The Home Health Care State of the Industry (Gentiva, CenterWell, BAYADA, Androscoggin, Home Helpers)

Summary

The panel discussion highlights the current challenges and future direction of home healthcare in the U.S., emphasizing the unprecedented transformation of the healthcare delivery system. With healthcare costs soaring and the industry's reliance on Medicare and Medicaid, significant reforms are necessary. The importance of innovation, policy advocacy, and collaboration with payers are crucial to sustain the system. The conversation underlines the need for a shift from transactional care to value-based care, discussing ways to reduce hospital costs and improve patient outcomes through home-based solutions.

Highlights

• The U.S. spends the most on healthcare globally without superior outcomes, necessitating system reforms. 💸
• Healthcare has grown from 5% to nearly 20% of GDP, with major spending on Medicare and Medicaid. 📈
• The workforce is shrinking, with fewer people supporting an increasing number of retirees. 👨‍👩‍👦
• Home-based services have increased from 18% in 1995 to 61% in 2020, indicating a massive industry shift. 🏡
• Political and policy advocacy is crucial for addressing healthcare system sustainability and innovation. 🗳️

Key Takeaways

• The U.S. healthcare system is at a historic transformation point, driven by rising costs and demographic changes. 🏥
• Home healthcare is shifting from institutional to community and home-based services, presenting new opportunities. 🏠
• Collaboration with payers and policymakers is vital to adapt to the growing need for value-based care. 🤝
• Addressing workforce challenges through innovation and immigration reform is essential for sustaining home healthcare. 👩‍⚕️
• Policy advocacy at local and national levels is crucial for creating standards and ensuring effective home healthcare delivery. 💼

Overview

The state of home healthcare is evolving under financial pressures and demographic shifts in the U.S. With healthcare expenditures climbing to nearly 20% of GDP, the overreliance on Medicare and Medicaid raises sustainability concerns. The industry leaders discussed the necessity for innovation, systemic redesign, and policy adaptations to ensure the efficacy of home-based healthcare solutions.

Panelists underscored the importance of collaboration between healthcare providers and payers to transition towards a value-based care system. This approach aims to optimize patient outcomes and reduce unnecessary hospitalizations by leveraging comprehensive home health services. However, achieving this requires overcoming challenges related to workforce shortages and reimbursement models.

With the changing landscape, political advocacy has become a focal point, emphasizing the need for national standards in home care. Workforce development, including immigration reform, plays a critical role in supporting the sector's growth. The panel advocated for more robust policies to maintain the sustainability and efficiency of home healthcare, ensuring it meets the increasing demands of an aging population.

Chapters

• 00:00 - 00:30: Introduction and Setting the Stage The chapter begins with the host, Ken Albert, introducing the session. He mentions that introductions will be skipped to save time, as detailed biographies are available in the provided materials. The chapter proceeds to emphasize the honor of convening a distinguished panel for discussion. The speaker aims to provide a contextual foundation by setting the stage with a series of important numbers indicating key statistics or points of interest.
• 00:30 - 03:00: Healthcare Spending and Enrollment Statistics This chapter discusses the unique and rapidly changing healthcare system in the United States. The U.S. spends more on healthcare than any other industrialized nation, yet its healthcare outcomes are not proportionately better. With 141 health systems in the world and 21 among industrialized countries, the chapter highlights the paradox of high spending without corresponding quality in outcomes.
• 03:00 - 05:00: Healthcare Costs, Workforce Challenges, and Dependency Ratios The chapter discusses the significant growth in healthcare costs from 1960 to 2022. In 1960, healthcare represented 5% of the GDP, whereas in 2022, it surged to nearly 20%. The chapter highlights the dramatic increase in healthcare costs, which reached $4.1 trillion, marking a surge from the previous year and an 11% growth in comparison to the year before that. Attention is also given to Medicare and Medicaid within the context of these increasing costs.
• 05:00 - 07:30: Opportunities in Home and Community-Based Services The chapter titled 'Opportunities in Home and Community-Based Services' discusses the potential shift towards privatization of Medicaid and Medicare services. It highlights the substantial enrollment in these programs, noting that in the previous year, nearly 40% of the U.S. population was enrolled in either Medicaid or Medicare. Financially, the government spent $690 billion on these services in 2021, and expenditure was expected to rise in 2022.
• 07:30 - 10:00: Policy Perspective and Workforce Challenges The chapter titled 'Policy Perspective and Workforce Challenges' discusses the significant financial growth within the healthcare industry. In 2022, there was an eight percent increase in spending, totaling 741 billion dollars. This trend is expected to continue with a ten percent increase in the following year. The chapter emphasizes that the industry is no longer functioning solely under the traditional Medicare Paradigm, which has substantial implications for all levels of provider organizations. Additionally, there are 11,000 new Medicare enrollees per day, highlighting a key workforce challenge that needs to be addressed.
