This transcript is auto generated
00;00;05;01 - 00;00;26;07
Meg Pekarske
Hello and welcome to Hospice Insights: The Law and Beyond where we connect you to what matters in the ever changing world of hospice and palliative care. What’s Good and Bad in Hospice Right Now: A Conversation With Greg Grabowski, a partner at Hospice Advisors. Greg, I was so excited for you to be here. Thank you for taking the time.
00;00;27;10 - 00;00;47;13
Greg Grabowski
I am immensely humbled by the opportunity to have this kind of crazy conversation. Well, it's not crazy, but I'm excited to have this conversation. Yeah. And I listen to all your podcast webcasts, and, yeah, I'm honored to be part of all the different folks that have been on this course. Thank you.
00;00;47;28 - 00;01;12;07
Meg Pekarske
This is super fun. And I when I was writing up our little blurb describing it, I was like, it just it just like I was in flow because I was like, this is going to be so much fun. I used exclamation points in my description, so thank you. And I better bat around a lot of ideas and it's like, we should just record this.
00;01;12;13 - 00;01;40;03
Meg Pekarske
This is genius, right? So here we are. So for our listeners, here, when we were preparing for this, I, I said, Greg, would you be game for coming up with a list your list top five of what's good and bad. I'll come up with my app list and then we'll compare notes. But I don't know what's on Greg's top five of good things and bad things.
00;01;40;03 - 00;01;50;18
Meg Pekarske
And so it will be I'm fascinated to know if they're going to match up or, you know, we're going to be widely I mean, there's there's a lot to say on that subject.
00;01;50;18 - 00;01;56;05
Greg Grabowski
So that's like is there is there is. Let's launch it. All right. You want to go first?
00;01;56;23 - 00;02;18;11
Meg Pekarske
I am going to go well, I'm going to have you go first. But I think we should start because, you know, I'm an optimist, a glass half full kind of gal, though, that start out with something that's good and hospice right now because all we talk about is bad things or maybe it's just because I'm a lawyer, but.
00;02;18;11 - 00;02;42;07
Greg Grabowski
Oh, well, and I think I think actually the things that are bad, we might even say they're challenging, we're trying to improve upon or we're discovering that we need to do better. So I think we can kind of put that optimism spin on that side. So, well, let's let's start out with something that's actually the hospice industry on their very positive side.
00;02;42;23 - 00;03;24;20
Greg Grabowski
We have seen consistent utilization, you know, so. Right, this is like the same as great great minds think alike. So we've seen great utilization, I think referral sources and let's let's say referral sources, I like to call them our customers are they understand and know hospice. So when you look at all the market segments and people that can refer, we have done a great job working with them related to utilization and I don't want to get into improvement, but I think with consumers we just need to continue to work with referral sources and I got that on my other list that need to improve.
00;03;24;20 - 00;03;26;27
Greg Grabowski
So yeah, well that's too funny that we're on the same.
00;03;26;27 - 00;03;57;23
Meg Pekarske
That is my very first one. I say utilization steadily growing. We're mainstream nearly 50% now because I just did a board presentation and so I did the snapshot of what had hospice looked like in 2000. What does that look like now and what is it going to look like five years and being utilized? Asian has been going up but it's not it's more, you know, increases in utilization.
00;03;58;01 - 00;04;14;27
Meg Pekarske
You know I don't know if it's ever going to be like 70%. And partly that's just, you know, how people die. I mean, people can die in accidents or, you know, very suddenly there isn't an opportunity. But but yeah. So. Oh, wow.
00;04;15;21 - 00;04;38;14
Greg Grabowski
Well, let me tell you what I would to tell you one really interesting thing. So so I've been a little bit on the speaking circuit with funeral directors, and funeral directors don't really understand hospice and interestingly enough, when I point out utilization to funeral homes, kind of their drawer kind of opens up and they go, wow, why are we not talking to funeral homes?
