Rae Woods (00:02): From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle health care's most pressing challenges. My name is Rachel Woods. You can call me Rae. Every year Advisory Board provides an update on the biggest trends shaping service line strategy. Our researchers speak with industry leaders, dive into data and forecasting models, and identify exactly what service line and strategy leaders should pay attention to in the year ahead. And because I know you have so much on your plate, I want to make understanding what's next a little bit easier. (00:35): In today's episode, we're going to give you the headline takeaways on the biggest trends impacting oncology, cardiovascular care, women's health, and neurology service lines. You're going to hear my conversations with four different Advisory Board experts as we talk through each of these terrains. We're going to cover some of the universal challenges facing specialties, and how service lines are managing patient access, workforce, policy, and clinical innovation. (01:02): My goal for these conversations is to equip you with the high level understanding of the biggest pressures and the biggest opportunities across these service lines. And we're going for breadth today. But if you want the depth, please click on the link in our show notes to explore more of Advisory Board's truly vast service line library. To start us off, I want to invite our resident oncology expert, Lindsey Paul. Lindsey, welcome back to Radio Advisory. Lindsey Paul (01:29): Thanks, Rae. Excited to be here. Rae Woods (01:31): I know that the oncology service line cannot be ignored, especially not in 2025, headed into 2026. I'm thinking about the fact that cancer volumes are only going up. We see them growing on the national level. Cancer incidence is projected to increase by 12% in the year 2028, which means more volumes than I think we're going to be able to handle, which means access is becoming even more of a priority as cancer programs face financial pressures, especially pressures from the ongoing policy and reimbursement landscape. My first question for you, Lindsey, is why does the incidence of cancer volumes keep going up and what does that mean for oncology service line leaders? Lindsey Paul (02:13): Well, I think one of the important things to look at is where are we seeing incidence increase? How do we break down that data a little bit? And so that's what we did with our recent market trends research. And when you look a little bit deeper at some of the data, you find that there are certain demographic groups for which cancer incidence is rising pretty significantly. Rae Woods (02:33): Like who? Lindsey Paul (02:35): Younger patients, patients that are under the age of 49 considered early onset. We're seeing a lot of increase in incidence among some of those patients that are usually not thought of as being the typical cancer patient. And then on the other side of the spectrum, you have older patients, those that are 75 and older, even 85 and older, where just at a national level in the US, we're seeing that group grow as people age, but that group will make up nearly 40% of overall cancer patient volumes in the next decade. Rae Woods (03:07): Wow. Lindsey Paul (03:08): So when you combine the young patients, the old patients, and then a third group we're looking at is cancer survivors, which is also a group that's growing, what you get is a bunch of patients that, yes, have cancer, and yes, cancer programs will need to care for them, but that have pretty unique needs and will have different pathways into the program and different challenges and barriers to care. Rae Woods (03:30): What does this rise in volumes mean for capacity? Lindsey Paul (03:35): Also the challenge is, just with any rise in volumes, pairing that with workforce shortages, it can be hard to fit patients in. And we know that the median medical oncologist is already seeing 13, sometimes 20 plus patients a day. So there's not a lot of time for them to be seeing all these patients. But even more so, they're struggling with how do we not only fit patients into the schedule, but really meet unique patient needs that are going to be different when you're thinking about a younger patient versus an older patient versus a survivor. Rae Woods (04:06): So my first reaction to this is just a pure numbers problem. We have a math problem of there is more demand than we have the supply to be able to meet. But because the groups of patients are so different and they have such different needs, what does appropriate care look like for these different groups? How can oncologists who are already feeling this huge capacity strain meet the needs of this specific and also quite large population? Lindsey Paul (04:37): And that's exactly what we've been talking with cancer program leaders about this year. One of the answers is we need to think more holistically about who is involved in caring for these patients. With the older patients, is there a geriatrician that can be involved? Is there an occupational therapist or a physical therapist that you need on your team? For the younger patients, a lot of times they're worried about things like emotional support or access to clinical trials or financial counseling. Many of them are in the workforce. And so that means the support they need might need to come from a different staff member than what you would think of. And then we're also seeing care delivery models evolve where greater uses of APPs, oncology pharmacists, even