• 10:00 - 15:00: Innovations in Value-Based Care The chapter titled 'Innovations in Value-Based Care' discusses the disproportionate spending within Medicare, highlighting that 50% of Medicare's budget is consumed by just 5% of its population, particularly the seriously ill individuals. This represents a $375 billion opportunity, emphasizing the need for sustainability in healthcare funding, especially considering Medicare and Medicaid's substantial role.
• 15:00 - 20:00: Provider Perspectives on Risk and Value-Based Models The chapter discusses financial challenges faced by the federal government, particularly in relation to healthcare spending. It highlights the unsustainability of current spending levels, with one third of government spending and a quarter of the budget going to healthcare. The chapter emphasizes demographic changes affecting the workforce, predicting a decline in workforce participation with 3 million fewer people entering the workforce annually until 2050 due to an aging population, as the median age increased by 3.4 years between 2020 and 2022. This decline impacts the sustainable financing of healthcare.
• 20:00 - 25:00: Role of Medicaid and Integration in Healthcare The chapter discusses the increasing dependence of the American population on the healthcare workforce since 2010, a trend expected to continue in the near future. It highlights that 90% of baby boomers will retire within the next seven years. In 1960, there were five workers for every retiree, indicating a significant demographic shift impacting healthcare.
• 25:00 - 30:00: Personal Care Services and Policy Advocacy The chapter discusses the demographic shift projected for 2040, where fewer workers will support each retiree, posing sustainability challenges for existing financial structures.
• 30:00 - 40:00: Immigration Reform and Workforce Solutions The chapter discusses the pressing need for immigration reform and workforce solutions in the United States, emphasizing the current demographic realities and infrastructure challenges. It calls for innovative approaches and system redesigns, acknowledging the lack of political will to address these issues. The chapter also highlights the significant impact on healthcare providers, referencing the healthcare delivery model of 1995 where 18% of services were provided at home.
• 40:00 - 48:00: Conclusion and Key Takeaways The chapter discusses a significant shift in the provision of services from institutional to home and community-based settings. In 2020, 61% of services were provided in home and community settings, compared to 39% in institutional settings. This represents a massive opportunity for the sector to grow and adapt to new demands. The chapter ends by posing a question to Dave Tatara regarding the direction of policy in this area.

The Home Health Care State of the Industry (Gentiva, CenterWell, BAYADA, Androscoggin, Home Helpers) Transcription

• 00:00 - 00:30 [Music] thank you [Music] my name is Ken Albert and we're going to forego the introductions this morning just in the interest of time all the BIOS are in your book I would encourage you to look them up we have a highly esteemed panel here which I'm very honored to facilitate in conversation I like to set the stage for you a little bit I'm going to give you a bunch of numbers just to set the stage around
• 00:30 - 01:00 the position that we are in in the United States with regards to the healthcare delivery system we are at an unprecedented change in U.S history and in the world according to Ken and a few others I think it's largely because of this we have 141 Health Systems in the world 21 of which are industrialized like the US of those industrialized countries no one spends more on health care than in the United States and our outcomes are not
• 01:00 - 01:30 Superior by far in 1960 Healthcare was five percent of the GDP and in 2022 it was nearly 20 percent massive growth in 2020 health care costs surged 4.1 trillion dollars up from 10 from the year before and grew another 11 last year 4.1 trillion dollars with regard to Medicare and Medicaid
• 01:30 - 02:00 a little controversial but some would say that the government is moving to privatize those two payer sources Medicaid enrollment last year was a 18.9 percent Medicare enrollment at 18.4 percent so nearly 40 percent of the U.S population is enrolled in either Medicaid or Medicare in 2021 there was a 690 billion dollar spent and in 2022 I thought it would be
• 02:00 - 02:30 roughly the same eight percent increase year over year 741 billion dollars spend in 2022 and slated to be 10 increase above that this year we are no longer this sector of the industry is certainly no longer operating within the Paradigm of Medicare massive implications for all levels of our provider organizations within Medicare we're seeing 11 000 enrollees per day eleven thousand
• 02:30 - 03:00 enrollees per day and within Medicare we're spending 50 percent of the Medicare spend is on five percent of the Medicare population those seriously ill populations that is uh 375 billion opportunity exists there who's paying for this and here's the rub right this is not sustainable Medicare and Medicaid account for one
• 03:00 - 03:30 dollar of every three dollars spend by the federal by the federal government and one in every four dollars budgeted and here is why it's not sustainable there are three million fewer people who will participate in the workforce year over year continuing through 2050. the median age from 2020 to 2022 increased by 3.4 years consequently the share of the workforce from age 16 to 64 is declining year over
• 03:30 - 04:00 year conversely the dependency of the American population on that Workforce in healthcare in particular has grown since the year 2010. and has shows no signs of slowing in the next seven years ninety percent of all baby boomers will leave the workforce seven years in 1960 there were five workers supporting every retiree
• 04:00 - 04:30 in 2040 slightly less than two will be supporting every retiree it is not sustainable and here's the rub payroll taxes by this population contributed 1.3 trillion dollars in 2021 which is one third of all all federal revenue the tax base to cover the cost of Health Care is declining at a time when the demand is increasing