00;04;39;00 - 00;05;08;24
Greg Grabowski
And I tell them the story that I said, do you realize, you know, the hospice benefit late seventies we're talking about, it comes into being late seventies, early eighties. We get the Medicare hospice benefit and then hospice launched and basically launches in after this point. Lots of conversations with referral sources like we fought to be understood, like think about how funky like we wrote legislation that said volunteer need to be involved.
00;05;09;09 - 00;05;30;25
Greg Grabowski
You have to do bereavement for 13 months. I mean, these are kind of counter culture almost kind of came out of the seventies feel when I tell I tell the funeral directors how hard are you fighting upstream and trying to understand the hospice industry like hospice tried to get the general continuum of care to understand and so on, so forth.
00;05;30;25 - 00;05;54;19
Greg Grabowski
And so, you know, there is some applause for hospice, really rallying with their passion, their why and so on, so forth upstream. I mean, it is more readily accepted. Think about, you know, it wasn't that long ago where you juxtapose that to like funeral directors who pretty much have bones to pick with hospice and are not as excited to work with hospice and so forth.
00;05;54;19 - 00;06;00;26
Greg Grabowski
So I just think from an industry perspective, it's great on how we have. Butch, to your point. I think it's a it's a positive. That's a positive.
00;06;01;02 - 00;06;25;24
Meg Pekarske
It's so funny. You bring back, you know, our roots because I'm going to then shift to something that's not by bad list, which is I and it's the fear that I have had for some time now is just that the unbundling of our service. And so the things that make us really unique, I feel like we're going to lose.
00;06;25;24 - 00;06;53;14
Meg Pekarske
So this more social model of health care where like you do have this volunteer requirement and bereavement and these things that are not medical and spiritual counseling like that as we get more like it mainstream and as a byproduct of getting more mainstream, are we I mean, we've seen that with ACA payments like well, it's only the nurse and social worker that can count.
00;06;53;14 - 00;07;22;08
Meg Pekarske
Like you call in that chaplain the last seven days of life. That doesn't matter. I mean, and then obviously we're elevating more and more the role of the physician and all the stuff. But as we move to this, is is the benefit going to look more like home health but for terminally ill people, because it really is just about the nursing visits and the physician and and especially this gets to something else on my list.
00;07;22;24 - 00;07;46;14
Meg Pekarske
I do think that there is significant reform that's going to happen to the benefit and that but what's going to get cut out? Because I think that sort of I'm a child of the seventies, so all of you know, we're spinning off the sixties. And this part a different way of viewing what someone needs at the end of their life.
00;07;46;14 - 00;07;59;12
Meg Pekarske
And so that's something that I feel is getting and could get lost into the future. So I'm I think that that's that's a bad thing on my list.
00;07;59;12 - 00;08;40;22
Greg Grabowski
I, I couldn't agree with you more. And you know, what's actually kind of fascinating to the counter to that is, is that when you look at kind of some of the successful hospices that really have grown now, there's growth because of acquisition and footprint and stuff. So take that out of the equation for a second. But when you look at some of the hospices that have been very successful, to your point, they have really embraced volunteerism in and not just volunteers for volunteer sake, but volunteers doing memory bearers and quilts and reading to patients in mass program, the massive volunteer programs that are, you know, very successful.
00;08;40;22 - 00;09;02;11
Greg Grabowski
And the same thing on the bereavement side, like bereavement groups, memorial services and so on, so forth, not just doing the basics. And so there's been some success and some growth because of that. Do you think we want to embrace that? And then I will say to you, you're absolutely right. Part of the negative that is that is that there's a big portion of the industry that doesn't embrace this.
00;09;02;23 - 00;09;20;27
Greg Grabowski
And they do just the basics because they have whatever kind of advantage they have or they have, whatever it is that they have. And you're absolutely correct. And so part of it is, is that as an industry, we have to say this is what we want and it needs to be more than just a regulation and the basics.
00;09;21;06 - 00;09;47;24
Greg Grabowski
Because you're right, when you read the regs, they're not ultra specific. You can really do the bare minimum in both of those areas if you want to. And as an industry, we need to say that is not acceptable. As accrediting agencies, we need to say that's not acceptable and push it from our associations or state associations. We need to say this is not acceptable because part of it to your point is, is we're letting it go to yeah.
