This transcript has been auto generated
00;00;00;00 - 00;00;31;25
Meg Pekarske
Hello and welcome to Hospice Insights: The Law and Beyond where we connect you to what matters in the ever-changing world of hospice and palliative care. Making Palliative Care a Win-Win-Win: A Conversation with Dr. Bethany Snider, Chief Medical Officer, Hosparus Health. Bethany, thanks so much for being here. You're so fun. So thank you for for making the time for me.
00;00;31;27 - 00;00;37;19
Dr. Bethany Snider
It is a pleasure to be with you and talk about one of my most favorite topics which is palliative care?
00;00;37;21 - 00;01;05;00
Meg Pekarske
I know, I know, and it's like when we were as I've gotten to know you throughout the years. Every time I talk with you, I learn tons of stuff. And then. Then I'm like, but you're a physician. How do you learn all this business stuff? Which we'll get to later. But you're a jack of many trades. So, but I guess just to to level that, as you know, did the extent our listeners don't know who you are.
00;01;05;01 - 00;01;13;10
Meg Pekarske
Tell me a little bit about your professional background and how you got to do your current role.
00;01;13;12 - 00;01;40;19
Dr. Bethany Snider
Well, it's an interesting story, Meg. So I am one of those that was a patient first, and I had an experience with the health care system when I was a teenager that kind of left a sour taste for me. And when I reflect back now, it really was around communication, or rather a lack of communication by a physician of mine that had a significant impact on my life and decisions I was going to have to make.
00;01;40;22 - 00;02;05;26
Dr. Bethany Snider
So that kind of spurred me into medicine. I love taking care of patients, also love my home. So I’ve lived in Kentucky my whole life, and I knew I would always serve my neighbors and my family. That's really important to me. So I went to medical school at the University of Kentucky. When I started, I thought I was going to be a pediatric neurologist because of my background as a patient.
00;02;05;29 - 00;02;08;29
Dr. Bethany Snider
Thank goodness that didn't work out.
00;02;09;01 - 00;02;15;04
Meg Pekarske
It all makes sense in reverse, right? You're like, oh yeah, I don't know what to put on that.
00;02;15;07 - 00;02;36;23
Dr. Bethany Snider
Right. So kind of went through schooling. I signed up to do internal medicine first, but I was like, that's the last thing I'm going to do. And it loved it. It changed my whole trajectory for my career. I loved seeing all the different specialties, and I got a lot of exposure in ICU during my internal medicine training.
00;02;36;25 - 00;02;59;24
Dr. Bethany Snider
And I was blessed by an attending that said, you really need to go check out palliative care, because when I was in the medical ICU or the cardiac ICU, I would always trade procedures with my colleagues to go have difficult conversations. And nobody else was doing that. And at the time the doc was like, oh, have you heard of this palliative care?
00;02;59;24 - 00;03;06;21
Dr. Bethany Snider
Which I didn't know anything of it. I'd had some family experiences with hospice but didn't even realize it was a medical specialty.
00;03;07;18 - 00;03;36;23
Dr. Bethany Snider
So I was blessed to rotate with Hospice of the Bluegrass as an elective during my residency. And then changed my whole career path and went straight into fellowship after finishing internal medicine. I got to hospice through that journey. As you all know, Hospice of the Bluegrass is an extraordinary organization that had a unique model where physicians spend a lot of time in the hospice environment and were full time physicians and a walk into somebodies home.
00;03;36;25 - 00;03;57;23
Dr. Bethany Snider
Such a humbling experience when they're going through something as difficult as a terminal condition and you learn so much about people, you also see why it's really challenging to adhere to the health care system that we're giving them today. And I knew in that moment that these were my people, and this is the type of care that I was passionate about.
00;03;57;25 - 00;04;21;00
Dr. Bethany Snider
So I haven't looked back. And I've been with Hosparus Health ever since I left fellowship. And it's truly been, rewarding journey. But as you alluded to in the intro, I learned a lot about, things that I enjoy and how my mind works. That's outside of medicine, but just I'm very grateful that I get to stretch those things.
00;04;21;05 - 00;04;21;28
Meg Pekarske
And to.
00;04;22;03 - 00;04;27;01
Dr. Bethany Snider
Think about building solutions at a system level, not just patient-to-patient, which is still very valuable to me.
00;04;27;01 - 00;04;56;16
Meg Pekarske
But I do think that grounding and being a caregiver and back, compassionate physician and I just think you can't there's nothing, nothing better than a physician leader who still, you know, has a foot in. I, I, I didn't just go to medical school so that I could advance from a leadership standpoint. I did it because I really loved it.
00;04;56;16 - 00;05;20;10
Meg Pekarske
But I also have all these other gifts, and finding a way to do that because I know as we're recording, you're sitting in a hospital now, like, you know, doing medical stuff. So. So, yeah, that's such a wonderful story. And, yeah. What is it about people? Because obviously I feel like hospice people are my people, too.
00;05;20;10 - 00;05;52;01
Meg Pekarske
And like people, I always say they they lean in to what everyone like, runs away from. And like, there's something about people that, you know, can do that. And, you know, I just had a hospice experience with my mom and, you know, being on the patient side of that family side of that. I totally get what you're saying of you're walking into a lot in that moment of, crisis.