• 04:30 - 05:00 the realities of the U.S demographic are such that we are not prepared we have to be innovative we need system redesign our infrastructure is not ready the political will to address the issues we face in my opinion we're not ready the provider impact is significant but in 1995 when you look at where Health Care was delivered 18 percent was in Home and
• 05:00 - 05:30 community-based Services and 82 was institutional today I'm sorry in 2020 61 percent was home and community and 39 institutional massive shift tremendous opportunity for this sector so where do we go from here Dave I'm going to Dave tatara I'm going to go to you first so with regard to policy
• 05:30 - 06:00 do you agree that the facts I just laid out are underlying the direction of policy within States and within the federal government well thanks again uh before I actually address that let me those are really dire statistics and let me throw out a couple of other data points that we just completed about a a crystal ball report for 2024 through 2026 and looking out maybe 10 to 20 years and the you know
• 06:00 - 06:30 just add to what you said the deficit is supposed to double in the next 10 years uh the deficit as a percentage of GDP is supposed to go from 98 today to 118 in 10 years to literally almost 200 percent 198 percent in 20 years Medicare is forecasted in in within 10 years not to be able to fund or the benefits for inpatient care and sniff care I mean it's it's deteriorating and it's it's very serious subject
• 06:30 - 07:00 we've known this though we've known this for a number of years this is not new Medicaid and Medicare cannot sustain the populations that they need to serve without significant reform and that's the political will that I was talking about we just we've known this was coming for years and there's been no political will to address it now on the positive side we certainly there's some good news in the fact that the government's going to have restricted funds to to be able to provide for care like this they're going to look for
• 07:00 - 07:30 value and we provide value but on the other hand unless we can address the two major elephants in the room which still have been for a long time Workforce issues as well as reimbursement issues we can't provide care if we can't provide care I'm sorry we can't provide value unless we can provide care and how do we get there Dave through policy like what's going on do we just sit back and let this happen to us I mean we've I've seen an increase
• 07:30 - 08:00 in advocacy uh in our sector over the last five years like never before I think all of these underlying facts are driving us in that direction I mean what are you seeing out there from a policy perspective and what's occurring rate of biotic well uh you know I found mark um Mark King's uh address last night very interesting because he he said we have to stop listening and talking just to ourselves bring other folks in and we did uh we took a page out of his book
• 08:00 - 08:30 that it did just recent uh in in the fact that we invited Helen K to come and uh and talk to our practice presidents to determine what problems they were having and what Solutions he might be able to offer and if you recognize the name Alan K perfect nobody so Alan K is probably the most famous individual who is not known by anyone who uh whose uh quote has said
• 08:30 - 09:00 almost every day if you see something say something Alan K came and joined us for approximately almost a day and our seven practice presidents uh addressed the workforce issues and the reimbursement issues and other strategic issues that they had and at the end of the day we asked Alan if he could give us his thoughts and he said well first of all I think you have to create a movement said you've got to get more people
• 09:00 - 09:30 involved in your issues secondly he said you've got silos all over the place in your industry you got to break those silos down you got to start working together and then thirdly he said bring that message home it's not only in Washington if things work it works at home as well all good things all good insight for today but do you realize that conversation that Alan K and we had was 14 years ago
• 09:30 - 10:00 14 years ago and things haven't changed but I can tell you at Bayada we did take that to heart and we created and are still developing a very strong National Grassroots program in which we're involving not only those individuals that are Enterprise office but all of the thousands of individuals that we have employed throughout the 23 states that we're we're in
• 10:00 - 10:30 Indy Dave mentioned that we have a commodity that America needs right now and how is Humana Solutions Home Solutions leveraging that commodity in the marketplace right now yeah I mean I think thank you man thanks for inviting me here you know I think the way we look at it in Humana is um it's always first of all through the the member lens what the patient's needs are but what we have to bring into that is some of the discussion we've already had
• 10:30 - 11:00 about industry challenges and also the need to move to value-based care so looking to the Future and saying yes there's a lot of challenges today in fee for service and by FIFA service I don't mean pay-per-visit I mean you know the fee for service world it's a lot of challenges but if you look at what's happening with the growth of ma we all need to be looking towards a world in which it's really about the holistic value-based care risk-based
• 11:00 - 11:30 contracts Etc so we're we're focused on that and so I would say that the themes that are in that that you know we're rallying around in Humana are um one value-based care and by that I mean quality cost um you know holistic approach bringing everything in whether it's Behavioral Health whether it's social determinants of Health bringing everything into the health picture not just the transaction of going out and and doing something in
• 11:30 - 12:00 the home but taking the whole picture of the patient together um integration so if you look at Humana we have the largest senior based Primary Care Organization as well as Center well home health for home for you know in the previously known as Kindred at home and then we have a very large Pharmacy as well so integrating those so that there's a seamless experience for the member or for the patient and obviously Center well home health is pair agnostic and then to when you think about the future of value-based care you have to
