Speaker 1: Hello, and welcome to another episode of the Votes and
Speaker 1: Verdicts podcast, which examines the intersection of business policy and law.
Speaker 1: My name is Duwayne Wright, and I'm a senior healthcare
Speaker 1: policy analyst at Bloomberg Intelligence, the in house research arm
Speaker 1: of Bloomberg LP. I'm looking forward to this discussion today
Speaker 1: because we'll focus on healthcare delivery system reform, specifically the
Speaker 1: hospital at home program, which took off dramatically during the
Speaker 1: COVID nineteen pandemic. To walk us through this, and we
Speaker 1: have Mark Braither, a leader at the forefront of change
Speaker 1: in the healthcare system. Mark is the co founder and
Speaker 1: executive chairman of Dispatch Health and has a deep background
Speaker 1: in business and hands on healthcare delivery. Mark, welcome to
Speaker 1: the podcast.
Speaker 2: Thanks for having me to.
Speaker 1: Now, before we dive into this topic, can you give
Speaker 1: us some background on Dispatch Health, which, as I said earlier,
Speaker 1: you co founded.
Speaker 2: Yeah, so, Dispatch Health has been around for almost a decade.
Speaker 2: At its simplest, it's a system of care that allows
Speaker 2: for the safe and effective provision of high acuity care
Speaker 2: in the home. So that's care that substitutes for an
Speaker 2: emergency department, substitutes for a hospital award admission or a
Speaker 2: skilled nursing facility admission. We can also bring in laboratory
Speaker 2: capabilities as well as X ray and ultrasound to your home.
Speaker 2: We've served I think over the last decade, more than
Speaker 2: a million patients and we do that across thirty states
Speaker 2: and during that time, the way that we've structured our
Speaker 2: care is that we do it in a way that's
Speaker 2: more cost effective than the building. So we've delivered almost
Speaker 2: a billion and a half dollars of medical cost savings.
Speaker 1: And so not just the co founder and executive chairman
Speaker 1: of a company, you have a deep healthcare background in
Speaker 1: your board certified emergency specialists, So what was the spark
Speaker 1: that led you to create a company focused on delivery
Speaker 1: system reformat in how we provide healthcare?
Speaker 2: Yeah, what's an old er doctor doing delivering house calls?
Speaker 1: Right?
Speaker 2: So you know, I spent I don't know two and
Speaker 2: a half decades at the bedside as an emergency medicine
Speaker 2: specialist and fantastic run. Enjoyed every moment of it, but
Speaker 2: was ultimately sort of drawn into the business side of
Speaker 2: healthcare and towards the end of my career helped create
Speaker 2: the largest clinically clinician owned staffing company in the country.
Speaker 2: So that's a company that provides er specialist hospital and
Speaker 2: extensivest people who staff skilled nursing facilities to hospitals. And
Speaker 2: so I learned a lot during that run. Ended up
Speaker 2: managing the West and for us that was about sixty
Speaker 2: four hospitals, somewhere close to fifteen hundred clinicians. But a
Speaker 2: few things started to concern me. And again this is
Speaker 2: probably twenty eleven or so. The first thing I noticed
Speaker 2: was we were so far off of our healthcare consumer,
Speaker 2: our patients expectations when it come when it came to pricing.
Speaker 2: So I was the recipient of a lot of complaints
Speaker 2: on my desk about the cost of care and the
Speaker 2: time with the clinician. And that had changed dramatically since
Speaker 2: I was a young resident in the nineties, and so
Speaker 2: I wasn't sure what I was going to do about that,
Speaker 2: but I wanted to do something that improved that issue. Secondly,
Speaker 2: was the concept of value based care. So in twenty eleven,
Speaker 2: we were still debating whether this was a a thing right,
Speaker 2: whether this was going to happen again. I was there
Speaker 2: in the early nineties when we tried it, but the
Speaker 2: second round, to me, looked like it could actually work.
Speaker 2: And if it did work, you'd have more and more
Speaker 2: patients in paneled to these smart primary care docs who
Speaker 2: would try to navigate patients to the appropriate side of care.