00;05;52;01 - 00;06;18;14
Meg Pekarske
And, you know, people are, like, making a lot of decisions. And there's this very tense experience. And to see the scale of this hospice admission, nurse Angie, it was like, I don't know how she did it, but it was like magic, what she was able to do. And so so it's it it really takes, you know, people with those gifts.
00;06;18;14 - 00;06;49;04
Meg Pekarske
So, so it's wonderful you found your path to hospice and palliative care. Because it's it's so needed and not every everyone, as you said, likes to do that, that work. And so I, I wanted to focus a lot of our conversation on palliative care because I think it's like this that we keep trying to crack, you know, as an industry, you know, probably 15 plus years ago, you know, people were starting palliative care programs.
00;06;49;04 - 00;07;28;11
Meg Pekarske
And the struggle has always been there's no payment models, you know, and you're just billing part B. And that really fell short of, you know, what I think people want to do and really making a difference for the patient and sort of all the different ways we probably and do. So I, I know you all have been able to build a palliative care model despite the care constraints or payment constraints we have into something pretty cool that is very impactful to patients.
00;07;28;13 - 00;07;49;03
Meg Pekarske
So, so tell me how you started that. Not because it's it's beyond just, we built part B for adults and we, you know, leverage NPS because they're cheaper. So that's like the model. I mean, you know, because we all know that that that's not really sustainable. So so tell me what you did.
00;07;49;05 - 00;08;10;25
Dr. Bethany Snider
Yeah. So I think a lot of wisdom was paid for me when I took on the role of chief medical officer and at the time, hospice knew they needed to get back into community based part of care. And they were trying to be strategic about how we did that. And so initially our focus was actually on payer arrangements.
00;08;10;27 - 00;08;39;05
Dr. Bethany Snider
So how can we learn better understand payers Medicare Advantage plans so that we can tell our story better? We can articulate our value to other partners with aligned incentives and then work to grow those models. So in 2015 to 2016, you know, we were talking to every payer that would meet with us. Most of them had no idea what palliative care was.
00;08;39;07 - 00;09;04;20
Dr. Bethany Snider
Some had some experience with some of those models you alluded to that they weren't actually delivering on outcomes. They were looking for. So through that work, and I always chuckle because I was sent to these boardrooms in these major national payers, by myself. Like we had a transition of my like, co-leader. And I'm going to these places.
00;09;04;20 - 00;09;31;00
Dr. Bethany Snider
And frankly, I had severe imposter syndrome. I was like, I don't know what I'm doing. I don't know why I'm here, but I knew what patients need, and I'd seen that firsthand. And so I could tell that story. And I think that the most critical lesson I learned early on in our pmpm arrangements, or remember from other arrangements, was I had to find the people that had aligned incentives.
00;09;31;03 - 00;09;56;07
Dr. Bethany Snider
And what I realized with just, hey, are arrangements in our market. At that time, they didn't really have an aligned incentive with what we were trying to figure out, but we had some big health systems that were starting to take on risk. So they were actually sharing some risk with Medicare Advantage plans and were struggling to control costs for their seriously ill population.
00;09;56;10 - 00;10;19;13
Dr. Bethany Snider
And so this is a strong partner of ours on the hospice side. And we had had some conversations. And so we brought them to the table with one of these large national plans. And they were willing to pay what we needed to build a out of care model that's interdisciplinary. That is a comprehensive wraparound service with 24 seven access.
00;10;19;14 - 00;10;47;27
Dr. Bethany Snider
You know, all the things that really speak to higher quality palliative care so that we could try to help them change the trajectory for that population. It's the program I'm most proud of because it still stands today. So we still are in partnership with that Ma plan and that health system to manage these high risk patients. And we're trying to figure out how do we continue to expand that to other plans and other, programs within their own health system?
00;10;48;00 - 00;11;03;18
Dr. Bethany Snider
And so, right, there were some really good lessons there. At the same time, we were talking to other plans or health systems. And I I'll never forget a CEO of a large health system. So I don't want you to keep him out of the hospital when they come to the hospitals when I make money.
00;11;03;20 - 00;11;03;29
Meg Pekarske
Yeah.
00;11;03;29 - 00;11;26;09
Dr. Bethany Snider
And so like that really caught me off guard. I was like, hold on, my patients don't want to be in the hospital. Yeah, we know that the data is there like but right. Business lesson for the doctor over here that it wasn't an aligned incentive for them. Now interestingly, today we now have a partnership with them because the incentives have changed.
00;11;26;11 - 00;11;52;16
Dr. Bethany Snider
Yeah. And so I think it just shows like it really behooved me, but also us as leaders in this space to learn about our partners and to understand how they're being graded and where are their financial pain points, so that we can figure out where does advanced illness or serious illness care kind of meet them to help solve for those solutions?
00;11;52;19 - 00;12;23;07
Dr. Bethany Snider
Recognizing that we are the expert in community based care, right? That really is our expertise. So I'm grateful that we've had a couple payer arrangements. We've had some health system arrangements. Now we have another At-Risk provider arrangements that are still interdisciplinary palliative care. And that's one thing we've really stuck to. Our mission is to provide care that enhances the quality of life for all impacted by serious illness.
00;12;23;09 - 00;12;46;21
Dr. Bethany Snider
And so I will not allow us, to compromise our values for what that actually is. And so sometimes we'll be in discussions with partners and we'll say that there's not alignment. Yeah. And mission. So this isn't the right partnership. Or we had a payer arrangement where we thought there was alignment. And then over time it didn't pan out.