greater connections to primary care to help care for some of these patients and survivors that have needs that span a range of different conditions, including cancer, but also stuff that primary care physicians could be involved in. Rae Woods (05:33): So there's two big strategies I'm hearing here. One is making the most out of your oncology care team using the entire care team, utilizing APPs, but it also means looking at the rest of the enterprise, what maybe should primary care handle, what does your geriatrician handle, what outside of oncology should actually be the right caregiver to be looking at those patients? Is that right? Lindsey Paul (05:59): Yeah, definitely. Rae Woods (06:01): Are there any other big or new developments or high level trends that you want leaders to pay attention to when it comes to oncology headed into 2026? Lindsey Paul (06:10): We're definitely continuing to explore what that relationship with primary care should look like and publishing a little bit about that. But the other thing that we're watching is the way that clinical innovations are also leading to changes in care delivery. We've published a lot on cell and gene therapies recently, and now we're researching radiopharmaceuticals as well because those are two areas where we're seeing major shifts in how cancer programs need to think about care delivery, who needs to be involved, what kind of workflows and processes they need to have. And so that's definitely worth paying attention to over the next year. Rae Woods (06:51): The growing demand for services, paired with decreasing capacity and workforce shortages, is absolutely threatening patient access, and therefore health system revenue. And that's not just an oncology story. In fact, this challenge is true in every single service line. Cardiovascular is no stranger to those pressures, and paired with cuts to reimbursement, rising costs, and a case mix that's pushing low complexity procedures out of the hospital, it might actually come as a bit of a surprise that health systems are continuing to prioritize capital investments for cardiology. So here to tell us what we need to know about the CV service line is advisory board expert Kristin Strubel. So cardiovascular care has long been a priority for health systems. What's the big headline we need to know headed into next year? Kristin Strubel (07:42): We know that the cardiovascular service line is a big revenue maker for health systems. Health systems have long time been investing in procedures like electrophysiology, structural heart, interventional cardiology, because the volumes are there. We're going to see a huge increase across the next five years in electrophysiology volumes in particular. So it has not stopped health systems from investing in this service line regardless of financial struggles or policy implications. Rae Woods (08:11): And to your point, this investment is not new. Health systems and service line leaders have already made the bet to invest in CV, and that bet has paid off. There's a ton of demand, at least that's what you're telling me so far. They're betting that investing in this service line will not only improve care but also drive revenue. Are we actually seeing that bet play out? Kristin Strubel (08:33): It depends, but largely no. When you look at the data, it's because the volumes are critical to financial success, yes, for these procedures, but they struggle to meet that procedure demand. So patient volumes are there, but increasing capacity, along with a workforce shortage, has long been an issue in terms of getting those patients in the door and not having huge wait times. Rae Woods (08:57): So they have the demand, but they don't have the space, they don't have the beds, they don't have the staff to get patients through the system. Kristin Strubel (09:04): Yes, correct. Patient throughput is a huge bottleneck for CV service lines right now. Rae Woods (09:09): This is a challenge that will probably feel familiar to our listeners, regardless of what service line or part of the system they're in. Lack of capacity means systems aren't getting the most out of the investment that they've already made. What are the big causes of that capacity constraint? Kristin Strubel (09:27): So there's a lot of operational inefficiencies going on with pre and post-procedure workflows. So getting patients on time starts for the procedure, getting them through the procedure, and then into their post-acute care setting. So there's been a lot of bottlenecks on that front. And then there's also, what we can't ignore is the workforce constraints. So there's not enough general cardiologists, there's not enough physicians in general, and the staff that have remained, they're burned out, they're overworked. The last thing they want to do is be in a cath lab from 7:00 AM to 11:00 PM. So you're working with an already constrained workforce on top of long wait times and the capacity constraints that is affecting the CV service line. Rae Woods (10:12): Let's go there. Because where I hear you on the fact that CV leaders can do all of this stuff to improve their operational efficiency, do the pre and post-procedure workflows, focus on length of stay as much as possible. Whenever I hear serious capacity squeezes like this, what I actually hear are warning signs about the state of the clinical workforce. So how are leaders innovating to improve their efficiency and make the most out of this investment while also protecting and supporting their