Speaker 2: And I knew that there was a ton of patients
Speaker 2: that I treated on a daily basis that could be
Speaker 2: treated elsewhere. And I think the thing that really moved
Speaker 2: me forward was that I had some family members and
Speaker 2: elderly family members that went through hospitalization a post acute
Speaker 2: stay that did not go well. They went really poorly,
Speaker 2: and I just saw the other side of that, and
Speaker 2: I think I had a little existential moment where I said,
Speaker 2: have I been doing that? Have I been putting patients
Speaker 2: in the hospital and maybe to their detriment? And the answer,
Speaker 2: if I was honest, was yes. And so I began
Speaker 2: looking for an alternative, and I wasn't sure what it was,
Speaker 2: but I reached out to some people who began publicishing
Speaker 2: this concept of hospital at home in the nineties, a
Speaker 2: guy like Bruce lef out of Hopkins and al Sioue
Speaker 2: out of pen These were Maverick geriatricians who were doing
Speaker 2: something different. I was also being done in other countries,
Speaker 2: but they were sort of the leaders in publishing in
Speaker 2: the States, and it looked really compelling to me. It
Speaker 2: looked like we could get lower costs and patient satisfaction.
Speaker 2: But importantly, there was something about it that looked like
Speaker 2: we could get more efficacy, we could get better clinical outcomes. So,
Speaker 2: like most naive folks when you're first starting out, I thought, well, too,
Speaker 2: I've managed ers, I've managed hospitals, I've managed post acute facilities.
Speaker 2: I could just do this in the home. So it's
Speaker 2: been much more of a daunting task than that. But
Speaker 2: that's the premise of dispatch, is that we would take
Speaker 2: what we could out of the emergency department, out of
Speaker 2: the hospital, ward, out of the post acute facility, delivered
Speaker 2: in the home for lower cost, better outcomes, and better satisfaction.
Speaker 1: And you mentioned and you're in thirty states. Now, how
Speaker 1: did that start? Was there an anchor and then you
Speaker 1: grew from there?
Speaker 2: Absolutely, it's a great question. So I practiced in Denver,
Speaker 2: and I was also an EMS medical director in Denver.
Speaker 2: And the reason that that's important is at about that
Speaker 2: time there was a concept growing up called paramedicine, where
Speaker 2: the paramedics would practice it the top of their scope
Speaker 2: of license and that's still going today. And so we
Speaker 2: started one of those early programs. But I said, during
Speaker 2: this whole journey, in the back of my head, could
Speaker 2: we not create a mobile er? Could we not do
Speaker 2: that respond to the nine one one phone call and
Speaker 2: treat a patient in place? And so that really was
Speaker 2: the beginning of it. We created a very forward thinking
Speaker 2: fire chief named Rick Lewis and I and a few
Speaker 2: other folks built this mobile er and started treating patients
Speaker 2: in lieu of a transport to the hospital. We did
Speaker 2: that for two years. In the data it was extremely compelling,
Speaker 2: and so we took that to our first payer partner
Speaker 2: and said would you pay for this? And they said yes,
Speaker 2: And that was the beginning.
Speaker 1: And so you had mentioned earlier as you were starting
Speaker 1: this company some of the conversations you had with folks
Speaker 1: who have focused on hospital at home for a while.
Speaker 1: So it's not a new concept, but it might be
Speaker 1: new for people who haven't been paying attention. Can you
Speaker 1: kind of give us some of the history here, and
Speaker 1: then when we think about hospital at home, what kind
Speaker 1: of services are we talking about? And if you look
Speaker 1: at a hospital at home program in one state or
Speaker 1: one geography, is it the same as another geography in
Speaker 1: a different state. Walk us through how the concept has
Speaker 1: started or how it's evolved, and where we are now.
Speaker 2: And the first thing I would say is that a
Speaker 2: hospital at home Moniker is a bit of a misnomer, right, honestly,
Speaker 2: doesn't necessarily have anything to do with the hospital. It's
Speaker 2: part of a macro trend that we've had since the seventies,
Speaker 2: really where we've moved care that is in that higher acuity,
Speaker 2: higher cost setting into the ambulatory setting. And you know,
Speaker 2: I would give you the example of the ambulatory surgery center,
Speaker 2: right that started back in the seventies. And I remember
Speaker 2: even in the nineties when I was training, lots of
Speaker 2: us were very concerned about these ambulatory surgery centers where
Speaker 2: they good quality? Could you safely do it? And you know,
Speaker 2: very similar situation that we find ourselves in today. But
Speaker 2: today there's fifty three hundred surgery centers across the country.
Speaker 2: They're performing twenty million procedures annually, and it's estimated that
Speaker 2: they are saving you know, call it forty billion dollars annually.
Speaker 2: I often use another really tangible example from my history.
