The Future of Healthcare at Home: Insights from Carl Brodarick, Senior Vice President of Managed Care Contracting and Hospice Development at AccentCare

[00:00:01] This podcast is produced by Outcomes Rocket, your healthcare exclusive digital marketing agency. Outcomes Rocket exists to help healthcare organizations like yours to maximize their impact and accelerate growth. Visit outcomesrocket.com or text us at 312-224-9945.

[00:00:29] Welcome to the Chalk Talk Gym Podcast, where we explore insights into healthcare that help uncover new opportunities for growth and success. I'm your host, Jim Jordan.

[00:00:47] Welcome to today's episode of Chalk Talk Gym. We're thrilled to host Carl Brodarick, a seasoned expert in managed care and hospice development with 18 years of experience in hospice, home health, palliative care and personal care services.

[00:01:01] As a Senior VP of Managed Care and Hospice Development at AxonCare, which is a $3 billion provider enabling healthcare across 31 states, Carl is going to share with us his insights into care coordination, value-based partnerships and innovations in home and community-based care. In this episode, he delves into healthcare innovation and business evolution around the themes of Medicare Advantage, hospice and the intricacies of managed care contracting.

[00:01:29] We explore how Carl's leadership is shaping the future of healthcare delivery for patients and providers. So, Carl, tell me in the audience a bit more about your path into driving change in home and the healthcare community. James, thank you very much. So, my title right now is Senior Vice President of Managed Care Contracting and Hospice Development with AxonCare, Inc. And prior to AxonCare, I was with Seasons Hospice and Palliative Care, where I was a chief marketing officer.

[00:01:57] AxonCare acquired Seasons almost three years ago to the date, just short of a few days, and transitioned into a little similar role. But we brought in a growth officer who's fantastic. And I morphed over to the managed care side of things because I'd always had that responsibility. So, I'm coming up on 18 years this April in both these organizations. As one of my colleagues had left the organization who oversaw the hospice development sales for hospice, I took on both those capacities.

[00:02:25] I've since brought in a VP of managed care contracting, but still have oversight into that. And prior to that, I'd been in managed care contracting type roles, census development roles within post-acute, within nursing homes, and prior to that, hospitals. So, I'd love to hear about how your organization fits within healthcare. And I think I need to, given how broad your company is, I think if we start at the company level first, we can talk about the segments that they're in and then just talk about your role specifically.

[00:02:54] But why don't we start out, you've got hospice, you've got managed care contracts for hospice, you've got home care. What else does your company do? We have three distinct divisions. So, we have traditional skilled home care, home health, and then we have hospice, and we have palliative care, which we provide through physicians and nurse practitioners, but it's part of the benefit, if you will, but also it's different than the benefit. And then lastly, personal care services.

[00:03:23] So, we provide at-home services. Some of these are compensated by Medicare Advantage programs, some by Medicaid, and some by private funds. So, three distinct service lines within the organization. And our goal is to, in our marketplaces, for the most part we do, to overlay all three services.

[00:03:44] So, if a patient is entering into home health and they might not be able to, if you will, get better, we're there to support them with maybe with just personal care services at the time. And then if the person would be eligible for hospice, we'll have that conversation with them. So, the timing of our discussion is really interesting to me because literally my last podcast was with the home care industry, focused on the personal assistance kind of support.

[00:04:10] And what struck me, it's a $6.3 billion business with the average company being $1.7 million. So, it's a lot of small companies. So, with the size of your company putting all those together, are you one of the biggest in the marketplace doing this right now? Yes, we're the biggest privately held organization. And I think we rate, if you will, in companies of our service line, I think we're the third or fourth largest. There's companies that just specialize in hospice, some with just home care, but I think we're the third or fourth.

[00:04:39] Holly might have the statistics on that. But we're a relatively large, I shouldn't say relative, we're in 31 states and have expansion plans, or responsible expansion plans for next year or two. Wow, that's wonderful. It certainly, from that interview, it seemed to me that we needed to have some skilled professional organizations moving into this area to help sort of get best practices. So, let's talk about your role specifically.

