0:02

Welcome to TCN Talks . The

0:04

goal of our podcast is to provide

0:07

concise and relevant information

0:09

for busy hospice and palliative

0:11

care leaders and staff . We

0:14

understand your busy schedules and believe

0:16

that brevity signals respect

0:19

. And now here's

0:21

our host , chris .

0:23

Como . Hello and welcome

0:25

to TCN Talks . I'm super excited

0:27

. Today , our guest is Bob Tavares

0:30

. Bob is the Chief Commercial Officer

0:32

with HealthPivots . Welcome , bob . Bob

0:34

, thanks for having me . Yeah , bob , I think we're

0:36

going to call our show today 100%

0:38

of health care in ACOs , or accountability

0:41

care by 2030 . What does that

0:43

mean and why should we care ? And

0:45

so I think that's going to be a fun thing for you and I to unpack

0:47

, but before we go there , I'd love for you to share

0:50

, as I do with all of our guests , what does our audience

0:52

need to know about you ?

0:53

Yeah , well , I've been in health care

0:55

for about 25 years

0:58

. I was , you know , four

1:00

or five years into my career . I was working at Forrester

1:02

Research and they were a thought

1:04

leader . They were analyzing what impact is

1:06

this new internet thing going to have on and

1:10

other technologies going to have on industry

1:12

, on strategy , and at the time I was in business

1:14

development and covering all industries

1:16

. I'd meet with a bank in the morning , I would meet with a

1:18

retailer in the afternoon and

1:20

we had an opportunity to verticalize our sales

1:22

force and I chose health

1:25

care and I chose it because , candidly

1:27

, it was so broken In banking

1:29

from a technology perspective . Even

1:31

back in the 90s things were really pretty

1:34

sophisticated . You

1:36

know you could put your ATM card

1:39

and a machine in France

1:41

and it knows your balance . It knows what you know

1:43

. It knows how much money you have and how much you can take out

1:45

. It's just interoperability , data

1:47

transparency , accuracy

1:50

. You know you check your bank balance

1:52

on the ATM and it matched . You know if

1:54

you called or it matched if you went into

1:57

the physical branch and in health care nobody

1:59

can tell you . You know when the last time you had your

2:02

hemoglobin A1C tested and

2:04

folks , providers didn't even know how

2:06

many diabetics they had , never mind how many

2:08

were overdue for certain services . So it was paper

2:11

based records . It was

2:13

an industry that had not embraced

2:15

technology . I said , if I'm

2:17

early in my career and I want to be at

2:20

the intersection of technology and improvement

2:22

, why not go into an industry that has

2:24

still started , hasn't even

2:27

started that process , and

2:29

we have come a long way in 25 years . Those

2:32

25 years have been largely

2:35

on the managed care side . I've worked

2:37

with health plans and I've worked , have

2:40

sold services into

2:42

health plans as well as

2:44

accountable care organizations , so

2:46

I have a pretty good sense of how they think

2:48

, how they operate , how

2:51

they use data , how they think about improvement . It's

2:54

been about five years now that I've been focusing

2:57

on the serious illness space

2:59

. I've done some work around advanced

3:02

predictive modeling and machine

3:04

learning on how to get essentially

3:06

the right care to the right patient , how do we predict

3:08

who's heading for avoidable admissions , who's nearing

3:10

the end of life and might need a palliative care

3:13

consult , those types of things . And

3:15

I really decided over the past several

3:17

years to dedicate my career to

3:19

technology improvement

3:22

and serious illness care and

3:24

I sort of have found myself at

3:26

health pivots . I joined in January as

3:29

the chief commercial officer , which puts me

3:31

in overseeing

3:33

customer success and product

3:36

strategy . So are we building what

3:38

customers need and are they using it properly , getting

3:40

value , and are they not just okay

3:43

with our partnership relationship , but are

3:45

they thrilled , are they getting more

3:47

value than they're certainly paying for and

3:51

would they recommend us to others ? And

3:53

so we're trying to really build that culture

3:55

around . We've always had exceptional

3:58

product . We've

4:00

always gotten the math right . We're mathematicians

4:02

, we're biostatisticians , but

4:04

we also want to make sure that the customers fully

4:07

know how to translate that into results

4:09

. So you have to really lean

4:12

in on the customers and , frankly , the customers need

4:14

to . We have several

4:16

hundred customers . Many of them

4:18

are hospice home health agencies . We

4:20

also work with health plans . We work with physician

4:22

groups , particularly geriatric primary

4:25

care groups . We work with accountable care

4:27

organizations , and

4:29

they all are at different

4:31

levels of sophistication as it relates to

4:33

using data for improvement , and

4:35

our goal is to raise

4:38

the data literacy across all of our clients

4:40

, no matter where they're starting at . They all need

4:42

to improve . There's always room

4:44

for improvement , of course , and

4:47

then some hospices have further to go and

4:50

, per the title of this talk , for

4:54

the past 40 years , you can kind of get away

4:56

without it . And in the next chapter

4:58

of this industry , of the hospice industry

5:00

, you're not going to survive

5:02

if you don't have a good handle on your

5:04

operations and your data and

5:07

your performance and your referrals and your

5:09

overall . What's going

5:11

right , what needs to be improved and how do you continually

5:14

get better , every single day ?