00;12;46;21 - 00;13;01;19
Dr. Bethany Snider
And we weren't trying to solve the same problem. And we didn't want to support patients in the same way. So we said, you know, it's okay, but we're not the solution for you. And so that's really hard, I think, especially for the legacy hospice organizations, because we want to be everything to everybody.
00;13;01;19 - 00;13;04;29
Meg Pekarske
Yes. Oh my.
00;13;05;01 - 00;13;18;19
Dr. Bethany Snider
And that's just I've kind of taught our team that we can't be everything to everybody because then we don't do anything well. And I really do believe in that. I think we had to figure out what was our specialty, and we had to lean into it.
00;13;18;21 - 00;13;48;05
Meg Pekarske
So I need yeah. Yeah, well, you need to have like a checklist of these are like our non-negotiables because they're wrong. Like, you start floating in the wind, right? Like, oh, I'll try to do this, then I'll try to do that. And then you're not really doing anything well, and you can't really get anything off the ground. But I think that's a real struggle for folks right now, because I think there's like the sense of urgency, like I need to get into the space.
00;13;48;05 - 00;14;12;06
Meg Pekarske
And so it's much more of, I need to fill their hole. I need to fill their hole. And they all sort of want different things. And it's like you sort of picked a this is what I want to sell, so to speak, or this is the solution. And is that does it match for, you know, is there a match, so to speak, with who that partner is?
00;14;12;06 - 00;14;31;22
Meg Pekarske
Because I just there's a lot of wisdom. But like you said, when people feel urgency like, oh, everyone else is doing it, I need to do it. I need to get one, you know, in the bag. I need to figure this out. And then you don't have like, well, is this really what aligned with what we were trying to do?
00;14;32;00 - 00;14;56;18
Meg Pekarske
I think it's so helpful. I mean, right in life too, like there is a zillion choices you could make every single day and like what matters to you? Like what is your life philosophy, right? And because if you don't have that, I think it can be a bit over wildly. And and I think especially at a leadership level, your staff ends up getting pulled in lots of different directions.
00;14;56;18 - 00;15;20;17
Meg Pekarske
And then if there's not sort of a unified vision and this is what we're doing and why we're doing that, then hard to get people, you know, behind. Not that we don't all pursue things. And then you're like, oh, I'm cutting the cord on that. That didn't work out. Go early like cut, cut out early. I mean, we've all tried things that don't work and but but I really like that.
00;15;20;17 - 00;15;49;07
Meg Pekarske
And my guess is that first, that first conversation, the first partnership was scary. And there's a learning curve and all that stuff. But I love that it started with stories of patients. I mean, it sounds like right. That's I mean, most people that went into health care went in there for the human to human part and to improve life.
00;15;49;10 - 00;16;10;11
Meg Pekarske
And sometimes you just sometimes get drawn into other things. And so it sounds like that was key to you establishing rapport and credibility, because you obviously had never done this before. So where do you start? You start with story, right?
00;16;10;14 - 00;16;50;23
Dr. Bethany Snider
Absolutely. And I think the beauty of that is it tells the story of what palliative care is. So when you think about these business leaders, frankly, that we're talking to as we try to get palliative care arrangements, most of them have a pretty small understanding about of care. But when you can articulate for them the patient that's been to the hospital six times in the last six months for their breathing difficulty and palliative care comes in and wraps them with, you know, 24 over seven access in this crisis plan that then has cut those emergency visits down to 0 or 1 in the following six months, and then the social worker finds them transportation or
00;16;50;26 - 00;17;19;21
Dr. Bethany Snider
helps ensure that their electric stays on because there was an issue, you know, like, yeah, that story is way more impactful than me saying, well, our model is this. And if you pay, you know, like it doesn't mean anything because most people don't, I think, understand what true palliative care can do. So those patient spotlights have been critical when we were getting off the ground, but also continually as we expand programs or add geographies to tell the story.
00;17;19;23 - 00;17;42;09
Dr. Bethany Snider
And I've seen so many system leaders or executives read them or hear those stories and, you know, they say, wow, like, like this is actually how health care can and should be. Yeah, if we invest in the right things. And so I think always letting the patient's voice and a guide us on what they need is the best strategy.
00;17;42;11 - 00;18;17;22
Meg Pekarske
Yeah. Well and I think and this goes into when you're, you know, in a per member per month, arrangement, the who is providing services matters. And I think, you know, nothing against physicians and nurse practitioners. They obviously are an important role. But there's lots of other people that can make a huge difference. Which is like if that's attack and service or whoever, they're calling on their crisis plan, it's probably in hour or whatever.
00;18;17;22 - 00;19;04;20
Meg Pekarske
It's like I feel and that's, you know, the challenge with the part B model is that it really just is about nurse practitioners and physicians, largely. And yes, there is a role for them. And so to meet the outcomes you're talking about, you're not going to be able to do that. If your model is just a physician. And and because it is that, you know, supportive care management, case management, whatever you want to call it is helping support people so they don't feel like the only help I can get is call an ambulance and go to the E.R. because I'm feeling very panicked, because I think we've all been in those situations when it's you
00;19;04;20 - 00;19;26;21
Meg Pekarske
personally going through that or your loved one, like having a number to call, like, you know, I wrote all the phone numbers of the hospitals by all the phones, like when we got that phone number, because we've been doing this for 25 years, I could see that my instinct might be to call 911 if something.
