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

0:16

believe that brevity signals

0:18

respect . And now

0:20

here's our host , Chris

0:23

Comeaux .

0:24

Hello and welcome to TCN Talks

0:26

. Our guest today is Peter Benjamin . He's a

0:28

well-known consultant . He's also a partner

0:30

with the Huntington Consulting Group . Welcome

0:32

, Peter , it's good to have you back .

0:34

Thank you , Chris . Fabulous to have another chance to chat

0:36

with you and your listeners .

0:38

I always value our time together , but before

0:40

we jump in , what does our audience need to know about you

0:42

?

0:43

I think all of us are the product of our experience

0:45

, so I think it's fair for folks to know the backgrounds

0:47

of speakers

0:50

so they can appreciate where our biases

0:52

may come from . I've spent my entire 45-year career

0:54

in healthcare . Interestingly , that's

0:56

almost an exact mirror of

0:59

the history of hospice

1:01

in the United States . I've spent

1:03

five years full-time engaged in hospice

1:05

in the early 90s and the rest of my

1:07

career anywhere from 20 to 70%

1:10

involved in hospice , and I tell your listeners that

1:12

because I take it some level , I'm an inside-outside

1:15

or an outside-insider . I think

1:17

hospice has played a very important role in

1:19

my career and engaged

1:21

me intellectually like nothing else I've done . But

1:24

I also think I have a perspective from outside

1:26

of hospice , and I think particularly where

1:28

we find ourselves today in

1:30

the hospice world . That's an important perspective .

1:33

That's well 45 years Dang . That's

1:35

why you're so dang wise , I guess . Right

1:37

, I didn't maybe

1:39

didn't pick that up the first time , but that

1:42

feels pretty profound . Well , peter , what I love

1:44

about you is you provoke my thinking . I feel

1:46

like you're a good provocateur . There are probably

1:48

a whole lot of other good adjectives I could use , but

1:50

I do appreciate that about you , because you really do make

1:52

me think and you make me question . Either

1:55

I get down to bedrock of why I really

1:57

believe something , or you make me rethink it . So

1:59

just , that's all my ways of giving you kudos

2:01

. So as I thought about what you

2:04

and I want to talk about today , I just thought it'd be good

2:06

to start Like what's your general advice

2:09

about where things are headed , and then also

2:11

how hospice and powder care programs need

2:13

to position themselves to be relevant and thrive

2:16

into the future .

2:18

I think we're at an inflection point

2:20

as community based hospice providers

2:22

. I don't mean that as

2:25

a parallel to technology

2:28

businesses where a technology comes and

2:30

immediately displaces or antiquates

2:32

something else . I don't mean inflection point as a literal

2:34

, the switch will be flipped kind

2:36

of metaphor . But I think we're going

2:38

through a five or eight year inflection

2:41

point where after

2:43

40 years of a one size fits

2:45

all benefit , the

2:47

market has and

2:49

continues to evolve . When

2:52

I think of the late 70s and the demonstration

2:54

project and I think of congressional

2:57

testimony which I recently reread for

2:59

somebody for some reasons we don't need to get into

3:01

, and when I think of the benefit passing

3:03

in 1983

3:06

, the hospice benefit was designed for

3:09

cancer patients who had caregivers

3:11

and could and wanted to die

3:13

at home . That's an oversimplification , but

3:15

directionally correct . It certainly didn't

3:17

envision people dying in assisted living , because

3:20

no one did . People literally

3:22

didn't even start to die in assisted living

3:24

communities until the early 2000s

3:26

. The original benefit didn't envision people dying

3:29

in nursing facilities . That

3:31

round peg was squeezed into a

3:33

square hole in the late 80s , early 90s

3:35

, and so we find ourselves today

3:37

serving most

3:39

of the folks in the hospice marketplace

3:42

in ways that were not

3:44

designed inside

3:47

the original hospice benefit . Then

3:49

we can talk about how the rest of the healthcare

3:51

world has not just evolved but

3:54

radically transformed itself

3:56

. And so , on the one hand

3:58

, I say to colleagues all the time there's

4:01

never been a better time to die in America

4:03

, because I think people at end of life have

4:06

access to better , more comprehensive , more

4:08

expertly provided , more careingly

4:10

provided , specialized services than ever before

4:13

. But two things

4:15

can be true at the same time . I think he can both be

4:17

the best time to die and

4:19

not good enough . And I'm

4:21

optimistic that disruptive

4:23

innovation provides

4:26

benefit for almost everyone

4:28

and , unfortunately

4:30

, provides potential cataclysm

4:33

for incumbents . But

4:35

incumbent providers are the minority

4:37

. The rest of the society is the majority

4:40

. So disruptive innovation

4:42

has been part of our economy

4:44

, a little less so in healthcare , but

4:46

increasingly so in healthcare . That's

4:49

where I think we are .