• 12:00 - 12:30 think about the clinical capabilities the innovations that are necessary to make that happen it's not just you know okay we're value-based it's you know how can how can we actually change the practice so that the clinical practice so that we can deliver on that and then of course with that comes payment methodology changes Etc so so value-based care versus value-based reimbursement yes so I you hear those
• 12:30 - 13:00 terms so are you talking about value-based reimbursement right now so so Humana has um a comprehensive approach to value-based care so we do have the with the utilization management the network management um we have that but what I'm talking about on the provider side because you know Humana has retail and has provider as well side on the provider side I'm talking about clinical care clinical capabilities and and that's
• 13:00 - 13:30 really that's really the the key to it is is really driving capabilities that drive down the cost improve the quality improve the patient satisfaction make it more seamless incorporate the whole patient's experience that's the that's the sort of the the Holy Grail element so Andy your Humana right and uh so and and with uh you know relative Nationwide
• 13:30 - 14:00 footprint for the provider out there who's like mine you know I'm in one state I serve 16 I serve All Counties within my state or whether you're 12 counties in Nebraska how I don't want to use the word compete but how how do we put ourselves in position because I agree with you that's the direction we're going that integration right that longitudinal care management
• 14:00 - 14:30 uh how do we put ourselves in position to be able to be at the at the table with somebody like Humana right well look everybody that's and Center well Home Health which you know is is in sort of my portfolio is out there experiencing the same thing that everybody else is experiencing it's very agnostic Home Health agency works just like everybody else um I would say and sort of having seen that and having looked at the industry I would say you know my my two cents in it
• 14:30 - 15:00 are that it's about um understanding that the the pairs they are looking for entities that can provide value-based care no one I mean it's a fragmented industry no one organization uh is going to be able to provide all the Care in the industry but what the payers are looking for well I speak for Humana what Humana is looking for is organizations that are thinking with a value-based mindset so what that says to
• 15:00 - 15:30 us is if you look to the Future yes you have to optimize what you have today obviously we understand that but if you look to the Future and where Medicare Advantage is going and the growth of Medicare Advantage and the decline of original Medicare you need to be thinking about how to get on to the path to risk right so what I mean by that is you're not overnight going to say you know I'm going to take risk on everything associated with well for example hospitalizations helping organizations to reduce hospitalizations reduce ER
• 15:30 - 16:00 visits right um uh you know other sites of care like sniff at home you're not going to go immediately into into that you're going to start somewhere it could be that you're choosing an area that you're particularly good at as an organization and you're offering that up as a as a as a part of a capability for a value-based ecosystem or it could be that you know you're accepting quality bonuses at first and then you're getting on the path and then it goes to upside risk and
• 16:00 - 16:30 then it goes to upside downside risk and and it's complicated I'm not trying to oversimplify because obviously there are value-based providers that own own you know risk um outside of the Home Health episode but those are the kinds of discussions I think that are organizations need to have with uh with payers and those who are who are moving to value-based care you know and even even original Medicare is going through alternative Payment Systems so I think it's it's just a capability that needs to be built
• 16:30 - 17:00 it definitely is the path of the future and what I was going to go to you but I'm going to go to Dave real quick here um it's it's it is the path for the future but there are two components of this right there's the care delivery component and then there's the rate negotiation component as M.A consumes more and more of the market and I think that's where where the the rub is between um organizations like yourself Andy you know where you are
• 17:00 - 17:30 um a provider within a you know within a pair of sorts right you're some would call it a pay Rider okay um but Dave how does within that framework of negotiating rates and rate structures for this still the vast majority of providers are the smaller providers who are focused on on smaller markets right and so um positioning for that path to risk how does one then position themselves to
• 17:30 - 18:00 be able to more effectively negotiate rates with somebody who is presumably large and with a leverage seems to be not with the smaller provider yeah good morning everyone it's good to be here and uh you know I I think uh as I say here today reflecting on all this I mean our industry has changed so much and it's continuing to change very rapidly um if you think about the Medicare Advantage numbers and how they're growing now if you think about home
• 18:00 - 18:30 health historically you know it was a transaction based service to where we were needed at a time period when a patient qualified for home health and they'd come on service their own service for 30 40 60 days sometimes 90 120 days we provide a service and then that patient went back to the world or the environment they lived in as the more penetration happens on the Medicare Advantage side I think everybody in the room has to start to
• 18:30 - 19:00 change their focus from being a transaction based service provider to more of a value-based partner Within These health care plans and it's it's two different models I mean it really is I mean one is a transactional based business and one is a value-based business and I think that it's going to evolve um more rapidly you know with Humana acquiring all of our home health business they had an opportunity to be a