[00:05:06] Can you describe what managed care contracting is and how does it fit within your organization? Sure. It's incredibly important because as we see the Medicare market transition, since I joined Seasons, it's gone from about a 22% penetration rate for Medicare recipients in Medicare Advantage programs.

[00:05:30] Now, it's up to 51% of the Medicare market is in Medicare Advantage programs, and we're projecting it to go to 60% by in the next nine years. So, when it goes to a Medicare Advantage program, our home health has to have contracts with those Medicare Advantage companies, United, Cigna, Aetna, Humana, companies of that nature. So, contracting is a critical portion of the component of our business.

[00:05:56] Now, hospice is different when a patient who's on a Medicare Advantage program and they go to hospice, they opt out of the Medicare Advantage program and go to the Medicare Hospice Benefit. Now, there are certain CMS programs that have developed over the years which are allowing agencies to become, if you will, the payer.

[00:06:18] There's REACH ACO programs, which the government created under, I believe it was 2020 with the Biden administration. And REACH, why the term REACH? REACH is realizing equity, access, and community health, accountable care organizations. So, organization has multiple contracts for hospice with REACH ACOs and multiple contracts for home health with multiple REACH ACO programs.

[00:06:46] So, the component of contracting is critically important to us as an organization to ensure that patients who just don't have Medicare, because Medicare has very clear-cut payment guidelines for home health and for hospice, and even palliative care if it's a Part B that's done by a nurse practitioner or doctor. So, oftentimes, that's where the negotiation process goes in for both of those service lines.

[00:07:13] I will say, though, that there is more of a focus on home health because a larger portion of our population needs contracts versus hospice, which is a much less we need the contracts for. Because, as I said prior, when a patient's on Medicare Advantage, they opt out of the program and go to the Medicare Hospice Benefit. So, if you're on a Medicare Advantage program, we don't. We, be it, Accent Care or any hospice need a contract with that agency.

[00:07:40] There are a couple of other instances called BBID programs, value-based insurance design, formulated by CMS, where we need to contract with the insurance company. They haven't grown as much as I think the thought was by CMS, but we still have some value-based insurance design contracts. We contract with the insurance company for the hospice program. And the thought process is, it's a demonstration project to see if there's value in doing this through insurance companies

[00:08:10] instead of CMS or Medicare to get reimbursed for. Do you get involved in the PACE program, which is the program of all-inclusive care for elderly, I think is what it stands for? Is that still it? Yes. So, in order for us to receive a patient, whatever service line, we need to have a contract with the PACE program. So, we contract with PACE programs around the country for our services. Excellent. Okay. It sounded like the PACE program and I was kind of curious. So, as you look out at this space, as I was characterizing earlier,

[00:08:37] it's space right now that it's not terribly consolidated yet, right? There's still a lot of little players, which has its advantages. But obviously, when you think about negotiating contracts like you're doing, that takes a lot of work and a lot of effort. What challenges is your organization facing as you look at these products and services matching the future? I think, as you brought up the amount of companies that are out there, there's a lot of, I would say, small companies who are just so happy to get a contract with ABC Insurance Company

[00:09:07] that they don't really understand the financial parameters of those contracts. Oftentimes, we've gone to a company and said, this is only 60% of the Medicare rate. We can't do business like this. And what we hear is, well, the market rate is this. Well, the market rate is what you have agreed to with other companies. So, it is difficult when you have so many competitors out there to under, and we're a sophisticated organization with systems and data systems that can produce results.

[00:09:36] We're willing to talk about add-on bonuses for ourselves on readmissions or ER diversions. But when you get flooded with so many different agencies, and more or less in home health, it becomes a little bit difficult to have what I would call responsible discussions with the insurance companies. And oftentimes, we're dealing with insurance companies. We're dealing with the provider relations who only deal with non-acute, which almost operates within a silo within the insurance company themselves.