4:52

Can you unpack a little bit more about cataclysm

4:54

for incumbents ? What do you mean by that ?

4:57

I think historically , inside

5:00

and outside of healthcare , business

5:03

historians , business school professors

5:05

would without

5:08

emotion stipulate

5:11

that innovation rarely comes from

5:13

incumbents , that's not to say never

5:15

. I didn't say that , I said rarely . And

5:18

again , you can do unemotional

5:20

examples outside of healthcare . We

5:23

can take examples closer to home . It wasn't

5:25

hospitals that pioneered outpatient surgery

5:27

. Oh how shocking . They

5:31

were the ones that were going to be disrupted

5:34

. So they were not in fact the innovators

5:36

and pioneers , and yet you

5:38

barely have to drive a mile or two from your house

5:40

today to find an ambulatory surgery center . And

5:43

I think those kinds of examples

5:46

are instructive for

5:48

us , meaning

5:51

40 year plus hospice

5:54

leaders , and so

5:56

I'm both cautioned by those

5:59

examples and

6:01

enthusiastic about the improvement

6:03

for recipients of care

6:06

from innovators .

6:09

And there's so much . You're being very precise

6:12

with your language . I love it actually , and

6:14

there's so many cool tangents we could go , but I'm gonna

6:16

go with our main line of questioning here . What

6:19

are some of our substitution competitions

6:21

out there for hospice and powder care leaders

6:24

that you feel like , hey , you gotta be aware of

6:26

this .