Speaker 2: So over the time that I practice, the standard of
Speaker 2: care changed, right, And if we talked about let's say
Speaker 2: a blood clot in your leg, you came and saw
Speaker 2: me in the emergency room, we made that diagnosis. Call
Speaker 2: it fifteen years ago. The treatment at that time would
Speaker 2: have been to admit you to the hospital on bed
Speaker 2: rest on an ivy medication called hepron. Now let's fast
Speaker 2: forward to today, and if you went to the emergency
Speaker 2: room had that diagnosis, what would happen. You'd go home
Speaker 2: in an hour on a medication, you know, a shot
Speaker 2: that you gave yourself for a pill. It's pretty interesting
Speaker 2: how we've evolved. And that's exactly what this whole hospital
Speaker 2: at home concept really is. So when people hear it today,
Speaker 2: they often equate it to the concept of the waiver,
Speaker 2: which is really a payment mechanism. It's not this delivery
Speaker 2: of the service. But during the pandemic, there was an
Speaker 2: initiative called the Acute Hospital Care at Home Initiative, And
Speaker 2: I remember getting a call from the administration one night
Speaker 2: and thinking, whoa good am? I in trouble. But I
Speaker 2: showed up the next morning and it was all of
Speaker 2: us in the community who were delivering this type of care,
Speaker 2: and they were very worried that the hospital beds were
Speaker 2: going to fill up and that they weren't going to
Speaker 2: be able to service all of the sick patients. And
Speaker 2: so I think very thoughtfully they said, well, can we
Speaker 2: take the reimbursement mechanism that we use for the hospital
Speaker 2: and just transferred to the home right and we'll use
Speaker 2: you experts to tell us what a good program looks like,
Speaker 2: and then that'll be the standard. And that really was
Speaker 2: a nice catalyst to get hospitals thinking that way, although
Speaker 2: you know, there were obviously hospitals doing it at that time,
Speaker 2: and so that was really the beginning of, you know,
Speaker 2: I think the popularization of the concept of hospital at home.
Speaker 2: So when you mentioned, you know, is it the same everywhere?
Speaker 2: So there are some standards that we put in place,
Speaker 2: you know, our program essentially, when you're admitted into the
Speaker 2: dispatch program, you are monitored continuously, you have access to
Speaker 2: our nurses and doctors twenty four to seven. You have
Speaker 2: you know, on demand rescue therapy, which would be either
Speaker 2: our mobile er units or ems UH, and then we
Speaker 2: provide all of the services that you would receive typically
Speaker 2: in your hospital stay. That could be physical therapy, that
Speaker 2: could be you know, oxygen, that could be help with
Speaker 2: activities of daily living. We bring all of that into
Speaker 2: the home and then I think importantly, our model continues
Speaker 2: for thirty days. So as you know, we have a
Speaker 2: problem in this country where we'll treat you in the
Speaker 2: hospital for call it three and a half days, discharge you,
Speaker 2: and one in four one in five times you'll come
Speaker 2: back to the hospital. So we continue to keep you
Speaker 2: on our service for thirty days, all the while integrating
Speaker 2: you back with your primary care doctor and ensuring that
Speaker 2: that care plan is continued throughout the thirty days. And
Speaker 2: so at the end about our readmit rates about half
Speaker 2: of what you get inside the hospital. And then you know,
Speaker 2: can you do this throughout the country anywhere? Well, I
Speaker 2: would tell you that it's being done in a lot
Speaker 2: of geographies today. We do this, you know, like I mentioned,
Speaker 2: I think we're in thirty states, but forty markets where
Speaker 2: we provide that on demand er substitute of care imaging.
Speaker 2: And then we have fourteen markets where we provide that
Speaker 2: ability to you know, quote unquote hospitalize in the home
Speaker 2: or recover in the home. And those are very disparate
Speaker 2: markets throughout the country, and so far we haven't encountered
Speaker 2: a situation where we couldn't provide that care.
Speaker 1: And so in this this sounds great in terms of
Speaker 1: an opportunity to rethink how we're delivering care that's not
Speaker 1: just good for the patient but good for the system.
Speaker 1: Good for the patient because they're getting good quality care,
Speaker 1: good for the system because maybe we're seeing this care
Speaker 1: done in a cheaper setting, we're a lower cost sitting.
Speaker 1: We're seeing care that doesn't lead to re admissions, which
Speaker 1: is good overall, but it takes a lot to actually
Speaker 1: make that successful. So, you know, when we think about
Speaker 1: what happened during the pandemic, this was also a time
Speaker 1: when the digital aspects of healthcare kind of blew up
Speaker 1: as well. So can you walk me through what the
Speaker 1: infrastructure is like or is needed to make it successful?
