Welcome to TC N Talks. The goal of our podcast is to provide concise and relevant information for busy hospice and palliative care leaders and staff. We understand your busy schedules and believe that previty signals respect. And now here's our host.
Chris Comeaux:Chris Com, hello and welcome. Our guest today on TC N Talks is well, it's me. This is actually the second time I've done a monologue and this is actually a follow-up to a show that we did last year which was called Grow, so, flow and Note. We're going to build on that in just a little bit, but, as I always do, I always want to start off with what does our guest need to? what are our listeners need to know about our guest? So here's what I would hope you would know about me.
Chris Comeaux:I'm actually going on 28 years now of hospice and palliative care experience. I feel like I've spent the vast majority of my life here doing this amazing work and being around such amazing people as many of our listeners that are doing the care by the bedside. This work of hospice and palliative care really is sacred ground and I've fallen in love with it. In fact, someone was asking my wife recently would Chris ever do X, y or Z? And she said you know, he just loves hospice and palliative care so much I don't think he'll ever do anything that wouldn't involve some level of hospice and palliative care. And I think that tells you a lot about me, my heart, my passion for this work. I do have a wife, as I just alluded to. We have five kids, ages of 23 down to 14 and various stages three in college, two teenage girls at home and they're just wonderful young ladies. And the interesting thing is now, looking back over my children's lives, having grown up, as that has been part of hospice and palliative care, how it's been part of their lives as well, and I'm sure for many of you listening, it's. For me, it's so cool now, where I actually see children of prior leaders within hospice and palliative care, that now their children are actually making a career in this amazing work that we do. I don't know if any of my five kids will end up doing that. It's still a little bit of time for that potentially to happen, but Lord knows that they spent a lot of time volunteering at grief camps and things like that. So hospice and palliative care has been a large part of my life And that's why I'm so passionate about this work that we do.
Chris Comeaux:The other passion I want you to know about me is leadership. It is definitely a passion, something that I'm constantly reading and researching about, and really what I'd say is leadership really is the art and science of how we get things done together. John Maxwell said it very well many years ago that everything rises and falls on leadership, and the older that I get, the more gray hair that I get, the more that I see what he means by that. And just I would illustrate with this simple thing Think about if you tried to get something done at home recently and if it was just you working on that project with your two hands, or if you had your family working with you, and then all of a sudden your two hands were maybe four, eight, like in my case. if all of our kids and my wife and I are involved in something, we have 12, actually 14 hands I can't do math involved in a project, and if all 14 hands are moving in the same direction, we get a lot more work done. And that's really the essence of leadership is how do you get people working together, common cause and purpose pulling in the same direction?
Chris Comeaux:I've spent a lot of my life thinking and researching and reading about that, even writing. Recently I've got my first book written about leadership. So there's the things I would want you to know about me. So to today's topic, and so we're actually titled the show about a year ago Grow, sew, flow and Know and I'm going to unpack that a little bit more. It's definitely a catchy way to answer this question, which is how do programs hospice and powder care programs plot a course for the future? And I spent a lot of time since we released the show last year with many great guests and also, obviously, my day to day role, many meetings, working with the hospice and powder care programs that we do and me just absorbing what's coming and how do you plot a course to go forward. And to me, it's actually affirmed what we shared last year, but also some additional things I'd like to add to it. So first let's actually talk about what's coming, and we do a lot of work in TCN.
Chris Comeaux:In fact, we use a really cool process called our fees, which is our future external environmental scan. That's what the acronym fees stands for, and we got it from a great friend, meredith Elliott Powell, who's written a couple of New York Times bestselling books about business and leadership herself. And so, effectively, what a fees is? it's a much more in depth and sophisticated version of something we've all been exposed to at one point in time in our careers, which is a SWAT analysis, which is Strength, weaknesses, opportunities and Threats. But what the fees is is basically a much more sophisticated model of that And if you do the work of a fees, like the thinking and the analyzing, what you get is like a detailed compass of what's coming and how to, at least to know what I'm going to deal with on the journey, so then you can actually plot a course.
