Analysis of competitors in the U.S. palliative care organizational consulting industry

Introduction

Palliative care improves quality of life in advanced cancer, and a key challenge remains how to develop and expand palliative programs (1,2). Experts in palliative care could assist organizations in these endeavors as organizational consultants. For example, community-based hospice programs are increasingly venturing into offering non-hospice palliative care, but billing models differ, and palliative programs require more collaboration with specialty clinicians. Similarly, hospital administrators may be interested in serious illness care but lack expertise in what palliative care is, hiring needs, models of care, and financial models. Overall, there is a high demand for specialized knowledge in how to develop and implement new palliative care programs.

Organizational consulting opportunities abound. Palliative oncology programs grew rapidly over the past decade and have continued to expand due to greater need and acceptance during the coronavirus disease 2019 (COVID-19) pandemic (2-5). Moreover, the non-profit Center to Advance Palliative Care (CAPC) has led in organizational consulting over the past 20 years, and with the retirement of Dr. Meier, CAPC’s founding director (6), we may see more competition and opportunities in the organizational consulting industry to support palliative care growth. Expenditures on palliative care are anticipated to rise as specialist palliative care services in hospitals are expected to continue growing, driven by the high prevalence of terminal illnesses among older adults and the increasing utilization of hospital settings for end-of-life care (7). The COVID-19 pandemic’s promotion of telemedicine visits has also expanded access to palliative care, further contributing to the upward trend in expenditure in this healthcare sector (8).

This article reviews palliative care organizational consulting companies to characterize the competitive landscape and suggest avenues by which palliative care experts can contribute to palliative care expansion. The investigators conducted an initial web search in April 2021 and a follow-up search in May 2023. Specifically, we conducted Google searches for the 24 search phrases (e.g., “healthcare consulting” palliative) identified in the table note (see Table 1). The initial web search included the top 100 results for each search (2,400 web results), and the follow-up search exhausted all Google results for each search phrase (3,686 web results). Analyses excluded organizations solely providing hospice organizational consulting, non-profits, and consulting at the individual rather than organizational level. Details on the organizational consulting companies were given final review in November 2023.

The investigators identified two large organizational consulting firms developed through mergers and acquisitions and five boutique companies that specifically mentioned palliative care. This paper summarized their history, estimated current revenue, staffing, strategy for scope of consulting, operational characteristics, and disciplinary backgrounds, to the extent details were available.

Palliative care consulting companies

Vizient

As the largest company, Vizient acquired Intalere in 2021, which historically was the largest palliative care organizational consulting company in its own right at that time. We begin by reviewing Intalere to understand the culture and history of palliative care organizational consulting to the extent it has persisted within Vizient post-acquisition. Intalere began as a group purchaser and supply chain company for the healthcare industry before diversifying opportunistically to meet client needs. A subset of services focuses on operations and finances, including in care for older adults and the seriously ill (senior living, long-term care, hospice, and home care). Their website (now defunct) noted a hospice and palliative care consulting program. Their website contained many whitepapers and videos. The palliative program flyer cited relevant scientific evidence, was well-grounded in the current issues facing the field, and focused on how their consulting program would reduce cost and improve patient outcomes. Intalere differed from the other companies reviewed in that their website provided less information on key employees and organizational structure.

In April 2021, Intalere was acquired by a parent company called Vizient, Inc. Vizient offers Performance Improvement Programs which address managing end-of-life issues with palliative and hospice care. In the same vein that Intalere used multimedia grounded in academic scientific evidence to promote its work, Vizient also includes newsletters, blog posts, and videos about palliative care grounded in academic scientific evidence, and often involving academic experts. The main differences post-acquisition seem to be a broader focused on offering comprehensive services aimed at supporting quality of care and the greater resources and advantages of a larger corporation.

SimiTree

From 2021–2023, six companies merged to provide comprehensive healthcare consulting services: BlackTree Healthcare Consulting, Simione Healthcare Consultants, Imark Billing, Infinity Behavioral Health Sciences, Afia Health, and GreenpointMed. BlackTree provided consulting to the healthcare sector on operations, finance, billing, and insurance codes, and increased client engagement in the early pandemic through monthly webinars in the early pandemic. Simione was highly focused on serious illness care—hospice, home care, and palliative care—and had many consultants involved within the non-profit National Hospice and Palliative Care Organization (NHPCO). Imark Billing primarily provided consulting services to home health and hospice facilities, and their areas of expertise included billing, coding, financial reimbursement, and Medicare revenue recovery.

In 2022 and 2023, SimiTree expanded into the behavioral health sector through acquisitions of Infinity Behavioral Health Sciences, Afia Health, and GreenpointMed. Infinity Behavioral Health Sciences specialized in offering consulting for mental health and substance abuse facilities, with services including billing, insurance collections, utilization management and enhancing profitability. Afia Health centered its efforts on behavioral health data analytics, and GreenpointMed focuses on delivering medical billing and credentialing services to behavioral health providers and practices.

SimiTree provides comprehensive consulting services to post-acute care services (including home health, hospice, palliative care, pediatrics), and their services include financial, clinical, operational consulting, value-based purchasing, cost reporting, growth solutions, training, education, development, information technology, compliance & regulatory risk, and internal staffing & management. Their website notes that they have served more than 16,000 agencies with 770 active clients. SimiTree has 11 members on the leadership, with several noting consulting in the home care and hospice industry.