[00:10:05] What's most important to an insurance company is their hospital contracts and their physician contracts. But the thing that is frustrating is the post-acute world that we represent, that Accent Care does a really good job with, is we can save the most money for the healthcare system when patients were eligible for our home health services or our hospice services

[00:10:31] or palliative care services or our personal care services is utilized more versus a trip to the hospital or a trip to the emergency room. We can keep people out of the hospital and where our discussions are with insurance companies. And we try to educate accordingly that we're willing to take on, if you will, risk to show you the good work we can do as an organization because we have the resources built up over time

[00:11:01] to keep people healthy and keep people out of the hospital. And when I say that, especially the latter form of that, what we learned during the pandemic, James, people do not want to be in the hospital. I think most people don't want to be in the hospital for anything unless you have a serious injury, but we want to keep people out of the hospital. I've seen, though, that there is a movement, albeit slower than I would like, with insurance companies to talk about, okay, let's talk about a bonus, if you will, if you meet these certain thresholds.

[00:11:30] So that is encouraging. It's not going as fast as we would like, but it's at least encouraging from some of the bigger payers out there that are engaging us in those lines. Have you heard of the concept of health care at home? You start seeing some small physician groups and some small groups starting to talk about it. And I haven't really found anybody that has had their proper scope of understanding what that model is. Well, yes. And there's also skilled nursing at home, too, nursing at home.

[00:12:00] And there's multiple companies out there who are really looking, and this is Carl Broderick speaking, James. So this is, you know, you could take that for what it's worth. But when you look at the Medicare population, you look at the 5% that consumes 50% of the resources. So that 5% of the people you're looking at, how can you engage that 5% to manage them at home, to keep them out of the emergency room, take a look at certain, if you will, drug therapies,

[00:12:28] but keep them at home along with monitoring along those lines, as opposed to coming into the hospital. We see so many people in our country utilizing emergency rooms as their doctor offices, which is incredibly inefficient. So yes, we've heard of that. We have high acuity programs at Accent Care that we work with in certain regions of companies. So we will take high acuity and we will work with, and in some instances, payers to target specific communities.

[00:12:56] So can you share with us maybe a time where you had to shift or adapt your strategy quickly? Clearly, there was an acquisition in your life, but anything else that you could give some advice on? Well, I think, I guess, with managed care contracting, it is the ability to secure a contractual agreement, but also walk away from one. Is there an opportunity to have a fair rate put on the table? And we might have to walk away. So I'm not sure that addresses per se your question, James.

[00:13:25] But in contracting, it's very, we can't agree to terms that don't make financial sense, just as a hospital wouldn't. Well, we've seen it in many areas of the country where hospitals will terminate an agreement with a large insurance company. Generally, they get back together. It's almost like a marriage. They separate and then they reconcile. But with our services, we know what we do from a metric perspective, and we know what we can do from a deliverable metric perspective, and we can provide this, this, and this,

[00:13:55] and it's going to save money throughout the process. So we have to be financially engaged so it makes sense for us. Now, again, from a hospice perspective, one of the things that we have done well is move into palliative care. So if you think about palliative care, it's really to work at the patient's pain. And if a patient isn't eligible for hospice, sometimes they can go on our palliative care programs if they choose to. We have palliative care.

[00:14:24] We actually do palliative care in hospitals for hospitals. We do palliative care in nursing homes and assisted livings. We have clinics associated with hospitals as well too. And we work with these entities. And if the patient is in need of hospice services and is more importantly eligible, for those hospice benefit, because we don't admit anybody unless they're eligible for the Medicare hospice benefit, then we have the discussion with the patient. Because palliative care traditionally is you might visit that patient

[00:14:53] or see that patient outside of the hospital maybe once or usually twice a month. Hospice, if they're eligible for it, is a much more enrichment program. And there's a whole interdisciplinary team. We have music therapists, obviously nurses. We have social workers. We have hospice aides, chaplains, volunteers. There's a whole range of service lines that we're seeing people on an ongoing basis. Now, do you have the physical facilities for hospice care or are you contracted in to manage them?

[00:15:23] So hospice isn't a place, right? Hospice is most of our patients. And I think it's pretty safe to say most of the nation's hospice patients are either in their home, in a nursing home, or assisted living. Now, we have 16, soon to be 17, inpatient centers where patients who meet the highest level of care need, which is the general inpatient level of care, can access. We have these in several hospitals. We have several freestanding hospitals.

