:14

Thank you, Edo . Super excited to be here as well, especially in follow up from our, our live presentations down in San Diego. Appreciate the opportunity here to, to kind of follow up in continuing the conversation between you and I and, and our audience. Um, as Ido said, I am at Sutter Health, specifically, I'm the Chief Medical Officer of Sutter Care at home, so have oversight of our , um, hospice advanced illness and home health divisions, and have a long history of working , uh, in different, different spots nationally and regionally and hospice and palliative care. So, thank you .

Speaker 3: 1:55

Thank you. And so, before we really go into a lot of detail about how palliative care is paid for and , uh, and how it kind of manifests itself , uh, out , out in our , our healthcare system. Let's get to a couple definitions , uh, because we don't necessarily , uh, assume that everybody listening understands what palliative care is. And I think the , the, the surprise here , um, is that not everyone agrees what palliative care is, and that's part of what creates some of the complexity. Um , palliative care is defined in the , uh, the code of federal regulations , uh, as being patient and family centered care that optimizes quality of life by anticipating, preventing and treating suffering. The trick, though, is that that's something that appears in the hospice statute. See, hospice is a type of palliative care that was established in the early eighties, but is palliative care for individuals that have a prognosis of less than six months to live, that have agreed to , uh, to give up , uh, curative care. Um, and it's, so, it's a , it's a , uh, it's a portion , uh, of palliative care, but it's not the entire spectrum here. What we're gonna be talking about today is the rest of that spectrum , uh, and for the most part, this non hospice palliative care space and how we define it, how we pay for it, and how we provide it , uh, given some of the changing demographics , uh, in, in this country. And really, that's where I wanted to start with Dr. Nie is, you know, how is palliative care delivered? How is it structured? How, how does it appear in the wild? Um, and , uh, and, and, and Sutter is a place where it happens. So tell us more.

Speaker 4: 3:43

Yeah, ITO . Exactly. So , um, I , I , you know, I think it's a very , uh, uh, great definition. If you're gonna try to just give kind of that , that one sentence bullet, that, that brings up patient, family center , family centered, and relieving suffering. Uh, fortunately there's been a lot of work nationally in actually defining the guidelines around this. Um, there's an organization called the Clinical National Consensus Project, which came out with the clinical practice guidelines for Quality palliative care. I think the first version was about 20 years ago. We're now up to the fourth edition done about in 2018. But there's eight domains. And, and the number one is, is an interdisciplinary team, which defines structure and process of care. So having , um, not just a , a physician and a nurse, but having that , uh, you know, spiritual care addressed , um, having, you know , pharmaceutical care, having a social worker to address social determinants of health. Those things are all, all part of the inter interdisciplinary care. Sometimes a dietician might be involved if you need rehab, those sorts of things involved. But it , it's using a team-based approach to care for the patient. And , um, I'm seeing this model more and more in other aspects of healthcare. I think hospice really kind of started it in the eighties, but, you know , there's pace models of care. Um, ICUs use interdisciplinary care. It's really, but you know, I think hospice and palliative care have really helped to set the stage for how patient-centered this approach to care is. Uh, number two domain would be physical aspects of care. So making sure symptoms, both physical and , uh, emotional and mental symptoms get addressed. Uh, number three, that would be , um, uh, in including the psychological and psychiatric aspects. Four, I alluded to the social aspects of care being addressed by the team, particularly , uh, the social worker. And number five, the spiritual religious aspects, six cultural aspects. And then seven is what eddo you referenced about hospice care, the ultimate kind of terminal piece of, of palliative care, making sure that this patient's approach end of life and move more from a chronic , uh, complex palliative approach into the principles of, of hospice care. And then in, in your , uh, line of work, the ethical and legal aspects, making sure there's surrogate decision makers , uh, living will, healthcare, power of attorney, advanced directives, whole , all those things that sometimes , um, uh, attorneys might be needed, but often, often not, but, but addressing at least the ethical and legal aspects. So those are the eight domains that really define , um, uh, true , um, good palliative care.