00;09;48;04 - 00;10;03;01
Greg Grabowski
So some of some of our hospices that have clout in power and basically, you know, to your point, well, it would be a lot easier if we don't have to do a lot of these extra special things. And you're right, that's what makes hospice tick. I'm absolutely with you.
00;10;03;17 - 00;10;19;01
Meg Pekarske
Yeah. And so I don't want to lose the heart of hospice or the mission of hospice as we work to transform them and be a better version of who we are now. And we don't lose sight of that. So what's on your bad list?
00;10;19;23 - 00;10;41;28
Greg Grabowski
Well, the first thing in my bad list is this is we've done a and I and I again, I don't want when I when I say these things, I'm not trying to overgeneralize. This is my perspective. I thought based anybody gets. But I think we've done a really, really terrible job on talking to patients and families that are quote unquote not ready for hospice.
00;10;42;21 - 00;11;03;22
Greg Grabowski
So on the front end of things, I think we have not listen, I think we don't have great intake in admissions processes because I hear this all the time when I talk to patients and families. The doctor referred me. I was in shock. Somebody came in the door and they wanted me to start signing a whole bunch of paperwork.
00;11;03;28 - 00;11;32;04
Greg Grabowski
In my understanding of hospice means my loved one is dying. This is a lot to take in within an hour and I can tell you that because I've been doing consulting now for a really long time. So over eight years I've sat in lots of intake departments and listened to phone calls. And I can tell you there are people that call and they say something similar to the doctor told me to give you a call and I don't know why I'm calling hospice because my mom's not dying.
00;11;33;08 - 00;11;57;23
Greg Grabowski
And what happens is the folks start selling hospice. Well, let me tell you. Let me tell you about the hospice benefit. Well, hold on a second. The woman just told you her mom's not dying. The doctor that referred you know that that doctor refers hospice patients. This woman is in denial. We need to hear her story. What's going on with your mom?
00;11;57;23 - 00;12;26;05
Greg Grabowski
You need to hold her hand. This is a psychosocial situation. There are so you know, I think when you take a look at people are afraid to die, patients, families don't want to give up hope. Patients and families are confused about their diagnosis. They're aggressive care options. They have complexity of care challenges. Family members in and out of town don't want mom and dad to die, have potential family unresolved issues.
00;12;26;13 - 00;12;43;28
Greg Grabowski
There's a lot of this on the front end. And you know what hospice says? I wish when I talk to hospice, I wish patients and families would use us sooner. Well, they they do want to use the sooner, but we don't want to take the great resources that we have on the team and put it on the front end.
00;12;44;27 - 00;13;02;27
Greg Grabowski
And guys, I'm not against marketing and sales folks, but you take late sales folks who answer phone calls and do all the intake process. And then they say to me, I say, well, why didn't they come on service? Well, they're not ready for hospice yet. Well, tell me what they said. And I said, Well, do you realize that this person's in denial?
00;13;03;04 - 00;13;41;05
Greg Grabowski
And do you have a masters in social work? Yeah. In order to handle that. And then of course, they get bristle and they get defensive and say, well, I talk to family members all the time and I say, Yes, let's do retro, guys. I have done so many retrospective studies where we take when these phone calls happen, whether it's from the referral source and then we call the family or the family calls in or when we're touching the patient and there are so many lost days because we can't handle these psychosocial issues, these clinical issues, the willingness to hold their hand and listen and hear where they're at.
00;13;41;13 - 00;14;02;19
Greg Grabowski
We are awesome at now forcing get them on hospice. Got to get them on hospice. Got to get that paper works. Our sense is what's going on. I will tell you, if folks were just to hold people's hands and be a little patient and not force conversations that you hear that they don't want to have, and I'll just end with this.
00;14;02;27 - 00;14;18;27
Greg Grabowski
I worked with an MP and I don't want to say where in the country. And she was working in palliative care and there would be phone calls come in and say, I don't want a hospice, I want palliative care. And the MP would go out, spend a couple of hours and she would come back and say, Is that okay?