[00:15:52] And these are small entities. We're waiting on licensure of one of our newest ones in Miami-Dade, county of Miami-Dade. And it's 14 beds. But these are for high-acuity patients that come to us from a hospital, or they could actually be one of our current patients who needs a higher level of care. It could be an exasperation of pain. Patients coming from hospitals could actually be on a ventilator. They could be on dibutamine drips. So those are the sites we have.

[00:16:20] But most of hospice is delivered in whatever the patient resides in, their residence. I don't know how many of our listeners have had, I don't want to say, an opportunity to have a family member in hospice because it's not an opportunity. But having to use an inpatient hospice center, it really is a relief for the caregiver so that they can, and the family, spend the last moments together being that, as opposed to being so concerned about caregiving and time. And it's just, for those who have gone through it,

[00:16:49] it's just an amazing, amazing gift. Now, James, I couldn't agree with you more. And I just, as you said that, I always go back to, you know, when my mother was on our program for a while, we had to take her off because she didn't meet medical necessity for the hospice benefit. And then she had an event six months later and she was placed at one of our inpatient centers and died there in three days. I'm in this industry for 18 years and I still think about it and I get emotional about it because the care that was delivered to her there through the interdisciplinary team and the comfort

[00:17:18] and how they brought our family together to be around my mother in her last days is significant. And I think it is a gift to have that level of care. Yeah, it really is a gift. Wow. Well, I'm sorry to hear that about your mother. Right, well, it happens. And you realize that it becomes a loving, peaceful moment. And so many times, even friends of mine that have been in this situation, you know, the funeral, the hospice workers are showing up. They're quite a dedicated group of people. Now, when you look at your personal care services

[00:17:47] or your home health care, how do you work telehealth into that at all? Is there any systems as being a bigger company that you deploy that maybe smaller companies don't have? Yes, we definitely have a telehealth process in place, if you will. And I want to set this up in the right manner because we have a number of joint ventures with healthcare systems around the company. The healthcare systems bring us in because of our expertise working with the home health hospice populations. Some are home health JVs, some are hospice.

[00:18:16] But when we work with their care departments, and really is trying to keep the patient in the best level of care possible, which is traditionally what they want is the home. What our telehealth monitoring is doing is to checking in with the patient. Are you taking your medicine? Personal care services can't administer medicines. We have to be cognizant of that. We're not going to suggest they're doing that. But when we have patients on, and it's just not our joint ventures, we're checking in to see, has anything changed?

[00:18:46] Are you taking your medications? If there's any monitoring going on, can we discuss that? And do we need to send somebody else out there sooner than the scheduled visit? We found that with the telehealth visits, we were able to, from our resource perspective, be able to keep people. We've reduced hospitalizations internally from what it used to be. So it is a tremendous opportunity for our patients and their families, and also our clinicians. We're using the resources wisely and making sure that the patient could stay in their home. And you know, it's funny.

[00:19:15] People hear the word telehealth and they think of technology, which leads them to think unpersonal. But the fact of the matter is that you can build models where you create a connection to the patient and a compliance because of that connection that you wouldn't give elsewise. I was involved in a McKesson. I worked for McKesson as a senior VP at one point in my career. And they had a congestive heart failure model. And the nurses figured out on their own that they would work in teams should one of them be out.

[00:19:44] And they had, I think it was five to seven minutes to collect the information. And the patients realized that if they were compliant, there was two minutes to report out and five minutes of chit-chat. And it became a statistically relevant component of the program of creating intimacy and compliance. And the pharmacists, obviously McKesson, Marisos, Bergenov, a ton of pharmacists, came in and analyzed the data. And they couldn't believe the results of how that personal aspect came and brought things forward. That's fantastic. So when you think about it,

[00:20:14] I apologize for interrupting you, but when you think about it, especially we see a lot of people in their homes who are isolated. And having that touch and even a phone call, knowing that your caregiver is worried about you and is thinking about you is significant. I think it goes to what you said about your model with McKesson. I think it's very significant. And I think our healthcare system has gotten very technical. And it is, I think, the more human touches we can make, the better.