• 19:00 - 19:30 business partner for three years and understand what home health is and and help teach us a lot the amount of sophistication that these payers have by running algorithms and looking at the total care of delivery of spend and different things I believe over time will evolve in to a better payment model I just think we're in a transition National period right now of where we look at a fee for service model transactional based model and then we
• 19:30 - 20:00 look at a Medicare Advantage model and we feel like that this fee for service based model is more profitable and it helps cover our costs and do a lot of different things but the world is Shifting to this model over here and so I think Andy said is you as providers as you start to look at what do you do extremely well with inside your organization you're going to have to come to the table with the payer groups and you're going to have to be willing to stand
• 20:00 - 20:30 behind not a transactional based delivery of care for 60 days but more of a risk bearing and say we're hiring quality nurses we're hiring people that really understand the value creation of reduction of er visits and and re-hospitalizations and you're gonna have to go at risk I believe on some of these things in order to earn you know a seat at the table and ultimately I do believe that the payment models will work out where it could even be even more profitable than a fee-for-service
• 20:30 - 21:00 delivery model because the value that you're creating to the payers is even more than what it is today but there's still a gap of of that being proved out and unfortunately if you're a small provider how many resources do you have to really behind the scenes build out algorithms and build out care delivery models and have you know 24-hour on call with a you know with multiple people able to go out to patients homes so I I
• 21:00 - 21:30 just I think that there's there's it's coming it's come a long ways I believe that by some of the payers now acquiring and owning Home Health they'll have a different perspective and understanding what the value is we realize that the payers cannot own every Home Care Agency in America they're going to have to have third party providers and I believe that the people that are willing to come to the table and sit down and try to look at some risk sharing models and try to look at things differently than just through the lens that the Medicare
• 21:30 - 22:00 Advantage plans are trying to cut reimbursement for their agency those would be the ones that will probably have the best opportunity for a long-term partnership yeah and I would I would just piggyback on on that I agree with everything there and I'll just piggy back and say in some ways from a provider perspective it's about looking at getting away from a zero-sum game of you know we negotiate you know you you know you negotiate back and forth with whoever is reimbursed saying on a fee for service and you say how can we
• 22:00 - 22:30 create how can we participate I'm talking as a provider how can we participate in more more value right uh and and where does that more value come from that more value comes from helping to keep uh the cost of care for those MA members the unnecessary cost for care down so for example in Humana uh we spend um nearly 900 million in annual Hospital span for hospital for for patients
• 22:30 - 23:00 during the Home Health episode and you know so that's people that's people during the Home Health episode who end up going into the hospital in now some of that is completely legitimate but some of that is is care that could have been provided in the home I'm not talking about hospital at home I'm talking about care that could have prevented the need for the person say well all I all I can do is go to the ER and then they get admitted because that you know so so that's an example of um just how you tap into value that
• 23:00 - 23:30 you're not tapping into today on a pure transactional fee-for-service Emma so when we're talking about personal care services at in-home services where do you see that sector tapping in to the value that we're talking about here you know I I think certainly we've seen during the pandemic that home care which is a sector of Home Health but it's proven to be a very vital sector in that we send and we spend more time with our
• 23:30 - 24:00 clients in the home than these 30 or 60 day episodes and we are able to discern through those that time with them and see changes that hopefully prevent them and from going to an acute care setting an ER etc for some type of service and so we see our role in that space as a critical component to partner with various payers
• 24:00 - 24:30 as such but our business at least for Home Helpers and we have agencies in 41 States all over the country and ours has largely been private pay family funded but long-term care insurance VA reimbursement and and we have for us about 25 to 30 percent of our portfolios and Medicaid services and so we see that starting to grow as these various conversations are occurring and
• 24:30 - 25:00 certainly through associations like the Home Care Association of America which um I'm on the board for or National Association of home and hospice care who I know is going to be on a panel we're working in collaboration to ensure that we do have a seat at the table as those models are being um are being you know kind of generated in with regard to Innovation and like where do we go from here where is your organization going from here innovatively as it's tying tying into the market as it's changing
• 25:00 - 25:30 yeah I mean certainly Home Helpers has been around for 25 years and we uh we've always I feel have had a spirit of innovation one of the things that we rolled out about three years ago was a new program called cared for and cared for because ours has been a very transactional based uh experience as well caregiver goes into the home care pro professional goes into the home they're there for X number of hours a week it's this billing rate and we
• 25:30 - 26:00 absolutely work on quality outcomes making sure that that clients have the best possible care to avoid those acute care settings as they continue to age however with cared four we took in and looked at it a little differently and somewhat of a bundled program that addressed more than just the the traditional care hours and so looking at those innovative ways to be able to extend the the care that we can provide that Continuum of Care continue to keep
