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 . Welcome to TCN

0:25

Talks . Our guest today is Dr Katie

0:27

Lanz . In fact , it's great to have Katie back . We

0:29

had her on last year . She's the founder and

0:32

principal of TopSite Partners . Welcome

0:34

, katie , good to have you .

0:36

I'm glad to be here again . Thank you for having

0:38

me .

0:38

Well , Katie , what does our audience need to know about you ?

0:42

I think just that I

0:45

myself am in transition . This is a fun

0:47

thing to talk about , I think , because the industry

0:50

is in transition as well . We

0:53

all have to evolve through this and I think

0:55

that's where the creativity and fun comes

0:57

. So I'm taking some time , even at

0:59

my advisory work , to really think

1:01

through and interview as many people

1:03

as possible to find

1:05

out what's happening out there . And

1:08

so what do they need to know about me ? A little context

1:10

I introduced myself in the last one

1:12

, but quickly . I'm a geriatric

1:15

and palliative nurse practitioner who got

1:18

my founding roots in North Carolina

1:20

when I was

1:22

working with a not-for-profit hospice

1:24

for about a decade and ended

1:26

up getting my nurse practitioner degree and helping them

1:28

in the local systems think through palliative care

1:31

and how we help people avoid

1:33

unwanted , unnecessary

1:35

things and that kind of

1:37

led to my journey into

1:39

more education and

1:42

to do some of the demonstrations

1:44

that have occurred over the last 15 years

1:46

. So I left the bedside almost

1:48

, I'd say , about 14 years ago now and

1:51

have been really focused on value-based care

1:53

ever since and looking

1:55

at the broad continuum of innovation in

1:58

that context , but always for

2:00

the frail seriously

2:02

ill . That's my heart .

2:04

And that's actually what I love about you , katie . I

2:06

was actually talking to a CEO I have immense

2:08

respect for and they were talking about one

2:10

of the podcasts that we just had was

2:12

just released , actually from another

2:14

well-known consultant , and

2:17

she asked me this question . She goes is there not

2:19

a consultant in this space who's been by

2:21

the bedside ? I said , oh yes , katie Lans

2:23

. And so they're

2:25

like well , I can't wait to listen to this show that you're going

2:27

to have with Katie , because I think it

2:30

gives you a different perspective and it gets you a lot

2:32

more cred , because you've been by the bedside , you've

2:34

held the hands of dying patients , you

2:36

know what it's like , you know the clinical aspects

2:39

, you know what it's like to be an IDG team member , you've

2:42

also been in the innovation of palliative care , and

2:44

so I just think that gives you such a unique perspective

2:46

. And what I love about you is

2:49

when I'm around you , you

2:51

always shift my perspective of something

2:53

I've been wrestling with , and so

2:55

you and I are walking by Home Care 100 . I swear

2:57

it wasn't maybe a five minute conversation

2:59

, and I'm like hey , katie , I want to have you

3:01

on my podcast , and this was my original

3:03

thought of the show . And just in a small

3:05

conversation you shift my perspective

3:08

. And so the original idea was hey , katie

3:10

, I think we did a show on

3:12

the flight of substitution

3:14

competition . And so , katie , you come to Asheville

3:16

, you get all these wonderful breweries and

3:18

you get a flight of beers . Right , you get like a

3:21

sample of all these different types of beers

3:23

. And I thought a flight of substitution

3:25

competitions would be helpful to hospice

3:28

leaders . And here's why I've

3:30

heard recently that this person

3:32

was talking about a lion . Tamer

3:35

uses a chair to tame a lion

3:37

because the four legs of the chair literally

3:39

paralyze the lion . And my concern

3:41

for hospice leaders is there's so

3:44

much stuff coming at us . We're like that

3:46

lion , we're just paralyzed , like if you go

3:48

to Home Care 100 , you're paralyzed like

3:50

oh my God , there's all these

3:52

things coming . And so my

3:54

original framing of substitution competitions

3:56

I thought you know , hey , here's kind of

3:59

the flavors . I'm just going to say it out loud because

4:01

then I'm going to quickly get to and

4:03

Katie shifted my perspective in a small conversation

4:05

. So the flavors I thought

4:08

they're out . There are like ACO aggregators

4:10

, value-based MCOs , they're

4:12

payviders , there's health tech

4:15

, fintech , there's equity

4:17

back portfolios , there's

4:19

network building , there's post-acute

4:21

provider service expansion . Then

4:23

there's emerging primary powder care

4:25

type models and when I first even talked

4:27

to Katie she's like well , those aren't exactly

4:29

mutually exclusive because there's a lot of overlap

4:32

even amongst those kind of flavors

4:34

or flights , if you will . But

4:36

this is what I love about Katie . In

4:38

a couple of questions I can't remember how you

4:40

said it I could fill my mind

4:42

, shifting from the term substitution

4:45

competition To much

4:47

more like wait a minute , these are collaboration

4:49

opportunities and why am I even

4:51

framing this as substitution competition

4:54

? So , katie , I want you to take it from

4:56

there . There is a lot headed our way

4:58

and so and use when

5:00

you are doing show prep , you start to share this

5:02

beautiful picture with me that I

5:04

we're gonna actually put in the actual summary , and I

5:07

think this picture really gives a current

5:10

reality , but a futuristic reality , of

5:12

where the series on this basis had it . Can

5:14

you describe that to our listeners and kind of take it

5:16

from there ?