00;14;18;27 - 00;14;39;14
Greg Grabowski
I was helping them run their operations and I saw that. She says, okay, if I go back tomorrow, I know I'm not supposed to. I know it doesn't. We can't charge for it, so on, so forth. But I think they just need time to digest pieces of information. So here's the thing it would take I heard this. Patients and families on the phone do not want hospice.
00;14;39;23 - 00;15;06;24
Greg Grabowski
And she would convert folks to hospice appropriately, sometimes over two or three days. And herself as a person generated 24 days on the front end compared to their normal, you know, kind of the same sort of patients. It's because it was patient, it released, it understood end of life care. It really understood the psychosocial dynamics. And the biggest thing, too, is this.
00;15;07;14 - 00;15;30;27
Greg Grabowski
People don't when when somebody says, well, there's hope or an experimental treatment or you're on this medication, so on, so forth. So anyways, I can go on and on. But the last thing I want to point out related to this is, is that same patient we're talking about right now, right when they come on service, what happens? We listen, we do an assessment, we get all their needs down.
00;15;31;08 - 00;15;49;12
Greg Grabowski
Dosage work says I got to work with that daughter because my gosh, she doesn't get hospice and she's got, you know, anticipatory, big time anticipatory grief needs. And the team says, yeah. And so the team rallies and then we do hospice. That same situation needs to happen on the front end.
00;15;49;19 - 00;15;50;22
Meg Pekarske
Yeah, yeah.
00;15;50;23 - 00;15;52;24
Greg Grabowski
Okay. That's my that's my big improvement.
00;15;52;24 - 00;16;29;21
Meg Pekarske
So that and that mind meld here. But when you were you started playing this and you ended up going there, it's like, do we have the wrong people doing this job? And it's like, clearly we do. And in your bright side and you're so bright sided, this is an opportunity. This is a but. Absolutely. Because I just think it and it it is so weird because we have the skills on our team and we know that physicians don't like having these conversations.
00;16;29;21 - 00;16;53;13
Meg Pekarske
So we know that people are coming to us in exactly as you describe, like I'm supposed to call you because my physician said so, but there wasn't a two hour conversation probably the physician had with the patient before they're calling us or their loved one. And so, yeah, that that's really a wonderful observation.
00;16;53;13 - 00;17;11;00
Greg Grabowski
Well, let me tell you this. So I you know, I go out in the field a lot to try to understand. And so I've talked to referring physicians and I say, look, no offense, but the hospice team complains that you don't have the conversation. And he said, I had a little training when I came through med school related to this.
00;17;11;29 - 00;17;31;29
Greg Grabowski
The majority of what I do is trying to cure. You're right. I'm not good at this. I thought hospice was going to be really good at this. Everybody tells me that there's great end of life resource. And Greg, what I will tell you is I love their clinical team, but I don't trust this was the word you used.
00;17;32;07 - 00;17;51;28
Greg Grabowski
I don't trust hospice to come and have a compassionate conversation and try to meet the families where they're at. Every time I introduce hospice early, the families call me in panic and say they were trying to get they're trying to send an admissions nurse. Somebody came and they wanted me to sign paperwork and so on and so forth.
00;17;51;28 - 00;18;08;15
Greg Grabowski
And you told me they were going to talk to me about what are my options and so on and so forth. So yeah, I mean, I think this is a fair point. Do we have the right resources, the right people? Are we handle it the right way? And in general, I'm going to give it a big I'm going to this is going to be I'm going to get in trouble.
00;18;08;15 - 00;18;46;01
Greg Grabowski
But I give it a big no, I give it a big hug and again, I think there's a place for sales and marketing, but with these kinds of patients that are not ready, this is not necessarily a good spot for laypeople who by the way, are usually freaked out. This is on my other list of we'll just keep going with this but that are incentivized by woe does we all know that they exist and the quotas are relate to admission bonuses and and sometimes there's immense pressure so they get in there and they are they can feel is I got to get this signature I got to get the signature.