clinicians? Kristin Strubel (10:42): So they're investing in things like jack of all trades cardiologists. And what I mean when I say this, it has long been known that hyperspecialization is something that cardiologists prefer. So only focusing on structural heart. But that also does a disservice to, not only service lines, but also health systems and patients because now you have all this patient demand, but a physician can only do one to two procedures. That's their bread and butter and that's it. (11:05): And then it's also recruiting this younger generation, but offering them more flexibility. They're not just wanting things like compensation. You can't just throw money at them and expect them to be happy. You have to work with your physicians, not against them, to work with what their preferences are. Because at the end of the day, the workforce is aging out and we're now dealing with the younger workforce. So these innovative health systems are working with their cardiologists, hearing what they want, part-time work, remote imaging readers, and keeping staff happy so that they don't have as much turnover is kind of the key goal. Rae Woods (11:41): I hear you on meeting the needs of the younger workforce, but when I hear things like more flexibility, more part-time work, how do we make sure we're doing that and it's also helping with the capacity problem? Kristin Strubel (11:52): You have to balance things on both ends. You have to keep patients happy and increase capacity, increase patient access, but you also cannot neglect your workforce. You have to also work with them and listen to their needs. When they feel involved, they're going to be happier, they're going to stay and you're not going to have as much turnover. Rae Woods (14:09): The next service line I want to cover is of course also being squeezed by a supply and demand mismatch. It's impacting accessibility, it's impacting the workforce, but what makes women's health different are the waves of policy and legislative action coupled with economic headwinds that are threatening closures across the country. It's not just an access problem, it's a care desert problem. (14:34): I've invited back advisory board expert Gaby Marmolejos to talk us through the major shifts impacting women's health. Okay, Gaby, level with me. This is a year where we've had perhaps more conversation about women's health than we could have predicted. We're seeing new investments in menopause care. Femtech continues to boom. But I also know that, generally speaking, things aren't good in the women's health world. Let's focus on the service line leader perspective specifically. What should these healthcare leaders pay attention to today to prevent things from escalating tomorrow? Gaby Marmolejos (15:07): The big story here is obviously the One Big Beautiful Bill Act. There are Medicaid cuts that are going to impact all providers, but it's going to be particularly painful for women's health providers. More than half of Medicaid recipients are women, and the vast majority of Medicaid recipients that are not currently working are women as well. And the reason I'm pulling that out is because there are new work requirements to able-bodied folks on Medicaid that are not currently working. And so most of them are women. And in many cases they are caregivers. They're caregivers to their children, to their maybe aging parents, to their family members. And so they're really going to bear the brunt. They may lose coverage altogether because they can't afford to work full-time in addition to caregiving. Rae Woods (15:59): And I appreciate that you're pointing out that that is specifically painful for this patient population, but because this patient population is also served by a specific service line, it is particularly painful for that service line. Gaby Marmolejos (16:12): Yes. Because this patient population is now probably going to lose coverage. We've seen that historically when a state has a work requirement, thousands of folks lose coverage. And so that means more uncompensated care from a health system perspective. So these service line leaders are now seeing more people come in the door without coverage. And specifically in the obstetrics space, what you could easily see is more patients coming in that are only eligible for Medicaid once they became pregnant, which means that they didn't have access to healthcare prior to pregnancy. And that could mean delayed prenatal care. That can also mean that they may have comorbidities that weren't treated prior to getting pregnant. And so it just complicates care delivery. Rae Woods (16:58): And those aren't the only headwinds facing women's health programs. The staffing shortages that we've talked about in other service lines are more severe in women's, or there's more variability if you look state by state. You already mentioned that patients might be sicker or have more acute needs. But we're also seeing population and therefore volume decline, especially if I think of something like birth rates. Add that to some of the policy changes with the Medicaid cuts, and we've really got a challenging margin picture. Gaby Marmolejos (17:30): We specifically see all the combination of challenges facing rural obstetric units. That's really where you're going to see the biggest impact. Because these programs, usually those hospitals, rural hospitals often have very little to negative margins, so they often can't bear the cost a 24/7 labor and delivery unit. Most rural hospitals don't have a labor