6:28

I think we have beginning examples

6:30

, so the good news is

6:32

I'll give you some . The better

6:34

news is I don't think

6:37

this chapter has been written yet . So

6:40

I think for our colleagues

6:42

, for hospice leaders around the country

6:44

, the decisions

6:46

are going to be around . Are

6:49

we willing to disrupt ourselves

6:51

? Are we willing to

6:55

think more broadly than perhaps

6:57

we have in the past ? So

7:03

I mentioned a couple of moments

7:05

ago the original hospice

7:07

benefit was not

7:09

written for folks

7:11

that live in let's just call it

7:13

, senior housing , whether that's independent

7:16

living , assisted living , nursing facilities

7:18

, and I think over the next decade

7:20

we're gonna see a real metamorphosis

7:23

in how all care is

7:25

provided there . So this is not a hospice

7:28

end of life thing at all

7:30

. I think we're gonna see , for

7:33

the three to four million people that live in senior

7:35

housing , an explosion in opportunities

7:37

for them to receive more holistic

7:40

, team provided

7:42

, patient-centric care . How

7:44

interesting . I think those are words and phrases

7:47

All our hospice colleagues would use

7:49

to describe what we do , but

7:53

have never really been characteristic

7:55

of how residents of these communities

7:57

receive all their care . And

8:00

so I think , to our credit

8:02

, I'm proud of all the things

8:04

our colleagues have done . I think we

8:06

have instilled in the system a

8:09

sense that

8:11

team , patient and family-centric

8:14

care can have real value , not

8:17

just in the last 60 days of life , maybe

8:20

for longer periods of time . And

8:23

so I think it's gonna be incumbent on us

8:25

, first and foremost , to

8:27

really learn about these

8:29

emerging models of care . What

8:32

does Medicare Advantage really mean ? Why

8:35

are dual-eligible special needs

8:37

plans unique ? Why are institutional special

8:39

needs plans unique ? What can we

8:41

learn from PACE programs ? I

8:44

do a lot of work in PACE and I don't wanna offend my PACE

8:46

colleagues by saying I don't believe that PACE

8:48

programs are quote unquote the solution

8:50

to all Y-Turb care problems , any

8:53

more than I think hospice is the solution to all

8:55

end-of-life care problems . I think in both

8:57

instances , pace providers

8:59

and hospice providers have

9:03

forced

9:06

everyone in

9:08

our adjacent spaces to realize

9:11

that the basic models

9:13

of care we pioneered work . So

9:16

I don't know that regulated PACE will

9:19

be the thing , but I'm pretty confident

9:21

that in 10 years we're

9:23

gonna see a smaller percentage of people

9:26

in nursing facilities , because

9:28

nursing home diversion programs , pace

9:30

programs , pace-lite , pace-lite programs

9:33

are gonna be fundamental to how fully

9:35

integrated , highly integrated DSNPs work

9:38

and succeed , and that's gonna

9:40

be better for the patient , better for their family

9:42

. No one's waking up in either of our

9:44

communities today , chris , and saying , wow , I'm

9:46

really excited about going to the nursing home

9:48

. Okay , that's just not how

9:50

it works . So

9:52

I think it's incumbent on us , first and

9:55

foremost , to learn and

9:57

that's harder than it sounds

9:59

, because for us

10:01

to learn means what does it mean

10:04

to run a delegated risk-taking

10:06

physician group ? What does it mean , circa

10:08

2024 , to be in the oncology

10:10

world ? What does it mean to run nursing

10:12

facilities or CCRCs or assisted

10:14

living communities ? What does it mean

10:17

to be in a multi-specialty practice taking

10:19

delegated risk Boy ? It's

10:21

never been harder to

10:23

be a hospice professional because

10:25

of all this going on around us . And

10:27

if you don't speak their language , then

10:30

you don't know how to solve their problems

10:33

and you're likely to

10:35

simply talk louder about

10:37

what we have , and

10:39

that's not generally effective .

10:42

So two things , because I'm thinking of all of our

10:45

listeners . We do have hospice and powder care

10:47

staff amongst our listeners , peter , and , of course

10:49

, leaders and even now board members . You

10:52

alluded to SNP plans . Can you just

10:54

give a quick little elevator speech

10:56

and give them a snippet on what is a SNP plan ? Sure

10:58

.

11:01

Going back a few decades now

11:03

. Through multiple administrations

11:05

the Department

11:07

of Health and Human Services and the Center

11:09

for Medicare and Medicaid Services has been

11:11

on a mission to

11:13

push could joe persuade

11:16

participants

11:18

in our healthcare system to embrace

11:21

value-based care ? Value-based care is simplistically

11:23

defined as , rather than

11:26

paying folks for what they do meaning

11:28

a fee for service model paying

11:30

folks for outcomes

11:33

and pushing risk onto

11:35

the provider so that they have to both perform

11:37

at an agreed upon level of quality

11:39

and be at risk for that which they do

11:41

, meaning you don't just get to do more , bill more

11:44

, make more . And this evolution

11:46

led by the

11:48

federal government , largely through the Medicare program to

11:51

push . Value-based care created

11:54

most recently was called the Medicare

11:56

Advantage Program , and so when folks turn 65

11:58

or any time thereafter , if they're eligible for

12:00

the Medicare program , they can decide if they

12:02

wanna voluntarily enroll in a

12:05

Medicare Advantage plan . Think

12:07

of it as HMOs meet Medicare

12:10

a little more complicated than that , but

12:12

the premise is that over time

12:14

, if Medicare is

12:16

able to push , could joe

12:18

persuade participants

12:20

in healthcare to embrace value-based , that there will

12:22

be a long-term opportunity to save money as

12:25

the Medicare Advantage Program has grown , much

12:28

like we were just talking about the hospice benefit . The

12:31

folks running it have come to realize , gee

12:33

, the Medicare Advantage Program was one size

12:35

fits all and we were designing

12:37

something for all 66 million Medicare

12:40

eligible's and maybe inside

12:42

that big cohort of folks there's some unique

12:44

cohorts that would benefit from

12:47

specialized programs . And so the

12:49

acronym SNP or Special Needs Plan

12:51

, came through Medicare's experience

12:53

working in this big market of 66

12:56

million folks and responding

12:58

to innovators saying , hey , how about if

13:00

we design a specialized Medicare

13:02

Advantage Program , for example , just

13:04

for folks who live in nursing

13:07

facilities or assisted living

13:09

? And that is the institutional

13:12

special needs plan or the variant

13:14

of it , the institutional equivalent

13:16

or institutional eligible special needs plans

13:18

. So those programs are now serving

13:21

about 130,000 folks

13:23

that live in particular kinds

13:25

of facilities . There's about 12 million

13:28

dual eligible's . So folks who have both

13:30

Medicaid and Medicare and the

13:32

federal government realized , gee , maybe

13:34

just the quote normal off the shelf Medicare

13:36

Advantage Program doesn't work perfectly for

13:38

them . What if we create a mechanism

13:41

where the states can innovate with

13:43

Medicare Advantage Plans and

13:45

be creative in how we take care of those

13:47

12 million folks ? And so I

13:49

think what we're seeing , consistent with our previous conversation

13:52

, is evolution and innovation is

13:54

everywhere in health care and the one size

13:56

fits all model that usually starts things

13:58

. As time passes

14:01

. You usually find itself subject

14:03

to some kind of segmentation model , and that's

14:05

what's happening in Medicare Advantage .

14:07

That's really good , and just use another

14:09

term that they could be hopeful to define a

14:11

delegated physician risk group , and I

14:13

may have butchered exactly how you said it .