Chris Comeaux:In fact, years ago I read this amazing book called Thou Shall Prosper. It was written by a Jewish rabbi I think it was Rabbi Lapine who actually wrote the book And what he said quite often in the Jewish culture people think that most Jewish people have the gift of prophecy And he said that is the case, certainly for a certain portion of the population. But he said there's wisdom that's handed down from generation to generation and that's what the book was unpacking and Thou Shall Prosper, but something that really stuck with me, that was involved in this kind of overall framework of wisdom. He said that the people that are attributed again, there are some people that do have the gift of prophecy, but like there's a lot of people in the Jewish culture that can predict the future And he said let me break it down to you. It's basically this they look at what are macro trends and those macro trends that are pretty sure bets. How do you plot a course amongst that? And I thought this is so awesome. And so we've really used that in the work that we do with Antelias to say let's use our fees, feature external environmental scan to determine what is coming at us. And then we plot a course amongst that. Just straight out of that wisdom from that book, thou Shall Prosper. So let me share with you almost like points on the compass, doing a 360 degree scan of what's coming. These feel like pretty sure bets. You disagree with anything about? ready to say please. We always welcome your feedback. So I'm going to give you kind of these.
Chris Comeaux:I've got a whole list of bullet points that have kind of come out of our external environmental scan, and so the first now use a couple of analogies. So sometimes I'll use technical terms, sometimes I'll use analogy to make it a little bit more explanatory. But the very first is there's one big river which is our reimbursement today. So if you picture how we get paid is there's this big river, deep and wide. It's going to split off into multiple tributaries as we go forward. So I love that visual because one of our board members in TCN it kind of prompted that visual And so that one big river how we're paid today as Hospice and Powered Care Programs is going to split off into multiple tributaries. Those new tributaries are going to be Medicare Advantage. Of course we're still going to have traditional Medicare, the Medicare Advantage, acos, accountability Care Organizations or Value Based Care, medicaid Managed Care, snp plans, which are special need plans, and of course, if I went to detail what each of these is, it'd be way too long of a show.
Chris Comeaux:Commercial Payor Innovation. So even the commercial payer is going to bring innovation, like I read something recently where a commercial payer has created their own version of like a PACE program. So there's going to be other commercial payer innovations that maybe don't fit into exact boxes as we think about them today. But then there's going to be one more, which is Employer Innovations. Employers quite often they pay the health care costs that go to these commercial insurance companies and employers are getting more and more to satisfy with what they're getting for the value of their dollar.
Chris Comeaux:So if you picture, one big river today is going to fracture into all those tributaries Also. So going to the next bullet point. Competition on the rivers is going to increase. So not only is it going to fracture, but we're going to have more and more competition setting up on the river trying to compete against us. And so we see this all over the country and you get. You have some really craziness out west in places like California, nevada, where the competition for number of hospices is just off the charts crazy, you know. I think in Las Vegas it's something like 200 hospices. Today There's over a thousand hospice providers in the state of California.
Chris Comeaux:So that's second bullet point. The third bullet point is substitution. Competitions will rapidly increase, and that's one I probably need to explain a little bit. So substitution competition is a substitution for what you do. So I'm actually a little bit less certain that this one will occur. But it's a good example that we were talking about several years ago that Medicare Advantage plans are going to have the ability to get a little bit more innovative in terms of what they pay for within the plans, and this is why, all of a sudden, you saw a lot of publicly traded for profit hospice out of care programs, buying private duty, because think about it, if you could hire a private duty company, let's say, for four hours at $25 an hour, which would be $100, compared to paying hospice $155 to $200 a day. That would be an example of substitution competition. Now some of you might be going but that's not the same thing as hospice. I totally agree. But sometimes a customer will accept substitution competition Maybe sometimes they don't know any better, or they just get the minimal value or maximum return for minimal cost, if you will. And so there's lots of examples throughout other businesses where substitution competition substituted for a product. One of the examples remember reading when the idea was first I'm introduced as like breakfast food And so like if you're a restaurant serving breakfast food and then all of a sudden LSA and McDonald's started actually doing a healthy smoothie shake, that is a substitution competition than maybe bacon, eggs and grits and sourdough toast. And so substitution competitions are going to rapidly and they're already rapidly increasing. A lot of interesting examples on what's a home care 100 earlier this year And on the stage we saw lots of substitution competitions, interesting competencies that are portions of the competency of hospice but being woven together in new and innovative ways and a lot thinner in terms of the overall scope of services And then selling that to payers. So that's the third bullet point. Substitution competitions will rapidly increase.
