0:00

Hello and welcome to TCN Talks . I'm

0:02

excited about today's show . Our guest

0:05

today is Carla Davis . She's a senior

0:07

vice president of Hospice and Powder Care Operations

0:09

and business development for LHC

0:12

Group . Welcome , Carla .

0:14

Thanks , Chris , i'm looking forward to it .

0:16

I'm looking forward to it as well . I've been a fan

0:18

for a long time . I haven't been stalking you

0:20

, but I've been a fan . I

0:23

just remember the first time I heard Andrew Reed talk

0:25

about you and I'm like I want to meet this Carla , and

0:28

I've said for years I think you're probably

0:30

one of the two smartest people in our industry

0:32

, and I

0:34

met you at the NHPCO conference

0:37

many years ago . It was at Wild Horse

0:39

Pass . It was the one that Jim Collins was at

0:41

and made such a great impression

0:43

on me . You lived up to all the expectations

0:45

. It feels like our past has been crossing in

0:47

interesting ways . I remember

0:49

hearing the story about when Dave

0:52

Reem and Caroline Kasin discovered

0:54

you . Maybe

0:57

you might weave that story in .

0:59

Out of proportion , i think , over the years

1:01

. The funny story about Andrew Reed

1:03

is I first

1:05

, my first job out of college was working at Medicare

1:08

, and on

1:10

the desk were a stack of the Medicare

1:12

regulations , right , but on top of the Medicare

1:15

regulations was a note from my predecessor

1:17

And she said if you have any

1:19

questions , call Andrew Reed .

1:22

Oh , that's too cool Yeah

1:24

that's too cool . And

1:27

you , of course , ended up taking

1:29

over a hospice where I was a coach for a while

1:31

, fell in love with the wonderful

1:33

people based out of Lafayette , Louisiana , hard

1:36

of hospice there , and I know you did a phenomenal

1:39

job with them . So again , i feel like our past has

1:41

crossed in multiple ways , but we've never really

1:43

spent much time together , so I'm super

1:45

excited about today . So let's just start with first , what

1:47

does our audience need to know about you ?

1:49

Well , i have been in hospice

1:51

all of my life . So I went to

1:53

Davidson College in North Carolina

1:56

, right down the street from you , and

1:58

this was around 1990 when

2:00

Bill Clinton was running for president

2:02

, and I was in this class on

2:05

rationing medical care And

2:08

I learned at that time that we were

2:10

spending about a third

2:12

of our Medicare dollars in the last

2:14

year of life , and most of that in the

2:16

last few months of life . And I think this is kind

2:18

of relevant to this conversation because that's

2:20

where I started And

2:23

I didn't know that hospice existed

2:26

, but I knew people were dying these miserable

2:28

deaths behind curtains and hospitals , and

2:30

so I decided I'd write my paper for that class

2:33

on end of life care and basically how this

2:35

could be the solution to this impending health

2:37

care crisis that we had . And

2:40

I remember typing into the

2:42

card catalog thing because "the Google

2:44

, as my mom calls it , did not exist at the

2:47

time And you

2:49

typed in things and then out popped

2:51

on the printer with the holes

2:53

on the side , the paper , you know

2:56

all the articles and books and things about

2:59

end of life care and health care cost

3:01

, and of course all of

3:03

them were about hospice . This is even in 1990

3:06

. And so I took all of these things home and

3:08

for Thanksgiving break and I learned

3:11

about hospice And I can tell you

3:13

where I was sitting and I feel

3:15

like I had a calling at that point to

3:17

help people at the end of their life . I knew

3:19

that this was part of our solution to our health

3:21

care crisis , but it was also just the right thing

3:23

for people . So that's when I was

3:25

19 . I ended up

3:27

writing my creating my own major

3:30

in medical ethics and focus specifically

3:32

on how the American health care system should change

3:35

to better integrate the hospice philosophy , which

3:37

is sort of nerdy when you're 19 and 20

3:39

to focus on

3:42

end of life care at that time . But I just , i

3:44

just knew , and never

3:46

in a million years would I have guessed

3:48

that God would have had me on the

3:50

path that I have been on . But

3:53

I feel really blessed to be where

3:55

I am now and helping to lead

3:57

LHCs , hospice and palliative care

3:59

and help more people , because that's what

4:02

it's all about .