and delivery unit. 58% of rural hospitals do not have a labor and delivery unit. And now 66% of women that live in rural communities have to travel more than 30 minutes to the closest obstetric unit. And if you're thinking about pregnancy, 30 minutes is way too long if you're in labor or you're experiencing a pregnancy related emergency. Rae Woods (18:16): So to ask bluntly, how are women's health programs staying afloat? What solutions are we seeing here? Gaby Marmolejos (18:23): There are a mix of solutions depending on the organization. So I feel across the board, most OBGYN service line leaders are focusing on building team-based care models to improve quality and maximize physician capacity. There's a shortage of OBGYNs, especially subspecialty OBGYNs. And so team-based models empower other members of the care team like nurse practitioners and physician assistants to deliver women's care, including obstetric care, as well as other women's services like menopause support. (18:55): Many are also looking for opportunities to expand their reach by building programs to support women as they age because we have an aging population. So from teenage years to golden years, many programs are looking on how do I expand and reach a wider demographic of women? And then in the rural side of things, choices are limited. I'll be honest about that. In many cases, programs are doing their very best, and that includes participating in government designations. Things like critical access hospital designations can improve reimbursement and sometimes reduce liability costs, in the case of federally qualified health centers. Many also take advantage of or try to use grant programs. So there's a lot of different federal and state grant programs intended to strengthen rural obstetric clinical training and trying to bolster rural telehealth programs to access subspecialty care. (19:47): And then the last part is it's not really an active choice. In many cases, they might affiliate with a health system. And once you affiliate with a health system, it provides access to shared staffing models as well as resources for fundraising. And so at this point, most rural hospitals are affiliated with some sort of health system. Rae Woods (20:08): Even with all of those actions, the reality is more obstetrics units will likely close, and that actually impacts everyone, rural or not. So even if you're an AMC, say you're in the next state over, and we're seeing spillover. And rural closures are associated with worse pregnancy outcomes, meaning higher costs for health plans with more NICU admissions and maternal ICU admissions. I'm not one to invent a silver lining when there isn't one, but what something that healthcare leaders can do today to start addressing these challenges? Gaby Marmolejos (20:40): I do think it requires cross-industry efforts to really address some of the root causes, especially of rural obstetric unit closures. But what I'll say is building a strong foundation is very important for any service line. Whenever I've chatted with an organization that has grown any service line, including women's, I find they usually start by building a strong foundation. Things like designing a service line governance structure with shared goals across facilities, prioritizing staff engagement and retention, improving care quality with data collection to better identify opportunities to strengthen revenue and minimize expenses when they're facing these headwinds. (21:18): But I would say in the policy context, advocating for women's health policies is really important. It's a great opportunity for you to really be involved with your state leaders and talk about the challenges you're facing with your rural obstetrics programs. And then from a health system standpoint, I think it's really important to partner with rural programs to really understand how can you be a good partner to rural hospitals and improve access to women's care in those communities, either with telehealth programs or even offering simulation trainings. Because in a lot of these rural communities, they have very low delivery volumes. And so these simulation trainings can help rural providers prepare for obstetric emergencies. (21:58): So I recommend just seeing what is a great way to be a partner as a health system. And if you're also a rural hospital, I will say there is a little bit of silver lining. The transforming maternal health model, it's a CMMI model, specifically focused on Medicaid and CHIP. That model, they just announced 15 states were selected to participate. So I would also see if there's an opportunity to get involved in that model. Rae Woods (22:29): Our last service line conversation actually sits at an interesting turning point, and that's neurology. Despite some modest growth in inpatient volumes, the hospital will no longer be the locus of neuro care because more and more services, think sleep studies, infusions, diagnostic testing, are all moving outpatient. And it's critical that health systems have the ambulatory infrastructure in place because innovation is coming fast and furious for this specialty. (22:59): In 2025, there were over 300 clinical trials in the Alzheimer's disease space alone. And advancements in AI have been able to use imaging to identify potential stroke patients and predict disease progression. But with every new innovation comes the age old question, how do we actually pay for this? To help answer that question, I'm joined by Ellie Wiles, our neurology expert. What