5:15

Well , we're going to go there in just a second . Bob , we just made

5:17

a couple of comments and sometimes

5:19

you just look back like , let's say , a restaurant

5:22

becomes very successful in your community and

5:24

you're like that just makes so much sense . I'm glad they

5:26

did that . You ending up at health

5:28

pivots just makes so much sense . I'm kind

5:30

of a talent connoisseur and just have

5:32

a deep appreciation for highly talented

5:35

, high performers . If you and I

5:37

happen to talk which we didn't and

5:39

you'd say , chris , where's the best place in the country for me

5:41

to end up ? Oh , my gosh , health pivots would have been

5:43

it . So I just got to call that out . Bob , I

5:45

can't tell you how excited and as you and

5:47

I were talking during the show prep , I mean just

5:49

, I'm just so excited now that I

5:51

even understand more of your background . In fact , that's

5:53

probably a good segue . I'll

5:56

ask the question up for you , but then I'll use an analogy

5:58

and the question is given your

6:00

background , is quality about ready to matter

6:02

for us , like it did in manufacturing ? And

6:04

I was sharing with you . I was a little

6:06

bit okay , it's

6:08

behind you and I didn't spend as much time in manufacturing

6:11

, but I did grow up . Ge

6:13

was like the Amazon of the day when

6:15

I was coming out of business school . That was a place to

6:17

go to work and I was fortunate in . The second

6:19

place I went to work was Cooper Industries and

6:21

they modeled their whole executive development program after

6:24

General Electric , and so I got to see

6:26

this whole Six Sigma lean

6:29

coming to manufacturing . Of course , all the offsuring

6:32

stuff , but the cool thing about

6:34

manufacturing and those you're on video I'm holding

6:36

up my cell phone , if we were making cell phones

6:38

and this is the ideal cell phone

6:40

to the exact specifications and then

6:42

the functionality we now have

6:44

an ideal and then , as other things

6:47

come off the manufacturing line , you've got systems

6:49

and processes to compare it to that ideal . That's

6:52

the general concept of quality and there's a whole

6:54

I'm oversimplifying a world of

6:57

thought and Bob and I were talking about , like our

6:59

hero is dimming , I love dimming , I quote

7:01

dimming quite often , and so

7:03

the challenge is and , bob , I was like

7:05

this 25 year old when I came into hospice , cfo

7:08

, and these nurses are like , yeah , but

7:10

Chris , I hear what you're saying about manufacturing . We're not

7:12

making widgets , this is all

7:14

art and the

7:16

loosey-goosey , artsy God's

7:19

people doing God's work has kind of ruled

7:22

a lot of the day in hospice care

7:24

maybe in all of healthcare for that matter

7:26

and I was also privileged for two

7:28

years to be part of the student group . And

7:30

what the student group did is they really were the people

7:32

that helped hospitals become

7:34

more disciplined about patient satisfaction

7:37

, and then I started to see there

7:39

was a whole world of a framework here , not

7:41

just service , but also quality

7:44

, also growth , in other words , every

7:46

facet of your organization . So a long way around

7:48

the born for me to say so , bob . Are we on the cusp

7:50

that finally , is quality going

7:52

to start to matter ? And we'll keep it in

7:54

serious illness space because gosh knows we go a lot

7:56

of tangents if we talk about healthcare as a whole . But

7:59

is it about ready to matter ?