Chris Comeaux:The fourth bullet point referral source challenges. Lots of competition for their time and attention. So our referral sources. So think about whether there are discharge planners, the hospital course, physician offices there's so many things claiming for their attention. As all this changes hitting healthcare, it's going to be hard for us to get their time and attention And for a lot of us this is where our furls come from. So an interesting remedy. I didn't want to go to remedy to all of these, but this is one I thought I would throw one out. Can we go direct to the consumer? We've not done that well, although some of the hospices I know we work with have actually seen really big increases in referrals directly from the patient and family. So referral source challenges there's just going to be a lot more competition for their time and attention. All right. Next bullet point, which is our fifth, which is customer.
Chris Comeaux:Demographic is evolving due to the baby boomers.
Chris Comeaux:So 28 years, i said in my introduction, I've got 28 years now in this industry, movement, segment, this thing that we love, we have served the greatest generation for the vast majority of the time. That's who has been the customer? certainly that the hospice and healthcare programs I've been a part of, who we've been serving. That is shifting as we speak, and so now you have more and more baby boomers, which are the people that we're serving as the greatest generation kind of. The last of them is passing away And you may go well. Why does that matter is because baby boomers have transformed every segment of our whole economy as they've aged, whether it was starting with first family, suburbia, homes, later vacation rentals, time shares, the whole vacation movement, and then SUVs and then retirement, and so baby boomers have had a huge impact on things that we now look at as part of our society, part of our economy. End of life care is one of those that they're going to transform And traditionally they've been much more demanding than the greatest generation, especially when it comes to healthcare. The greatest generation was very compliant, very respectful. Baby boomers are a lot more demanding, so much more of a customer focus is going to be absolutely critical going forward.
Chris Comeaux:Then also demographic challenges. So I'm going to the next bullet point demographic challenges in terms of volume of people needing our services. We brought in an incredible guy who does interesting statistical analysis for chambers throughout the country, so chambers of commerce and we're actually going to bring Jay Cushman from Health Pivots, who was on our TCN talks earlier this year, to redo this towards the end of this year for our TCN members. But the last time we did this analysis with this guy from the chamber he projected deaths through 2040. And I will tell you that the incline was, it was very steep. So, in other words, many of us are having challenge staffing today. Those challenges are going to be and that's my next bullet point is going to get even more challenging because the demand for our services is going to be quite steep, which is great If you're looking at from a mission standpoint, from a business standpoint, very difficult from a staffing standpoint, which gets to our next one, which is workforce challenges. We know, especially after in the wake of COVID, we've had major challenges And so inflationary pressures on wages, staff coming to an interview and then don't even show up or call back or show up for the first day of work, a lot of competition for a smaller staffing pool, and that was before the volume increases that I was alluding to earlier, through 2040. So workforce challenges are a very big challenge on the horizon. It's also with us today, but it's also an horizon going forward.
Chris Comeaux:Next bullet reimbursement per unit challenges. In other words, we're going to be paid less. Now we find it's kind of funny, and so we have the centers for Medicare and Medicaid innovation In certain aspects. When it comes to CMS, the centers for Medicare and Medicaid services, they're not very innovative from this perspective. If you just look at what's happened to hospitals, what's happened to, let's say, home health, there's a good chance it's coming to a healthcare entity near you. So getting paid less for what we do is going to become more and more the reality as we go forward. One of the big examples I could think of I think it was probably 98 or so is when home health got a major change in its reimbursement when they first moved to Oasis, and while that changed, the overall structure is certainly also began to decrease, kind of the per unit revenue for what home health was making. The same is going to happen in hospitals when they moved to cost based reimbursement, to DRGs, and so you could bet something like that's going to be in our future as hospice and pedicure programs.