00;18;46;01 - 00;19;01;11
Greg Grabowski
And to your point on the front end, this is kind of where this is not so good for the industry. And there are there are plenty of patients and families that will continue to use hospice. We don't have to have super aggressive techniques and stuff. So anyways.
00;19;02;10 - 00;19;37;06
Meg Pekarske
And I think that, you know, this shifting to the good here and I think this ties in I mean, I think that we're getting out of our box a little bit because we're trying to get upstream and it's like, who cares if they end up going on hospice? If I can provide support to them in other ways, whether that's palliative care or I'm doing job health or I have a cool case management project or product that I'm doing with like Managed Care or Medicare Advantage plan or, you know, whatever.
00;19;37;06 - 00;20;04;29
Meg Pekarske
But like if we're not a one trick pony anymore, we have more to offer. It doesn't really matter. We want to be of service. And so I think that what I have good on my list is I think that payers are seeing the value and opportunity that, you know, our skill set brings to managing people with serious illness even if they're not, quote, terminally ill.
00;20;04;29 - 00;20;29;02
Meg Pekarske
With this artifice of a six month prognosis, but that there is a lot that we can do that helps manage cost but also provides way better care to people at the end of life and getting paid to do that and like. But I think if the only thing we have is, well, if you go on hospice, then there isn't anything we can do for you.
00;20;29;02 - 00;20;51;09
Meg Pekarske
So if you don't go on like there's nothing when you have more to offer. I think the challenge historically has always been, well, I got to get paid to do that, right? Because there's something called beneficiary inducement. And I think that that's always been a real challenge to the growth of palliative care and the growth of some of the staff.
00;20;51;09 - 00;21;15;13
Meg Pekarske
But in my practice, I've seen a meaningful shift in working with a CEO or then working with Medicare Advantage plans. Even though we paid the way. I don't think that palliative care was really growing as a result of that. But I think Medicare Advantage plans are interested in in working with us, even if it's not like traditional hospice.
00;21;15;13 - 00;21;36;11
Meg Pekarske
And so I think there's a real opportunity there for us, though. So maybe that can also be a cure for like if I am only having one thing I can offer people, I want to put them in that box and who cares if they're not ready to be there, then I can still be of service to you.
00;21;37;04 - 00;21;59;18
Greg Grabowski
Absolutely. Absolutely. Well, and I think the I think the other where my other positive links right up to what you just said is is that the amazing thing I will say is despite a lot of these kind of on the business side challenges, I meet incredible nurses, incredible social workers, spiritual care. Oh, my gosh. AIDS. Oh, my gosh.
00;22;00;10 - 00;22;27;16
Greg Grabowski
For what aides get paid, they are some of the most compassionate, affectionate people. Now, some people you know, some of some organizations have turnover and so on, so forth. I would just simply say the workforce, even though there is a little change, but people if they kind of I always say, you know, like in, you know this too, you get for whatever reason, it's contagious about hospice and there are people that come and go.
00;22;27;16 - 00;22;41;16
Greg Grabowski
And so it's not their thing. But I can tell you, you know, people say, what's the big thing, Greg? What do you work on? You're at a cocktail party and you go, I'm a hospice consultant, a man. Am I passionate about it? And I go, Oh, yeah, nice to meet you. And they just keep on to that. Yeah.
00;22;41;20 - 00;23;05;07
Greg Grabowski
Cheers. Goodbye. Oh, no. You know, so it's kind of like hospice. Yeah. So, yeah, yeah. So but I think there are on the plus side, there really is the workforce that is passionate. Now, how we navigate them and their ratios and those other things are probably on the needs to improve side for some of the for some of the folks so yeah.
00;23;05;16 - 00;23;08;06
Meg Pekarske
You're good is we have passionate people.
00;23;08;25 - 00;23;09;17
Greg Grabowski
Yeah there are still.
00;23;10;07 - 00;23;10;27
Meg Pekarske
There people.