4:03

Wow , that's awesome And that I learned some

4:05

stuff I didn't know there Carla . I , didn't know

4:07

about the Davidson connection . That's actually really cool .

4:10

We did more than Steph Curry .

4:15

So talk a little bit more about the seat that you're in now

4:17

. You're now part of one of the few vertically integrated

4:19

health systems and really the largest

4:21

one in America . So maybe what are some of the positives

4:24

and maybe some of the challenges ?

4:27

Yeah Well , just to orient the audience a little bit

4:29

, lhc has been

4:31

a part of and building really

4:34

a vertically integrated care

4:36

continuum in the home for

4:38

25 years , starting in 1994

4:42

with Home Health and 1998 with Hospice

4:44

, home and Community-Based Services

4:46

and other services sort of complimentary . But

4:49

in March of this year we

4:51

were purchased by Optum

4:53

Health Services And

4:55

so just at this point we're just in the beginning

4:58

stages of trying to

5:00

integrate in . I mean , i'm excited

5:03

about it because we are in a position

5:05

to be able to create really

5:07

the most comprehensive suite

5:10

of services to wrap around

5:12

the beneficiaries that

5:15

are aging in our country and

5:18

to help shepherd them through

5:21

whatever needs they

5:23

have as they wax and

5:25

as they wane , and especially

5:27

people that are living with serious

5:29

illness . It's exciting to

5:31

me to be a part of a

5:33

payer organization because

5:36

I think that will allow us to

5:38

innovate and to

5:41

change and figure out what

5:43

the care delivery model needs to

5:45

look like and

5:47

not just improve the

5:50

quality but also

5:53

come up with solutions to knock down

5:55

barriers to people getting the right

5:57

care at the end of life And I don't know

5:59

that it's going to look like it does

6:01

today And I quite frankly hope

6:03

that it doesn't But

6:06

to kind of get to the challenges

6:08

, i think you know , and just

6:10

even in my career , i started

6:13

after Medicare . I worked

6:15

for what is now Kindred

6:17

well , argentina whatever

6:20

the name is now But at that time it was nursing

6:22

homes and LTCHs and also

6:24

Home Health and Hospice . And

6:27

I've also worked for HCR or Medicare

6:29

, which of course is a large post-acute

6:32

healthcare continuum and just

6:35

because you are inadvertently

6:38

integrated continuum

6:40

doesn't make it function that way right

6:42

. And I think today

6:45

in America , unfortunately

6:47

, you know , reimbursement tends to

6:49

drive us to

6:52

be relatively siloed , and I think that's

6:54

what we're all trying to solve , for I

6:56

mean , we all want the patient to get the right

6:58

care at the right time

7:00

, but the structure of the

7:02

way that we're reimbursed , you know , isn't

7:05

all the incentives are aligned . So

7:07

that's why I'm honestly thrilled about

7:09

this opt-in

7:12

purchasing us , because I think that we are

7:14

in a place that we can really figure

7:17

out what it needs to look like to transform

7:19

end-of-life care , and

7:21

I'm not naive enough to think that it's not

7:23

going to be a lot of work . And we're going to mess

7:25

up and we're going to have to figure some things

7:28

out , because to really change

7:30

end-of-life care we have to change

7:33

ourselves , and

7:35

so what that looks like I don't know , but I'm excited

7:37

to be a part of helping figure it out .