Speaker 2: Yeah, you're spot on. So I'll start with the care teams.
Speaker 2: You know, when I first started, I thought, well, I
Speaker 2: could just take my er care team and bring them
Speaker 2: into the home. And yes, some of the skills translate,
Speaker 2: but there's a there's a different approach, and there are
Speaker 2: different things that they need to be aware of, and
Speaker 2: so I think number one, having adaptable care teams, having
Speaker 2: you know, a quality education program I think is important.
Speaker 2: Number Two, you mentioned technology, This is key, This can't
Speaker 2: be done without it. So we use remote monitoring, we
Speaker 2: use telehealth. We've had to build a lot of our
Speaker 2: own capabilities because you know, every EMR in the world
Speaker 2: is built around the concept of a building where everybody
Speaker 2: is in the building. And for us, you know, the
Speaker 2: patients in a building, but everybody else is driving around,
Speaker 2: right the physical therapist, the pharmacists, the everything, And so
Speaker 2: we've had to become logistics experts. We literally had the
Speaker 2: team that built early Uber come in and build our
Speaker 2: logistics model. And that's a logistics model that's clinically informed,
Speaker 2: meaning you know, is to something need to be happened
Speaker 2: faster because of the clinical acuity of that patient. So
Speaker 2: those are things that we've had to build over the
Speaker 2: decade that I think, are you know different. And then
Speaker 2: to me, you know, I'm an old hospital doc that
Speaker 2: manage lots of other docs and clinical quality is super important.
Speaker 2: So the foundation here really is built on what we
Speaker 2: used to do back inside the hospital. So a patient
Speaker 2: center to focus that is you know, highly focused on
Speaker 2: clinical quality and consistency.
Speaker 1: And so you talk about the care teams that you
Speaker 1: bring to the table. Dispatch Health brings to the table
Speaker 1: the remote monitoring, the technology, and the capabilities that you
Speaker 1: have built to make this work. So help me think
Speaker 1: about how a hospital or a health system would work
Speaker 1: with you, Like how does that conversation start? And then
Speaker 1: when you think about what it is that you do,
Speaker 1: what makes you, what makes Dispatch Health unique from some
Speaker 1: of the other players in the system.
Speaker 2: Yeah, so I'm going to start with the second half
Speaker 2: of that first because I think it'll help us answer
Speaker 2: the first. And when I originally looked at these hospital
Speaker 2: at home models, the first thing that struck me was
Speaker 2: how few admissions there were actually work right. Why hadn't
Speaker 2: this scaled? Why hadn't we done more of it? And
Speaker 2: I would ask some of the folks who were doing this,
Speaker 2: and they mentioned things like, well, it's hard to get
Speaker 2: oxygen to the bedside, or it's hard to get reimbursed,
Speaker 2: and you know, in my head, those are all things
Speaker 2: that we could solve. I thought that the fundamental problem
Speaker 2: that we had in scaling this was the site of origination,
Speaker 2: meaning we were starting the care after the patient had
Speaker 2: already arrived in the emergency department. And as an old
Speaker 2: er doc, I can tell you there's so many people
Speaker 2: that once the patient gets there, they really don't want
Speaker 2: them to leave, right. It's a hassle for the er
Speaker 2: doc to keep that patient longer than is needed and
Speaker 2: work on getting them back home. That's a lot of work.
Speaker 2: If you think of then about the hospitalist. You know,
Speaker 2: is it easier to arrange all this stuff in the
Speaker 2: home or is it easier just to admit them upstairs?
Speaker 2: And frankly, there are some incentives and their pay that
Speaker 2: would you know, make them maybe want to admit the patient.
Speaker 2: And then you know, if I'm the CFO of a hospital,
Speaker 2: it's very hard for me to send the patient out
Speaker 2: if I could have kept them in. And there's the
Speaker 2: whole idea of like, let's keep the lower acuity stuff
Speaker 2: out and just do you know the higher acuity stuff
Speaker 2: in the building. But in the moment, I think that's hard.
Speaker 2: And so with dispatch, what we said was, let's create
Speaker 2: a system in the home. Let's be able to bring
Speaker 2: an er to the bedside and diagnose and treat somebody
Speaker 2: just like I would have in the er. Now, short
Speaker 2: of a cat skin. But everything else I can do,
Speaker 2: and that's really important because you have to risk stratify
Speaker 2: the patient in terms of their clinical condition. So you
Speaker 2: have to have a moderate complexity lab, you have to
Speaker 2: have EKG, you have to have X ray, ULTRASOUM, all
Speaker 2: those things, but we do, and then we can do
Speaker 2: that work up at the home and admit directly to home.