00;19;26;22 - 00;19;27;16
Dr. Bethany Snider
Absolutely.
00;19;27;16 - 00;19;58;00
Meg Pekarske
Yeah. And so I just think it it's like the small stuff that not small in the sense to minimize it, but it's not like the fancy technology. I mean, you know, I think I want to ask you about how you guys leverage technology in this, because I do think as a role. But I, I just think it's there's just a lot that can be done outside of, you know, just physicians and peers.
00;19;58;00 - 00;20;22;12
Meg Pekarske
But. So how do you guys use technology to deliver this? I mean, are you doing telehealth stuff or are you doing just a phone call? I mean, you cover a lot of Kentucky, which a lot of that's rural. And so, I don't know, broadband is a challenge. And so tell me a little bit about how you leverage technology or bottle.
00;20;22;15 - 00;20;49;12
Dr. Bethany Snider
I'm so glad you asked. Meg, because I think this is the solution for part B practices. And I want to encourage my colleagues across the country, but also challenge them. And I think our traditional thinking. So we operate a very large community based practice that is part B primarily and it's taken us three and a half years to get it to a healthy place.
00;20;49;14 - 00;21;22;03
Dr. Bethany Snider
And I'll talk some about that over the next few minutes, if that's okay. I think it can really help people as they try to solve what you just said. How do we serve this population that's likely distributed across a large geography with very limited revenue streams? One way we have to do that is through leveraging technology. So our leadership set and pulled goal two years ago that they wanted us to get a third of our visits by telehealth or telemedicine, third of our visits in the home and a third of our visits.
00;21;22;03 - 00;21;57;25
Dr. Bethany Snider
And I facility based settings so I could be a clinic, a hospital, whatever, nursing facilities. Because with that model, we knew there was a path to more sustainability financially. We started at zero telemedicine 100%, frankly, you know, maybe 2% nursing facility. And our CEO wanted us to get to patients within seven days. So at the same time, we were taking around 28, 32 days to admit a patient, which is you can then take these seriously ill people that it's way too long.
00;21;57;25 - 00;22;17;19
Dr. Bethany Snider
Yeah, because you're trying to go to the home for everybody. And we had limited resources that we could invest in. So you can imagine our leadership team, but overseas our pallet burn was like, okay, well, this is a nice challenge. And I'll never forget the medical director that reports to me. He was like, this ain't going to work.
00;22;17;19 - 00;22;46;00
Dr. Bethany Snider
Like I remember that like it was yesterday. But we went after it anyway. And so, today, right now, 70% of our admissions occur via telemedicine, because what we found is we can leverage that to onboard them to the program. We can get to them a lot faster, and we can triage their needs. Now, we you know, so then, you know, okay, this person has something acute.
00;22;46;00 - 00;23;05;00
Dr. Bethany Snider
We need to follow up quickly. Or this person kind of just needs to get in the hole. Let's do some advanced care planning that's not as urgent. But it helps us to build a relationship with Lee. And I challenge my colleagues all the time when we're at national meetings talking about telemedicine. Oh, well, our patients can't do it.
00;23;05;00 - 00;23;26;02
Dr. Bethany Snider
Or, oh, it's connectivity or a very small percentage. That is true. And we have to augment our model. But the vast majority of people in this day and age have figured it out, because we all were forced to during the pandemic. Like one bright spot of the pandemic is we all had to adopt technology very quickly in health care.
00;23;26;04 - 00;23;46;16
Dr. Bethany Snider
And so we don't have that issue. We our script for our patients is we admit you through telemedicine, that's our quickest way to get you into our program, right? That is a billable service. So we have a provider to actually do that initial visit. But to your comment, we've had social workers on our team, we've got nurses on our team, and we have nurse practitioners in position.
00;23;46;16 - 00;24;08;05
Dr. Bethany Snider
So we truly have the interdisciplinary team and we leverage spiritual support kind of based on need, identified. But we had to change how we delivered care. And when you come from hospice, these high touch models where everybody wants to be in the home, and that's the only way you can care for people. It's never going to work like we used to.
00;24;08;08 - 00;24;28;21
Dr. Bethany Snider
For probably two years before we took on this telemedicine initiative, we were trying to move the needle on productivity and visits per day, and we were banging your heads against the wall like we couldn't. We couldn't figure it out. Yeah, we couldn't solve the problem. Even with scheduling and all the sophistication. We tried to build. But telemedicine really shifted that for us, you know?
00;24;28;21 - 00;24;41;28
Dr. Bethany Snider
So I think it was actually 41% of all visits we made last month for me at telemedicine. And then it was the rest were home or facility. So we got to our Pi and a third, a third, a third.
00;24;42;00 - 00;24;42;05
Meg Pekarske
But.
00;24;42;05 - 00;24;45;08
Dr. Bethany Snider
We're actually heavier on the telemedicine side.
00;24;45;11 - 00;25;15;22
Meg Pekarske
So that's it. Hard, hard to get your clinicians because I think in hospice, you know, that clinicians like the touch who you know. And so how did you any resistance there and then have so like, do you have the poster child who's like I hated this. Didn't think I could make a difference. I didn't feel like the the same passion for what I'm doing.