7:40

Well , i'm excited for you to be in that role as well

7:42

. I've said for years I've

7:44

watched LHC Group , because I don't know if you

7:46

know this so I grew up in Appalachus , louisiana

7:49

, which was the Oh my gosh , I didn't

7:51

. Yeah , so you know the connection then

7:53

, because that's where Key started . Really . LHC

7:55

Group is really that think it was that Doctors' Hospital

7:58

Home Health Program , something like that . So

8:00

a lot of interesting kind of connections to that

8:02

. So I've said for years

8:04

gosh , if they get an incredible leader , it'd be

8:06

really interesting to see what someone does with that platform

8:09

. So I think you found yourself in an

8:11

amazing position to shape what the future looks

8:13

like .

8:14

Yeah , I'm very excited .

8:15

Well , let's talk about some really

8:17

good common ground , which is the NORC

8:20

study , and you're on

8:23

the board for HPCO , is that right , carla ?

8:25

I am .

8:26

So talk so that study has been huge

8:28

. I'm a huge Don Taylor fan . You

8:30

probably remember before the NORC

8:32

study . That's the last thing that we've really had to say

8:35

data . We know Hospice Saves

8:37

Money because of this wonderful study

8:39

. So talk to me about the study . What

8:41

have you kind of taken away from it ? Have you

8:43

utilized it ? Anything

8:45

along those lines ?

8:47

Well , i think it's one of the most comprehensive

8:50

studies , looking at the

8:52

claims data for all of the

8:54

Medicare decedents in 2019

8:58

. So I think it is

9:00

one of the most

9:02

comprehensive studies And

9:04

it shows what I think we all

9:07

know is that

9:09

the problem isn't that people are getting

9:11

too much care too

9:13

early . They're getting referred to Hospice

9:15

too early . It's that

9:17

they're getting referred to later not at all

9:19

. And it proved certainly

9:22

cost savings 3.1%

9:24

, which was about three and a half billion dollars

9:26

, compared to people that were

9:28

end of life that did not access the hospice

9:31

benefit . I really think

9:33

those estimates are incredibly low , because

9:35

what it also proved two

9:38

sides of the coin that I think were

9:41

maybe surprising to some

9:43

people although I think not most

9:45

of us that have been in this work for a long time

9:47

And the first side is that

9:50

the patients that actually

9:52

cost Medicare more

9:54

money than

9:57

anything are the patients that are in the

9:59

last two weeks of life , really the last 10

10:01

days of life . In fact , the line is

10:03

really a day between day 10 and

10:05

day 11 . And yet

10:07

25% of the people we see

10:10

die in five days are less

10:12

. So we have those

10:14

patients deserve care They deserve

10:17

. of course , we're going to serve them , even

10:19

though we are referred an actively dying

10:21

patient And we're going to move with

10:24

expediency to help take care of them

10:26

. but they are expensive

10:28

to hospices , they are expensive to

10:30

the system that that patient

10:32

. if that patient had gotten access to care

10:35

earlier , they would have had

10:37

a better experience . They would have been

10:39

with the people that they love , comfortable

10:42

, not not

10:44

in the ICU . you know spending

10:46

all of these resources , but we also would

10:48

have saved Medicare money . So

10:50

I think it you know the front side

10:52

of things the only patients that

10:54

were proven to actually cost the system

10:57

more were the patients that

10:59

that live less than a couple of weeks and

11:01

really less than 11 days . And

11:03

on the flip side of that , what I think was

11:05

really interesting is

11:07

that even for the patients who live

11:10

greater than six months , regardless

11:13

of diagnostic category which I think

11:15

shocked a lot of people , including

11:17

, you know , neurology , respiratory

11:20

and all of them they

11:22

, those patients also saved Medicare

11:25

money , in fact 11% . So so

11:27

I think that the sort of the

11:29

position that MedPAC has

11:32

taken historically over the

11:34

last few years and concerns

11:36

about patients living too long

11:38

and abuse in the system and we'll kind of get into this

11:40

in the next article as well . But really

11:44

the problem is get more people care that

11:46

are facing end of life and get it to them earlier

11:49

. And we know that , like

11:51

we know that when we talk to patients and families

11:53

. they are so

11:56

relieved to

11:58

actually have someone coordinating

12:00

this discombobulated healthcare system

12:02

that we live in And to have

12:04

everything centered around them

12:06

to be patient centered , to really

12:09

be patient centered , and to have all of

12:11

the support and resources that hospice

12:13

provides in the comfort of their home . But

12:16

they're almost angry sometimes

12:18

when they wish

12:21

they'd known about it sooner .