14:16

One of the trends over the last

14:18

three

14:20

decades but increasing more

14:24

geometrically than arithmetically over the last

14:26

decade is health

14:28

plans deciding

14:30

that the way they can work best

14:33

with healthcare providers . So

14:35

think of a licensed insurance

14:37

company , whether a Medicare Advantage plan , or a commercial

14:39

insurance company , or a managed

14:41

care organization working with Medicaid . Those

14:44

organizations have concluded gee , the way

14:46

we can best partner with healthcare providers

14:48

is to align

14:50

our financial incentives

14:52

. So if we , the health plan , are

14:55

given a flat amount of money in material

14:57

of the services performed underneath it , then

15:00

maybe the best way to get docs in the same

15:02

boat , with us rowing in the same direction

15:04

, is to align their incentives

15:06

. So I'm just going to make up some numbers to be illustrative

15:08

. So let's say I'm a health plan and I

15:10

get a dollar in healthcare premium

15:13

a month . Historically

15:15

, I then went out and contracted with folks

15:17

on a fee for services basis and

15:19

I then tried to manage how I spent

15:21

my dollar , mindful

15:24

of the fact that if I spent more than a dollar I had

15:26

a problem because that's all I was going to get every

15:28

month . And so the phrase

15:30

delegated risk comes from

15:32

the construct

15:34

of the health plan saying okay , I

15:36

have my dollar and all the risk

15:39

. Delegating

15:41

risk means I , the health plan , am

15:43

going to give you , chris , and

15:45

your physician group , some part

15:47

of that risk . I'm going to delegate

15:50

some part of that risk to you

15:52

. So , for example , if you're

15:54

a primary care group and you have

15:56

a thousand patients that you've become

15:58

the primary care doc for

16:00

, rather than paying you fee for

16:02

service , I may give you six

16:04

cents of my dollar and

16:07

tell you you don't have to bill

16:09

me every time you see that patient , and

16:12

some patients you might see a bunch , and some patients

16:14

you might not see at all , but I'm

16:16

going to give you that six cents every

16:19

month , immaterial of how many visits

16:21

you make . By

16:23

the way , all sorts of crazy things happen during

16:25

COVID that could be a source of a whole other

16:27

conversation , many

16:29

innovative , I mean as horrible

16:31

as COVID has been continues to be

16:33

. I don't want to put any positive

16:36

gloss per se on COVID , but

16:39

there were , as in all crises , some learnings

16:42

and evolutions and creativity

16:45

that came out of it . I think an awful

16:47

lot of physician groups figured out you know

16:49

what , boy , particularly

16:52

during the first 12 months of COVID , it

16:55

sure was good financially to be getting

16:57

a delegated risk payment rather

17:00

than having to figure out how to see patients

17:03

the old fashioned way , and

17:05

if I called them or we did zoom

17:07

, I was getting paid because

17:09

I was taking delegated risk , so

17:11

I wasn't subject to the old model

17:13

. So lots of interesting

17:15

things have happened that we never would have predicted

17:18

were intended Along

17:20

these lines . Humana

17:23

just recently , as in this week

17:25

, announced the expansion of their center

17:27

well program . So Humana continues to aggressively

17:30

employ docs and

17:33

they delegate risk to the docs in their own

17:35

system . United has yet

17:37

to deny this number . The last number

17:39

that United publicly confirmed was that they employed

17:41

70,000 physicians in

17:44

the last 60 days . The number 90,000

17:46

has been thrown around in a bunch of different venues

17:49

by Wall Street folks . Others no

17:51

one has denied the number , so I'm willing to say

17:53

I can't confirm it , but there's at least enough

17:55

data points to suggest that's entirely plausible

17:58

that United now employs 90,000

18:01

doctors , both

18:03

united in Humana . I'm just trying to get the dots , for you

18:05

often will have delegated

18:07

risk contracts with free standing

18:09

physician groups and if they perform

18:12

well , will buy their practice , and

18:15

so delegated risk also becomes a way

18:17

that physician groups can demonstrate how

18:20

they perform if they want to imagine

18:22

a different financial relationship over time

18:24

, like selling a practice .

18:26

Thank you to our TCN Talks sponsor

18:28

, deltacarerx . Deltacarerx

18:31

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18:33

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18:36

leadership immersion courses

18:38

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18:40

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18:46

is a premier vendor of TCN and

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provides not only pharmaceutical care

18:50

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innovations that save their customers

18:55

time , stress and money . Thank

18:57

you , deltacarerx , for all the great

18:59

work you do in the end of life and

19:01

serious illness care .

19:03

This does a masterclass right there , peter , thank

19:06

you . So I think you're painting a beautiful picture

19:08

of there's these disruptive

19:10

innovations we're going to have to evolve

19:12

. You've given us some really good definitions . So

19:14

as people start to think about , okay , what do I do

19:16

about that ? It kind of strikes me

19:19

, do I build , do I buy or

19:21

do I partner ? And my guess is

19:23

and you may come up with a couple other flavors

19:25

but how do you counsel folks like which

19:27

one do I go ? So I don't

19:29

just get paralyzed by these things coming at me

19:32

. And so how would you unpack

19:34

?