00;23;11;07 - 00;23;23;29
Greg Grabowski
There are still yes there are still those people. I'm not sure I on my flip side, I'm not sure that we have all our business folks aligned around that as well. So yeah.
00;23;24;13 - 00;23;52;00
Meg Pekarske
Well and maybe I'm going to stick with the good because it sort of goes with like you're saying. So I think that there is growing legislative interest in changing that benefit in meaningful ways, like because I don't think it's working very well. I mean, I'm so sick of fighting about six month prognosis and I'm a broken record on that.
00;23;52;00 - 00;23;52;27
Meg Pekarske
But then.
00;23;53;06 - 00;23;53;17
Greg Grabowski
There are.
00;23;53;19 - 00;24;24;19
Meg Pekarske
I think because I'm just talking to people in the community, neighbors, whatever I was talking to this woman, I ran into on my walk with my dog, Wally, and I had never met her before. She's a wonderful woman. But we were talking and her husband had just passed away and I got into that. I work with hospice and then I said, Oh, how is your hospice experience?
00;24;24;19 - 00;24;56;14
Meg Pekarske
And this is not the first time I heard it is. Wow, they really didn't. I was surprised about what they didn't do. And you know, this is an elderly woman caring for her dying spouse. And like there is lots of dressing changes and people have a lot of pretty intense health care needs. And it's like, well, we just sent the hospice nurse like once a week or twice a week and it's like they want more AIDS services, they want more help.
00;24;56;14 - 00;25;22;07
Meg Pekarske
And I think the family doesn't feel like what we're doing is that now. But that's sort of the benefit was designed just to be much more intermittent care than like you're not in a nursing home. It's a it's built it's a model of care that says you have a caregiver at home that can do essentially nursing help for you and will send a nurse that can help.
00;25;22;07 - 00;25;48;01
Meg Pekarske
And so I think that I think it's both an expectation issue, but I also think the benefit isn't really designed so much. Obviously, it's designed much more to support people who are dying of cancer. And now we have all of these elderly individuals who are everyone wants to age in place. So there are aging in place. And your primary caregiver is 85 years old.
00;25;48;14 - 00;26;19;08
Meg Pekarske
And it's like and I think people think hospice, you know, it's all inclusive, right? Everything's related to the terminal illness and it's like, oh, but you have 24 seven needs. Like, we don't we don't cover that. Like, does there need to be something that's more holistic? Because I feel like people are saying they didn't like their hospice experience, but it's actually we provided the benefit as it is written, right?
00;26;19;09 - 00;26;52;26
Meg Pekarske
Because it's like we're not there to help with every dressing change. Right. But they need that support and then they feel like we're not doing something that we should be doing when we really, you know, that whole thing. And so I do think if we can look at end of life care and, you know, from a legislative standpoint and rethink it because how we're doing is different and the needs everyone wants to die, you know, age in place, be where they are and not have to go to a nursing home if they don't want to.
00;26;52;26 - 00;27;21;28
Meg Pekarske
So how do we provide a bundle of services to help support people and get them the support they need? And it's not like, well, I'm hospice, so I can't do those additional aide services for you, but, you know, whatever. So I'm still even though I said, say this, it sounds like a bad thing. I think the good thing is I think people are seeing holes in the hospice benefit.
00;27;21;28 - 00;27;44;14
Meg Pekarske
And what people's needs are at the end of life, given that people are dying in different ways than they were 40 years ago. And so having meaningful discussions about what that is now, is it a happening, you know, in the next year? Probably not. But in the next like five years, I think things could look pretty different.
00;27;44;25 - 00;28;02;03
Greg Grabowski
Mm hmm. I think you're I think you're absolutely I think they're absolutely right. And I. I will say, there is a there's a little again, I'm going to go back to the industry as well. So I absolutely agree with you. There needs to be reform and we absolutely need to take a look at all the issues that you also said.
00;28;02;03 - 00;28;31;28
Greg Grabowski
But I also do think we do push again as an industry, and that doesn't mean everybody. So we're really push the envelope to your point and you kind of use it to an excuse a little bit. So your example is this you're absolutely right. She needs to understand how to do wound care. But on the flip side, did the nurse really have time on the front end or did she have an expectation that she is supposed to get or visited today and all her productivity is measured and so on and so forth?