Speaker 3: 6:42

So let's try to unpack that a little bit. There's a lot in there, and as you were speaking it , it sort of occurred to me that a lot of the things that you were saying makes , uh, that make a , uh, a quality palliative care , uh, program are actually the things that, you know, this many years in, are the things we point to as a good , uh, healthcare program or good, good, good, good system generally. Um , or , or even , uh, you know, e everything I learned, I learned in kindergarten. I mean, so many of the things here are , uh, wait a minute. So it's not one person , uh, that has a monopoly on some of the best ideas. Maybe it's an interdisciplinary team, and maybe , uh, it's not just the physical needs that people have, but maybe it's their emotional and , and , and kind of spiritual needs. And on down a lot of the things that you were talking about to describe palliative care should and could be used to describe the larger healthcare system. So where do we sort of go from , um, hey, that the entire healthcare system should evolve in this direction, and, and where do we sort of leave off and say, but there's a special , uh, uh, need for additional social and emotional supports , uh, and additional , uh, uh, uh, um, maybe being tuned in to some of the , uh, to the , some of the spiritual needs that people have, especially as they have serious illness. When does that become sort of a , a heightened , uh, and when does palliative care essentially take over?

Speaker 4: 8:13

No , you're, you're exactly right. Ido , I mean, you know, this, you know, I just mentioned a lot of different highly trained disciplines, and it can be costly. So, you know, not everyone needs this if you're generally, you know, a healthy person and might have one or two medical conditions, I think is, and sometimes it's related to normal aging. Typically, as we get older, we have more complex chronic medical conditions. So a lot of, a lot of energies often get done in, in Medicare populations, but there is pediatric palliative care, there are chronic disease states that begin very early in life. And so I think, I think it's important that , um, we acknowledge that this is not just for people at the end of life or, or Medicare, you know, beneficiaries. So making sure that no matter what age and no matter what your health insurance is, and no matter what your, you know , uh, background , um, what your financial situation is, this sort of care is, is meaningful, patient centered and, and important. Um, so I think that's where a lot of the work has been. We've come a long way in, in, in 20 years. I mean, I'm old enough that , um, this wasn't even addressed in, in my medical training in medical school or residency, started to hear about hospice, but palliative care fellowships are not much more than 20 years old. So , um, there is a degree of specialized training for specialty palliative care, but there's some component of that. As you listen to Edo and I speak you , you know, it's something that all healthcare pri providers should probably be touching on. You know, like, what are , what are your goals? What's important to you? Um, you know, by the way, do you have , uh, are you suffering from depression? Does , is spiritual care important in your overall health? And there's a lot of variability in that.

Speaker 3: 10:16

Yeah. I mean, and picking up , uh, on something you just said , uh, if, if, if folks don't get anything else out of this podcast, and I hope you get a lot out of it , um, everybody should write down what their wishes are. They should do it in writing , uh, and they should do it in video, and they should articulate what they want to their loved ones, right? That's not palliative care. It is , um, the realization that we, we don't always know what's gonna happen next in life and when it happens, we want to make sure that everybody understands what we want. Um, so that's, that's advanced care planning, that's advanced directives. It's , but it's not just the pieces of paper. It's the conversations that , that, that , that kind of surround that. Um , so, so that's, that is, you know, sort of an initial sort of thing,

Speaker 4: 11:00

You know, on that, on that note, kind of public service announcement there . Yes . There , you're aware . National Healthcare Decisions Day. I mean, there's a, a yes a day for almost everything in our country, but yes , I think we value this. It's actually , uh, right around tax day, it's April 16th, so it

Speaker 3: 11:17

Is, it is tax day. And you know why, you know why it's on tax day.

Speaker 4: 11:20

I do not know why it's on tax Day.