5:18

Yeah , absolutely , and thank

5:20

you for all the nice things that you said to the feelings

5:22

you know mutual , and I Hope

5:25

that others shift my thinking . The

5:27

way I think about it and the things

5:29

that you just described as

5:31

Substitution competition in my mind

5:34

are business structures , potentially

5:36

payment structures for Services

5:39

, and they aren't necessarily services

5:41

that are defined yet right . They are

5:43

services that anyone can

5:45

build . It's happening more readily

5:47

in the private world that there's some innovation

5:50

being built . But let's be honest

5:52

, even over the course of the last I

5:54

don't know 15 years since , and

5:56

20 years I would say , since the for-profit

5:59

integration into the hospice world

6:01

, we've seen even hospital systems create

6:03

new products , services that

6:06

are potentially duplicative to the some

6:08

of the things that we have historically built

6:10

in our industry . And I don't think it's

6:12

Necessarily substitution . Anyone

6:15

can build new models of care and in my opinion

6:17

, it becomes like a super creative time

6:19

to either collaborate , build by

6:21

our partner , right , because now we have

6:23

new payment structures to work within to

6:25

build things , and so what you described

6:28

as substitution competition I think of

6:30

in my mind business models

6:32

to support products that we

6:34

, a IE , the workforce

6:36

that does this work . I'm a nurse at heart , nurse practitioner

6:39

. You know that we can build

6:41

to actually meet the needs of the patients

6:43

that we serve . And so if you look at that diagram

6:46

that I I shared with you , you know

6:48

I think about what used to be and

6:50

we have these episodes . If you look

6:52

at the left axis , this is function and

6:54

health and , for those that know me , I've been kind of

6:56

, I'd say , evolving

6:59

this , this picture , for some time

7:01

. But we have a traditional juncture

7:03

of care , critical junctures and a

7:05

person's life as they're dealing

7:07

with serious illness , and you see over time

7:09

that they have these episodic

7:12

critical points where they have a crisis

7:14

that go into the hospital . Potentially

7:17

they go to the ER , they might

7:19

get home health services , they might

7:21

get hospice , they might have , you

7:24

know , I would say even skilled

7:26

care , but they're time limited and

7:29

that time limitation is becoming more

7:31

and more governed . It's not only it's the utilization

7:33

management that we hear about , it's it's more

7:35

and more defined and it's not a forever episode

7:38

. And unfortunately , when we discharge

7:40

patients , the clinicians , we know that patients

7:42

gonna get sick and go right back into the hospital

7:44

and as

7:47

you enter this new value-based kind of

7:49

care world , we shift to the right and

7:51

we think about the patient's experience Over

7:53

time . You know function health on the

7:55

left , again time in the last two to three years

7:57

on the right , and I just think , as a clinician

7:59

, what do people need ? Let's say , chris , you get

8:01

sick , you know , I'm gonna give you

8:04

a disease . What do you want to have ? Let's give you

8:06

I don't know . Let's give you COPD

8:08

. Okay , you and

8:10

your wife and your kids are gonna have to make

8:12

some decisions about the type of care that

8:14

you get . And in the left side , these

8:17

are benefits and services that are paid for

8:19

in a fee-for-service way . But what you

8:21

really want is something creative that meets your

8:23

needs when you need it . You want a

8:25

practitioner and perhaps even a social

8:27

worker or a guide to help Stay

8:30

with you the whole way through your illness . You don't want to have

8:32

to let go of them for some service or

8:34

elect something and let go of something you

8:36

know . I think that you

8:38

know what we really need as we

8:40

get sicker . We need the things that are in the

8:42

boxes down below . We need care

8:44

, navigation and support . Really good assessments

8:47

that are not just focused on what we you

8:50

know , what we can do and our functional

8:52

, nutritional , cognitive status . That are

8:54

like , focused on who we are

8:56

as individuals and what we want , because

8:58

, I gotta tell you , not everybody

9:00

wants to go into the hospital once they get a

9:02

disease like this and not everybody wants to

9:04

be in a skilled community community , and

9:07

so with good planning , you might be able to avoid

9:09

that and integrate things like geriatric

9:11

crisis care and that doesn't mean Geriatric

9:14

doctors , even it could be paramedics coupled

9:16

with nurses that are doing , you

9:18

know , and even enabling home health kind

9:21

of skilled needs like IVs and

9:23

Even breathing support for

9:25

you , a COPD when you need it , so

9:27

that you don't have to go into the ER and

9:29

as you get sicker and your your condition

9:32

changes , you might need personal care and

9:34

even intensive palliative care . You know

9:36

where people really know how to manage your symptoms

9:38

. They know how to manage your

9:41

disease . They know how to keep you as

9:43

comfortable as possible and as strong

9:45

as possible for as long as possible in your

9:47

home . So I believe

9:49

that it's not necessary what we're seeing

9:51

in the new products coming

9:54

through and I'm calling them products

9:56

instead of Substitution competition , because

9:58

they could be built by the home health

10:00

and hospice industry in Partnership

10:02

with some of the at-risk we'll talk about

10:04

that in a minute entities or just

10:07

health systems that need support and or

10:09

people Direct to consumers public

10:11

that needs support . I mean , think about if you could go on Amazon

10:13

and find the , the , the colored , you

10:16

know boxes down below and see

10:18

who's best in class at that and

10:20

who's in your area and how much you

10:22

know you , what you get for what you

10:24

pay for . So I

10:27

just think that we're shifting the

10:29

way that we're paid for is going to change

10:31

the way we deliver services and I'm actually

10:34

glad for that , because not everybody needs

10:36

Everything that home health officer

10:38

offers or everything that hospice offers

10:40

. It should be dose escalated based

10:42

off of what you need , chris , with your COPD

10:44

, as you decline at home with your family and

10:47

I'm sorry , I just Gave

10:49

you a terminal diagnosis .