is your big takeaway for healthcare leaders looking to develop their 2026 neuro service line strategy? Ellie Wiles (23:30): The biggest overarching trend that we're thinking about is this confluence between a patient population with increasingly complex care needs with shiny, new, expensive treatments and diagnostic tools. Everything is getting more expensive. No one is quite sure how to pay for it or who's responsible for paying for it, and no one's quite sure how to meet this growing demand for neurological care, given that costs are so high and the supply of neurologists is so low. Rae Woods (24:00): When we say costs are high, how high are we talking? Ellie Wiles (24:03): For example, Medicare spends about 22,000 per year on seniors with Alzheimer's, which is almost three times as much they spend for those without. And by 2030, Medicare Advantage spending on Alzheimer's care is projected to double to 15 billion. Rae Woods (24:20): There's the question of who pays for this, but for me, the better question is how do we pay for this? And how we pay for this makes me start thinking about alternative payment models. It makes me think about value-based care. I'm curious what is the case in neurology? Are neurology leaders moving forward with alternative payment models? Ellie Wiles (24:41): Neurology has been a little bit of a late adopter in the value-based care movement, but that is beginning to change. Things like inadequate reimbursement rates, increasingly expensive therapies in complex patients, and other economic pressures are definitely pushing neurologists in that direction. So there's a growing number who now participate in alternative payment models. They aren't necessarily at the forefront, and fee-for-service is still dominant, but they've at least moved away from the sidelines. And I think upcoming payment reforms will most likely accelerate that shift towards value-based care. (25:14): So in the coming years, I definitely think that we'll see neurologists more fully embrace these models, both because external pressures won't really leave them much of a choice otherwise, and because when they're done well, value-based care offers a path to better outcomes for neurology patients and to better financial sustainability for neurology providers. And I will also say that neurologists are beginning to show leadership in care innovation. So we're seeing things like higher telehealth uptake for chronic condition management and stroke consultations, collaborative care models that leverage different members of the care team beyond just neurologists. All of those types of things really support the goals of value-based care. Rae Woods (25:52): And I should also say these clinicians might not ultimately have a choice. We see more mandatory models coming out of CMMI that could impact neurology, which means we need to understand who's doing this well now so that we can adopt for the future. Are there early movers here who are capitalizing on innovation to get into risk? Ellie Wiles (26:14): Yeah, for sure. There are a couple of really good examples that come to mind. The first one is Ochsner. They identified basically a few key financial metrics that were valuable to their system. Things like provider billing, risk score optimization, system savings. And they tracked those to build a business case for the sustainability of an expanded suite of neurological services beyond just diagnosis, which is essentially what the initial program scope was. Within the first few years, the expanded program yielded $200,000 in direct revenue, 150,000 in coding improvements, and over 560,000 in total cost of care reductions, while also increasing caregiver satisfaction scores, I should say. So very good example there. (26:59): Another one I can think of is Stanford. Stanford has been building out a value-based neuro program focused on reducing costs and improving quality. And they've done that by investing in real-time consultation tools, cutting down on unnecessary imaging, creating a cost conscious rounding checklist for clinical operations. And that focuses on things like room turnover, diagnostic scheduling, coordination with primary care. So those changes limit avoidable costs. They also reduce ICU length of stays and improved operations. And the thing that both of these two organizations have in common, they both really started small with small changes that were anchored in the value metrics that matter to their organizations, and they built institutional buy-in as they went. Rae Woods (27:43): Well, you didn't know that you were doing this, but you actually perfectly teased a future Radio Advisory episode that we're going to be doing with Ochsner that is all about value-based care. So thank you for that. Ellie Wiles (27:53): Of course. Rae Woods (27:55): And thank you for coming on Radio Advisory. Ellie Wiles (27:56): Thanks, Rae. Rae Woods (28:01): We talked about four service lines today, but these aren't the only service lines you may care about, or frankly, that we are watching. Check out our specialty care landing page on advisory.com and in the show notes for more in-depth research on these and other service lines, including an orthopedic service line update coming later this fall. And remember, as always, we're here to help. (28:52): New episodes drop every Tuesday. If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Chloe Bakst, and Atticus Raasch. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. Special thanks to Kaci Plattenburg. See you next week.