Speaker 3: 11:22

Well, because , um, uh, it , it is said that , uh, there are two things that are certain in life , uh, death and taxes. And that's why , uh, it was originally put on National Healthcare Decisions Day , um, uh, as we said , uh, healthcare proxies, advanced directives, not just about death, but that, that's why it's on , uh, uh, that's why it's on tax day. Um, and, and it just passed. But that doesn't mean that people shouldn't have that conversation. You know, anytime you , you're getting together with your family, you're having a great time on the beach, what a great time to sort of bring up this topic. But, you know, any opportunity that people have , uh, when they get together to just, you know, share what their wishes are, I think that would be a good thing. We just lived through a pandemic, right? Um, uh, things can be sort of uncertain. Let's back up just a slight bit because, you know, we're having this conversation in the context of , uh, an American Health Lawyers Association , uh, uh, long-term care meeting where we talked about , uh, things in theory. This is, you know, but , and , and , and , and now let's, let's kind of move into things in practice, right? And so in practice, how is palliative care paid for? How is it reimbursed , uh, uh, by Medicare, by Medicaid, or in any other way? Uh, how are you able as a provider to actually provide these services?

Speaker 4: 12:45

Yeah, this is , um, this is still an , a big issue. And so again, there's been some progress made. Um, I know you and I have been chatting about this that , you know, I'll , I'll start with some of the, the good things that, that are happening and then, and then kind of go into, you know, future where , what I'm most worried about, those, those sorts of things. But, you know, there's been where the positive work's been happening, for better or worse, is in, in Medicaid. So the states , um, and you know, where I'm practicing right now in California , um, they really, really did take a lead and have done a lot of great work. I think it was, yeah , 2018 Senate Bill 1004 was passed where it required access to a palliative care benefit for all Medicaid beneficiary. Just to remind everyone, I just looked at these stats. Our population in this country is around 330 million, 80 million , um, res , um, of our, of our citizens are on, on Medicare, and about 15% of them live in California. So it, it, it's a big chunk of our population, but, but we're still missing a lot. So some other states have followed, so Colorado, Hawaii, Maine , um, have been some , um, early adopters, and even recently in New Jersey, some other states are, there's a lot of work being gone on. Some of it's kind of attached to , to, to hospice. But that, that's been one area. But again, you have to qualify for Medicaid and , and such. The other area I've seen it is in , um, Medicare Advantage plans . So , um, you know, the opportunity, and that's about half of our, there's about 65 to 70 million Medicare beneficiaries, and about half of them are enrolled in a Medicare Advantage plan. So within that space, some by quality Medicare Advantage plans have made investments in either a supplemental benefit or, or investing in delivering a home-based medical and palliative care program, things like Aspire, Caremark, Prospero Landmark, which it , it's good. Um, I'm , I'm happy about it, but I , I feel like there's a little bit of an issue when , uh, a , a Medicare Advantage is driving the models per se, and private equity. Um , I'm gonna pause there, <inaudible> that that was a lot and let you Yeah ,

Speaker 3: 15:13

Well let , yeah . Yeah. Thank you. No, let , let's, as they say in the biz, let's double click on that for a second. So , um, different states have different , um, definitions of palliative care or manifest itself in different ways and in , uh, in Medicaid, in , uh, California or in Hawaii or somewhere else. Um, different , uh, managed care, Medicare managed care plans have different , uh, palliative care models. Um, and so there's a part of me that's sort of the innovation sort of part of me, the federalism part of me, that, that, that is happy to hear that there, there are a lot of different experiments out there. Um, there's another part of me, the, the kind of consumer advocate part of me that says, well , what, what exactly is the standard? Is there a standard that , uh, that , that , that states , um, and that plans are following and determining what they're gonna cover, what they're gonna pay for? Um, or is that standard still in developments? And maybe that's the rub. So I'd love to hear your thoughts on that.