10:50

Actually , you don't know this , but actually as soon

10:52

as you and I are done Actually I've got to go to a funeral

10:54

, and so what you said is actually just

10:56

really close and near and dear , because we just saw a Dear

10:59

family member go through a situation that end

11:01

up in they passed away yesterday

11:03

and there's so much in what

11:05

you're saying and that we're definitely going to include

11:07

that picture , katie , when we actually put it out

11:09

. And so your blue oval can

11:11

you just talk about that a little bit more ? Because that blue oval

11:14

feels like that is where

11:16

the creative space , that's where the opportunity

11:18

is , because the old picture is just here

11:20

the silos right , people throwing

11:22

people over and there's a lot

11:24

of white space in between the silos . But the

11:26

blue oval , can I paints the picture

11:29

of a different night . I love that you use blue

11:31

, by the way , do you know ? Like the whole book blue ocean

11:33

.

11:35

I don't , but I just sit my favorite color .

11:36

If you can't tell , by the panel of all my jacket

11:40

there's a whole world of wisdom out there , of that

11:42

like the blue ocean is like the world of possibilities

11:45

. The red ocean is where the sharks are

11:47

kind of fighting over what was . The blue

11:49

ocean is what could be , what could be possible .

11:52

Well , the blue . It happens to be my favorite

11:54

part of this continuum because if you think

11:56

about what okay , let's get

11:58

, let's take to think about any disease , any chronic

12:00

disease , when you get

12:03

this diagnosis , your doctors

12:05

talking to you about it . They're talking about treatment

12:07

Upstream

12:09

we're saying maybe three to five years upstream

12:11

, their decisions that people are worried about

12:13

. They don't really know what this means to them , they don't

12:15

really have somebody involved in their life . And I

12:17

see the blue is potentially Primary

12:20

care coupled with really great

12:23

social support . And

12:26

those products could be billed . They aren't mutually

12:28

exclusive . They could be built separated , but

12:30

I don't think they could be living in

12:32

silos . They really should be connected

12:35

. The primary care Of the patient

12:37

with this should be supported

12:39

by something in the blue box and that is the engagement

12:42

, meaning , you know , continuous connection

12:44

with families , really

12:46

great social , determinant assessments

12:49

and not just assessments . I hate just

12:51

the word assessment because all that does is

12:53

like ask people questions what are you gonna do about it

12:55

? So , navigation , support services

12:57

, what's available to you in your market , what's in your

12:59

network , and then counseling as

13:01

you make the decisions , as you fluctuate

13:04

up and down that continuum . And

13:06

I also believe it can't be just

13:08

a call center or just stand

13:11

alone . It has

13:13

to be supported with on the ground

13:15

intervention . So 24 seven

13:17

Call support , yes , but then the

13:20

capability to upfit

13:22

someone , to go out into the home as soon as possible

13:24

to help support someone , because that's when

13:26

the crisis , you know , can really take a downturn

13:29

and you end up with unwanted , unnecessary

13:31

things in the hospital . So the

13:33

blue is that continuous person

13:35

. Let's name them . I don't know Susan

13:38

and Susan's your person and

13:40

you're gonna call Susan and your PCP

13:43

and you know Susan works really closely with your PCP

13:45

and shares all the information that she gets with you

13:47

, with them and an integrated way

13:49

. And Susan knows everything that's available

13:52

to you in your market and she's just your trusted

13:54

person and I'm making her a sheet because 85%

13:57

of that workforces women . Could

14:01

be Paul too , we don't know , but I

14:03

think that you know this is a really important

14:06

piece of the puzzle and , in my

14:08

opinion , the jump ball . So

14:10

if you're going to work with at risk individuals

14:12

and you want to create a network and

14:14

you want to see who is the best quality , this

14:16

particular group knows that and

14:19

they will be the ones likely making that

14:21

coordinated care and referral . And so , as

14:24

you're building things out , that being able

14:26

to work upstream is the way

14:28

that you assure that they're referred into

14:31

your systems products

14:33

and you know , I would

14:35

even say traditional products , like home health and hospice .

14:38

So maybe that gets to what I was gonna ask

14:40

you next , katie , is people start to get their minds wrapped around this In

14:45

the special where you grew up , because most of our listeners

14:47

are a community base , mission , focus

14:50

, nonprofit hospices . What

14:52

is your hope for them is as community programs

14:54

. Where would you like to see them grow up into the

14:56

future , grow into what you're describing ?