8:00

like you know what you saw in your background in

8:02

manufacturing , yes

8:04

, and I'd like to broaden

8:07

the conversation to not just quality but

8:09

performance efficiency

8:11

. I hear a lot of organizations not

8:15

for profit hospices who are

8:17

disgruntled with

8:19

the profit margins of for

8:21

profits . And why is

8:23

profit bad and why are ? Is your inefficiency

8:26

in the wastefulness in your processes

8:28

somehow something we should

8:30

be striving for ? So I think about performance

8:32

across all aspects of

8:34

an operations , yep , and

8:36

in gathering data

8:39

and using that data to improve . And

8:41

you mentioned earlier the

8:44

outcome is , you know , the process

8:46

gets the outcome . And if you don't

8:48

have a design , as the

8:50

your colleagues were

8:52

advocating for , it was don't . We can't design

8:55

this care model . We can't cookie

8:57

cutter this , we can't find it , we

8:59

just have to go with , just wing it and

9:02

, and there's going to be no con , no consistency

9:05

day to day , there's no consistency between clinician

9:07

and clinician . We have to somehow somebody

9:09

get to the point where we are more

9:11

adamant about designing the

9:14

process across all

9:16

aspects of what we do , and

9:18

one of the things that we do is hire salespeople

9:21

and then we train salespeople . So how do

9:23

we enter , how do we target the right

9:25

ones ? How do we train them ? You know , in the

9:27

pharmaceutical world , before you're allowed

9:29

to go talk to customers , I mean you're

9:31

going through weeks and weeks

9:33

and weeks , 40 hours a week , training

9:35

in order to make sure you've got the knowledge

9:38

and the skills to go represent that

9:41

brand . And when talking to clinicians

9:44

and I don't see that in

9:46

the hospice and home out there you know we just

9:48

hire whoever seems like

9:50

the right fit and then within days

9:52

they're out talking to important customers with

9:55

with often big knowledge gaps and

9:57

boy there is a lot of truth right

9:59

there , bob .

10:00

Just a couple of comments there's . There's

10:02

several things that we do and I've seen exactly

10:04

exactly what you're saying . I

10:08

may be a slow learner because now I'm about

10:10

28 years in the industry and the last seven

10:12

of my life have been in teleos , but

10:15

what you're poking on is exactly why we're doing this

10:17

work with Intelios . And so when

10:19

I look back like four seasons is where I was

10:21

first as CEO we grew

10:23

dramatically . We went from about 20 , 30

10:26

patients a day to 200 . And

10:28

then I left for two years work for a student group and then I came

10:31

back to four seasons . The greatest blessing of my life

10:33

was coming back to an organization that

10:36

I was at before , because when you start

10:38

going , who's this clown

10:40

that just grew us and put no system in

10:42

process and you got to go ? Oh , that's

10:44

me , I'm the guilty one . So in

10:46

other words , you could show up

10:48

in hospice because so many people were dying

10:50

and it was such a unmet need

10:52

and you can grow and you

10:54

think you're successful just because you're growing

10:56

and then that makes the financial numbers look good , but

10:59

if you're not bringing that system in process

11:01

, it's kind of a house of cards , and I

11:04

hope some leaders listening to this are

11:06

getting a little uncomfortable , because that was my

11:08

reckoning and it's the blessing of my life

11:10

of coming back to four seasons a second time . Realizing

11:13

it takes both . And so

11:15

there's two things , bob , when I listen

11:17

to you . Number one we talk quite often about the quadruple

11:20

aim , which I recently here is actually going out

11:22

to the sixth tuple aim . I think that's the right

11:24

word . But we talk about the quadruple aim

11:26

and the Don Berwick said hey , if you want to

11:29

take it to the future , you got to be working in better

11:31

service , better quality or lower cost of

11:33

care and a great employee experience . And

11:35

so we have a framework , bob , that we work with all

11:37

of our hospices . Like you think about

11:39

what makes hospice special and different , it

11:41

looks at the human being as body

11:43

, mind , spirit , social , emotional component

11:46

. It looks at them holistically . What

11:48

I'm hearing you say is you've got to look at

11:50

your organization holistically and

11:53

have a framework that challenges you to do

11:55

that . And if you do do that , you're going to see that actually

11:57

show up in the quadruple aim . But

12:00

then the other way is what you were

12:02

talking about . You know we're talking in a pre-show . I

12:04

love that dimming quote

12:06

every system is perfectly designed

12:09

to produce a result , to produces . Our

12:11

family were a little bit of smart but sometimes a little

12:13

sarcastic to mess with each other . It's

12:16

kind of a sarcastic comment , like people

12:18

are sitting in the room and going man

12:20

, we're having this problem . And then sometimes

12:23

I'll say every system is perfectly

12:25

designed to produce the results it produces

12:27

. It's kind of a tongue-in-cheek way to go

12:29

is there a system , is there a process

12:31

? And if it is , is it working for us ? And

12:33

so I love what you're saying because I think in

12:36

many cases throughout the country , just because

12:38

hospice was so much of an unmet need

12:40

, you could have grown . And you

12:43

think you're successful because you've grown

12:45

and you hired a lot of people . And

12:47

one of the analogies we use Bob , you

12:49

and I are somewhat of a similar age . I

12:51

can remember we still had forms in the organization

12:54

. You had all these forms floating about and

12:56

then when the form is on the copier it gets

12:58

a little sideways and then it gets further sideways

13:01

and you get the copy of the copy of the copy

13:03

. And that's actually what happens in organizations

13:06

. So like , let's say , bob's the high performer , we hired

13:08

him , he's a great hospice nurse

13:10

, but then Chris is the one after him and

13:12

he's not so good , and then Chris

13:15

is training the third one after that and

13:17

there's no systems in process and I think that's

13:19

an interesting kind of editorial on

13:21

what we've kind of seen in hospice and powder

13:23

care and the positive side is

13:25

we could do something about that . Would

13:28

you push back on any of that , bob , or is that resonated as

13:30

another way of saying what you're saying ?