00;28;33;01 - 00;29;04;13
Greg Grabowski
I get calls from usually more entrepreneurial. I'm not going to necessarily pick on private equity because I don't think private equity is, you know, just ownership and leadership in general looking at productivity and saying, could we within the benefit do a better job? Because I'm going to go back when we were kind of in our heyday and folks were doing hospice, people were financially successful as hospices.
00;29;05;03 - 00;29;34;05
Greg Grabowski
But now, you know, we find our place. We find our place where I'm just not sure that we have consistently as an industry kind of quality that we should have. And to your point, part of it is there are holes we're never going to be able to fill them and we are delivering hospice benefit. But I mean, I also say I don't think we're always delivering the hospice benefit because when I again, when I go out of the field, I see gaps with, well, why did we do that and why did we do this?
00;29;34;11 - 00;30;02;04
Greg Grabowski
And why is the plan of care all cookie cutter and people are just checking boxes and so on and so forth. So part of it is, is on our own responsibility table as an industry to really point this in the right direction. And we have lots of competing demands as an industry. So, you know, I mean, lots of different perspectives that get to talk, you know, at CMS or who are talking at big conferences and so on and so forth.
00;30;03;00 - 00;30;10;01
Greg Grabowski
And I'm not going to say they're bad, but they are they are very different perspectives. And how you look at things. And yeah.
00;30;11;05 - 00;30;49;23
Meg Pekarske
Well, what struck me, what you said is that is really interesting. I hadn't really thought about it this way, but is that it's a time issue, like maybe the hospice benefit as it is, could support my neighbor, but we didn't take the time. And it goes back to what you said earlier. Everything's about time seems like is we're we're too rushed and like we need to slow down because we're it if we did more education that nurse with doing this wound care would she felt more competent and therefore more supported.
00;30;50;00 - 00;31;19;17
Meg Pekarske
And then the fact that we're not doing that for her is okay because she really feels competent. Like did the nurse like every day for three days to do it with her? And then and then yeah, you got it down. And then she though bit by point the benefit I still think it needs to change and it is this whole I need to sign a piece of paper that says I have six months to live.
00;31;19;17 - 00;31;50;09
Meg Pekarske
I think. Is that barrier to your earlier point? Oh, for sure. Yeah, sure. I feel like I don't think that people should have to sign a piece of paper that because I see that as a line that people have to cross and do they really need to in order to get the value of this service then whatever. But I like what you said in terms of thinking about I don't know if this is I guess that's on the bad list of it.
00;31;50;10 - 00;32;18;17
Meg Pekarske
We're just not taking the time like and I'm on the front and I'm in the education and we're supposed to all be about time, right? The slogan of somebody's hospices is, you know, the quality of the time and are we not sort of drinking our own bulleted being like, it's the quality of this time and it's it's putting in good time with with patients.
00;32;18;17 - 00;32;45;29
Meg Pekarske
And it's not that they can't do this or that they're not ready. It's just we need to take the time to have those meaningful conversation sessions or the education. I mean, I'm thinking if I had to change dressings for my husband and he's done all the stuff is happening, like I'm a somewhat competent person, but like that's a lot to deal with and put on top of that.
00;32;45;29 - 00;33;13;00
Meg Pekarske
I'm 85 and have a hard time walking. I mean, there's just so much there that it's like, of course, of course this, you know, this wife is not feeling confident and wants more support. And that and I think this whole idea that you're talking about, it's also the who is doing this that's important. So it's part time, but it's also the who are we assigning to do some of these tasks?
00;33;13;00 - 00;33;15;27
Meg Pekarske
And do we need to rethink that in terms.
00;33;15;27 - 00;33;37;21
Greg Grabowski
And in in your example, if you were to if we were to walk into that hospice is diabetes. And that woman that you just described called 911. So I do this I one of my fun exercises and I do this in a nice place is I'm not trying to pull anybody out or anything. But when we're in it and I see that there's a revocation I bring up.