19:34

that I'll give you the

19:36

sort of BS consultant

19:38

answer , which is yes

19:40

, you know , which depends

19:43

, of course . But the real answer

19:45

is , on the one hand , every

19:48

client I've ever worked with starts

19:50

a conversation with me by telling me how

19:52

unique their program is and their

19:55

local geography is . And

19:57

I try early in our relationship

19:59

to come to agreement about that , because

20:03

we actually agree in principle

20:05

and generally disagree as

20:07

to the math . In other words

20:09

, when I push a prospective client , they'll

20:11

tell me well , 80% of our

20:14

organization and market is unique and 20%

20:16

is like everybody else . And I push

20:18

back and say well , I think 80%

20:21

of your organization and market is like everybody

20:23

else and 20% is different . The

20:26

reason I'm teasing that out is because

20:29

, of course , local matters

20:31

period hard stop . But

20:34

in delegating risk taking group , a

20:36

multi-specialty group , an oncology group

20:39

, a senior housing owner operator , the

20:41

principles of how they operate their business

20:43

are identical market to market . The

20:45

local situations vary immeasurably

20:47

. There can be five health systems in a market

20:50

or one . That creates a very different competitive dynamic

20:52

, but the business model of the health system

20:54

or hospitals is the same . So

20:57

I think the first step , chris , is our

20:59

colleagues have to simply

21:01

understand the business models

21:04

of our health care colleagues

21:06

better . That means our

21:08

hospice can't engage with

21:10

the now hundred person delegated

21:13

, risk taking multi-specialty specialty practice

21:15

down the street by simply saying I'm

21:17

here , do you have any hospice referrals ? We

21:20

need to know what's the actual

21:23

strategy of that group . We need to know the

21:25

business manager as well as the person

21:27

who handles hospice referrals . We

21:29

need to understand their contracts with payers

21:32

. That's often a very different set

21:34

of interactions . It may or may not

21:36

fit the competence of the person we currently

21:38

have relationship managing that

21:40

organization . It may involve the

21:43

CEO , it may involve a board member

21:45

. It's a complicated map but

21:48

as our referral sources and business

21:50

partners businesses have evolved and become

21:52

more complicated , we're behind . We

21:55

I'm judging . My experience

21:57

is our colleagues don't

22:00

understand where our customers

22:02

are as well as they did 10 , 20

22:04

, 30 years ago . So I think this

22:07

construct of do I buy , build , partner

22:09

starts with I have to understand my local market

22:11

and , yes , every local market

22:14

is different . But the business model

22:16

of these entities is not different

22:18

and so you're not starting from

22:20

scratch . Whether you're in Asheville or

22:22

Charlotte or Raleigh , you

22:24

bet the local markets matter , but

22:27

I think we sometimes get a little

22:29

more wrapped around the axle of that than

22:32

we need to , then I think you can find

22:34

. Well , what

22:38

does it look like in your market ? Are there

22:40

D-Ships now ? Are they coordination only

22:42

or highly integrated or fully integrated

22:45

? What does the institutional special needs

22:47

market look like ? And

22:49

we may or may not be able to own

22:51

interests in any of those businesses

22:54

? But I don't think we're gonna have a clue

22:56

what makes sense until we fully

22:58

understand who the incumbents are

23:00

. In our geography

23:03

and adjacent geographies

23:05

the insurance market tends to

23:07

be very state-oriented

23:09

. So if I saw that

23:11

, for example , there was a new health plan that

23:13

was doing ISNIP and DSNIP in

23:15

Charlotte and Raleigh , I'd

23:18

be pretty confident that wasn't their end

23:20

game . I'd be pretty confident

23:23

they were gonna look at expanding throughout

23:25

the state . And so , again

23:28

, when we define our market as

23:30

a hospice , particularly ones with CLN

23:32

or CON histories , we tend

23:34

to think about county

23:36

zip codes , the way we've been regulated

23:38

. We have to think differently

23:40

when we look at our customers and how they look

23:42

at geography and maps and their business

23:44

model .

23:47

That's really good . Well , and I thought

23:49

about asking you this question , and I think it's even

23:51

even think is a better question even now , because

23:54

I think you have such a unique purview , peter . So

23:56

if you had a loved one that needed

23:58

some type of serious illness , care let's say it's a

24:00

very close family member knowing

24:03

what you know , how and where would

24:05

you steer them ?