13:32

No , it's what I'm saying , and

13:34

it reminds me of a conversation I had with a client where

13:36

50% of their patients

13:39

die within seven days , so they have

13:41

, as a result , one of the lowest overall length

13:43

of stays in their market . And I

13:45

said how do you compensate your sales reps ? Oh

13:48

, it's , a big part of their compensation is based on number

13:51

of admissions , regardless

13:53

of length of stay . So

13:55

they're going to the hospital where the admissions

13:57

are easy to come by and

14:00

they're all very short stays and it's affecting

14:03

. And meanwhile

14:05

they've got let's just say they have 50%

14:07

overall market share , market share of patients

14:10

or market share of days , and

14:12

what's your market share in assisted living and

14:14

nursing homes ? Because

14:17

your competitor has a defined strategy

14:19

and process to target

14:22

those settings , and

14:24

so how you compensate your employees

14:27

will get the outcome it's designed

14:29

for Every system is perfectly designed to produce

14:31

the results they produce .

14:32

Wow , that's well said . Well

14:34

about one thing I wanted to . I'm going to add someone that

14:37

texts me I don't remember it was , it feels like it

14:39

was a couple of months ago and said hey , I just read

14:41

that by 2030 , 100%

14:44

of all of Medicare will be in

14:46

ACOs and

14:49

the interpretation was that means

14:51

a lot of us have ACOs in our area

14:53

. A lot of them sometimes are whole system driven . There

14:55

are other physician led ACOs , et cetera

14:57

. But that person's interpretation

15:00

is well , that means we don't have to worry about Medicare

15:02

advantage . They're all going to be in ACOs . Can you impact

15:04

that ?

15:05

Yeah , I don't think that's what Medicare means . I

15:07

think it's about 100% of beneficiaries in

15:09

value based care or in an

15:11

accountable care relationship . So

15:14

I think both Republicans and Democrats

15:16

are more than happy for Medicare advantage

15:18

to grow . As you know

15:20

, for Medicare to delegate the risk and to get

15:22

out of the risk management business and there are

15:24

some patients who will not choose to join a Medicare advantage

15:27

plan and for

15:29

those they want them assigned to

15:31

an accountable care relationship . That

15:34

could mean it doesn't necessarily

15:36

mean the Medicare church savings program or

15:38

the reach program . Those are the two most common

15:40

accountable care contracts

15:42

for fee for service beneficiaries

15:45

. It could mean you

15:48

know that you're in a primary care first , or

15:50

that you are in making care primary , which is the

15:52

new model that's out , or maybe even enhancing

15:54

oncology or the kidney

15:56

care choices model . But it's some type

15:59

of value based contract . They want every patient , every

16:01

beneficiary to have somebody managing

16:03

the total cost of care , somebody accountable for the total

16:05

cost of care . And certainly Medicare advantage

16:08

is now , you know , 50%

16:10

In some markets

16:12

60 or 70% of all beneficiaries

16:14

and then whoever's left over

16:16

is going to be assigned to

16:18

an ACO or some type of accountable

16:20

relationship . Patients have to

16:22

opt in for Medicare advantage , but

16:24

they do not have to opt in to be assigned

16:27

or attributed to an ACO

16:29

and in fact , not only do they not

16:31

opt in , they cannot opt out of

16:33

that . So you may want

16:35

to stay on original Medicare and be , you

16:38

know , have original fee for service , but

16:40

whether you'd like it or not , there's

16:43

this third party that's going to be managing

16:45

your total cost of care . You

16:49

can opt out of what's called data sharing , where

16:51

your claims data won't go to that ACO , but

16:53

you can't opt out of the notion that

16:55

somebody is overseeing your total cost of care

16:57

.

16:58

Bob , if they change primary care providers

17:00

, does that potentially change their

17:02

attribution over the course of time ? Or how does that

17:04

work if they change primary care providers

17:06

and they're in an ACO ?

17:08

Yeah , if they , just if they actively

17:10

choose a different primary care provider , that'll

17:13

be triggers what's called voluntary alignment

17:15

. So they can say you know

17:17

, I used to be with Dr Smith , I now want to go to Dr

17:20

Jones and I want Dr Jones to be accountable

17:22

for me . I want to . Essentially they're switching

17:24

ACOs at that point , okay . Otherwise

17:27

it takes time for that new

17:29

provider to eventually build up the

17:31

plurality of primary care claims and

17:34

they could get attributed a quarter later or two quarters

17:36

later or maybe the following year , depending

17:38

on what model it's in .