Chris Comeaux:Next one is EMR Electronic Medical Record Challenges. There's not a person I've met who loves their electronic medical record, and so that continually provides challenges. It creates friction with our staff to do their work on a day to day basis, creates friction with patients and families for us to serve them well, and so that is going to continue to be a challenge, and one of which I hope that the EMR vendors, partners really do step up to the plate and really start to make a better product. But as we look into the future, navigating that is going to continue to be a challenge. So, continuing with these kind of macro challenges, technology rapidly moving and then how do we incorporate?
Chris Comeaux:I don't know if any of you have utilized chat GPT. We actually have Jack Neil talking about artificial intelligence on TCN talks, and that's just one of the many examples of how technology is being adapted and is moving very rapidly in terms of where it's going. And then how do you incorporate that? I mean, just think about chat GPT has been something that is kind of taking the role by storm. In fact, i was even sitting with my son the other night and we were working on his resume and he had to add something to his resume and he popped it in a chat GPT and got a perfect paragraph. He popped into his resume, and so that's one of many examples of how technology is moving rapidly. Robot process automation is something you're going to hear a lot about. Also, different types of technology that looks at frequency of visits. It looks at projection of what's going on with the patient. So how do we need to interject or intercede much quickly?
Chris Comeaux:So all of this technology happening and how do we incorporate in something that has been more traditional, a very high touch care model, is going to be a huge challenge, but also an opportunity as we go forward, and you can say opportunity for all of these I'm going over. So the next bullet is regulatory challenges. We know that the government has figured out for every $1 they spend in audits etc. They make about $5. So that's why we've seen continual increase of audits. No, it's very frustrating to many of our TCM members, certainly a net Kaiser on our team and nationally, a lot of hospice and powder care providers. It is a challenge and it does not look like it's going to wait anytime soon.
Chris Comeaux:Next up is access to capital to navigate these challenges And so, especially as community based nonprofit hospices that's, who, teleass, collaborative network works with access to capital. Now, this is why we really work with our members to make sure that they maximize their fundraising and philanthropy competency and their organization and their community. Because, unlike the for profits, who could actually raise money in the capital market or with private equity, the core layer for us is with donors, and so getting capital so we can invest in how we meet all of these challenges and place those bets wisely is a huge challenge. And then next we've got social challenges, and so, and again, all of this came out of our own work within our teleass collaborative network, and this is one that was identified several years ago and doesn't look like it's gotten any better. But social challenges are things like opioid addiction, the collapse of family units, so who really is in charge of the family, who's kind of the patriarch, the matriarch or the decision maker, healthcare, power of attorney, also who's the caregiver, or even a caregiver being available, And then just the widening gap between the haves and the have nots and all the implications of that. So we kind of put that all under one category called social challenges. Certainly anyone close to the IDG team nurses, social workers, chaplains they know exactly what I'm talking about. They've seen these challenges get worse and worse, especially the last 10 year period. The next we have political challenges, don't need to say much about that, just turn the TV on at night. But how do you get anything done at a national level or even maybe a state level? And sometimes it's better to pivot to the state because the national is so dysfunctional to be able to put things in place legislatively. That could alleviate some of the things that we just alluded to in these other bullet points.
Chris Comeaux:And this is one I almost was going to leave out. It came up through our work, in our fees, but it was customers perception about healthcare and then serious illness care and hospice care, and I was going to leave this out, but it's interesting. I wanted to actually utilize chat GPT and ask the same question about what challenges do you see facing the hospice and healthcare industry? and interestingly, this was in its top five. So I was going to leave it off and then chat GPT tweak me that, okay, we can't. If you think about healthcare typically, or kind of traditionally, when you think about compared to, let's say, attorneys, has been very well respected. But COVID really did hurt us, as I hate to use word industry, but certainly as a movement, a segment, and I'm making the broad statement of healthcare. But the customers perception about healthcare and the value for their dollar healthcare. As far as us, partnering around the patient and family, that took a hit and it has not actually come back.