12:22

Like why ?

12:24

did someone not let us know sooner ? So

12:27

I think it

12:29

proved what we know . But

12:32

it is the definitely

12:34

the most current and most comprehensive

12:36

research based off the claims

12:38

data . So in terms of how we

12:41

should use it and how I'm

12:43

using it right now within our

12:45

organization , so

12:47

just , i think , first of all , it has incredible

12:50

policy implications with

12:52

Congress

12:55

, certainly with MedPAC too

12:58

, and anybody who's in a position

13:00

to influence policy

13:03

and influence the

13:05

future of our reimbursement rates . Certainly

13:08

this is in the context of MedPAC recommending

13:11

, over a period of years , a significant reduction

13:13

in our reimbursement

13:15

rate At the same time that we all

13:17

experienced all of the inflation through

13:21

COVID , you know where

13:23

not only are nurses more

13:25

expensive and social workers more expensive

13:28

and physicians more expensive , but mileage

13:30

is more expensive , dme is more expensive

13:32

, all of the things

13:34

. So I think it puts that

13:36

declaration

13:40

that MedPAC and others have been

13:42

concerned about . It puts it

13:44

in perspective Like we're focused

13:46

on the wrong thing here

13:48

We need to focus together on

13:50

how to get more people this care

13:52

, not how to , you

13:55

know , to cut the hospices and

13:58

basically and send them to serve

14:00

less people . So I think

14:02

it's a really , really powerful statement

14:04

. We're also using it organizationally

14:07

in our communities . We've developed educational

14:10

tools using all of the

14:12

materials from the study that NOC

14:14

and HPCO sponsored Both

14:17

of them co-sponsored it which I think also

14:19

is a great step forward

14:21

for the industry to work together on

14:23

this kind of thing , and

14:26

we're using it to educate people

14:29

in our communities , whether those are more

14:32

regional health plans , whether those

14:34

are ACOs certainly

14:37

health systems And I think

14:39

physicians care about this too . You

14:41

know , periodically you'll hear

14:43

physicians talk about the . You

14:45

know they read something somewhere about the expensive

14:47

hospice And I think this is really

14:49

really helpful for them

14:51

to understand that in fact , the

14:53

opposite . So we

14:56

do follow up on all referrals with

14:58

our referral sources , including physicians

15:00

, and if

15:03

that referral source or if that physician referred

15:05

a patient that either died

15:07

before we were able to get them

15:10

care , despite how fast

15:12

we moved , or , you

15:14

know , died within the first month , we

15:16

try to follow up very specifically to

15:19

help provide education about how together

15:21

, we could have identified this patient earlier And

15:24

I think this study and again

15:27

, we're just starting to use it now , but I think

15:29

this study will be a helpful part of that conversation

15:31

.

15:32

That's great , carla . Well , carla , there's another

15:34

study , and actually I want to give Craig Jeffries

15:37

with Compass's credit He's the one who brought it to my attention

15:39

The abbreviations

15:42

the Niber study , the M-B-E-R

15:45

study , and Jonathan Gruber

15:47

is one of the main authors on that

15:49

paper . I don't think it's kind of hit like national

15:52

press yet , so it's not in everybody's

15:54

hands . Trying to see what Niber

15:56

stands for National

15:58

Bureau of . Economic Research

16:00

. There you go , so , if you

16:03

had a chance to take a look at it , and what were your impressions

16:05

from it .

16:06

I did . I did not read all 75

16:08

pages .

16:09

Me neither , in all honesty .