00;25;15;22 - 00;25;22;12
Meg Pekarske
And then they start using it and then feel, you know, that goes out the window like.
00;25;22;15 - 00;25;45;14
Dr. Bethany Snider
Yeah, I think we employed two strategies, then change management to help get this across the finish line for our team. And and just to put it in perspective, it's around 14 nurse practitioners now and five positions that generally work on this team. In addition, our social work and nursing resources, we found the early adopters. So I had a nurse practitioner.
00;25;45;14 - 00;26;17;05
Dr. Bethany Snider
She's worked in our arenas for years. It done hospice for probably 6 or 7 years and then wanted something different. Had relocated to a more rural area that we serve, but transitioned to palliative care. Well, what she found is her community desperately needed palliative care, but the wind chill time was killing her. But she was all about trying out telemedicine, and she adopted swiftly to where now she does two telemedicine days in a week and the other three are in the home or in a facility.
00;26;17;05 - 00;26;40;13
Dr. Bethany Snider
Yeah, but we don't even have to ask her. She went after it. Yes, but she couldn't get to her patients otherwise. Right. Like she had this caseload that she was managing. It was growing. And she figured out, well, if I do telemedicine with these kind of routine follow ups, that allows me to continue to touch them and interact, but then I can get to these other patients or I can get to these admissions quicker.
00;26;40;15 - 00;26;59;23
Dr. Bethany Snider
So she was our mouthpiece, frankly, right? Yeah. This great experience she saw had helped her manage her patients better and to manage the volume that she was experiencing, because she didn't want us to have to put a limit on the patients we could serve in her market because she just saw the need was so great. It's extremely rural.
00;26;59;25 - 00;27;25;06
Dr. Bethany Snider
It's at least an hour south of Louisville Metro. So these people really only have a critical access hospital close. But like they have no healthcare access. They needed support desperately. So we leveraged her stories during team meetings. But then the other thing we did is we early on surveyed family, and we asked them about the telemedicine experience, like, rate it for us for years.
00;27;25;07 - 00;27;58;18
Dr. Bethany Snider
Yeah, yeah. Did the technology get in the way? And families and patients overwhelmingly reported as positive experience. I think it was like 4.7 out of five how they rated it. So that also reinforced for me as a leader this is the right thing. Like they've adjusted to this interaction. Now we have to adjust. Yeah. And so we continue to find those champions early and had them tell the story because frankly nobody wants to hear from me.
00;27;58;18 - 00;28;24;19
Dr. Bethany Snider
Right. Like I'm the doc in the office. Right. And then what we saw over time is more assimilated to it. And they started to adjust their schedule to add that day in or two days. And then eventually after we got enough traction, then we changed our model to say, okay, everyone has to have two days a week that either our telemedicine days or in a clinic or facility.
00;28;24;21 - 00;28;49;17
Dr. Bethany Snider
So we just kind of said, like, this is now our new model. Yeah. So that we can be sustainable. And everybody's in that model now and they're doing fine. Because what that allows us then is you still have home days where you're making half as many visits as you make on a telemedicine or a clinic facility day. And that balance has pushed our program to a sustainable path, which I'll talk about in a second.
00;28;49;19 - 00;28;52;09
Dr. Bethany Snider
But I did want to address the nurse social worker piece.
00;28;52;15 - 00;28;53;16
Meg Pekarske
Yeah.
00;28;53;19 - 00;29;22;08
Dr. Bethany Snider
So I, like you agree 100%. We have to be interdisciplinary. And if anybody listens to this podcast that's trying to figure this out, they need to go spend time and energy learning about principal care management, which is a care management code that we can use to build for clinician time under the direction of a provider. So we saw that code come on the scene.
00;29;22;08 - 00;29;47;24
Dr. Bethany Snider
I think it was 2021. And we started to figure it out out of the gate because we already had these resources on our team that we were investing in because it was the right thing. But we wanted to try to get credit for the work they were doing. It's an easy process. You have to change some of your workflows because it's planet care driven, which is not traditionally in a pallet care space, something we worry too much about now.
00;29;47;26 - 00;30;27;22
Dr. Bethany Snider
But in 2024, we generated $360,000 in revenue just from work. In and social workers for doing so. If you think about that team. Right. We paid for our social work team just by capturing what they're doing. And then billing for it in that way. And so that to me is you're right. RB by itself isn't profitable. But when you pull all the levers of some pmpm a large volume of part B, but you have to maximize these additional codes and then evaluate the contribution to your hospice.
00;30;27;24 - 00;30;41;21
Dr. Bethany Snider
There is a win. And we saw that this year where when we count all of those things together, our out of care program covered its expense. And for us that was the game changer, right? Yeah.
00;30;41;24 - 00;30;52;20
Meg Pekarske
That is yeah, that is amazing. And I mean, it didn't happen overnight, but so I'm trying to think back. One was that you said you went to your first meeting.
00;30;52;20 - 00;30;54;26
Dr. Bethany Snider
Was it what do you think? Funding.
00;30;54;27 - 00;31;25;06
Meg Pekarske
Okay. I was gonna say 2015. Okay. So you know and I'm sure. Yeah, many bumps along the way and retooling and all this stuff. But, like, you're doing it and, yeah, it's like, not afraid to try, but, you know, then being grounded by what are our values, what are we trying to accomplish. And then, you know, staying up to speed on like principal care management codes, like other things that are going on.