Speaker 4: 16:13

Yeah, I mean, we, we talked about, you know, the, the, the domains and , and the definition. And, you know, I think , um, I'm seeing the more likely that the Medicaid programs are following a lot of the, the , the national standards of, of everything we just reviewed. I don't, I don't have to go through that again, but I feel like the managed Medicare programs, it's a little all over the place because they don't, they're a payer. They , they don't really know how to deliver care. And that'll keep that thought in mind as we talk about V bid and why V bid's going away. Um , right , right . And so they contract for it, and there's, there's private equity there, there's risk, there just programs coming and going, and there's virtual and some are just nurse driven , and it , it's a little all over the place. And , um, that worries me.

Speaker 3: 17:09

So we're , because we're talking to lawyers, let me let , let me sort of boil it down. Uh, let's say you're enrolled in a health plan or your , or your mom is, and , uh, the health plan says, we cover this thing called palliative care, and your summary benefits , uh, include some reference to the palliative care services that, that , uh, that, that she'll receive or that you'll receive. And , um, uh, they , um, uh, they, they decide that you're eligible or not eligible for those services. Let's say you disagree. If we were talking about a home health benefit, you would disagree and you would appeal. You'd say, you say it's medically necessary, or you say it's not, and I say it is, and we're gonna have an argument over what's, what , what's what , what do you do here when you're talking about a benefit that where there is no set standard and essentially it's a made up supplemental benefit that they've got, it's not made up, right? We've been talking about the fact that it's a real benefit and really important, but if United Healthcare says no, and you say, I disagree, how is it that you can never get to a place where you win that appeal if they're the ones who decided what the benefit was to begin with?

Speaker 4: 18:20

Now , that's a great point. I mean, I , I actually haven't kind of thought about it from that, but that's very, it's a very patient centered, and there's this, I, I've kind of been on the delivery side of one of these programs and, and it , it's really, it's really tricky who contacts the patient. The patient's kind of suspicious, you know, they're getting, they're getting all kinds of crank calls and there's Medicare Advantage consumer protection stuff going on, and what they're , which is good, but, but there's still, it's not really, we talked about this . It's not really being enforced, you know , uh, about enrollment periods and, you know, the , these MA plans, it's all about , um, star ratings and, and, and the reimbursement and limiting utilization. So , um, it, it's really complicated. And I don't know that the current delivery in that particular space has a lot of patient-centeredness to it.

Speaker 3: 19:19

Okay. So we've got, you know, the , the , the good news is that in a sense, you know, we've got this ideal model that we sketched out in the beginning, then we've got the way in which it manifests itself right now, let's then shift to, okay, so where are we headed? How is the system evolving? How is it going to , uh, innovate? So that maybe the ideal is more of what we see sort of out there in, in the field. And I wanna focus first on, you know, the way in which our population is evolving, and second on the way in which the sort of the benefits design is evolving. So , um, it used to be that most of the people who received hospice care had a cancer diagnosis, and now we're seeing that most of the people who receive hospice under Medicare have a dementia diagnosis because cancer is , uh, it has, there , there are therapies for, for cancer that, that then used to exist. And so what does it mean , uh, in terms of the demographics of this country, that we see people living longer and living longer with various chronic illnesses, COPD and and , and heart disease and , uh, and , and , and , and even cancer. Um , and how , what does that mean then for the, the palliative care benefit that has to sort of be wrapped around their needs? Is it a single benefit for all of those different manifestations of serious illness, or is it different benefits for those different serious illnesses? What do you think about that?