15:00

I think the cool thing about North Carolina

15:03

it is it is different and that it is a

15:05

certificate of need area , and so a lot of times , the traditional and historic

15:07

Programs

15:11

are already partnered with the health system

15:14

, already aligned with some acos and potentially

15:16

at risk . You know , providers , you have a step ahead of some of the states that are gonna have

15:18

to compete for these things . What I would say to them is I hope that

15:20

they find a way to come together and

15:25

highlight their capability to do the things that are

15:28

needed in these boxes that I just described , and

15:35

specifically for the homebound population

15:37

. We don't need to compete , you know

15:39

. We really just need to showcase our value and

15:42

build systems to support

15:44

it , and so I know that

15:46

that's gonna require a lot of innovation

15:48

. I know that it's gonna require a lot of cash

15:51

, because to play

15:53

in this now environment , you often

15:55

have to come forward with the ability to

15:57

support some of that downside risk , and

16:00

together there's some pretty deep pockets

16:02

in these organizations , you know

16:04

, and I think we need to be aware of that foundational

16:07

support that is to make really Necessary

16:10

products for the communities that we serve , the communities

16:12

that have given us that funding , and

16:14

in order to do so , we've got to adapt

16:16

and we've got to think like entrepreneurs , and

16:19

I would say don't work alone . This

16:21

is the most important time

16:23

to come together and coalesce

16:25

and build something brilliant . That's when

16:27

blue cross , blue shield and at risk

16:29

providers are gonna look to you and say we can't use anything

16:31

else . Let's say , team help they have doctors all

16:33

over the state , pearl

16:36

help they need partners to support

16:38

. They're gonna need something that's a fit catch

16:40

all solution for every single environment

16:43

that they have patients , every single zip code

16:45

. So together or better , and so

16:47

I'd like to

16:49

see people convening

16:52

and really thinking about how we build

16:54

these products together and

16:56

go together to to find

16:58

ways to support the risk . Or or

17:01

else here's the bad part

17:03

we might have other

17:05

people coming in with ad hoc products

17:08

in each one of these categories that

17:10

don't necessarily work within our systems

17:12

and or refer to our systems , and

17:14

we might find ourselves with decreasing census

17:17

in our traditional products which will make it , which

17:19

will make it harder than for them not only to survive

17:23

, much less be able to innovate into

17:25

the areas that you're talking about .

17:27

So , as they think about who are their best potential

17:29

collaborators we kind of alluded to it , but when you think

17:31

about collaborators in that whole blue space

17:33

, katie kind of , who do you think are the ones

17:36

they need to be thinking about ?

17:38

well there's , there's incremental steps to get there

17:40

. So if you are personally like gosh

17:43

we , you know it's hard to do business , as is

17:45

with our workforce shortages . We don't need to . We

17:47

should at least acknowledge that change management

17:49

is nearly . It's really tough right now . People

17:52

are burnt out . There's

17:54

a lot of turnover . You want to take care

17:56

of your employees , so to build new things or ask them

17:58

to do new things can sound scary right . My

18:01

experience with that , having done that the last 15

18:04

years , is that the workforce is ready for it

18:06

. They're actually burnt out because the old system's

18:08

not working . Let's just say a home health nurse

18:10

and you know she's she's feeling

18:12

like kind of checkboxy with her work and

18:14

she is , you know , going in and she's

18:16

not allowed to continually do

18:18

the things that her patients necessarily need , because

18:20

she's there to do a service and

18:22

leave and and that's not

18:25

doesn't feel good , right ? We , we

18:27

want to be able to provide services for our patients

18:29

. That's part of our DNA . So

18:31

I think that what

18:34

that looks like is it doesn't need

18:36

to be mutually exclusive

18:39

, that you do this or that , or that

18:41

you build everything together . I

18:43

would say it's a great time to test out new

18:45

products and and or

18:47

build together , and so

18:49

there are products that are

18:51

out there that are in the care navigation and virtual

18:54

palliative care space that can , you

18:56

know , serve as an extension to you to reach

18:58

out to people in your communities and

19:00

, you know , a vehicle to partner with

19:02

that primary care and assure that you're doing and

19:05

referring into the quality services

19:07

that the patients are both eligible for and

19:09

desire . So you

19:11

know , I think it's shopping for those types

19:14

of services , and there are , I would say , two

19:16

or three companies that are doing it around

19:18

the country that are they're doing a pretty good job

19:20

so , katie , it feels like as you

19:22

can talk about then those potential collaborators

19:24

, people are going to have to go through a thought process of

19:27

do I build , do I buy

19:29

or do I partner .

19:30

Can you unpack that a little bit ? In fact , the

19:32

more that I keep , I keep bumping into some multiple

19:34

podcasts , it feels like there's a tool to be developed

19:37

, like a decision tree . But can you just

19:39

talk about like what should guide people to

19:41

go ? Well , you know what we should just build that

19:43

, or you know what we need to just go buy it from

19:45

somewhere else . Or maybe there's another interesting

19:47

way to collaborate or partner with someone thank you

19:49

to our TCN Talks sponsor , delta

19:52

Care RX .

19:53

Delta Care RX is also the title

19:56

sponsor for our April and November

19:58

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20:00

immersion courses . Delta Care

20:02

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20:04

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20:07

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20:09

RX is a premier vendor of TCN

20:11

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20:14

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20:16

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20:18

time , stress and money . Thank

20:20

you , delta Care RX , for all the great

20:23

work you do in the end of life and

20:25

serious illness care yeah , so

20:27

build it would be , you know , to

20:29

just foundationally build the services

20:32

that we define in that video .