[00:20:43] So you've been in this business for a long time. And as you've gotten acquired, you're in these other segments that are four or five segments that are growing. How do you keep current on all the rapid changes, not only from a legal regulatory perspective, just market perspective and new techniques and new operations and new technology in all these areas? Well, that assumes that I am. But, you know, I try to read as much publications in our industry as possible. So I get five or six a day and trying to continually be updated.

[00:21:12] I find that almost is better, that's better for me than it is to go to a conference. Conferences are, I usually go to one a year, but I find just the act of reading the cycles to be very informative. And I also will follow a lot of publicly traded companies quarterly results. I see that, I understand that there's a certain language spoken there, but to understand what is happening with competitors and seeing what they're doing to work in their environment. And using the managed care contracting as example,

[00:21:42] many of the things that I'm experiencing, I read almost daily that other large companies are experiencing as well too, trying to get fair rates, at times walking away from things. So I spend a significant amount of time reading, and I find that to be useful to me to understand what's going on. How much time do you spend reading a day? On the field itself, it's about 45 minutes. Yeah, it's amazing talking to executives such as yourself. People are easily spending an hour a day in the morning or at night. When do you do it? Do it first thing. Yeah.

[00:22:11] And I can hear the audience asking me, you're not asking him, what are the sources that he reads? So what are the magazines that you were talking about or the places? Well, there's some specially, Home Healthcare News has a, and I forget if that's the right title, Becker's is like some easy reads. There's easy reads with Modern Healthcare. There's actually, Crain's does some good things in healthcare as well too. I have some, I'm going to make, I apologize, is it HealthExec? It's a subscription to that.

[00:22:38] And they do some incredible detailed research, which sometimes I find extremely useful. And then just some of the data points, when I say reading, looking at the data that comes in is significant as well too. And that's external data that I get with some of our managed care resources, the Mark Farah data, and things of that nature, which are very helpful to provide a strategy to what we do. So as you look back at your career, what's the biggest lesson that you've learned on this journey?

[00:23:08] Well, the biggest lesson is always follow the dollar. And what I mean by that is not personally, but following the dollar will tell you why things operate the way they do. When DRGs, diagnostic related groups, were put into effect in 1983, length of stay was very long in hospitals. Someone told me it was 28 days. I'm not sure that's right, but it was clearly more like 15. Now it's five days. Why? Because the hospitals get paid this lump sum. So hospitals have figured out a way

[00:23:38] to utilize that money to safely, that's the goal, safely discharge a patient. Otherwise they get reimbursed less if the patient gets readmitted. So if you look at Medicare Advantage, per member, per month, or late payment system to them, they're at total risk for their patients. You have to understand that when you contract with them, when you work with them on any capacity. So once you understand where the dollar ends, so to speak, that's where you can find

[00:24:06] the necessary working points to develop a clinical referral relationship. Because if you treat their dollar like it's your dollar, generally speaking, organizations will want to work with you. Yeah, I work with a lot of startups who don't know that lesson. They'll talk about the dollar and then you'll realize another person in the value chain is in control of 70 cents of that dollar and it's not a good business model. That's where you go to that, that's where you want to be. So looking on the future of healthcare,

[00:24:36] what do you see as the biggest opportunity for growth or threat? Well, I'm going to start with a, I'm not sure if it's a threat, but I find it fascinating that insurance companies are vertically integrated at the rate they are with their own home health, with their own hospice, with their own physician practices. I'm not telling you that's right or wrong. I'm not judging it, but I think that's changing the landscape of healthcare. I think that when you have the ability, when you have the responsibility

[00:25:05] to pay for things, you're much wiser with how you use your resources. It's no different than companies that have their own insurance plans and we have to pay for it like JacksonCare does and Medicare, well, I got Medicare, I'm just going to go wherever I want to. So I think those dynamics are an interesting development in terms of where the healthcare organizations are going in the company. I think 60% of our people, Medicare recipients, on Medicare Advantage,