16:11

In all honesty , so just for

16:13

the audience who may not be as familiar with it

16:15

, it was focused on

16:18

patients with Alzheimer's disease and related

16:20

dementia , with the hypothesis

16:22

that those patients are

16:25

more profitable and , with the rise

16:27

of for-profits over the last

16:30

15 , 20 years in

16:32

America , that they're incented

16:34

to serve these patients disproportionately

16:38

and that that's potentially bad

16:40

for the Medicare system . And

16:43

, in fact , what it proved was opposite

16:45

that even

16:47

these patients these patients who

16:49

tend to have a maybe

16:52

a longer length of stay and therefore maybe

16:55

more profitable even these

16:57

patients save Medicare

17:00

money , and it really is

17:02

both primarily

17:05

cost avoidance , like nursing facilities

17:07

, home health , pharmaceuticals

17:10

, of course , hospitalizations , and

17:12

so the article goes on

17:14

and I think it probably didn't get

17:17

as much traction because it wasn't peer

17:19

reviewed in terms

17:21

of that category

17:23

But it even

17:25

goes on to really kind of

17:27

assert that

17:31

the policy issues that are

17:33

going after

17:35

the potentially longer

17:37

length of stay patients , like Medicare

17:40

caps or any kind of antifraud

17:42

lawsuits or those kinds of things

17:44

those have an inadvertent impact

17:46

or could have an inadvertent

17:49

impact on restricting access , and

17:51

even if a patient lives longer

17:53

than six months with Alzheimer's , they

17:57

still save the system money . So

18:01

I looked at the 2020

18:03

data , which , of course is the last data and of course , is a

18:05

little bit skewed because of what we were all dealing with

18:08

in 2020 . But

18:12

the average length of stay , even for that Alzheimer's category

18:16

of patients , was 143 days And

18:19

the median length of stay was 56 days . So certainly

18:21

, where there's a few patients that

18:26

live longer , definitely . But

18:28

even with it , it saves Medicare

18:31

money . And when

18:34

hospice behavior , because

18:36

of all of the

18:39

either the cap or

18:41

government regulation targeting

18:43

the nickels rates or whatever it is , when

18:45

that behavior starts to create a pendulum swing

18:47

such that we start to restrict access

18:49

because we're so fearful

18:52

to take a risk on a patient who looks like they're dying but

18:54

may not be checking

18:56

all of the boxes , it

18:59

ends up actually costing

19:01

the government money . So

19:04

to me , to put these two important

19:07

pieces of research together and

19:10

for them to come out in

19:12

the earlier part of 2023 together

19:14

really does say something very

19:17

strong , and

19:19

we need to sort of shout it from the mountaintops

19:21

to make sure that all of

19:23

our regulators , including

19:26

the max , understand

19:28

it , because they have the way

19:30

that they've been doing things for a long time

19:33

And I think that , because

19:35

they laid off during COVID , they're definitely

19:37

in full force now trying

19:39

to catch up for all of that

19:42

downtime . But

19:44

we need to certainly get the message out And

19:46

I just want to say , to be

19:48

clear , that doesn't mean that

19:50

there aren't bad apples out there and

19:52

we don't need to do something about that . The

19:56

National Hospice Organization and NOC have

19:58

also been a

20:00

very vocal about recommending 34

20:03

different strategies to mitigate

20:05

some of the fraud and abuse that

20:07

has developed over the last few

20:09

years . Again , some of that happening during COVID

20:11

, when maybe the survey processes weren't

20:14

quite as tight as they

20:16

were in years past , or

20:18

are now , and

20:20

I think we have really an entry

20:22

issue for the most part with the proliferation

20:25

of hospices that opened in 2020

20:27

, 2021 , and 2022

20:29

. And there are solutions

20:31

and not one of them is going

20:34

to be a panacea to

20:36

solving that section , but it is

20:38

a very limited section . And

20:40

I think what we have to be very careful about is

20:43

that we don't have unintended consequences

20:45

to providers

20:47

who are doing the right thing and

20:50

helping people live the last

20:52

stage of their life and saving

20:54

Medicare money . So if we

20:57

need to be able to

20:59

sort of incisively address the

21:03

fraud and there is some , but

21:05

for the most of the hospices out

21:07

there they're trying to do the right thing , doing

21:09

the right thing and that's high quality

21:11

here And

21:14

that's , i think . but both of these articles

21:16

stated regardless of the

21:18

tax status .