20:33

So like care navigation , virtual palliative

20:35

care , social supports that report

20:37

out and then the tech that's required to report

20:39

into the primary care partner systems that

20:41

we're sharing information about what we glean

20:43

from the patients and families and what their needs are . Geriatric

20:47

crisis care that could be a product

20:49

, with , you know , paramedics , potentially

20:52

social work , a lot of telemedicine and

20:54

pulling in the right services

20:56

for that patient to be able to stay home and

20:58

the right expertise to help them stay

21:00

at home . It could be , you know , renal doc . It could be

21:02

behavioral support , it could be their primary

21:04

care , intensive palliative

21:07

medicine that's when somebody really needs the specialty

21:09

and they needed a practitioner that can

21:12

help . You know when , when the cure is not

21:14

necessarily an option and the patient

21:16

starting to choose to stay home and have

21:18

more comfort , that extra level

21:20

of support , which is both you know , we know , is

21:22

interdisciplinary , team

21:24

, team support , and then you know , the personal

21:27

care too . So each one of

21:29

these , you need to assess your capabilities

21:31

in-house and then also what

21:33

you can and can't do , knowing that

21:35

if you in-house this yourself , you might

21:38

. It might be more of a regional

21:40

play for your region or a local

21:42

market play , versus something that

21:44

you're a part of . That's much bigger . That

21:46

is going after larger support services

21:49

which are alone you could not

21:51

do . You know it might be harder to get , for example

21:53

, a contract with Pearl Health or upstream

21:56

, or you know some of the the

21:59

players in the market who are at risk if

22:02

you go alone . But if you go with a group

22:04

and you have something to offer them , then

22:06

it's a lot easier . I

22:09

think there's certain things that have to be done in person and

22:12

those are the ones that those those

22:14

they need to be thinking about build locally okay

22:16

, okay .

22:18

I don't know if you find this , and I think it was IBM

22:20

years ago that it was the not invented

22:22

here syndrome , and so

22:24

I find in healthcare sometimes we suffer

22:26

from that , like there is no , there's only

22:28

one option . I must go build it , and it's

22:30

like a hubris behind it , like not invented

22:33

here , it's not invented . Have you seen

22:35

that yourself ?

22:36

and I

22:38

have , and part of

22:40

it is just baked in our history as

22:42

hospice providers . I'm just speaking

22:44

to a majority of your audience here and

22:46

that is , you know , just , we go into

22:48

the market , we build it . If there's a need

22:51

, we figure it out and we , we own

22:53

it . This is different . This

22:55

is this is very different , especially with the M&A

22:57

and activity and large at risk

22:59

contracts across the whole regions , and when

23:02

I say region , I mean like state or multiple

23:05

states . So I

23:07

think that part of it is also ego

23:09

, you know , and that's just . We

23:11

could build that and like , yeah , you could

23:14

, but what is the downstream impact about ? Let's really

23:16

think about the market influence and and what

23:18

would happen in the event that you do that , could

23:20

you eventually be competing ? So , for

23:22

example , if you wanted to own your own primary care

23:25

, you might be competing with some of your primary care

23:27

referral partners that are

23:29

historically , you know , referring to you

23:31

. So you're biting the hand that potentially feeds you and

23:33

taking patients away from them . So

23:36

I think that there's you don't need to do both . You

23:38

need a partner to and create solutions

23:41

together , but really think about your

23:43

. This is going to be messy . I'm not going to be . I'm

23:45

not gonna lie , this transition is going to be

23:47

very hard and it needs to be market

23:50

specific , based off of the demands that we're

23:52

talking about , and you know , I

23:55

think that it just has to be strategic in

23:57

every single location .

23:59

Something that occurs to me Katie years ago I was at

24:01

a what's now in PHI

24:03

, but it was the National Hospice Work Group , and there

24:06

was a book written called Zilch

24:08

and it was about how nonprofit

24:10

people tend to make something out of nothing

24:13

. And where I'm going with this is people are had by

24:15

their habits , right ? So our matriarchs

24:17

, who have created this amazing

24:19

thing , took the before there was a benefit

24:22

, and then there is a benefit , and now there's this movement

24:25

that's become an industry in many respects , but

24:27

the habit has been we invented

24:29

, we took something out of nothing and made something

24:32

. But we're at an interesting inflection

24:34

point and so I

24:36

just it just occurred to me just listening to you , I think you

24:38

nailed it and that we've got to think about those

24:41

differently . To go forward doesn't mean you totally

24:43

throw that habit out by the side

24:45

, but you're gonna have to have wisdom of bill by

24:47

our partner , and it's not always billed . Because

24:49

that served us well in the past , it's

24:51

not gonna serve us perfectly in the future .

24:54

I push every . I totally agree

24:56

and I would push everybody to say

24:59

how do we get involved in

25:01

patient's lives as

25:03

far upstream as possible and

25:06

as sticky as possible , meaning a product that , just like

25:09

a partnership , that just is evergreen

25:11

? You know that won't go away

25:13

Because that will assure

25:15

that whatever happens in healthcare

25:17

, you're part of where

25:20

that patient goes . You have a touch point

25:22

early on that helps support

25:24

the

25:26

kind of guide path where that person will

25:29

go , based off of their needs . So that

25:31

part I really push people to partner on because

25:33

it's beyond the walls of a county

25:36

you know , and it goes further

25:39

than that and our patients go further than that . And

25:41

the people who own the risk largely

25:44

and if we just look at the data which we've talked about before

25:46

, retail owning primary care I

25:48

mean , these are massive companies and

25:50

it's not just health plans who are owning pay viters

25:53

is what I would call them . There's retail doing this

25:55

too , in partnership . So if we wanna

25:57

be with them , we might need to

25:59

think about how we , you know , build

26:01

in you know kind of

26:03

large collaborations

26:06

that enable them to scale across

26:08

massive systems and have a

26:10

one you know kind of easy button that

26:13

fits all .