Speaker 2: Patient never leaves their h never leaves the bedside, So
Speaker 2: that's really the difference. And we're one of a handful
Speaker 2: of programs that can actually do that in the country
Speaker 2: because of all the infrastructure that's required to do that
Speaker 2: now hospital systems and we partner with many of them
Speaker 2: across the country. We're better together than a part and
Speaker 2: they understand that we built infrastructure that other people haven't,
Speaker 2: we have technology that other people haven't, and so we
Speaker 2: can integrate with them help them deliver this care. They
Speaker 2: may want to use some of their own staff, they
Speaker 2: may want to use some of our staff, but we
Speaker 2: can work together to decide how to do that as
Speaker 2: long as the clinical quality meets our standards.
Speaker 1: And I think you raised a fundamental component of as
Speaker 1: you raised earlier, the desire to shift to value based healthcare,
Speaker 1: which is focus on not creating that episode of care,
Speaker 1: which is keeping them out of the hospital. And it
Speaker 1: seems like you all are focused on that, and maybe
Speaker 1: the follow up question there is like how do you
Speaker 1: identify those patients so they don't go to the hospital
Speaker 1: and what kinds of patients or what types of patients
Speaker 1: do you regularly see in terms of primary diagnosis.
Speaker 2: Yep, and overall need. So, you know, I and we
Speaker 2: can treat just about anyone, but I say our sweet
Speaker 2: spot are the high medical needs, high social needs patients.
Speaker 2: And just so happens that many of those folks are
Speaker 2: in value based arrangements, and so we spend a lot
Speaker 2: of our time working on educating and catching folks before
Speaker 2: they end up, you know, in the wrong setting. And
Speaker 2: that could be through you know, just their own physicians.
Speaker 2: They're talking to their physician. Use my mom as an example.
Speaker 2: Let's say she has emphysema and let's say she's on
Speaker 2: the phone with her doctors saying, I'm really struggling breathing
Speaker 2: and I think I've had a fever and a cough. Well,
Speaker 2: that's a pretty sick patient potential, especially if she's you know,
Speaker 2: eighty years old. And the work up. You know, doing
Speaker 2: all of that inside a primary care office is almost impossible,
Speaker 2: so typically that patient we get sent to the er. Instead,
Speaker 2: that doc could say, oh, you know what, I have
Speaker 2: a partner, and we do function as an extension of
Speaker 2: a primary care doc. We don't impanel our own patients,
Speaker 2: and so they can say, I have a partner that'll
Speaker 2: come and evaluate you that you know, emphysema, COPD, congestive
Speaker 2: heart failure, pneumonia, complex UTI. The classic medical admission diagnoses
Speaker 2: are our bread and butter and right.
Speaker 1: Up our alley. And so maybe we can talk about
Speaker 1: how it's working right now. You know, there's a couple
Speaker 1: of things that's always needed when and we'll jump into
Speaker 1: this further when we end the conversation, which is the
Speaker 1: policy outlook, because you mentioned the waiver that was initiated
Speaker 1: or in the pandemic and it needs to be extended.
Speaker 1: We'll talk about that. But there's a lot of conversations
Speaker 1: about whether the data is showing that this is successful
Speaker 1: and there's concern or maybe making sure we focus on
Speaker 1: how this is equitable for everybody in terms of you know,
Speaker 1: people this program works for people in certain geographies versus
Speaker 1: it doesn't work well in others making sure that everybody
Speaker 1: has access regardless of where they live, regardless of demographics.
Speaker 1: And so I want to get into kind of the
Speaker 1: data and the health equity and racial disparities discussion that
Speaker 1: it's going to be probably a conversation when Congress looks
Speaker 1: into whether they should be extended or not. And so,
Speaker 1: you know, you said, you know this can work in
Speaker 1: various geographies, but how do kin of some of the
Speaker 1: demographic factors play in to how this can work and
Speaker 1: whether it works? And you know, for example, somebody living
Speaker 1: with a couple of different generations in the same household.
Speaker 1: I guess where I'm trying to go is how do
Speaker 1: we ensure that as many diverse patients as possible benefit
Speaker 1: from the program?