17:41

Thank you to our TCN Talks sponsor

17:43

, deltacarerx . Deltacarerx

17:45

is also the title sponsor for our May

17:48

and November 2023 leadership

17:51

immersion forces . Deltacarerx

17:53

is primarily known as a national hospice

17:55

, pbm and prescription

17:58

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18:00

is a premier vendor of TCN and

18:02

provides not only pharmaceutical care

18:04

, but also niche software

18:06

innovations that save their customers time

18:09

, stress and money . Thank you , deltacarerx

18:12

, for all the great work you do in

18:14

end of life and serious illness care

18:16

.

18:17

Well , that's gosh . You and I can , and we probably should , do a couple

18:19

of podcasts together because , gosh , we could chase the

18:21

rabbit trail of Medicare Advantage . There's

18:24

all these other interesting things like SNEP plans

18:26

, pace program . You just did a great

18:28

presentation , by the way , and thank you . We

18:30

got a lot of great compliments for a presentation you just did

18:32

for our Tilly off CEOs . But I want

18:34

to focus the last half of the show on specifically

18:37

ACOs . It seems

18:39

like and I was an early

18:41

mover , an ACO that was in the

18:43

Western North Carolina area we

18:45

went to them because we thought , hey , this is logical , we've

18:47

got great powder care services , we can decrease

18:49

the overall spin , and just never

18:52

felt like we got any traction . And

18:54

so Is there a reason why ACOs

18:56

have not paid attention to hospice and healthcare

18:59

programs and do you think we're maybe in a

19:01

space where that might be changing ?

19:03

Yeah Well , if you go back a decade

19:05

, none of the ACOs had downside risk , they

19:08

were upside only . So

19:10

if you generated savings you got to check and if you didn't

19:12

know , harm no foul . Increasingly now

19:14

I think two thirds of MSS P ACOs have downside

19:17

risk . So if things don't go well you're

19:19

writing Medicare a check for the difference and

19:22

so you up your game a little bit there . The

19:25

other thing that's new is that you

19:28

know in the early days , you know , if I've got

19:30

50,000 patients in my

19:32

ACO , maybe three , three and

19:34

a half percent are dying each year . Meanwhile

19:36

, you know . So I've got it's still a meaningful number

19:38

of patients who are dying 1500

19:41

, 2000, . And they aren't

19:43

costly and you would think

19:45

that there would be processes to strategies

19:47

for managing those . But

19:50

meanwhile I have got 50,000

19:52

patients who need flu shots and need . I'm going to figure

19:55

out how to get mammograms and colonoscopies and diabetic A1C

19:57

tests and I've

20:00

got all these quality measures I have to focus on

20:02

where there are . The numerator

20:04

is thousands and thousands and thousands

20:06

of patients who are eligible for these screenings . I

20:09

got to get my clinicians focused on this blocking

20:11

and tackling of quality , and

20:14

so you know , I think

20:16

just the law of numbers took over and

20:19

all of the population health

20:21

tools that were released

20:24

a decade ago , even several years ago , were really focused

20:26

on guiding care to those types

20:28

of patients , closing those gaps in

20:30

care , closing HCC coding opportunities . End

20:35

of life was , I think , the time has come .

20:38

So I was going to say it feels like you're building

20:40

up to and it feels like now we're getting into a different place

20:42

and ACOs have been

20:44

around for what about like 10 years , 10 plus years ?

20:47

Closer to 15 . Okay , you

20:51

know , the Affordable Care Act really opened the doors

20:53

for these programs and

20:55

in fact , the Medicare Shared Savings Program is in law . It's

20:57

in the federal register . It

20:59

came out of the Affordable Care Act

21:01

, which was late 2000s , yep

21:04

, and

21:07

so I don't know if we're near 14 .

21:08

And again , so

21:11

if those early ACO patients were in their

21:13

65 or so , now they're actually getting

21:15

close to 80 , which is a pretty big

21:17

demographic where you're dealing with end of life

21:19

care , certainly serious illness

21:21

. Am I reading that right ? I think there was

21:23

80-year-olds back then too .

21:26

But you know , it

21:28

was more of just that . The ACOs were hospital-led the early

21:30

days because they're the ones that had the capital

21:32

, they had the relationships with the

21:35

physician networks and

21:39

they , I think , largely started the ACOs so they can get the claims data to see what their

21:42

competitors are doing . And

21:44

they had no downside . So

21:46

what's the harm ? And over time

21:48

physician-led ACOs

21:51

emerged and it turned out

21:53

physician-led ACOs significantly outperformed

21:55

hospital-led ACOs , because

21:58

the hospitals don't really want to empty the hospital

22:00

beds right , I can't believe you

22:02

said that on air , but I totally agree with you . Well

22:05

, it's true . I'm sorry , it

22:07

is absolutely true .

22:09

I've sat in many a meetings trying to make the case for

22:11

a powder of care in the hospital . Cfo

22:13

goes we don't really want to prevent that patient from

22:15

coming back because we get another DRG

22:18

. Yeah .

