Q&A: BJ Miller on an Accessible Model of Palliative Care

Note: This interview has been condensed and edited for clarity.

EOL: BJ, we're excited about your new company, Mettle Health. Tell us about this unique model of palliative care that you and Sonya Dolan have created.

Dr. BJ Miller: The problem Sonya and I were leaning into was access. As we all know, there are zillions of issues, opportunities, and problems in and around healthcare, especially end of life. We've been feeling that the world we're in, well that we've all been in, is in some amount of free fall. In large part, Mettle Health came out of COVID.  

It was something we have wanted to get to, but COVID really kicked it up a notch. A lot of us have been trying to clarify what palliative care is. For awhile, there were so few people who understood it and were seeking it out. That meant the volume was manageable. When I did my fellowship in 2006, I could spend four hours with every patient because we just didn't have that many patients. The good news is palliative care has come off the margins in important ways. We have a ways to go, but more people know what it is and are seeking it. 

EOL:  What obstacles are people running into? 

Dr. Miller: There are geography limits for palliative care. It's isolated and is largely in big city areas. Whole regions, like the southeast, are relatively underserved. So, the first problem is to get attention to the field. Now we've got some attention, but we don't have the capacity to handle it.

Second, as we know, the demographics around baby boomers aging means we've got a mess now, and a bigger opportunity ahead of us. Now that telehealth has arrived and the technological barriers are relatively low, this felt like a really good time and place to open our doors.

One distinction about our model is that I'm not becoming people's physician. We're not medically active and that's on purpose. In palliative care, we talk about this beautiful roundtable, we talk about how it's interdisciplinary. We all know though that the medical piece has a lot more momentum. It has a lot more weight and tends to run the show. All of our attention around non-medical issues is, in many ways, lip service. It comes down to how healthcare is wired and structured and who can bill for their services.

Third, we felt that the medical piece was relatively well-tended to, but the psychosocial, spiritual, relational, intra- and inter-personal dynamics, developmental issues, cultural overlays, needed to have a seat at the table. We wanted to offer an outlet to uplift and to work on those pieces of the puzzle.

Lastly, there is the health care system, which is problematic. Trying to build a company to bill within the system or payers was going to take a lot of work, and we wanted to get this going pronto. So, we decided to go direct to consumer and sidestep the medical industry.

EOL: Brilliant.

Dr. Miller: I love medicine, it saved my life. Healthcare does amazing things, but this subject is way bigger than just medicine. We wanted to place ourselves on the periphery, with lines into the healthcare system. We also wanted one big foot out of the healthcare system, to open up what palliative care provides, to welcome so many other issues into the fold. And that's what we've done. 

EOL: In what ways can people engage with Mettle Health? 

Dr. BJ Miller: We're starting this direct to consumer. Access is key right now, so people can spot treat with us in one session if they have a question, or we can have ongoing sessions. Patients, caregivers, and other clinicians have reached out through the website to debrief on a case, or to address having issues of burnout. It runs the gamut; it's a wide open field.

Our hope, and what we're working on now, is a business plan to move beyond direct to consumer to begin working with employers, as a way to cover these services. We're providing the service while we're figuring out our business model. So, it's early for us, but very exciting too.