Speaker 2: Yeah, yeah, and we're we're fully in support of that.
Speaker 2: That's exactly you know, back to my comment about high
Speaker 2: medical needs, high social needs patients. That's where we want
Speaker 2: to be. And you know, interesting the way we've approached
Speaker 2: this again, like the waiver. We like the idea. We'll
Speaker 2: talk about that later, but when we get reimbursed, we're
Speaker 2: partnering with managed care plans and some of our earliest
Speaker 2: partners were in Denver and they were managed Medicaid plans,
Speaker 2: and they were pace programs, so dual eligible folks who
Speaker 2: were who were Medicare age but then met criteria for Medicaid.
Speaker 2: And so we've been in you know, homes that aren't
Speaker 2: you know, the fancy suburban home since we started. And
Speaker 2: when we think about is a patient safe for admission?
Speaker 2: We have obviously our clinical checklist, but we also have
Speaker 2: you know, a social checklist. But you'd be surprised how
Speaker 2: short that is. Is the electricity on, is the water
Speaker 2: running right? And if those basic things are there for
Speaker 2: the most part, we can generally deliver care. So I
Speaker 2: would agree with you. I think that's very important that
Speaker 2: we keep this as equitable as possible. I also understand
Speaker 2: the concerns. When I first read about hospital at home.
Speaker 2: You know, I was a bit of a snobby doctor
Speaker 2: who trained in the nineties at UCLA and thought, well,
Speaker 2: only you know, real medical care can happen inside that building.
Speaker 2: I've come to change my tune quite a bit over time,
Speaker 2: but I understand the reticence. I do think it's important
Speaker 2: that as we broaden this, that we are measuring safety
Speaker 2: and quality, and you know, frankly, we're inviting regulation. We're
Speaker 2: in the process of sort of being regulated, and we're
Speaker 2: okay with that.
Speaker 1: So you mentioned the safety and quality aspects. There's been
Speaker 1: some criticism and just going back to how you may
Speaker 1: have looked at this program when you are in the field,
Speaker 1: how do you respond to some of the critics that
Speaker 1: these types of programs essentially we define what care is
Speaker 1: and it's not necessarily for better because maybe there's an
Speaker 1: overreliance on technology and there isn't enough in person care
Speaker 1: that at the end of the day doesn't benefit the patient.
Speaker 1: It seems like you have some experience on both ends
Speaker 1: of this, So how do you respond to some of
Speaker 1: the criticism.
Speaker 2: So here's what we know is that this is done
Speaker 2: at scale in other countries, you know, Australia, New Zealand, Norway.
Speaker 2: So we've got a lot of data. If you look
Speaker 2: at the largest meta analysis of hospital at home, there's
Speaker 2: a twenty percent mortality reduction for admission to the home
Speaker 2: versus the hospital twenty percent. Now, I don't honestly think
Speaker 2: that the number will bear out to be that high,
Speaker 2: but there is something if we do this the right way,
Speaker 2: that is more efficacious delivering care in the home. I
Speaker 2: think the concerns. Yes, let's make sure that we are
Speaker 2: touching the patient as much as possible, but let's continue
Speaker 2: to measure. Let's understand what's gone so well in these
Speaker 2: other countries and try to replicate that, because it looks
Speaker 2: to me, and you know, I'm not the only one,
Speaker 2: that we are getting better clinical outcomes at a lower
Speaker 2: cost with higher satisfaction. You know, there's also a point,
Speaker 2: and I'm not sure if you were going to get there.
Speaker 2: People have brought up the fact that caregivers might be
Speaker 2: burdened in this model. I think that's a legitimate question, right,
Speaker 2: And so what we did, and again it's it's not
Speaker 2: massive numbers, but what we did was we looked at
Speaker 2: the experience of forty four caregivers, right, and these were
Speaker 2: caregivers who's loved one had been both admitted to a
Speaker 2: hospital recently and then admitted to our program in the home.
Speaker 2: And ninety five percent of those caregivers voiced a clear
Speaker 2: preference for our in home model, and overwhelming ninety six
Speaker 2: percent of them cited, you know, a significant decrease in
Speaker 2: their stress levels when managing their loved ones care. So
Speaker 2: I think you got to keep an eye on that.
Speaker 2: But to me, and maybe it's our program or something,
Speaker 2: but it looks like, at least in our experience, that
Speaker 2: the caregivers are pleased with the program.