Speaker 4: 20:54

I mean, the, the Medicare hospice benefit, I, I just can't not comment on it, but, but it , you , you know, you you brought up, yeah, it was built, you know, in the early eighties, you know, thank God, I mean, it started as a, a volunteer movement for cancer patients. And so the benefit, the six month prognosis, by prognosis, I mean , uh, a physician, two physicians technically determine that a patient has six months or less to live. And that's where the benefit re you know, there've been some tweaks, but the essence and the eligibility for the benefit remains the same. It never said you had to have cancer. It , it didn't call that out. But over time, I mean, it's just the reality more, it , it mostly has happened. Non-cancer patients are a terminal, want the benefits of interdisciplinary hospice care at the end of life. But, but the problem is there is there's a gap, a huge gap. Yeah. There's home health. Yeah. There's like Medicaid waiver. Yeah. There, you know, there's kind of this, but, but there's this gap between seriously chronically ill patients before they transitioned into terminal care. Now, sometimes there's not, in a direct continuum, someone can get a , a very abrupt terminal diagnosis, but there's a large chunk of people. So Medicare's looked at Medicare choices model model hundred hospice study, looking at, you know, bringing people on earlier and not, you know, that had more than a month to live, I'm sorry, more than six months to live. There was this v bid model for a couple years, which is value-based insurance design through CMMI. They've done CHF, they've done renal disease, and, and they decided to take on hospice to allow Medicare advantage payers to, to provide what's called concurrent care, to help this exact patient who could benefit from interdisciplinary palliate of principles of care, who's not six months or less of life. And it just, it was just announced three months ago that, that, I think it was when we were at the conference in February, the , the news came across that they were sunsetting it at the end of this year. And, and , uh, the, the word on the street is, you know, you're a little closer to this, is , well, they, they, nobody was joining the MA plans. They were lo they couldn't figure it out. So, I don't know, I don't know if I answered your question, but I

Speaker 3: 23:26

I <crosstalk> Well, yeah, I mean, I think we, you know, we started talking about the, the people, and then I think we, we actually segued nicely to the, to the system, you know, delivery system reform , um, you know, the creation , uh, of a more integrated , uh, benefit in, in , in managed care , uh, the tweaking of the, of the hospice benefit itself and , and statute. Um, I think, you know, one of the things, if we can kind of for a second talk about the demo , um, I think the , the flaw in a sense in the demo was that , um, instead of hospice getting carved out of Medicare Advantage, when people became eligible for hospice and carved out, just meant their, their hospice was delivered through and paid for three through a fee for service , even though they, they remained enrolled in a managed care plan, instead of that happening, it was all sort of in. And so conceptually, that makes all the sense in the world. Uh, it doesn't make any sense to sort of , uh, change the payer or change the way in which reimbursement is provided when there's a new diagnosis. The folly , uh, I think in the problem is they still didn't fix the problem we were just talking about, which is, how do you define palliative care? How do you define concurrent care? And there's this tension, I think, in this country , uh, between the government wanting to dictate the kind of care that's be gonna be provided , uh, and being paternalistic actually when it comes to that, and the government being sort of laissez-faire and saying, we're just gonna let sit back and we're gonna let the private market sort of figure it out. Yeah . And I think that, you know, and I'm of two minds, and honestly, some of this crosses political parties. On the one hand, you wanna provide enough space for the health system healthcare system to innovate , um, on the other , um, you do have to have some minimal protections in there and minimal standards in there , uh, especially when you're talking about a government payer to say, you can innovate as much as you want up. You can provide as much as you want, but you can't provide less than this. And what you didn't see in the demo was what, less than this meant. There was no standard for palliative care and no standard for, for concurrent care. And, and in a way, I think that kind of leads to, you know, my next question, which is, let's say the election comes out. We have, we have the election that's coming out , and not to be political, but one of the guys wins, one of 'em , and they, and they give your call Dr. Ese , and they say, listen, we've, we've heard about the great things that you've been doing at Sutter. Uh, we want you to be in charge of the, the new palliative care program that we're gonna have in this country. And , um, and you say, what? Palliative care program, and they say, the one you're gonna create, you're gonna figure this out. Uh, what's your next step? What do you do? And how do you do it? Uh, because sooner or later , uh, given the demographic changes that we have in this country, someone's gonna have to do that. Uh , so what would your first step be?

Speaker 4: 26:32

Well, thanks for not throwing me a , uh, softball as , as we're winding down this podcast.