22:20

I remember working with a large

22:22

ACO customer over 100,000

22:24

attributed lives and

22:26

you know we were designing

22:28

predictive

22:31

models to identify folks who had avoidable

22:34

admissions and things like that and we had proposed

22:36

addressing overuse

22:38

of orthopedic procedures . You

22:40

know hip and back surgeries that are overutilized

22:44

. We

22:46

knew one of my clients you know was

22:49

especially a hospital doing orthopedic

22:51

surgeries and they do

22:53

a lot of second medical opinions and

22:55

they're like at least a third of the time , 40%

22:58

of the time we get to refer to patient we

23:01

conclude they are not a good candidate for surgery

23:03

at all 30 to 40% 30

23:06

to 40% of . and then even the American

23:08

College of Cardiology

23:10

said , you know , 40 , 50% of stents

23:13

are unnecessary

23:15

or inappropriate , and

23:17

so there's just massive overuse . But if you

23:20

propose to an ACO , hey , we want to design

23:22

a program to reduce ortho procedures . They're

23:24

like okay , hold on .

23:26

Keeping heart failure patients out of the .

23:27

You know , keeping heart failure patients out of the

23:29

hospital we'll buy into , but

23:32

we're not really ready to tackle the

23:34

cardiologists or the orthopedic surgeons right

23:36

now . Wow , we still

23:38

want the volume where it's at because it's still

23:41

a fee for service world in most hospitals .

23:43

You're a treasure trove , bob . We

23:46

could keep talking hours on this , but at least thank

23:48

you , because I think there are a lot of hospice leaders out there who

23:50

kind of suspect that that was the case . Now

23:53

that ACOs are becoming

23:56

more important for hospice and health care programs

23:58

to look at , is there data and health pivots

24:00

that they can utilize that can

24:02

kind of direct them to ACOs within their

24:04

area ?

24:07

Yeah . So to conclude that last

24:09

concept is it time

24:11

Right ? Will we start to see traditional

24:14

ACOs , community-based providers that

24:17

take care of tens of thousands of ACO

24:19

patients ? They have a three to four

24:21

percent mortality rate and there's

24:23

a segment of improvement that could be had at the

24:26

end of life , and I think we are close

24:28

to that becoming a reality .

24:31

Thank you because actually sorry , my mind was working

24:33

so quickly . What I heard you clearly say

24:35

. This is my interpretation . They've picked a lot of the low-hanging

24:37

fruit off the tree , and this is now

24:40

the time is really coming where

24:42

. Now this is a good focus for them . They

24:44

probably got their basic blocking and tackling down

24:46

as an ACO , and so this is

24:48

a new frontier where us

24:50

partnering with them could help them find

24:52

additional savings within their total spend

24:54

that exists today . Does that sound accurate ?

24:56

Yeah , that's right . Yep , now that

24:59

they've got downside risk , they've got

25:01

the blocking and tackling in place in terms of closing

25:03

gaps in care for screenings and other

25:05

preventative measures . They've

25:08

got the HCC coding down

25:10

, pat these more mature ACOs

25:12

, and now I do

25:14

believe that they're evaluating

25:16

how to get the most out of end of life care , because

25:20

we talk about the carbon into Medicare Advantage . Well

25:22

, hospice is already carved into

25:24

ACO budgets , so

25:28

it is their . The average

25:30

ACO has a budget per

25:33

capita budget of about $10,000 , $12,000

25:36

per patient . Under

25:39

what scenario can we afford $60,000

25:42

of hospice care for a year of care ? And

25:46

so certainly those higher cost patients

25:49

are factored into the overall

25:51

budget number , because some patients cost nothing and some patients

25:53

cost $60,000 or $100,000

25:55

and you end up with an average of $11,000

25:58

, $12,000 , $13,000 per

26:00

patient per year . But these are big ticket items . If

26:03

you're an ACO , you're trying to go after

26:05

the big ticket items . Hospitalizations They've

26:07

all been trying to keep people out of the hospital admissions

26:10

, readmissions , and

26:13

now we're looking at this other relatively

26:17

large spend on

26:19

a per capita basis . It's not there because not that

26:21

many patients receive a year of care , but

26:24

it's $12,000 , $15,000 , $20,000

26:26

in a very short amount

26:28

of time and they want

26:30

to make sure that hitting

26:33

the sweet spot in terms of value Got it and

26:36

in fact I want to .

26:37

we'll talk about that and we'll go into some

26:39

extent play for Tilly Ask Network . I want to ask

26:41

you some specific questions about that dollar amount . And

26:44

so can health pivots help people , Because I think

26:46

you're making a good case , that kind of our time is coming

26:48

now . So can people utilize health pivots

26:50

to find and kind of mine

26:53

, some data to start kind of doing some

26:55

market analysis and ACOs in their area ?