Chris Comeaux:And then there are a couple other challenges and these are specific to nonprofits. Tax status is more of an issue for hospitals. Seeing a lot of articles hopefully all of you are listening to our monthly podcast at Mark Cohen and I do the top news stories of the month. Every month we're seeing more and more news stories where hospitals are being challenged about being nonprofits And as our economy gets tougher and people are looking for tax revenue, this is going to become a bigger and bigger deal. And why we're concerned about it is what if they come for hospice and healthcare and say are you guys really like nonprofits because you're not paying taxes? And of course we've done some work with our members to be proactive on that front, to talk about what is the community benefit of our programs, whereas hospitals have been a little bit behind the eight ball and kind of already trying to defend themselves as opposed to being proactive.
Chris Comeaux:And then also governance challenges as nonprofits, we've got community based boards that volunteer their time. The challenges is these board members come into our meetings once a month. They're not living in this like most of us and they have to make very tough decisions And it's actually one of the reasons why we started this podcast is to give them a resource in a small amount of time that they can know what's coming. But even with that, it's just difficult. They make major decisions and they have a little bit of knowledge because they're doing their day jobs, which is maybe being a banker or being a teacher or being a local legislator, whatever it is. They're really busy and the rest of their life volunteering their time. So nonprofits have the governance challenge of people that are making very big decisions and have very limited knowledge just because of how much the rapid increase of challenge in things coming out of hospitals and power of care programs.
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Chris Comeaux:And then after this is all that's come out of our work in TCN, then I did a little bit more research and there are two more things that kind of popped up that weren't within our fees of TCN. Number one is Medicare's looming insolvency. So somewhere between 2028 and 2030, medicare is predicted to go bankrupt. I can remember when I was in college I actually wrote a paper about increasing the retirement age and a couple of the things like that. So this was in probably 89, 90 when I wrote that paper. And so those chickens are finally coming home to roost and you can imagine as our government grapples with that And many of us where most of our revenue comes from. That's going to have a huge impact. So that's a huge challenge.
Chris Comeaux:And then the last one is private equities influence on healthcare and healthcare innovations. So you can imagine you might be like me you've got a 403B or 401K. You want that thing to grow. That's your retirement account, right? Well, there are a lot of people that pull their money and private equity funds and they want that thing to grow. Don't blame them. Everyone wants their investment to grow. Well, when you look at macro trends and say what's a sure bet Remember I alluded to earlier in these challenges is the projected number of deaths for our countries, the baby boomers age. We've been business people look at that and say, wow, healthcare is a pretty sure bet. So then you see all of these private equity dollars and that's been exacerbated due to the amount of dollars through quantitative easing that has been flooding our economy for the past three years. So then you got those dollars a little bit kind of freer, looser, if you will, hunting a good investment. So you've seen literally all these challenges I've been sharing. But then private equities like throwing a gasoline on the fire, especially when it comes to competition, substitution competition, et cetera. So all of those are the challenges that we see. So it's like a 360 degree assessment of what's coming. So I would be remiss if I gave you the challenges and didn't give you the solution.
Chris Comeaux:So when I was discussing this with my wife last year that I need to do a monologue and talk to hospices about what's coming, she said you know, you really need to kind of break it down and make it simple as far as what do they do? And it really should be sticky in the brain. And of course, my wife is a very wise woman and because she's right, this complexity is overwhelming, and so where we ended up with is grow, so flow and know, and today I'm going to add an R and D, so it's a pretty catchy thing grow, so flow and know. So let me unpack. So, first off, grow. What does that mean is, from a mission standpoint, there is still many people to be served from a hospice and powder care perspective within our communities And we've got to be doing everything possible, certainly within our TCN network Alison Kutchaus, our chief growth officer, working with their different members to get very sophisticated in terms of how we reach the patients and families earlier in the disease process to get them the care that they need. So we need to be growing at all fronts in terms of our service lines.
Chris Comeaux:Now, that's kind of an alluding to the next one, which is so And so is about. So, sow and springtime. As we're recording this show is actually going to be airing a little bit later, but SOWing is what you do during the spring. You plant all these different seeds. Well, hospice and powder care is the core business of most of our members. Some just have hospice. They need to be SOWing, seeding a new powder care program. But what about other innovations like home based primary care. We've got a TCN member that has a PACE program. We have a member who has a care navigation slash kind of concierge services. We have several different innovations that we've been vetting for TCN members and interesting innovation in the home care side and interesting innovation in bringing lawn made house cleaning services to people that are dealing with serious illness. So SOW is seeding those different innovations And when you also have to have the balance sheet to be able to do that as well but you have to, otherwise you're just going to keep riding the curve down in terms of what the current business does.