Speaker 1: So maybe just to connect the dots, and you've probably
Speaker 1: laid this out, like what do you think is behind
Speaker 1: those numbers? And you just say, okay, ninety five percent
Speaker 1: support because it helps them? What is it that helps
Speaker 1: them feel better about this program?
Speaker 2: Yeah, and you know, we talked a little bit about
Speaker 2: equity as well. Our program is highly focused on addressing
Speaker 2: gaps and care, you know, noticing those social determinate differences
Speaker 2: and doing something about it and then frankly, having hard conversations.
Speaker 2: So you know, in the emergency room, I used to
Speaker 2: consider myself pretty good about talking about end of life issues.
Speaker 2: You could imagine that a lot of program, a lot
Speaker 2: of patients in our program are end of life and
Speaker 2: so our providers are highly skilled at this and they
Speaker 2: have thirty days, right, it's not just one day, it's
Speaker 2: not one hour. We develop a relationship by the nature
Speaker 2: of our program that allows us to address that. And
Speaker 2: you know, the goals of care are changing almost twenty
Speaker 2: percent of the time a patient's understanding of their disease
Speaker 2: at the beginning versus the end. Do I really want
Speaker 2: to be resuscitated? You know, having those tough discussions, even
Speaker 2: enrollment in hospice and palliative care, I think that's like
Speaker 2: seven or eight percent of time when we admit our patients.
Speaker 2: So I think that's some of it. You know. It's
Speaker 2: not that other programs don't do that as well, but
Speaker 2: that's been a focus of ours.
Speaker 1: And so yeah, you mentioned some pretty good data points
Speaker 1: about how this is working and how it's working for
Speaker 1: you all, and there's going to be a big debate,
Speaker 1: and I think you mentioned earlier. You know, it seems
Speaker 1: like you all are doing this apart from the hospital
Speaker 1: home waiver, which again was started during the pandemic. It
Speaker 1: set to expire at the end of twenty twenty two,
Speaker 1: but it is now extended to the end of of
Speaker 1: twenty twenty four. It doesn't seem like maybe I should
Speaker 1: just ask the question of rgin your mouth, but does
Speaker 1: your business model rely on Congress extending the waiver again?
Speaker 1: And you know, regardless of the answer, you know, are
Speaker 1: you confident that that Congress will extend the waiver?
Speaker 2: So you know, our model does not require extension of
Speaker 2: the waiver to continue, So there's that. That said, we
Speaker 2: work with several hospital partners to help them deliver the
Speaker 2: waiver right, and I think collectively we're actually better. I
Speaker 2: am all for for extension, extension of the waiver, and
Speaker 2: you know, I can't really predict this, but it seems
Speaker 2: to me like it's it's low risk, and I think
Speaker 2: we just need more time and data right this. You know,
Speaker 2: if we had an extension for five years, that gives
Speaker 2: us more time, data and you know these every time
Speaker 2: you admit a patient. The way the work waiver works today,
Speaker 2: you're you're sending in your case, right, You're letting CMS
Speaker 2: know how you did. So this isn't a black hole.
Speaker 2: This is very transparent what's going on. And I think
Speaker 2: if we can get you know, ten twenty thirty thousand
Speaker 2: of these admissions, were really going to know how safe
Speaker 2: this is. So that's why I would completely encourage extension
Speaker 2: of the waiver.
Speaker 1: So let me then talk about this aspect. And you mentioned,
Speaker 1: you know, if we can extend the waiver for say
Speaker 1: five years, you know, we get these additional data points.
Speaker 1: And one of the things that I've heard Metpack Medicares
Speaker 1: Payment Advisory Committee took up this topic in one of
Speaker 1: their sessions, may have in March of this year, but
Speaker 1: at this point, at some point this year, it was discussed,
Speaker 1: and one of the things that were topics that came
Speaker 1: up was, well, hospital at home or this care at
Speaker 1: home should we be thinking about whether the reimbursement model changes,
Speaker 1: because you know, it's my understanding that the payment rates,
Speaker 1: the reimbursement rates are all the same for care that's
Speaker 1: in a theoretically lower cost setting. Is that a concern
Speaker 1: for you or the industry that Congress could come in
Speaker 1: and say, or maybe the administration say, you know, we're
Speaker 1: going to make this a two tiered approach. If we're
Speaker 1: talking about care at the home, for these hospital level services,
Speaker 1: we should have a different reimbursement level. What goes through
Speaker 1: your mind when you hear.