• 26:00 - 26:30 that client at home partner with Medicare Advantage plans uh where appropriate is where we've we've really kind of tagged on and did they come to you or did you go to them well this started for us you know back when Medicare Advantage was just kind of rolling out and we we were there in the beginning now some of that has waxed and waned a little bit depending on the provider for the Medicare Advantage uh plan uh simply because
• 26:30 - 27:00 trying to figure that out in those early days of what those reimbursements were going to be and then you hit Workforce shortage in a big way in the pandemic and then we know that within that Home Care sphere or those personal care services family funded care I like that term family funded model versus private duty I think it's more descriptive of of what the market actually is um where do you see from a policy perspective right I mean we know we don't have there's no National Standard
• 27:00 - 27:30 of care with regard to home care services does that is that a barrier to having the conversations with the large payers to become a partner it's an ongoing education more than anything and what is home care and how does that sit in the home health Continuum it's it many people try to to say okay you have to have Medicare certification or you
• 27:30 - 28:00 have to be approved to do Medicaid and that should be the standard of care and that's not where we're we're advocating and we certainly do as an association through the Home Care Association uh we are on full force as a policy priority to have national standards of care in the Home Care sector right now this at the state level it is it is all over the place and we think that clients patients in the country deserve better
• 28:00 - 28:30 than that um and we want to see that standard of care be adopted within the industry and we and we want but we want to see it at the table as we do it which is where we are today and do you from a from a payer perspective Humana I know does that is that a conversation at all in the Home Care side is the standard of care is having a National Standard is that important or is that entering into the Paradigm at this point well I mean I I think that it I think it
• 28:30 - 29:00 could be with the standard of care but I think at this point we need to think about the fact that the payers can actually help us in our industry at this point because I think that we really need to focus on National Home Care Association leadership what Dave's doing some stuff we're doing in our company we have got to get these facts in front of the decision makers at CMS and in Washington and I believe because of now the ownership structure of the mid of
• 29:00 - 29:30 the managed care company is getting into this we can rally their support to go with us to look at you know should we have some type of a carve out for personal care pay should there be a carve out for palliative care which is a absolute necessity and anything that happens in regard to reimbursement for the industry any payer that is in this with the Medicare Advantage could absolutely win as well and so I think rally into history trying to figure out some standards of care and really trying
• 29:30 - 30:00 to focus in Washington on advocacy and to really try to change the landscape of what this industry and what the Post Acute world could look like is really going to be first and Forefront because we've been so fragmented we're just the recipient of what we get and what comes Downstream and and now that there is 50 penetration and Medicare Advantage I think we should lean on the the managed care companies to be a voice and stand behind us and go to try to fight for the industry I mean I think that's a
• 30:00 - 30:30 fascinating Andy I'll go to a second I think that's a fascinating uh concept and David you've done a lot of time on the hill right you spent a lot of time on the hill whether that's National Association your own organization do you think having payers as partners in delivering the message of healthcare at home would change the dynamic as we're talking with with members of Congress oh sure I think the more voices that you
• 30:30 - 31:00 can have supporting the same or carrying the same messages is very effective um you know we we about invested and have invested a lot in advocacy we in fact it's considered to one one to be one of our core beliefs um we created a program almost 10 years ago I guess in which we started just with a few people and it was focused on some very specific locations we left the
• 31:00 - 31:30 DC operations to our our great National associations but we focused on certain state capitals but since in in the 10-year period we have grown now to 15 16 Professionals in our government Affairs office we have over 375 volunteer ambassadors in each one of our service operations offices they each have PODS of three to five people um we call it hearts for Home Care in
• 31:30 - 32:00 which their responsibility is to develop relationships at the local level because we believe strongly that all politics is local and when you have the opportunity to meet with your legislator not in D.C where you usually get to meet with a millennial you in at home you get to meet with the member you get to spend more time with them now most telling though is the states which we have not had any advocacy
• 32:00 - 32:30 program they're basically running on their own those States in total have shown an average cut of about seven percent so there's almost a thirty percent difference between putting a program together where you have your your employees carrying the message to their legislators and those who remain silent Andy you were going to comment earlier no I was just actually I'm glad you you asked me to pause there because um I think what we just said here by David
• 32:30 - 33:00 was uh is is absolutely true I mean having worked in state government myself um you know I can tell you how important advocacy is um particularly with the customer stories and the customers um being there so um I think that's really important from a Humana perspective I would just say uh you know our focus is always at least you know talking now from the provider side of Humana but I think it's the same for the whole of Humana is our focus is really on the the customer need because