Chris Comeaux:Next is flow, and so what does flow mean is we have not done a lot of work in the hospice and powder care segment in terms of looking at workflows. In fact, one of our really good CEOs within the TCN network made a comment, said when I look throughout our processes, we've got a bunch of old excel spreadsheets kind of holding things together. That's not uncommon in hospice, and so getting much more sophisticated in terms of flow anywhere where it's causing friction with our patients and families, with the delivery of our product, that is an opportunity to get a much better flow in terms of the work that we do just a very seamless, well delivered product, whatever that is, even whether it's a contact with patients and families, and then also flow in terms of our staff. Anywhere where there's friction with our staff, we need to actually bring efficiency there. And then the last one so we got grow, so flow and no, and this is one that we've not been very good at in the hospice and powder care space, because we come from at it from a mission standpoint. And let's have this beautiful community bereavement program, let's have this beautiful children's program, because we want to do the right thing. Challenges is we're going to have to say no to more things. We have a very sophisticated way to help our members look at their balance sheet and then basically say these are our resources, here's the places that we need to place those bets, and there's just not going to be enough resource. So we're going to have to get better and better at saying no to certain things that we just can't do it all. So then, so we got grow, so flow and no. And then added R and D And so and of course it's kind of catchy because R and D sounds like research and development, but that's not it. The R is reculture.
Chris Comeaux:As I think about the future and I love the term reculture. It comes from this book. Actually picked it up at Home Care 100. This young lady, melissa Daimler, actually was one of the keynote speakers And I love the way she phrased culture as reculture, because I think someone was like, oh yeah, culture, been there, got the t-shirt. Culture is like the fertile soil within your organization where you can plant all these different things I've just been talking about within grow, so flow, and no, or it could not be such fertile soil. So reculture and culture. I love the definition she has in this book.
Chris Comeaux:She says culture is how work happens between people, and here's a great quote from the chapter nine in her book Culture is a reflection of the people that lead the organization and how well their actions match their words. If you want to change culture, you have to change yourself first. So whole work around culture is going to be huge as we go forward And it's hard work, because culture is this weaving together of our day-to-day interactions with each other, and certainly these challenges that I've been speaking about are going to make that harder or easier, and more than likely they're going to become harder. And then the last one is the D, which is dig a moat. I got this analogy years ago from a book about investing, and so a guy named Phil Town he actually was mentored from a Warren Buffett kind of acolyte And he is the first one ever heard use this term He said if you had a castle, to defend your castle you have to have a moat, and the deeper your moat, the more defensible your castle. But what he was talking about is where's the moat on your business? So as we go forward, especially with all this different competition, where's our moat?
Chris Comeaux:Recently I heard Carol Fisher, the president of MPHI, just talk passionately about something that I wholeheartedly agree with her about That hospice and powder care is a specialty. Like any other specialty out there like neurology, pulmonology, any of these other kind of high level technical areas of healthcare hospice and powder care is huge And it is a huge specialty. Many of us have spent our lives working this area, but then the other part of it is it's about high quality care. So the more work that we do to help elevate that specialty, increase our competency throughout our organization, the systems and processes, and then also all about quality of care, the more you are digging your moat and making your castle defensible. So those are my thoughts. I gave you a whole list of challenges. This will be a great education tool for your staff, your board, of course, all of your leadership team. And then you can take Grosso Flo, no R and D reculture and dig a moat and just keep unpacking that, because I think it'll be a really good framework to keep building out your strategic plan as we navigate these challenges that are coming.
Chris Comeaux:So, as I always do, i want to leave you with a quote. This one. I'll leave you with two quotes. One is security is mostly a superstition. It does not exist in nature, nor do the children of man as a whole experience it. Avoiding danger is no safer in the long run than outright exposure. Life is either a daring adventure or nothing. And that's by Helen Keller And this one by TS Elliott. Only those who are risk going too far can possibly find out how far one can go. Thanks for listening to TCN Talks.