21:19

Yeah . So when we do these

21:21

, Carla , we usually we're taping several podcasts

21:23

. So I have Joan Tino later today Her

21:26

show will be aired And so , Joan

21:28

, in the prep for the show she said

21:30

something profound . She said you know all this , the

21:32

fraudulent stuff , Her back of the envelope

21:34

calculation is about 7

21:37

to 8% . Let me be very clear 7

21:39

to 8% of the providers . So

21:42

you know you're . And then , of course , that's

21:44

what gets sensationalized in the past , etc

21:46

. You said something a couple

21:49

moments ago , Years

21:51

ago . There's a physician that both you and I know

21:53

said something that literally was like a brain tattoo

21:55

, Said wouldn't it be awesome if the distribution

21:58

of our patients looked like a bell shaped curve ? But

22:00

it doesn't right . It actually looks like someone's , like

22:02

a backwards J , depending upon the tail

22:05

of longer length of stay patients , And

22:07

I've always held on to that . I'm a bit of an idealist

22:09

as part of my kind of part of

22:11

my issue , But I love kind of that would

22:14

be so ideal . And

22:16

what do you think about that ? Like when I'm hearing you talk

22:18

about this study , I mean could

22:20

, could we use that to one day

22:22

? It really did look like a bell shaped

22:25

curve or like maybe our median was 50

22:27

or 60 . And the tail

22:29

you didn't have a lot of short length of stay and you didn't have a

22:31

lot of long length of stay . What

22:33

would it take for us to live in that kind of panacea

22:36

, if you will ?

22:37

Well , I don't

22:40

know that . that's the answer

22:42

I think that's not how . I

22:44

mean . I'm not saying that what he said

22:47

wasn't correct , i mean it is dreamy

22:49

, right , but how do you drive

22:51

behavior to be bell

22:54

shaped And how

22:56

it , when we all live

22:58

and die of such variety

23:01

of diseases and there

23:03

are so many things that impact prognosis

23:07

that are not on an LCD

23:09

, you know , worksheet

23:11

? I think about my dad . My dad died

23:14

five years ago , father's Day , and

23:16

he outlived every

23:19

prognostication . You know

23:21

there's no absolute

23:23

reason he would be the tail , right

23:25

? I mean , he was the tail , of

23:27

course I'm his daughter , so I did advocate strongly

23:30

for him to get hospice

23:32

, of course , but there was no

23:34

reason . Physically he was alive at

23:36

the you know the last bit of his

23:38

life . But I know now

23:41

, looking back on it , that they

23:43

found his brother who was

23:46

shot down over Laos in the Vietnam War

23:48

, 50 years almost to

23:50

the month that he was shot down and

23:52

they found his friends And

23:54

my dad got told that . I got to

23:56

tell him and my dad got to go to the funeral

23:58

And there's no way he should have been there

24:00

. He was bed bound in a nursing

24:03

home But he got to go and

24:05

he got to say goodbye and hello to his

24:07

brother . So there's so many things

24:09

that are off the bell

24:12

curve chart .

24:13

I'm sorry I forget the national . No , that's awesome

24:15

.