• 33:00 - 33:30 we we own the care for the customer right for the member and so when we think about political advocacy it's really looking at it through that lens making sure that it's not just the transactional it's the whole you know the whole needs of the of them of the member is one of the lenses that we look at it through and then the other lens is really looking at uh again some Medicare Advantage is very important as you know as humana's uh you know main main focus is looking at where
• 33:30 - 34:00 the puck is going in terms of Medicare Advantage and being very thoughtful because one of the something that's very important is that I think with with government whether it's the state or the federal level is if you see where things are going making sure that you're part of helping to shape that and that you're being very very uh you know open-minded when appropriate so you're saying as the state or federal government if you see where the puck is going no sorry as as a as a as a provider okay if you see where the puck
• 34:00 - 34:30 is going with the state or the federal government getting in early and trying to help shape that right for the future yes is important sorry I wasn't clear there no it's okay it's okay um so it sounds to me like you know partnering with payers with with your value proposition is where we need to go and that's regardless of of what component of care you deliver in that home setting it's understanding that
• 34:30 - 35:00 value proposition and then partnering with um with the payers from an innovation standpoint is there is there something else that we're not talking about here today that needs to hit the table well I I think it's been mentioned but obviously the workforce so work you know we talk about Innovation around condition specific and all of that and that's important in clinical care but also Innovation around uh the workforce
• 35:00 - 35:30 because obviously uh you know when you have a situation where uh uh are there's other options for the nurses or the therapists or whatever um we've got to be innovating to make their work as um as balanced as possible taking the burden off them from an electronic standpoint and just looking at all aspects of their work work life and we've known that again here's another another topic that we've known
• 35:30 - 36:00 is coming for a while right and the pandemic certainly exacerbated that scenario but we're not seeing the political environment change with regard to immigration reform uh we're not seeing tax incentives for for growing Workforce some states are are getting Innovative around that what and perhaps I'm just ill-informed with regard to the immigration reform issue but Emma are you seeing anything out there you know it it is very
• 36:00 - 36:30 interesting and I went back and preparing for this to look at some studies that were done and they they're they were pre-pandemic but it cited that you know a Visa applications or approvals were down about 48 percent um it noted that about 27 of our my Workforce and personal care services is uh immigrants
• 36:30 - 37:00 um compared to 14 of the population overall and over the years since 1970 you've seen the Immigrant population in the U.S be as high as 15 and as low as five that was about in the 1970s it also is to show that if you're a first generation immigrant legal immigrant to this country that your it costs the U.S about sixteen hundred dollars a year that's what it showed but second generation
• 37:00 - 37:30 you're seeing a positive of 1700 a year per immigrant and then second generation is 1300 and so there's a lot of reasons why immigration makes makes sense for us I mean this country was built on it it was given a path to people to come and do better and so as we think about where our industry is going uh or in general right now as a as a country we do not have the
• 37:30 - 38:00 ability to pick to keep up with our own GDP we don't there's not enough people being born and there and there's three million people a year leaving the workforce on top of it with an aging population so there's just this amazing perfect storm that's happening and that we've got to pay attention to immigration legal immigration can be a great source for us in the U.S to continue to grow as a country as an
• 38:00 - 38:30 economy and provide great opportunity to so many other countries have done it and they've done it well and we just have not been able to kind of figure that out from a political landscape standpoint so one of the things that we are pushing for and trying to work for an advocacy is some revision or to a new h2c Visa which would be specific to home care which would allow providers to be able to to attest to the
• 38:30 - 39:00 Secretary of Labor that they have exhausted all means to hire and that by hiring legal immigrants it brings a path to the U.S for continued growth development opportunity it also and when you think think about it though we serve a very diverse population all over the country each of us in this room a very diverse population and by doing having that step it also brings diversity and linguistic
• 39:00 - 39:30 reality to the work that we do as well which I think is really compelling but it's going to take a lot of people working together to to get and understand that research do the education and try to find a path forward in our current political climate I was just going to say working together or working across the aisles there right in their mind yeah exactly we're a position for that at this point but clearly we need to it's not and it's not just in the health care sector either
• 39:30 - 40:00 it's across well 60 of of those who work in math and science right now are immigrants I mean we we have a huge opportunity I think to Leverage The Best Around the around the world and the the you know yes it is Nurses and physical therapists and all of those disciplines as well but it's Care Professionals that we employ that that provide a great path to a better life for them and their families than than where they are today
• 40:00 - 40:30 just real briefly in the few minutes we have left I do want to create opportunity for some questions here from the audience Chris are you out there to be able to help with that perhaps but um so be thinking of your questions if you have any I'm going to go to ma real quick so go back there it is I it's it's you know it's no secret right that there has been and I would say an adversarial role between Medicare Advantage and the traditional