[00:25:34] I don't know if I have a crystal ball for that, but what I see happening is we're going to see a prolification of services that continually try to address the high-risk patients and try to look at how to use our limited healthcare resources to take care of that 5% that eats up 50% of the dollar. So in terms of a vision for things, I think that our systems are all going to be needed, but I still believe that evolution-wise, we're going to see more acuity

[00:26:03] in our nursing homes. They're going to replace hospital days. I think we're going to see more involvement by delegated risk providers who are managing those Medicare Advantage lives, working within and utilizing the post-acute network more with the goal of post-acute getting paid better than what some of our contracts are today. So I'm not sure if I answered that question, James, because I often get into this cycle of we have to get paid better. So I apologize. So what do you say that takes the opportunity?

[00:26:32] Well, I think one of the things is I feel blessed that we're this size. I really do because it affords us the opportunity. I mean, we have joint ventures with some of the more significant healthcare systems in the country, UCLA, UCSD, Memorial Hermann, Baylor Scott and White. I've got three or four more just to talk through, but it allows us the opportunity to work with systems and it elevates us to some degree because we're having these conversations because we do this

[00:27:01] on a day-to-day basis how we can solve your problems. And your problems being get the patient out, get them home, take care of them and make sure that they stay out of the hospital. So I'm really excited about how we look at systems per se. I think we have the necessary tools to maneuver even as big as we are. We can do the same things in a market like Houston, Texas and in Miami, but we can also do it up in Amarillo, Texas as well too or Sacramento, California

[00:27:30] because we can customize our approaches to what the healthcare market needs at that time. That's what I feel good about and that's the beauty of post-acute care. You're not limited by a hospital. Once you build a $2 billion hospital, you're there. We, because we're field operations, we can always be in our laboratories working with MD at home, if you will, or working with an insurance company who wants a skilled nursing replacement program at home so we can work at these things

[00:27:59] and that's the exciting part to branch out and kind of push the care continuum out a little bit farther. Well, that's fantastic. Anything else you'd love to share with the audience? I would say to your audience, I hope that the holidays are wonderful. I would say to you that if you have a loved one in need of home health or hospice, please reach out to them. Obviously, reach out to Exit Care, but it's the best thing you could do is work within the system of healthcare to reach out to the things that you need. Keep your loved one at home if at all possible. And the other thing I would say, James,

[00:28:29] is always be in control of your healthcare. Don't be a passenger. Be the driver. Ask questions, ask questions, and ask questions. That's what people need to do with Exit Care and we need to provide you answers because our area has gotten much more complicated, as you said, and we just need to make sure that our patients and families understand what's going to happen to them and that communication will make for a better patient experience. And given that you are in 30 states, I just, maybe I'll do my own plug for your website. If you go

[00:28:57] careers.accentcare.com, you have an amazing website, I think, for being able to search for jobs. I had just gone on. Yeah, so I had just gone on and I searched what's going on in Pittsburgh, what's going on in St. Louis, and all these jobs come up. So I would just share that, you know, you have triage nurses and recruitment management and hospice operations and visiting physicians. So there's a ton of different people that you guys are looking for and I think the website's what we're going to do. And there's a ton of opportunities here that we've

[00:29:27] promoted so many people within. Most of the folks who report to me have been promoted within. It has a tremendous track record of developing leadership programs and we have, we just developed a leadership program for my folks. So really excited about that. A tremendous thought process in how we try to retain our folks. So thanks for the plug there because I do think it's a tremendous organization to work for. Yeah, congratulations. Well, thanks again for being a guest. We learned a lot and look forward to talking again in the future. Thank you, James. You have a great holiday season.

[00:29:57] Take care. Thanks for tuning in to the Chalk Talk Gym podcast. For resources, show notes, and ways to get in touch, visit us at chalktalkgym.com. This podcast is produced by Outcomes Rocket, your healthcare exclusive

[00:30:26] digital marketing agency. Outcomes Rocket exists to help healthcare organizations like yours to maximize their impact and accelerate growth. Visit outcomesrocket.com or text us at 312-224-9945. Thank you.