26:58

Yeah . So we have tools to help you understand who

27:00

are the ACOs in my market , how

27:03

many . There's a lot of publicly available data

27:05

on the fact that

27:07

XYZ ACO has 100,000 lives

27:09

. How many of those are in my county , how many

27:11

of those are in my service area and

27:15

how many of those patients in my service area

27:17

die and do they receive hospice care or not

27:19

? And if they do , do they use my agency . So

27:22

if you want to go talk to the ACO , you should be armed with

27:24

all that information . You

27:26

should say listen , you've got 100,000 patients

27:28

in your ACO . A

27:32

third of them are in my service area

27:34

and we're delivering care

27:36

to 80% of your hospice patients and I'd like

27:38

to talk about our quality and how we can help you . We're

27:41

not doing burdensome transitions and

27:43

we're keeping people out of the hospital . We're

27:46

contributing to the overall total

27:48

cost of care management and we'd

27:50

like more than 80% of your referrals

27:52

, because I think we do a much better job than your

27:55

other choices in terms of keeping people out of the hospital

27:57

and we have a mind toward

27:59

total cost of care management . Our

28:01

goals are your goals and

28:06

I think the hospice customer

28:09

is changing . The customer

28:11

has largely been Medicare and

28:14

to keep Medicare happy . You have to . There's

28:16

a very low bar . You have to try to avoid audits , but

28:18

other than that it's

28:21

an interesting customer who pays full price , on time

28:23

and not

28:25

a lot of haggling . The customer is

28:27

changing and we have to know the

28:30

customer , If that customer is an ACO or

28:32

if that customer is a Medicare Advantage plan . We

28:34

have to think the way they think , we have to understand their incentives

28:36

and we have to realize that in

28:38

large part their top

28:40

priority is total cost of care management .

28:42

Yeah Well , bob , I'm

28:45

going to ask you one more question and I'll let you do final

28:47

thoughts so we can wrap up . It

28:49

also seems like physician practices that

28:51

are involved in at risk models , so

28:53

an ACO could be one of them . Thank you , but

28:55

should hospices be paying attention at the

28:57

physician practice level and

28:59

now assuming that their world is changing

29:01

, and do they approach those physicians differently

29:03

? By the way , that was a beautiful masterclass

29:06

just now . Just that little segment on

29:08

. I mean literally you could probably take that little , you

29:10

could do kind of a little capture

29:13

of that , and I could see many people

29:15

using that . Here's a teaching tool of how to go to the hospital

29:17

, talk to their ACO . But what about some

29:19

of those physician practices ?

29:21

In large part ACOs are physician practices . Right

29:23

, the organizers of the

29:25

ACO are . There's a wide

29:28

range . There are ACO enablement companies

29:30

like Caravan

29:32

or Alidate

29:34

and Agilon . They their

29:36

mission is to enable providers to

29:38

get at the risk and they're sort of that's their business models

29:40

, to enable . And Passion is an ACO enablement

29:43

platform for high needs ACOs . There

29:45

are ACOs owned by hospitals still and

29:47

they think differently . They have different priorities

29:50

. There are physician led ACOs

29:52

. Bluestone is a good example . Bluestone

29:54

is a large geriatric primary care

29:56

group focused on assisted living patients 20%

29:59

mortality rate and

30:01

they have their own . They're a provider group who

30:03

runs their own . They're large enough to

30:05

have their own MSP ACO . So they got over 5,000

30:08

alignable beneficiaries on their own

30:10

and so it's an ACO with one participant

30:12

and it's them . They own the ACO and

30:15

they are the only provider in it

30:17

. Most ACOs are

30:19

a collection of independent providers who

30:21

have signed a contract with the ACO , who

30:23

in turn signs a contract with Medicare . So

30:25

you can , you know we have data

30:28

and insights on how to sort

30:30

of understand that . But

30:32

calling on physician groups and

30:35

calling on ACOs , you know

30:38

they're one and the same in some regards . I

30:40

don't a lot of ACOs don't have really

30:43

most ACOs are this

30:45

organic collection of

30:47

individual autonomous

30:49

groups and if you really want to

30:52

drive more hospice referrals or be

30:54

the preferred palliative care provider , I

30:57

think you're doing that one provider group at a time . I

31:00

don't know many ACOs that say we're mandating this

31:02

palliative care program across all of our ACO

31:04

affiliates . I've not seen that work very well

31:06

.

31:07

Yeah , which makes it difficult , then , because it's not a one

31:09

stop shop for you to try to use as a leverage

31:11

point to kind of move the needle on that . Well

31:13

, bob , what final thoughts there's ? Gosh , you

31:15

and I could go on all day . We're definitely going to have to have

31:17

you back and of course we'll bring you back a couple of

31:19

times to the tele-ass network , but any

31:21

final thoughts are listeners , and you've

31:24

got hospice palliative care leaders , but you also have

31:26

a lot of staff members that actually listen to this

31:28

, and it feels like you're painting a picture

31:30

that our world is changing and

31:32

you're not making it change , it's just the world is changing

31:35

. So what final thoughts would you share with them ?