00;31;25;13 - 00;31;56;27
Meg Pekarske
Because there there has been, you know, some changes in part B billing codes that it's not just evaluation management. I mean, there's other opportunities. And so that sort of brings me to the whole and this in addition to telling patients stories, and maybe they're the illustration of it, but is really about the data, the impact and the impact being measured.
00;31;56;27 - 00;32;25;23
Meg Pekarske
And I think when we've worked on negotiating pair agreements, you know, really trying to push on this data piece and not just a one way street, it's got to be a two way street, because if you have have blinders on and you don't really get to see the bigger picture and only the your payer partner is seeing that like that doesn't really is very helpful.
00;32;25;26 - 00;32;48;03
Meg Pekarske
So tell me about the data piece. Like what do you measure and how do you, you know, work with the the payer to get you that data? And like what what data do you think is important? And how did you begin that process? Because it's a real heavy lift to show value when you've never done it before.
00;32;48;06 - 00;32;51;26
Meg Pekarske
So how do I show value? Because it's like the chicken in the egg.
00;32;51;28 - 00;33;20;27
Dr. Bethany Snider
So, yeah, data is king. And I think my guidance to people is be narrow and scope. Initially and validate that your data is accurate and it's telling the story it needs to tell. So I'm the type of person on my team knows this. I always say, well what's the data. Tell me. Because clinicians especially, we love to operate by the exception, not by the rule.
00;33;21;00 - 00;33;45;05
Dr. Bethany Snider
And so I'm always challenging. Well, show me the data. Go get the data. So so I love data. So I'll say that is kind of my disclaimer. However, what I've learned in this process is we had to be really strategic around the data elements that we captured consistently and measured. And then they helped us to augment our models or adjust our practices over time.
00;33;45;08 - 00;34;08;15
Dr. Bethany Snider
So there are a thousand things you could measure, but I would try to be narrow. I think on the clinical side, going off the National Quality Foundation kind of guidelines and what they recommend is a great place to start. But on the business side, it's really important to think about what's the value to your organization, right. What are you trying to show value to your board or your stakeholders, you think?
00;34;08;18 - 00;34;30;17
Dr. Bethany Snider
And to your comment that we have to hold our partners accountable, that the data that we need payers especially, they want access to everything like they wanted us to send data hourly. It felt like like, oh yeah, can you do this or pour this day that support that day? And I mean that can be really overwhelming to organizations our size.
00;34;30;17 - 00;34;54;25
Dr. Bethany Snider
So we did push on them. We also with all of these agreements asked for transparency around claims data, particularly, part A and part B spend because that's what we can impact. So I do think it's important for organizations like ours do. And part of care to recognize part D is not where we are. The most medications that are extremely expensive, we have very little influence.
00;34;55;00 - 00;35;20;23
Dr. Bethany Snider
Think of your cancer drug like immunotherapy or pulmonary hypertension meds. We actually had a story with one of those early payer programs where we were serving a couple hundred patients, and they were doing a claims data review, and it kind of showed some data we weren't impressed with. And neither was a health system like we had seen through, you know, EHR avoidance, like behaviors were changing.
00;35;20;23 - 00;35;46;27
Dr. Bethany Snider
So why is the financials look this way? But when we dug in, there were seven patients out of the 200, that had medications that were canonical and there was no way to, augment those medicines. Right. So then that taught us a lesson for all of us, all three of us. But we had to actually cut the data differently in a meaningful way that truly evaluated is palliative care, meaning the outcomes that we've agreed upon or not.
00;35;46;29 - 00;35;56;04
Dr. Bethany Snider
So that was one thing we learned early on, like total cost of care is important, but we shouldn't take on responsibility for total cost of care. We can't influence total cost.
00;35;56;04 - 00;36;27;09
Meg Pekarske
The elderly say no to that because I just feel like when you Utah, everyone's gets so excited about, you know, ofs and and it's like, but what can you really impact because there could be awesome outcomes. But do you think you can have a measurable impact on that? Because it just I just think people get real excited and it's like, you don't want to be the downer, the Debbie Downer.
00;36;27;09 - 00;36;50;04
Meg Pekarske
But like, yeah, it's like is right. Any conference you go to, it's like you got to find out, you know, what they need. And then you got to provide the solution for what they need. And so they want to reduce overall costs, like you say, but like, okay. And they might say something I don't have a great example.
00;36;50;04 - 00;37;08;15
Meg Pekarske
I've had my head, but like, you know, you're not going to be able to influence that ride or, or so it just I think that's it sounds simple, but I think so wise because that your example with the the drug is like huge.
00;37;08;17 - 00;37;30;19
Dr. Bethany Snider
And here's another piece of that. You're absolutely right where this again goes back to legacy hospice. Oh we want to help them. We want to be a great partner. Yes. And we've got to be able to deliver, which is what makes it a great partner. And and so I chuckle. The other thing people need to really be thoughtful around is the patient population they're targeting.
00;37;30;22 - 00;37;59;27
Dr. Bethany Snider
So when we talk to our payers or our at risk providers that we're working with, I am very intentional that this population we're serving with this high needs program or we're getting this pmpm that's sustainable. That's not for anybody with serious illness, palliative care eligible. That's for people who have high heart a spend. They are utilizing of the system because you can have advanced heart failure that on paper looks terrible.