24:06

First of all , that's not a hypothetical question . I

24:10

get a call like that at least

24:12

every month . My wife gets at least

24:14

another call like that every month . That

24:16

would be a slow month , I

24:18

think you know my wife , who's now mostly

24:20

retired , was the

24:22

co-author of Five Wishes and has the Long History and Advanced

24:25

Care Planning . So between us we get those

24:27

calls . So

24:29

the first question we ask is to try and

24:31

understand just where our friend

24:34

family member colleague is , because

24:37

three months , six months terminal

24:39

is a lot different than gee . I think

24:41

my mom really

24:43

is in the last chapter , but I think she needs

24:46

to go to a nursing home . That's different than

24:48

a three to six month terminal conversation

24:50

and this is only awkward because

24:52

both of those are

24:54

terminally ill folks . I

24:57

mean , if you're ready to go to the nursing home , the macro

24:59

data says you have two to three years to

25:01

live . That's

25:03

just the macro data . Now you might live 10 years and you

25:05

might live 30 days . But again , I can only deal

25:07

on the aggregate data . But I'm just trying to

25:10

tease out my reply to your question because if my

25:12

wife and I come to the conclusion that

25:14

there's a chance you

25:17

are hospice eligible , we have

25:19

our own kind of screening tool

25:21

that we use , and 75-ish

25:26

percent , I think , maybe even more , maybe

25:28

85% of the time . That ends up with

25:30

us doing the six

25:32

degrees of separation and calling

25:35

Chris Coma or calling you

25:38

pick the person in our broad , extended

25:40

network . But that means 85-ish percent

25:42

of the time . My wife and I conclude a nonprofit

25:44

, community-based hospice is the best

25:46

organization

25:49

to take care of our friend family colleague , and

25:51

the reason we come to that conclusion has nothing to do with

25:53

tax status . It has to

25:55

do with we believe that the first

25:57

four levels of care matter . So it's hard

25:59

for me to get excited about working with an organization

26:02

that doesn't

26:05

do all four levels of care . There's

26:08

lots of good reasons why patients are discharged

26:10

alive , but if a hospice discharges 80%

26:13

of its patients alive every year , that sort

26:15

of hits my trigger around

26:17

. They're not gonna be on the top

26:19

of my list . I'd

26:22

like to see , frankly , a bigger rather than

26:24

smaller hospice , because I'd like to see that they employ

26:26

at least some of their own docs

26:28

. I like to believe that if four patients call

26:31

on Friday night , they have enough nurses that they can

26:33

see all four . So

26:35

maybe it'd be a whole other conversation

26:37

one day . I could sort of share our family

26:40

evaluation tool we

26:42

do that .

26:43

That's actually a great idea .

26:44

The bottom line is it's not perfect

26:46

, and you and I have kidded about this before

26:48

. It's not perfect because I don't think we

26:51

the hospice movement now market

26:53

have done a good job in identifying quality

26:55

metrics . So I'm subject to what's

26:57

publicly available . I can only look at CAP scores

26:59

or HIS scores or these other implied

27:01

statistical measures like

27:03

discharge , alive percent , four levels

27:06

of care , et cetera . I

27:08

can identify if the hospice

27:10

has a physician group and provide supportive

27:13

care outside the hospice benefit . That usually also

27:15

gets a checkbox , because all

27:17

sorts of things could happen in terms of whether

27:20

my friend , one colleague , is literally hospice

27:22

appropriate that day . So that's not

27:24

a hypothetical for me and

27:26

frankly I think it's a great role

27:29

play for hospice

27:31

leaders , meaning I think it'd be a

27:33

great for you and your senior team

27:35

to go through the exercise of hey , if we all

27:38

got a call from a loved

27:40

one in Seattle , los Angeles , las Vegas

27:42

, how would we decide

27:44

who to steer them to ? That

27:47

would be a hell of an exercise for

27:49

a senior team to do .

27:52

When we go in and extend the play . I want to tell you about a really

27:54

cool project I got to work on several years back

27:57

. It occurred to me when you were talking

27:59

earlier to Peter senior living

28:01

is going to become more and more place

28:04

of Dull Messiah

28:07

and so do

28:09

you believe that ? Do you think it's going to become a lot

28:11

more important for a hospice and powder care

28:13

leader going forward and why and maybe what they need

28:15

to be aware of related to that ?