24:17

That don't fit right . So how

24:19

do I think it should be ? at

24:22

this point in my thinking

24:24

, i wish honestly

24:26

and this is not going to happen tomorrow , but this

24:28

is one of the things I'm excited about I wish

24:31

we could kind of get rid of the

24:33

word hospice or the word palliative care and

24:35

have these artificial

24:38

lines of demarcation that are

24:40

based off prognosis . You

24:42

know , eventually I would like for it to be based

24:44

off of need and every person living

24:46

with a serious illness

24:48

, you know could receive

24:51

the care that they needed at that time And

24:53

perhaps there would need to be some kind of stratification

24:55

or some kind of case mix that

24:58

helped go up and down

25:00

with patients as their needs went up and

25:02

down , But it wasn't

25:04

prognosis based And I think

25:06

ultimately that's the new bell curve And

25:10

I have a dream that that happens

25:12

. I'm so glad to ask you that

25:14

Thank you .

25:14

And then thanks for sharing that personal story , because

25:17

you know , as I think , about some tools out there

25:19

that retrospectively

25:22

look at claims data and then say they're going to be

25:24

predictive . I mean , you know , i've grown up in this

25:26

, you've grown up in this , you've grown

25:28

up in this . We see stories like your

25:31

dad's and You know the

25:33

human , the will of your human

25:35

being , and then the care and love that hospice

25:37

brings , that is so hard to build into an algorithm

25:39

And and and then see how that

25:41

becomes predictive and so well

25:44

. Last question , karla , and then we'll wrap

25:46

up and so maybe , or there's some unanswered

25:49

questions that you think , maybe future studies

25:51

need to Kind

25:53

of address that neither the Niber or they

25:55

know our C study that have kind of addressed .

25:58

Yeah , and I , you know , I think it

26:00

to me it goes , it goes towards what I just said

26:02

. Actually , you know , like , so what , what would

26:04

that need to look like if we took

26:07

away everything that we know

26:09

to define benefit

26:11

structure right now and we really

26:14

looked at and and

26:16

Studied what do people

26:18

really need and want

26:20

and at what phase and

26:22

what would that cost ? I

26:25

think that that something

26:28

around more comprehensive care

26:30

for the seriously ill and

26:32

Look and trying to figure

26:34

out what the reimbursement structure should look like . I

26:36

think that's one thing to deal with what we have

26:39

today and to

26:41

sort of move from you

26:43

know 1.0 to 1.3

26:45

or something , versus sort of 2.0

26:47

or 3.0 that I just described

26:50

. I mean I think we should start to test stuff

26:52

more comprehensively than the

26:54

CCM . You

26:57

know demonstration so so What

27:00

would it cost if hospice

27:02

, when it complete full risk and by

27:04

that I mean really No

27:08

non-related , related , you know , full

27:10

risk , i mean we are mostly with all risk

27:12

, especially the way that the government has , you

27:14

know , come back and reemphasize that we expect

27:16

Most everything to be related but

27:18

full risk , and what would

27:20

it ? what so do that ? What

27:23

would it do to add concurrent

27:25

treatment ? What does that need to add to our PPD

27:27

? Because

27:29

of course the hospice benefit today does

27:31

cover palliative treatments , but most

27:34

hospices are not able to afford to

27:36

do that or to do that as

27:38

thoroughly and extensively , both

27:40

because of the advent of medicine

27:43

and how Advanced

27:45

it's gotten . Inexpensive It's gotten . But

27:48

what would that look like ? What would palliative

27:50

concurrent care really cost if

27:53

we were really to reimburse

27:55

the hospice separately for that ? I

27:57

think those things could move

27:59

the needle More

28:02

towards your bell curve With

28:04

the benefit structure that we have today

28:06

.

28:07

That's awesome . Well , Carla , any final thoughts ? .

28:10

Awesome .

28:11

Well , you've been great and Carla gave me a quote

28:13

, so we always in our podcast for our listeners It's

28:16

a Marcus Aurelius quote had no idea she

28:18

loved Marcus Aurelius . I love Marcus Aurelius

28:20

as from his meditation's book 5.2

28:22

or 5.20 is the

28:25

quote the mind adapts and converts

28:27

to its own purposes . "The obstacle

28:29

to our acting , the impediment

28:32

to action , advances action

28:34

. What stands in the way becomes

28:37

the way . Thanks for listening to

28:39

TCNtalks .