Speaker 3: 26:37

You're welcome,

Speaker 4: 26:39

<laugh>. Um, yeah, this is, this is tricky. This , this is complicated. I mean, I, I, I certainly don't have all the answers, but here , here's what I'll say. Um, I, I feel that we've, we've been at this long enough, we're far enough down the path of, we, we have training programs, we have definitions of model, we have patient satisfaction, we have value studies that show, you know , um, you know, meeting the quadruple aim of healthcare, decreasing utilization. But we still, the majority of programs outside of Medicare and Medicaid, advan Medicare Advantage are, are funded through delivery systems at a loss. Um, so they're, they're either delivering it from philanthropic funds, at least a , a , you know, a direct measure of, of loss. So I feel that there's still not the degree of incentive that there, there should be, or some disincentive, because I still think there's a lot of education and understanding a deficit in that, both for patients, for payers, and for providers, and kind of the hospital c-suites, which, which drive a lot on the delivery end to invest in, in these models. So that creates inequity and, and troubles with access, and there's so much work and, and , um, you know, it's thrown a, a lot , uh, uh, around of, of, you know, healthcare inequities and , and addressing social determinants of health. So I feel like that would be kind of, you know, my groundwork. I would, I would work with this incredible role I would have with, with coming up with a Medicare benefit that, that truly, it's, I feel like it has to build off of hospice , um, it , whether it's separate and continuous, but I don't, I don't think you can ignore the carve out hospice medical benefit , um, you know, as part of it, because what, right now, it , it , the Medicare Advantage plans, their incentivization is built around for their high spenders and their chronically ill patients to get them out of the plan and in the carve out . So they're not taking the onus and responsibility. And I feel like Medicare's put their toes in the water with Medicare choices in vbi around hospice. So I, I feel getting the, the subject matter experts , um, and most of them live in academia. Um, but I, I think there's enough literature out there that we should be able to come up with something that in a value-based model, which we're, we're trending towards, that, you know, add or strictly addresses the role of palliative care in value-based models and not building value around avoidance in, in utilization. So , um, uh, I know that maybe not be the, the , the answer you wanted to hear, and maybe it was just kind of a general philosophical, you know, kind of , kind of tap at it. But I feel like the stakeholders, the data, the evidence, it , it , it's all, it's all there for, for patients. And we just need to, to do better. There's so many problems with healthcare delivery in the way we spend, and this is not, we focus on things that generate revenue. And palliative care isn't one of those, and it never will be. But you know, I've seen, you know, advanced care planning, they reimbursed for that. They , I think goals of care and , and training. We didn't bring up pita , but I, I, you know, I think that we still have a lot of work to do. I, I , I'm not that old. I'm in my late fifties and I told you I never, this topic wasn't, wasn't part of my training. And so I think, I think we're making progress there, but nursing schools , hospital system , I'd say we're about halfway there in the big picture of palliative care as a form of delivery in our country.

Speaker 3: 31:05

Well, the good news is , uh, that we , uh, we'll fix this by the time it's your time , uh, if we're halfway there, right? Uh, I think , uh, you know, the, the, the , this, what this conversation has sort of brought home is that we've made some progress. We have a bit of a ways to go that there are reforms that we need to make , uh, kind of , uh, organ structurally , uh, in terms of how the , uh, the hospice benefit is, is defined, allowing for concurrent care, thinking about the six month diagnosis, thinking about the way that people die today. Um, and then there are also things that we need to do in terms of the delivery system. Um, and , uh, yeah , think about how Medicare Advantage works and what the default rules should be. We haven't talked about ACOs, but that is a value-based system. There's a reach a CO , which is focused , um, uh, on, on on health equity. And the reality is that if you have the means , um, you can , uh, put together a holistic , uh, interdisciplinary model for yourself. And if you don't have the means , uh, then you have to cobble one together. Yeah. Uh, and cobbling one together means really you have to , uh, rely on various payers and various providers to deliver those things , uh, uh, to you. So I think, you know, in, in, in summary , um,