28:18

Yes . Have I ever answered

28:20

a question that simplistically ? Tell

28:24

me more . I think that's

28:26

a perfect example of the research

28:29

that our colleagues

28:31

need to be doing in their local communities

28:33

. Because , well

28:36

, give me an example . I first

28:38

started looking at what

28:41

we now consensually

28:43

call the death service ratio in the early

28:45

1990s

28:47

. There was no internet . There was no way

28:49

to get Medicare claims data . These

28:51

were Freedom of Information Act requests

28:54

to the CDC and to Medicare to try

28:56

to get data about how

28:58

many people were using hospice and what

29:00

all that looked like . So I've been looking at that

29:02

data for 30 years . I

29:06

mentioned in a slightly different context . If you

29:08

go back to the early 90s . First

29:10

of all , death service ratio was 7% , 8%

29:12

aggregate . Now it's 50%

29:15

. It

29:17

was zero in assisted living because

29:19

no one died there . It

29:22

was significantly lower than it is

29:24

today in long-term care because you hadn't

29:26

seen the proliferation of for-profit

29:28

hospices until a half a decade

29:30

, a decade later . That really stimulated

29:32

that business . I'm

29:34

boring you with this , because the senior housing

29:37

market has evolved in

29:39

ways that we

29:42

sort of know and

29:44

recognize but

29:46

don't . So , as

29:49

an example , the originators of assisted living

29:51

were organizations like Hyatt and Mariah

29:53

. This was going to be a hospitality

29:55

play . This wasn't a healthcare

29:58

thing and

30:00

you could imagine there was a whole bunch of smart people way

30:02

back when that thought there'd be a risk-carlford , a Mariah

30:04

, a residence in an

30:07

assisted living building . Well

30:09

, it didn't exactly work out that way because

30:11

hospitality folks realized that as this became

30:14

healthcare that wasn't

30:16

for them . Over

30:21

the last 30 years we went from

30:23

hospice deaths only

30:25

occurring in nursing homes , not at all in assisted

30:28

living , to in much

30:30

of the country today that's 50-50

30:32

. And I just

30:35

looked at a few counties for some clients

30:37

in the last week where it was five

30:39

to one assisted living . Right

30:42

, tell me more . Five to one there were five

30:44

times as many hospice patients in

30:47

assisted living as in nursing

30:49

facilities , wow . So

30:52

the range county to county

30:54

is extraordinary and

30:57

there's lots of reasons for that , and

31:01

the analysis sort of template is

31:03

uniform back to 80-20 , local

31:05

, national . But every community is

31:07

in a different place in terms of that evolution

31:10

, and so I think doing

31:12

a local map of exactly

31:15

what's going on in senior housing is

31:17

not something most of my clients have or

31:19

have done . It's

31:22

, again , more daunting than it sounds , you and I bantering

31:24

on a podcast . It's a real piece of work

31:26

. It's not so easy

31:29

to understand who

31:31

the owners of all these buildings are

31:33

, because the owners of the buildings are oftentimes

31:35

not the ones who run it and the management

31:37

company is different than the real estate investment

31:39

trust . Well , this

31:42

is our future , chris . And a

31:44

lot of my colleagues don't like it because they say that's

31:46

not hospice . I don't want to do that . Okay

31:49

, I don't know what to tell you . You

31:52

either have to keep up with

31:54

our customers or fall behind

31:57

. And so again I'm a little fearful , sometimes

31:59

a lot fearful that we're falling

32:01

behind in understanding the

32:04

evolving business models of our customers

32:06

because there are specialized

32:08

ACOs that deal with law and

32:10

term care facilities . They're specialized

32:13

reach pro , both MSSP and

32:15

reach ACOs that focus there . We've

32:17

talked a little about institutional special needs plans

32:19

. The evolution of who's going

32:21

to employ the doctors and MPs that go

32:23

into that set of buildings as evolving

32:26

and influx . So kind

32:29

of goes back to I think we're in this seven

32:31

to 15 year inflection point , but

32:35

with potential cataclysmic results

32:37

for folks who don't

32:40

want to change .

32:42

Well , and that's . You just made me smile

32:44

. That's why your friend Mark Cohen and I

32:46

do our monthly podcast

32:48

of the top news stories , of kind of our way to

32:50

just say hey , here's intelligence gathering

32:53

, there's a lot of stuff coming because you're so right . Well , peter , this is a {\an2 Lősстаточно

32:55

fantastic stage . It's always just a photograph of your policy based on what you've laid out before

32:57

you're resuming it of question . I really want to ask

32:59

you and so you and I were joking about

33:01

our gray hair , our wisdom

33:03

you have a little bit more wisdom than I do . Actually , I have

33:05

a whole lot more wisdom than I do . But if you were

33:08

a young Peter Benjamin coming

33:10

into healthcare but you happen

33:12

to know what wise Peter Benjamin

33:14

knows where would you advise that young

33:16

Peter Benjamin to go make a difference ?