26:15

Well , kate , let me kind of wrap us up with

26:17

two kind of final questions . I mean , first off , you were

26:19

so gifted . If you can wave

26:21

a magic wand for the future of the

26:23

serious illness space , what could

26:25

and should it look like ? I feel like you've been hitting it

26:27

in pieces and parts . This is your opportunity

26:29

to kind of Katie waves the magic wand

26:32

. This is what the future should look like .

26:36

At-risk healthcare meaning , you know , value-based

26:38

care , where people are held accountable

26:41

for the quality and cost is only

26:43

going to grow . And I'm glad

26:45

that it is , Because it's not

26:48

about doing more , it's

26:50

about doing right . So

26:52

I would say build

26:55

things that do right by people . Don't

26:58

just build around a product , a partner

27:01

you know like . Really think about how

27:03

you build things that are right for people

27:05

. Like Chris , when I gave him the diagnosis

27:08

, you know , and that's

27:10

going to include things that aren't necessarily

27:12

part of it is the things are traditional

27:15

models of care , but part of it are those

27:17

in-between spaces of connectivity

27:19

to assure that people don't fall

27:21

through the cracks , that their social needs are met

27:23

, that we are doing

27:25

lots of anticipatory thinking

27:28

and that we're supporting

27:30

patients based off of how

27:32

they're doing , not the benefit and

27:34

as it's defined . So my

27:37

magic wand would be to think like entrepreneurs

27:40

and find ways to

27:42

convene and problem

27:44

solve , to catch that jump ball so that

27:46

you can really define these products together . I

27:49

also would say I'm hopeful that

27:51

you start budgeting to

27:54

protect some of the downside , because

27:56

if you want to be taken seriously in this new

27:58

model of care , you have to be able

28:00

to tell a person be

28:02

a pay vider retail primary

28:05

care that you're willing . You're

28:07

so good at taking care of people in the home that we're

28:09

willing to pay 50% of that downside

28:12

if you allow us to participate in your

28:14

network . We want to be a good partner to you . We

28:16

know you're already having to pay for this , so this

28:18

is what we want , and so

28:21

my magic wand is that through those

28:23

business models , through these

28:25

types of thinking , that

28:27

these beautiful new products are born

28:29

that will take great care

28:32

of us based off what we

28:34

need , not necessarily a benefit that's out

28:36

there that might have too much or too

28:38

little . Yeah .

28:40

Good deal , katie , all right . Final

28:42

thoughts , any final thoughts ? Last time I

28:45

framed it this way I'm like you've

28:47

grown up by the bedside and you've got . We actually

28:49

have a lot of staff that listen to this , not just leaders

28:51

. Final thoughts and words of wisdom

28:53

from Katie .

28:56

I think last time I talked directly to the workforce

28:58

and I'd like to do that again . Don't

29:02

necessarily rely on

29:04

the executives

29:07

in your organization to

29:09

figure these things out . Share

29:12

what you think might work , partner

29:15

with your chief financial officer

29:17

or someone who really can economize your

29:19

ideas that's not a strength always

29:22

of us and

29:26

know that you can build things

29:28

as a clinician too , and ask

29:30

for responsibility in those areas to test

29:32

it . Now , how do you do that on top of your job

29:34

as it already exists ? I think you have to create

29:36

space for it , and that is something

29:39

that's challenging to do . But

29:41

starting to ask questions

29:43

, lean into people who are trying to figure these things

29:45

out , companies who

29:48

are creating solutions like this , and

29:50

you'll be surprised in awe

29:52

of what you might find

29:54

out there that is really working

29:57

for people , and so I challenge you to find

29:59

your leadership as clinicians . I

30:01

challenge you to ask questions and

30:03

to lean into the change that's happening

30:05

instead of resisting it , because it's happening

30:08

whether we like it or not , and as

30:11

our patients don't like dying , there has to

30:13

be different levels of acceptance of that when

30:15

we're teaching them about it . So

30:18

healthcare as we knew it is also dying , and so

30:20

it's time for us to step up and

30:23

help be part of the creation , instead of sitting

30:25

back and letting it happen to us .

30:27

Wow . Well , and Katie is walking

30:29

this walk , and so when she and I were walking

30:31

at Home Care 100 , she introduced me to someone

30:33

that heard our last podcast

30:35

, who reached out to Katie IDG

30:37

team member and had an idea , and

30:40

now they're living that idea , their innovation

30:42

that they saw , they're in a value-based

30:44

contract and they're doing incredible work

30:46

, and so I love what Katie just

30:49

said and that's what to me .

30:50

Yeah , she's a , I think , my friend's

30:52

at the Holdings Group .

30:53

Yes , exactly .

30:55

Yeah , yeah , or Care , Ally

30:57

, one of the two I was gonna say . They're both founded by

30:59

IDT members but , both

31:02

social products , social

31:05

, socially determined products

31:07

that partner with primary care , so in

31:09

hospice .