Boutique companies

The investigation identified five boutiques providing organizational consulting in palliative care: Schramm Consulting, Hospice Advisors, Integriti3D, Understanding Hospice Matters, and Hospice & Palliative Board Review. Schramm Consulting offers a range of consulting services tailored to hospices and palliative care providers. Their areas of expertise include hospice strategic planning, palliative care startups and contracting, hospice investor analysis and support, hospice affiliations, mergers and acquisitions, market analysis, facility planning, and certificate of need process support. For palliative care startups and contracting, Schramm consulting specifically assists with Medicare enrollment, budgeting, staffing plans, and market analysis. The founder, previously the managing director of the consulting division at the NHPCO, along with other members of the leadership team, brings extensive experience in hospice and palliative care settings. This company could serve as an illustrative example for professionals seeking to venture into palliative care consulting full- or part-time.

Hospice Advisors and Integriti3D offer useful examples for small, highly focused consulting companies. Hospice Advisors consult on hospice, home care, health systems, funeral home services, oncology home care services, and emergency management services. Their palliative care work involves helping hospice organizations grow into the palliative care space. One of the six leaders of the team is board-certified in hospice and palliative medicine. Their website includes news, blog posts, and a video library, though most content is more than five years old. Integriti3D offers consulting services that emphasize planning, board engagement, and cultivation of ethical culture within hospice and palliative care organizations. The website provides learning modules and resources related to healthcare, hospice, and palliative care. These boutique companies provide a useful example of a small, focused consulting company.

The final two companies offer useful examples for those interested in part-time or smaller opportunities. Understanding Hospice Matters is led by an individual part-time consultant. Her work has mainly focused on supporting nurses working in the hospice setting but occasionally mentions palliative care. Hospice & Palliative Board Review, led by a board-certified internal medicine physician, provides consulting and educational services in both hospice and palliative care. These two boutique companies could serve as a useful model for someone interested in entering organizational consulting amid other ongoing career activities.

Conclusions

We reviewed each U.S. company providing organizational consulting on palliative care, identifying two large, diversified firms that developed through a history of major mergers and acquisitions, and five boutiques. Vizient was estimated by external sources to have revenue approximately 100 times its next biggest competitor or SimiTree, though it remains unknown what proportion of Vizient’s revenue is derived from consulting on palliative care. Thus, the industry can be seen as dominated by one or possibly two main players. Palliative care clinicians may wish to reach out to some of these companies, especially those that share a similar vision, priorities, and goals, particularly if one’s unique personal expertise would be an asset. We were surprised by the small number of companies in this space (at least that have a documented web presence in this space), the extent of mergers and acquisitions, as well as the lack of geographic coverage across the U.S. In addition to joining existing firms, clinician entrepreneurs may wish to consider starting their own company as a new entrant in the industry, using the strategies of a market follower or market nicher. A market follower allows the market leaders (Vizient and SimiTree) to spend their substantial resources on innovation, research, and development, and the market follower quickly follows their lead with lower cost options due to avoiding research and development costs. A market nicher focuses on an untapped region or specialty service not offered elsewhere. Given the history of mergers and acquisitions in this space, a geographic nicher could be a wise financial strategy if the goal is ultimately to have one’s company acquired by a market leader. Attempting to enter this space head on as a true market competitor, rather than follower or nicher, would be challenging, given the larger resources available at the two main firms. Thus, clinicians should join existing companies or enter as a follower or nicher.

The limitations of this paper should be appropriately contextualized. First, similar reviews will need to be replicated in other countries and healthcare systems to observe how the landscapes of organizational palliative care consulting differ. This can stimulate discussions and provide ideas for enhancing end-of-life care initiatives in diverse healthcare context beyond the U.S. The present paper may also serve as a guide for analyses in other countries. Second, our paper focused on a competitive analysis of the industry. This analysis is relevant to broader strategic frameworks. For example, according to Porter’s Five Forces (9), an analysis of competitors is one of five key factors that drives strategic decision making, along with considerations about the ease of entry into an industry, the power of suppliers (clinicians, scientists, and staff with palliative expertise), the power of customers (medical centers paying for consulting), and the threat of substitutes (e.g., non-specialty palliative care). The paper suggests that entry into the industry is feasible as a follower or nicher. Moreover, suppliers and customers are vast and lack centralized bargaining power, and non-specialty substitutes face challenges billing insurance. These forces warrant in-depth attention for careful strategic planning, and our analysis of the competitive landscape suggests enthusiasm for taking those next steps.

In sum, this paper suggests that palliative care experts can contribute to the development and growth of palliative care programs by offering organizational consulting to healthcare systems as a new entrant, in partnership with an existing boutique company, or in partnership with two large corporations.

Acknowledgments

Funding: This work was funded in part by the American Cancer Society (No. 134579-RSG-20-058-01-PCSM to M.H.).

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Palliative Medicine. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-23-592/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-23-592/coif). M.H. serves as an unpaid editorial board member of Annals of Palliative Medicine from June 2023 to May 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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