00;37;59;29 - 00;38;24;27
Dr. Bethany Snider
But if you're not utilizing the system in a way that we're trying to augment, then again, proud of care can actually deliver on the outcomes desired now in a community based program, can we support them and add value and and improve their quality of life 100%? But when we're thinking about the business of palliative care with these providers and payers, that's not actually their alignment, right?
00;38;25;00 - 00;38;46;20
Dr. Bethany Snider
Yeah. They care about their members and their patients, but they're looking at the value in a different way. So we always push them when we look at, you know, the analytics that are going to drive patient referrals to say yes, they need to have a qualifying diagnosis and they have to have a threshold of acute care utilization, breast impact.
00;38;46;23 - 00;38;57;11
Dr. Bethany Snider
Otherwise we're not going to win. Right? We we don't know what winning looks like. Yeah. Because they're trying to get us to curb expense. Well there has to be expense. You curb.
00;38;57;13 - 00;39;02;06
Meg Pekarske
Yeah. Exactly. That's so,
00;39;02;09 - 00;39;23;10
Dr. Bethany Snider
So I think that's one piece. The other thing I would say, especially if you're a legacy hospice organization like we are, we didn't do this initially. We should have. You've got to build the data out of the gate to show the contribution to your hospice, because there's this tension culturally between hospice and palliative, even within organizations under the same house.
00;39;23;13 - 00;39;46;10
Dr. Bethany Snider
And so some of the value we can show to our colleagues in hospice is that they get these patients sooner. They have double or triple the length of stay in hospice, which is better for everybody, not just the patient and family, but also financially for the hospice because they're getting better length of stay the turns not as significant on their clinicians.
00;39;46;12 - 00;40;17;13
Dr. Bethany Snider
So that's the other piece we learned along the way. External data and outcomes critically important to continue these type of arrangements. But internal buy in is just as important as you're expanding your services. And so I think that's the other piece that we learned, the hard way, but now have built, you know, dashboards to guide us across all of those stakeholders so that we can easily say, these are the patients that were impacted.
00;40;17;16 - 00;40;45;03
Dr. Bethany Snider
This was their value and length of stay added by coming through palliative care. This is actually the financial contribution that that then translates to because our board, it really challenged us. They wanted to see what is the value of this investment. And I can say thankfully in 2025, they are 100% behind this investment and the programs that we built in palliative care, because they've seen that value proposition and how it's.
00;40;45;05 - 00;41;18;00
Meg Pekarske
Doesn't happen overnight. But it happened, right. You know, and and that's just really, really exciting. And, you know, I want to have you on the podcast because I think, I think your passion about what you do and how you did it is contagious. But I also think, like, you're just really smart and thoughtful and patients are at the center of what you're doing.
00;41;18;03 - 00;41;45;09
Meg Pekarske
And it's not, I mean, right, the always said no money with no mission kind of thing, right? Yeah. There is a business of health care, but it doesn't mean that it we don't care about, you know, quality outcomes and all the things we we have always. What got us into this work to begin with is having an impact, positive impact on patients lives and reducing suffering.
00;41;45;09 - 00;42;17;16
Meg Pekarske
Right. So absolutely, we're doing all of that stuff. And, you know, it takes smart minds like yours to, you know, connect, you know, the patient stories and that passion because that's what gets you up. You know in the morning about to serve is like I remember some of these stories, with those floods in North Carolina, was it like fall or whatever?
00;42;17;22 - 00;42;45;21
Meg Pekarske
But these, these nurses like going out, like crossing, rushing rivers and tearing up these makeshift clinics, caring for people in these rural areas that no one could get to. And you're like, and, you know, stories of clinicians like West Virginia, rural areas, like doing amazing, amazing things for people. And it is that like, right. It's just it is amazing.
00;42;45;23 - 00;43;10;12
Meg Pekarske
And it's so we're so lucky to have people in the world that do such important work. But you need to have all of this business stuff too, right? And so to be successful, you need people like you that are thinking big picture. You need the people that are at the bedside. You know, it takes all. But so but all of this stuff is really hard.
00;43;10;12 - 00;43;34;27
Meg Pekarske
And I think, you know, where as an industry, we're really relying on Medicare, we're trying to diversify. But, you know, Medicare is going to always go bankrupt in the next couple years. I mean, who do we have Social Security of? And all of this stuff? I mean, it can be and, you know, regulatory enforcement dealing with all the time.
00;43;34;27 - 00;44;02;06
Meg Pekarske
And so I'm sure you have your days that you're down. But like, how do you stay motivated and inspired. Is it doing something totally different? Like, I love making stuff. So I mean, to me, I make jewelry and I garden and do all this other stuff that has nothing to do with what I do. In my day job, like, what keeps you inspired and enthusiastic?
00;44;02;09 - 00;44;40;14
Dr. Bethany Snider
Yeah, I think a couple things. One, my team knows very well that I think boundaries are the most important. And I didn't have great boundaries a long time ago and knew what that felt like. And I'm blessed that I have this keen awareness of when I'm falling over the cliff. And so I had my first child, and I realized that, like, had to be different because at the end of the day, this organization will go on without me and they'll replace me and it'll continue, right?