31:10

Yeah , and share it with your leaders , because hopefully

31:12

the organization certainly I hope I work with

31:14

that , your leaders would hear that but in that

31:16

case , these people are part of an organization

31:19

that their leader either they weren't

31:21

interested or whatever so they basically

31:23

worked on it on their own reached out to Katie

31:25

and now they have a thriving business

31:27

doing some incredible work and I

31:29

think that bottom-up

31:31

kind of approached innovation the people who have

31:34

been by the bedside again , I think that's what gives

31:36

you so much credit , katie .

31:38

Oh , thank you , and I'm willing to talk to anybody

31:40

who wants to talk about it , because we can figure

31:43

things out together . There's lessons learned

31:45

, isn't there ?

31:46

Yep , yep , and she's legitimate about that . Thank you , all

31:49

right , this is an addenda

31:51

to TCN Talk . Katie and I recorded this

31:53

originally on March the 1st , and here we are

31:55

on March the 8th . Well , a big announcement came out

31:57

Katie , I think they were listening to us and

32:00

so , on March the 4th the afternoon

32:02

, big announcement from CMI

32:04

that the VBID demonstration

32:06

is basically being stopped

32:08

at the end of this year , and so I definitely

32:11

thought I've got to get Katie's thoughts on that . So

32:13

, katie , what are your thoughts ? What's going on here ?

32:16

I think they were listening to us . We

32:19

were kind of , I

32:21

think , proactive in saying , yeah

32:23

, there's going to be something new happening

32:25

here , but we don't know what . And then , okay , here's now

32:27

the what , but I wouldn't pull out the champagne

32:30

yet is kind of my feeling . I

32:32

have taken a couple of days

32:34

to really let all this sink in and talk

32:36

to some colleagues who are big thinkers , and

32:38

even some colleagues around the capital

32:40

, about what is happening , what's going on

32:42

, and so I feel like we can have a good discussion

32:45

now about what the implications

32:47

are of this for the industry and what

32:49

might be happening next

32:51

. Why not ?

32:52

Yep , let's do it .

32:53

Let's do it .

32:55

You want to jump in then . So I

32:57

mean , is it worthwhile ? It might be a little bit interesting

32:59

to just go . Why did they make that decision ? Because

33:02

you've probably got a little bit of information , but I do think

33:04

the better part is . So what are the implications

33:06

? Where do we go from here ?

33:08

Yeah , well , I mean , let's just look

33:10

at what it was first and

33:12

then what could be . You know what it was , we

33:15

know what VBIT is and anybody who's listening

33:17

, you know , can read about it . But

33:20

generally the numbers have been small

33:22

and the incentive for most

33:24

of the participants has not been incredibly

33:26

strong to participate

33:29

and refer as many people , and so it's just not

33:31

had as high of an uptake . It's been a very

33:33

small demonstration . We haven't had as many

33:35

patients as we would have liked to be in

33:37

it . So that's just part of it and I think that

33:39

they've learned pretty quickly

33:41

about the setup , how they might change

33:43

some things . It also

33:45

was derived during a time

33:48

when there was a different group in office

33:50

, you know , at CMMI , and I think

33:52

that there is definitely a difference in some

33:54

of the models that came out during

33:57

that time period , especially geared towards

33:59

populations that the leaders

34:01

like Brad Smith and Adam Boller were used

34:03

to managing , and that's , you know , the serious

34:06

illness population , and

34:08

so in working with health plans and trying to figure that

34:10

out , and so you know there's , I

34:13

think that they knew that

34:15

things weren't necessarily as successful

34:18

as they were , but even if it doesn't break

34:20

even , they've learned a lot of information

34:22

about the workflows that need to be created

34:24

, the quality and governments that needs

34:27

to be input , and then how that they can

34:29

integrate other hospices that might not

34:31

have been involved , because most of

34:33

the groups that were involved also own their own hospices

34:35

.

34:37

So it sounds like um , so there

34:39

is probably a group of people going dodge

34:42

that bullet and we could just go back

34:44

to where things were before . That is not what

34:46

I'm hearing from you at all . I almost feel like

34:48

I'm hearing in the background like , okay , they've

34:50

got enough information . So what do

34:52

you think is next ?