Speaker 4: 32:29

You know, before you, before you summarize, I , I , I really, yeah, wanna make sure you address, because you have kind of the experience in a little bit of a broader stroke than I have as a, as a provider and more of a health system delivery guy being in CMI, being the leader of the National Hospice and Palliative Care organization like I do that what gimme give you may disagree with what I said, like, gimme your thoughts on, on, we're , yeah, we're about to face an election, but I, I think we've seen democrats, republicans, you know, other than the Affordable Care Act, we haven't made a lot of , lot of progress. So I'd love to hear a little bit deeper thoughts from you about the , the model and focus moving forward with the magic wand.

Speaker 3: 33:15

All right . Turn , turn around on , on , on me. So, yeah, I, I think that what, what I think, I think what I've seen is that actually as you take a step back, even though it's been a frustrating last 20, 25 years or whatever it is, we have the , the , the people who put together the hospice benefit intended not to just create a hospice benefit, but to change the healthcare system. And if you think about the way that the healthcare system has evolved over , over that time, we often lament the fact that the hospice benefit hasn't changed. But we should celebrate the fact that we have a healthcare system now that is more interdisciplinary, where behavioral health is a bigger part of the healthcare system, where we're focused on social determinants of health. That is stuff that happened not despite the hospice benefit, but I would argue because of it. And what I expect the trajectory to continue to be is that because of the demographics, right? We have more people aging, you know, every day and becoming , uh, Medicare eligible, the , the baby boomers, we have less money to pay for their care. And the care that we're talking about here, the social, the emotional, the home-based care happens to be less expensive than the care that has traditionally been given to this population. That those two things combined, one, the demographics, and two , the reality of the delivery system, that those two things combined are gonna end up backing our way into backing our way into the system that we've been arguing we should have. So even if we do nothing, and I'm not arguing we should do nothing, I think we should proactively try to , uh, create a concurrent care benefit and a real palliative care benefit. We can wrap our arms around. But even if we don't do that, we're gonna end up backing our way into some semblance of that system. What I fear is that unless we're proactive, that system is essentially gonna be the lowest common denominator that the, the private market is gonna create this lowest common denominator, palliative care like program for the entire population. And I think if we do it right, and if we're proactive and we look at the , at , at what it means to provide a quality palliative care program, then we're actually going to do that much more to improve the health , uh, and the outcomes that we see for , uh, for our parents , um, and, and their generation. And , um, and the bonus will be Keith , uh, that will fix it for when it's your time , um, uh, which means my time as well. So that's, I guess what I would say in, in closing, I'm hopeful, but I think it's gonna require some work going forward.

Speaker 4: 35:52

Yeah, no, thanks, EDA . I , I , I mean, I couldn't agree more patience. It's so clear , um, being close to patients that this is what, what they want. Um, when they get chronic illness , when they get terminal illnesses, they want their providers to be connected. They want the continuum of care to be a continuum of care and not have gaps. And , and , well , what do I do now? I don't qualify for home health. I don't qualify for hospice. Uh, I can't find a palliative care provider. My insurance doesn't cover it. What do they do? And so we, you know, we, we claim we're the, the best healthcare in the world. So , um, I think filling that gap will continue to put us on, on the forefront of, of delivering care from the beginning of life to the end of life.

Speaker 3: 36:43

Alright , let those be the final words. Let's do it for , uh, Jimmy Carter and , uh, for , uh, Dr. Keith Lin at Sutter. This is ETO Bock at Monat . Uh , thank you so much.

Speaker 4: 36:54

Thanks Ito .

Speaker 2: 37:02

Thank you for listening. If you enjoy this episode, be sure to subscribe to a HLA speaking of health law wherever you get your podcasts. To learn more about a HLA and the educational resources available to the health law community, visit American health law org .