• 40:30 - 41:00 Medicare home health provider whether it's Medicare enrolled Home Health provider and while at the same time there's this intellectual acknowledgment that this is the direction we're going and we need to find a path forward to be able to demonstrate that value proposition to the payer and are we seeing a shift from that kind of adversarial relationship to more of that partnering relationship that we're talking about open up to anybody
• 41:00 - 41:30 yeah I mean I think that the industry has to understand and has to accept where this is going as we said you know half the Medicare population is enrolled in the Medicare Advantage plan um some people say you know they're not very happy with the Medicare Advantage plans buying Home Health hospice personal care agencies I think it's great because I think they'll learn the business and they'll learn the analytics and they'll learn the value creation that's there so I hope the industry does
• 41:30 - 42:00 uh you know look at an adversarial relationship I hope we Embrace where it's going and look at the opportunity opportunity to to learn from much larger organizations that have better data analytics than any one of us have the opportunity to become with a new creative value-based models and payment models the ability to utilize the managed care companies to help us be a stronger voice in Washington in regards to the value that we do create that will
• 42:00 - 42:30 all that will help on the traditional fee for service side of the business as well so I may be in a little bit different spot with a relationship with Humana because of the of the cell the transaction but it was been very impressed with the analytics and the detail and how they look at their patient population and the patients that we were actually treating inside of our organization in helping us to understand how to do things differently I also think that you have to think about when
• 42:30 - 43:00 we talk about the workforce issues you have to get creative and the workforce issues are not going to go away so you know really having a voice for tele Health Medicine and trying to figure out a way for payment models around that trying to figure out utilization of Care Management and case management maybe with not as many visit frequencies out in the patient's home but really close oversight utilization of LPNs and other non-rn professionals on the nursing side so for organizations that just kind of get
• 43:00 - 43:30 stuck and say you know we have Workforce issues we have issues with Managed Care in regards to reimbursement and you know we're stuck in this spot we're in well you're always just going to be stuck there the industry has to advance and think through it a different lens and I think some of the things that are happening will benefit us down the road I will say though David I think that uh you know as a as an independent provider I also think there's opportunity for
• 43:30 - 44:00 those for the ma plans I mean the rate negotiations with these companies is so vastly different than it ever has been and um you know there there has to be some a different path forward either elevating because you're dealing with a negotiation at a you know you're not having the same people that's negotiating rates with hospitals as you are with the home care right and um so it's just a different level of negotiation and so I think there's some opportunity there for the payer side to
• 44:00 - 44:30 also um identify a path forward in those negotiations it makes more sense to capture that partnership true partnership that we're talking about here too if in fact those payers want partners and I think I think last night for those that were here to hear Mark King speak he talked about his career and and some of the disruption that has occurred and I think it was a really important note for all of us to to to look at to say listen you
• 44:30 - 45:00 know we've had disruptors come into our space and largely have not done well for whatever reason however we've got to find that path forward because if we don't someone else will and that's you don't want to be at that seat you don't you aren't at the table at that point Chris we have any questions out there one question this has got to be real quick here go ahead Tim this may be oversimplifying but I I do
• 45:00 - 45:30 that all the time um you're talking about ma plans um trying to teach home health and home care how to be more efficient how to control utilization but at the same time you're talking about their need to reduce what did you say David 900 million dollars in hospital expenses for people in the home health care what about delivering to them the
• 45:30 - 46:00 message that's spending more on post-acute saves overall is there not an effort in that direction reduce the hospital expenses by being Freer with encouraging more Home Care yeah someone wants to briefly answer that word kind of rap trying to wrap up but go ahead Andy yeah I was going to say I mean I don't think those those are
• 46:00 - 46:30 mutually exclusive and I think when when when Ma when when Humana for example is working with a partner provider to improve to decrease hospitalizations decrease emergency department visits Etc um there's often an investment that is needed around that so depending on what the arrangements are but but certainly I mean one of the advantages I think with payers on getting into the provider space is that they do have the ability to
• 46:30 - 47:00 invest in um in capabilities that will you know down the road increase uh not just improve for the patient the quality and the care and the satisfaction but also prevent uh unnecessary costs that that come from going to facilities so where are we going from here we have to put some more boots on the ground with regard to policy right um uh policy is local um
• 47:00 - 47:30 value-based or a path to risk around the value-based market um with full scope of services in the home to help decrease that overall health care spend or perhaps spend a little bit more in the home to to decrease that overall spend and partner with payers uh with our value proposition are some key and some immigration reform potentially that we need to have to help us out on the workforce side are some areas certainly not exclusively but some areas where we
• 47:30 - 48:00 will go from here today thank you very much for your time thank you thank you