31:37

Yeah , I think . The

31:40

first is I think we need to look at

31:42

our organization and honestly

31:45

evaluate our data literacy

31:47

. How strong are

31:49

we at data and

31:51

at math and measurement ? And

31:56

if we're not where we want to be , how do we get better ? Because

31:59

I do think we're entering a new phase , a

32:02

phase that is dominated by HCC

32:05

scores that

32:07

most executives and staff

32:09

members alike have never heard of . But

32:12

HCC scores are an important component

32:14

of the language of Medicare Advantage and the language

32:17

of ACOs , your future customers

32:19

. County rates there's

32:21

. Medicare publishes an actuarial table of

32:23

what patients should cost in every county

32:25

of the country . You sort of take the

32:27

complexity , you multiply by the county rate

32:29

and you get an idea of what Medicare thinks your patients

32:31

should cost . So I think we need that's data

32:34

fluency , literacy . We need to understand

32:37

that math . We need to know how our

32:39

customers get paid and how they

32:41

think about total cost of care . And

32:44

if we can't have those conversations , we're

32:48

not gonna be well prepared to have negotiations

32:50

with these new customers . And the new customers

32:53

are . It is an inevitability . 90%

32:56

of your revenue as a hospice 85

32:58

to 95% comes from CMS

33:01

and it just arrives full

33:04

price on time . And

33:06

the future is gonna be very , very different . It

33:09

could be that half your revenue comes from Medicare Advantage

33:11

plans and you'll

33:13

have to deal with prior authorizations and

33:16

other mother may I processes

33:18

and they're not gonna pay full price

33:20

. And this assumes that volume

33:22

stays the same , length of stay stays the same , all things

33:25

equal but they're not gonna pay as much . So

33:29

how do we sit across from the negotiating table with

33:32

knowledge ? We've got a few

33:34

years to get that knowledge , but we

33:36

can't assume that it's always gonna

33:38

be the way that it has been , even

33:40

though it's been decades and decades the same

33:43

way . In

33:45

the very short term , the

33:47

pair mix is changing and

33:49

those payers think differently and they have different incentives

33:52

and we have to start to learn

33:54

. What are the incentives for different types of ACOs

33:56

? What are the incentives for different

33:59

types of Medicare Advantage plans ? I , snps , d , snps

34:01

, c , snps , pace they

34:03

all are gonna value different things and

34:05

they have different priorities and we unfortunately

34:08

have to become really smart about how to position

34:10

our programs and our value to those

34:13

new customers .

34:14

That's what I'll say , bob . You know there's a picture

34:16

I get in my mind and Dr

34:18

Will Faber , who we work with , is the amazing

34:20

gentleman voted one of the top value base thinkers

34:22

in the country . He said so

34:25

this is an analogy to interpret what you just

34:27

said . There's this beautiful river that we're

34:29

getting that's our reimbursement today , and that river

34:31

is about ready to fracture into all these tributaries

34:33

. And not long after I heard him say that , I

34:35

saw this picture that literally haunts me

34:37

. And it's in South America somewhere

34:40

and there's this big river and they built this beautiful

34:42

bridge across the river . So the river's Medicare

34:44

reimbursement , the bridge is hospice today

34:46

. And this hurricane came and

34:48

the river totally got moved and

34:50

you got this bridge and the river somewhere else

34:53

, and so that is what I think

34:55

you're kind of cautioning us against , and

34:57

we could talk about some of these things for hours

34:59

. And , bob , you're a treasure trove . I'm so

35:02

glad that you're doing the work that you're doing . You and

35:04

the team at Health Pivots are amazing . You're

35:06

gonna be very important to our future . So

35:08

thank you and to our listeners

35:11

. Bob provided a really good quote . That's almost

35:13

like a rallying cry . Maybe a little bit of word

35:15

of warning , it comes from Akaveli . There's

35:17

nothing more difficult to take in hand

35:19

, more perilous to conduct or more

35:22

uncertain in its success and

35:24

more dangerous to carry through than

35:26

to take the lead in the introduction of a

35:28

new order of things , because

35:30

the innovator has against him those

35:32

who benefit it from the old system , while

35:34

those who should benefit from the new

35:37

are only lukewarm friends . Being

35:39

suspicious has been generally , or if something

35:41

new and not yet experienced . In

35:43

seeking of innovations , it's first necessary

35:46

to establish whether the innovators

35:48

depend upon the strength of others or

35:50

their own . In the first case things

35:52

always go badly , in the second

35:54

they almost always succeed . And

35:57

that's a quote from Akaveli and feels

35:59

very appropriate to our conversation , to our

36:01

listeners . Thanks for listening to TCN

36:03

Talks .

36:06

ITTL Tip .