00;44;40;14 - 00;45;06;05
Dr. Bethany Snider
The work will continue, but my family gets one. Bethany right. One version of myself. And like I believe this work is a calling that you alluded to. Like people are drawn to this work for a reason. You don't just happen here. It's like to me, motherhood is a calling. And so I have to value both. And so I'm very intentional, like, yes, I'll work hard and I'll do my part and I'll come to the hospital.
00;45;06;08 - 00;45;26;20
Dr. Bethany Snider
But when it's time to be at home, I'm at home and I, I love doing different things. So I studied music in college. Oh. What? Oh. Oh. And music has been my life as long as I can remember it. So I am the pianist for our church.
00;45;26;23 - 00;45;27;27
Meg Pekarske
Amazing.
00;45;27;29 - 00;45;56;17
Dr. Bethany Snider
Lead the children's choir. So, that's the fun I get to do tonight when I get out of the hospital as go work with 30 crazy children and turn it into beautiful art through music and, those things remind me of why I do this work. How did. Then? Hospice changed my life. Medicine. It's not easy. And it was extremely difficult in training.
00;45;56;17 - 00;46;20;03
Dr. Bethany Snider
And I was a different human and it was bitter. And then I found this beautiful place where we valued people, and we realized that it's an art and it's not a science. And we got to understand, like, what mattered to them and what their values were and the things that they loved. Like we got to know them as people, not just numbers or a diagnosis.
00;46;20;05 - 00;46;49;07
Dr. Bethany Snider
And like, I couldn't be more grateful today. And so I think that that's really helped shape my perspective. I mean, I think you can hear in it like faith is a guiding place for me and it keeps me grounded. And it reminds me of the main thing. And I think in this work, like all people like this, the reason I get up and do this work is all people that have access to this, and I'm going to fight like hell.
00;46;49;09 - 00;46;50;00
Meg Pekarske
Yeah.
00;46;50;00 - 00;47;22;08
Dr. Bethany Snider
To try to get that for them. And I think about that in Kentucky. But beyond, I don't care if you live in Pikeville or Paducah or somewhere in between, you should have access to high quality palliative care. Even if you're not interested in hospice, like that should be a thing that you are entitled to, because all of us deserve to have a good quality of life and we're dealing with serious illness and our patients families deserve support, and so it makes it easy to do the work when that's what you're fighting for.
00;47;22;11 - 00;48;04;20
Meg Pekarske
Oh boy. Totally so, so amazing how parallels. Because I too found going to law school like almost. It's very hard, but also sort of lost myself. And then through finding my way to hospice and then by doing this for 25 years, like I don't think I could have been successful, nor would I still be a lawyer if I didn't find the, you know, hospice people because it's like the uniqueness that I bring to what I do like resonates with hospice people like probably, you know, I want it resonate with like real estate people or, you know, whatever.
00;48;04;24 - 00;48;35;03
Meg Pekarske
Like my, my, my vibe is not. But it's like, yeah, like life really makes sense in reverse about how I found my way here. And I think it is where I went supposed to be and just really, yeah, I've gotten to meet amazing people and be part of in my small way, like helping people do really important things in the world that really matter.
00;48;35;06 - 00;48;57;26
Meg Pekarske
And then, you know, I started hospice volunteering, and I really that was something I was scared to do because it just like it's going to be uncomfortable. And then you just realize it's like humans cared for humans, and it just like, yeah, it's prepared me really well to, like, be a better human in the world. Like, absolutely.
00;48;57;26 - 00;49;20;02
Meg Pekarske
So hospice has completely changed my life in so many, so many ways for for the better and how I want to live my life and everything. So, so thank you so much for sharing your story. And just like all of your wisdom and just pizzazz for life. And so this all got started because I think several years ago I was like, you need to be on my podcast.
00;49;20;02 - 00;49;27;09
Meg Pekarske
And then, you know, life gets in the way or whatever. And then you were in the New York Times. I opened up like.
00;49;27;09 - 00;49;28;24
Dr. Bethany Snider
Oh yeah, that's crazy.
00;49;28;24 - 00;49;40;09
Meg Pekarske
I was like, oh my God. I go there every time I see by someone in the New York Times, I know them. I was like, oh my God, that's so cool. And so and we rehashed star. That's for a podcast.
00;49;40;09 - 00;49;42;20
Dr. Bethany Snider
So we made it, we got.
00;49;42;23 - 00;50;13;14
Meg Pekarske
It, we got it done. And we are just awesome. So so thank you, thank you egg. For all of your time and just what you do. You're really inspiring. And so I'm not it's like you have there must be like amazing women finish and said like West Virginia, Kentucky, North Carolina like I've read very inspiring stories of women in like, rural areas that are like just the ends of the earth.
00;50;13;14 - 00;50;26;04
Meg Pekarske
They would go for you. So, thank them. Yeah. So thank you for all you do. And thanks so much for your time today. This has just been a wonderful conversation.
00;50;26;06 - 00;50;31;05
Dr. Bethany Snider
My pleasure. We can do it again soon, you know.
Meg Pekarske
Yeah.
00;50;31;07 - 00;50;51;13
Meg Pekarske
Well, that's it for today's episode of Hospice Insights: The Law and Beyond. Thank you for joining the conversation. To subscribe to our podcast, visit our website at huschblackwell.com or sign up wherever you get your podcasts. Until next time, may the wind be at your back.