34:53

Well , think about this . Remember when they pulled the sip

34:56

for a year when ACO Reach came out , there

34:58

was a change in the office and then

35:00

they came back out and now it's called ACO Reach

35:02

. It's got more around access and more

35:05

about inclusion and they

35:07

they were also the constituents and

35:09

applications . They didn't want

35:11

to take as much on the privately vested

35:14

side . They were looking more at community assets

35:17

being given the ACO Reach contracts

35:19

towards the future or smaller practices that

35:21

were owned independently or not

35:24

funded by venture capital

35:26

. That was just what I saw and that was

35:28

one of the participants through my

35:30

work with PCMA , which was an independent and

35:33

physician owned practice essentially

35:36

. So I think we've

35:38

already seen that If we read the tea leaves there

35:41

, you know like I think it's going to be interesting

35:43

to see what happens with the next election and

35:45

how that impacts . You know what this

35:47

looks like . I feel when they

35:50

take something off the table like this is like okay

35:52

, we've learned what we need to learn , and

35:54

now I think they're going to come out with

35:56

something . And there's something we need to really

35:59

talk about here and you and I haven't even

36:01

talked about this and that is the direness

36:03

of the Medicare trust fund and

36:05

what that means in the coming years

36:07

and we've really got to look at that and think about

36:09

it . And I think with this new ? We've

36:11

already seen the strategic refresh around . They

36:14

want 100% of

36:16

primary care and some accountable care organization

36:19

or in some type of accountable care relationship

36:21

. I believe we're going to see this

36:23

offloading of the

36:25

government managing patient decisions

36:27

and benefits and

36:30

it kind of keeps them out of it . It puts the healthcare

36:32

decision making back in the hands of healthcare

36:34

. I'm not saying the hospice benefit

36:36

is going to go away , but in a situation

36:39

like this where they're preparing to offload

36:41

a lot of that clinical ownership

36:44

to plans

36:46

and or companies or pay viters

36:48

or doctors groups who would manage it , I

36:51

see the carbon is happening again

36:54

. I do . And if you

36:56

just look at like ACO reach , where

36:58

you've got a serious illness population right

37:00

and you've got some primary care people let's say , bloom

37:02

healthcare , the highest performing group

37:05

in ACO reach and look it

37:07

up , they're incredible . They're the people who own

37:09

it . They're amazing people . They're

37:12

a group of geriatricians

37:15

and they said we're going to apply for this . They were in

37:17

the very first part of the serious

37:19

illness portion of this and they

37:21

ended up building their own hospice

37:24

because they really wanted to manage

37:26

the appropriateness of those patients and making

37:29

sure that they get what they need and

37:31

they've done very well with that in terms of links of

37:33

stay , access to the right services

37:35

when they need it and , in the event that they're not

37:37

quite eligible for hospice , they've built programs

37:40

to basically be that glue between

37:42

them and the patients when they're a little bit sicker and have

37:44

higher needs . So

37:46

in those circumstances where the trust fund

37:48

is dwindling , we're seeing more and more pay

37:50

viters that are accountable for people all

37:52

the way through . I see the carbon happening

37:55

. I do Wow . Now

37:57

, on the Medicare Advantage side , this

37:59

is different today . This is more

38:01

about getting ACO . Reach

38:04

is not a Medicare advantage , this is straight

38:06

Medicare . So

38:08

Medicare Advantage . They are wanting

38:10

to get people off of their books as

38:12

soon as possible , into hospice as soon as

38:14

possible if they're high risk and high need , because

38:17

that is a risk to them . So

38:20

in my opinion , that's not

38:22

always a great thing as a and we talked

38:24

about this earlier in the podcast . I just

38:26

don't see . I think the government

38:28

wants to get themselves out of that decision making

38:30

.

38:31

Wow . Well , katie , then just kind

38:33

of prescription to people , because I feel like a

38:35

lot of what you said in the original podcast

38:37

is still applicable . But , listening to you

38:39

, if people go , okay , then what do I do

38:41

as community based hospices ? What's

38:43

your recommendation ?

38:45

Well , I want to recommend something too , and if there are

38:47

any government people listening , I mean , I think

38:49

they might be . There are some of

38:51

these have a demonstration that allows

38:54

hospices to apply independently

38:57

and or create some relationships

38:59

with some of these pay viters and or health

39:02

plans , specifically

39:04

hospices that are not owned by

39:06

the health plans and and

39:08

incented in a perverse way

39:11

. Can we just have some governance and try

39:13

some of that out , something like a hospice

39:15

snip we talked about , or like a larger

39:17

demo that supersedes VBID

39:19

? That's bigger and better . Can

39:21

we not allow the industry to enter

39:24

in that way ? That would be wonderful

39:26

to see that and and allows

39:28

them to put skin in the game

39:31

on the downside of their care along

39:33

with their primary care partners . Like , wouldn't

39:35

that be cool ? Okay , that's there . So

39:38

what does that mean for the hospices ? The prescription

39:40

, though , for them is like prepare

39:42

yourself , make sure that you

39:44

are saving money to

39:47

be able to pay to play in this new

39:49

era of health care . And I mean

39:51

on the downside of your care , further

39:53

upstream , proving that you are getting

39:55

the right people to hospice at the right

39:57

time with the right services and

40:00

, in the event that that means a length of stay

40:02

that's more , like you

40:04

know , 60 to 90 days on hospice

40:07

that you've got upstream products

40:09

that are profitable and also

40:11

are what people need as

40:14

they're going through that transition of functional

40:16

, nutritional and cognitive decline pre-needing

40:19

the hospice benefit , and

40:21

make sure that you can report on how well you're doing

40:23

there , because there's nothing CMI

40:25

likes better than people saying

40:28

we've already practiced this . And here's the outcomes

40:30

of what we've done in these areas and here's partners

40:32

and relationships that we've been building the

40:34

last year in preparation for this . So

40:37

, for example , if there's a pay vider or

40:40

a health system that owns an ACO in your area

40:42

, like thinking of ways that you can really work

40:44

together to take care of patients pre-hospice

40:46

and get them the right amount of hospice

40:48

for the right amount of time .

40:50

Perfect , Katie . Well , Katie , thank you so much for

40:52

coming back and again , to all of our listeners

40:54

, we appreciate this late breaking news . Well

40:57

, to our listeners , I always like to listen with a quote

40:59

that makes us think about what we were listening

41:02

to today , and Katie came up with this one . It's

41:04

actually from May Jamison and

41:06

it says never be limited

41:08

by other people's limited

41:11

imaginations . Thanks , Katie

41:13

. Thanks to our listeners for listening to

41:15

TCN Talks .