33:19

I think about that a lot because in

33:22

some ways it's

33:25

the question I ask myself . Thinking about

33:27

retirement . I think to myself

33:29

, boy , if I'm going to work for a limited

33:31

period of time , what's the most

33:34

exciting place to

33:36

do that ? And so it's

33:38

not so much a speculative question

33:40

to me and the

33:43

answer I would give someone in their 20s kind

33:45

of matches the decision I've made for myself

33:47

in terms of I've

33:49

never had greater reward

33:52

than working in the

33:54

broad end of life care area

33:57

, Because I think that the difference

34:00

you make for people in their families is profound

34:03

. It's not to minimize what else you can do in healthcare

34:05

and the reward you can get . But I'm speaking personally

34:07

, selfishly , and

34:09

as I said at the outset , I

34:11

think we're in this sort of amazing

34:13

extended year

34:16

inflection point , and so I think

34:18

if someone in

34:20

their 20s can identify

34:23

an organization that

34:25

, for example , has

34:28

historical roots in a

34:30

community and

34:33

either already has or is evidencing

34:36

not by what they say but what they

34:38

do the

34:41

ability and risk orientation to

34:43

move from , for example

34:45

, being a

34:47

hospice provider to also

34:50

owning a frail elder physician practice or

34:52

being in an ACO or

34:54

having a PACE program or being a partner in

34:56

a PACE program or participating

34:58

in an ISNIP or having a strategic

35:00

relationship with an ISNIP . If they

35:02

can find an organization that they think has

35:08

a fighting chance to come out the

35:10

other end of this inflection point , I

35:14

think they'll have as rewarding a career as

35:16

I've had . And if we

35:18

can't find folks who want to do that

35:20

, then

35:23

I think we'll be the worst , because

35:26

organizations like yours need to be able to attract

35:28

those folks and we need to be

35:30

able to not just tell them

35:32

what we've done but

35:34

what we're going to do . And

35:36

if what we're going to do only sounds

35:38

like what we've done , a

35:41

whole bunch of those young people aren't coming

35:43

, and

35:45

I think that's on us . I

35:47

don't want to shamelessly

35:50

plug your book or some of your work , and you

35:52

didn't ask me to , so I

35:54

can say that openly and honestly but

35:57

I think the leadership

35:59

challenges of the moment

36:02

are greater than they've

36:04

ever been in our line of

36:06

work , because I think leadership is

36:09

most tested in times of change . I've

36:13

kiddingly said to folks I can say it with enough

36:15

gray air closer to retirement

36:17

, I'm as guilty as any number of my colleagues

36:19

that thought we were geniuses when we had tailwind

36:22

.

36:24

I've never put it that way , but I've said it in a different

36:27

way .

36:27

That is so good and you only really

36:30

realize how smart you are or how

36:32

good a runner you are when there's

36:34

headwind , and I think

36:36

, through no fault of our own per

36:38

se . Markets evolve and

36:40

change , and traditional hospice

36:43

now , I think , only has headwind

36:45

to look forward to , and

36:48

so either we find some related

36:50

, adjacent opportunities with some tailwind

36:52

or we suffer the consequence

36:54

of headwind , and that's partly

36:57

a market phenomenon . But I'm more

36:59

optimistic than that . I think that's on us

37:01

, and I think that the idea

37:03

of leadership starts with

37:06

helping people see

37:09

differently , helping

37:11

people role play what their

37:13

customers and competitors are

37:15

imagining , and

37:18

so I think that the

37:20

emphasis that you've

37:22

chosen to place on leadership is

37:24

prescient and current , and

37:27

be careful

37:29

what you wish for . Which

37:32

is going to get to our quotes in a second

37:34

.

37:35

That was awesome , Peter . Well , any final thoughts

37:37

to close this .

37:40

First seek understanding . I think a

37:42

lot of our colleagues are fast

37:45

to judge and

37:48

a little slow to take a deep breath and really

37:50

try to understand what's

37:52

going on all around us , at

37:55

attempt , with good leaders

37:57

, encouraging them , supporting them , holding

37:59

them up . Do the role

38:01

play . If I got hired

38:04

by an ISNIP and that's how you were going to have

38:06

to make a living , what would you do If

38:09

you got hired by a PACE program and that's

38:11

how you were going to have to make a living ? What

38:13

would you do ? Because I

38:15

think in many instances we'll

38:18

learn from that forced exercise

38:21

and we'll be the better for it .

38:24

That's well said . Well , Peter , thank you , and

38:26

Peter and I . So I chose a quote and you

38:28

chose a quote , so I'm going to . So Peter's quote

38:30

will be first and then mine , and actually I

38:33

think is a great way to end this show . So

38:35

Peter's is from a senior business leader

38:37

, executive at American Express . When

38:40

you want something in the worst way , that's

38:42

how you're likely to get it . And then

38:45

mine was from George Loyce . Creativity

38:48

can solve almost any problem . The

38:50

creative act , the defeat of habit

38:52

by originality , overcomes

38:55

everything . Thanks for listening

38:57

to TCNt alks .