Speaker 2: Something like that, Well, the first thing is that you know,
Speaker 2: we didn't build this company without the concept of the
Speaker 2: quadruple aim in mind. Right, we believe that what we
Speaker 2: should what we are doing should improve provider and patient
Speaker 2: satisfactor and improve outcomes but lower cost. Right, And so
Speaker 2: I'm not opposed to those conversations, right, I don't have
Speaker 2: to pay for an on call neurosurgeon. I don't have
Speaker 2: the certain you know, the debt service of the brick
Speaker 2: and mortar like all of that. Right, So, I think,
Speaker 2: you know, we've been able to demonstrate on average five
Speaker 2: to seven thousand dollars of savings per admission in our model.
Speaker 2: And that has to do with some of those readmission reductions.
Speaker 2: It has to do with a few other things the
Speaker 2: way we've you know, set the reimbursement. But I think,
Speaker 2: you know, a bottom's up, look, that's fair because you
Speaker 2: want to incentivize this, right, I think that's perfectly reasonable.
Speaker 1: I think i'd be surprised if there are major changes.
Speaker 1: You know, Congress is bogged down on a number of things.
Speaker 1: I think we'll get to the end of the year
Speaker 1: and we'll probably see a date change for a couple
Speaker 1: of years. I don't know if that's three or five years,
Speaker 1: but I'd be shocked if at the end of the
Speaker 1: day this program does not get extended. But I will
Speaker 1: say this, you know, as we look ahead, as somebody
Speaker 1: who started a program from scratch and has grown into
Speaker 1: what it is now. You know, one of the things
Speaker 1: I like to ask our guests about some of these
Speaker 1: policy questions. Is well, look in your crystal ball and
Speaker 1: not just tell us what's going to happen in five years.
Speaker 1: But you'll be disappointed in five years if something happens
Speaker 1: or something doesn't happen. So let me ask you this
Speaker 1: fast forward five years. You'll be disappointed if.
Speaker 2: Well, I hate to admit this, but I'm I'm running
Speaker 2: up on Medicare age myself. So I would hate it
Speaker 2: if I couldn't get this care because I've seen how
Speaker 2: beneficial it is. I would hate it that if at
Speaker 2: that time I need an europe placement, that I have
Speaker 2: to still go to a rehab facility or skilled nursing facility.
Speaker 2: I can't rehab in my home, So that's what I
Speaker 2: would hate.
Speaker 1: Let me wrap up with this question. You know, as
Speaker 1: again somebody who started out in the field and now
Speaker 1: leads this organization and has this focus on how we
Speaker 1: deliver care and innovating how we deliver care. You know,
Speaker 1: what's a life lesson you share with your your team,
Speaker 1: your family, What's something that drives you and how you
Speaker 1: ouperate your personal or business life.
Speaker 2: Interesting. I'm terrible at these questions, but you know I
Speaker 2: do tell my kids, and I tell you know, some
Speaker 2: folks that I talk to, if I notice they're a
Speaker 2: creative and a leader, right, and you know who you
Speaker 2: are right when you're both of those things, I always
Speaker 2: encourage them to stay authentic, right, stay weird. The people
Speaker 2: who matter really appreciate that, and that's going to get
Speaker 2: you far. Real transformational ideas. They're not dreamed up by
Speaker 2: a bunch of stiffs with spreadsheets. Right. You're you're the future,
Speaker 2: and we need you to enact your dreams and vision.
Speaker 2: So have the guts to go do what you believe.
Speaker 1: You know it's say, based on this conversation you've used,
Speaker 1: it seems like you've used your experience to build something
Speaker 1: that is going to be part of how we look
Speaker 1: at healthcare. And to your point, you know in five
Speaker 1: years you'll be disappointed if that may ultimately be a
Speaker 1: lasting change and how we deliver healthcare. But you know
Speaker 1: that's not for me to decide, and we'll see how
Speaker 1: this Congress will see how the data comes in and
Speaker 1: what it means for these types of programs and how
Speaker 1: this moves forward. So I think that has been very
Speaker 1: helpful for me that help me understand what it is
Speaker 1: we're talking about, and I think that's a good place
Speaker 1: to wrap up this episode of Boots and Verdicts. Mark,
Speaker 1: thank you for joining us today and you have a
Speaker 1: lot on your plate and I appreciate you taking the
Speaker 1: time to talk with us, and thank you all for
Speaker 1: listening and for joining us. As a reminder, you can
Speaker 1: read all of our BI research on the Bloomberg terminal
Speaker 1: at BI go. Once again, thanks for listening, and you
Speaker 1: have a great day.