00;33;37;21 - 00;34;08;04
Greg Grabowski
So what happened with that revocation? Did you guys expect that? And probably 90% of the time, everybody in the room goes, Oh, yeah. I go, Oh, really? And they go, Oh, yeah, the daughter is crazy. The second that Dad started having trouble breathing, we knew they were going to call 911. We knew they were going to revoke. We knew that they didn't really understand addressing that they were frustrated and so on and so forth and yeah, I mean, it's whoa, whoa, hold down for a second.
00;34;08;04 - 00;34;30;10
Greg Grabowski
How about and I see see, we talk about those folks that have they have the most intense need right in this 14 day period. And then the other folks where things are kind of rolling and so on, so forth, we're a little bit quicker instead of what are we? You go alphabetically or if you've got two medical directors or you've got to get through a lot and so on, so forth.
00;34;30;10 - 00;34;51;06
Greg Grabowski
Well, let's spend a little time. Yeah. I mean, that is one of the things I think when you see revocations most of the time it's because, you know, then people say, oh, well, they wanted curative care. Well then how come we weren't trying to address that specific subject right when they came on board. Are there? They are just really, really difficult and they just done it.
00;34;51;06 - 00;35;13;21
Greg Grabowski
I don't add it up well. But again, how long have they been on service? Should we have not been able to work with it? And don't get me wrong, there are patients that probably are never going to not have them kind of revoke or potentially need to be discharged for cause. But there is a whole subset to your point where I just think, yeah, we're and don't get me wrong, I think the benefit, if it was more robust, would help this.
00;35;14;01 - 00;35;17;05
Greg Grabowski
But I also think in the current environment we could do better.
00;35;17;28 - 00;35;26;12
Meg Pekarske
Well, I like that idea. See, we're getting into fixing mode because lawyers sultans can't help but like we.
00;35;26;12 - 00;35;30;19
Greg Grabowski
Can solve everything. The listeners are like, Yeah, right. Well, yeah.
00;35;31;01 - 00;36;12;06
Meg Pekarske
But I like that sort of simple solution of even thinking about the order in which we talk about people at ID and like prioritizing that. Not that, you know, is that everyone needs the same stuff for a boss at the same time. And so like, yeah, new admits or you know, something happen and and how we, we order that because when I've sat in on it too, it's like you run down the list, it's alphabetical and then you know, and then the person with the Z last name is probably always attracted at the end, right?
00;36;12;06 - 00;36;41;08
Meg Pekarske
Because it's like, Oh, they're doing fine. And it's like thinking about because I don't think all of it is, even though I think there's, there's roles for technology and all this other stuff. But the old fashioned, like operational, like how who's doing it? How much time are we taking doing this task? Are we ordering things right? Like not all of this has to be like fancy, fancy and cost lots of money, right?
00;36;41;29 - 00;37;20;16
Meg Pekarske
Correct. So, you know, anyway and I think that's a that's a great observation. And so well, I should probably but I'm going to say something as we wrap up here. I'm going bad list now. I mean, I don't think we can talk about bad without talking about just this really suffocating enforcement environment and just the deluge of audits that that good providers are getting, that are taking up so many resources off of folks.
00;37;20;25 - 00;37;51;17
Meg Pekarske
And I mean, I think everyone agrees, like people should get reviewed, but there's data analytics that the government claims is behind these reviews. We just had a case that it started out as an 80% denial rate. And then after ALJ that error rates less than 1%. What happened? They're like, that just seems like a big waste of time, including for the government.
00;37;51;17 - 00;38;15;20
Meg Pekarske
Like so at the end of the day, you collected $7,000 of, you know, this overpayment. I mean, that doesn't that's misguided on so many different levels. And there's many, many stories out there. And I think that you talk to anyone that knows anything about the hospice industry, and they would say, okay, look at these five data points. That's it.
00;38;16;02 - 00;38;38;11
Meg Pekarske
And then focus on those things that length of stay, right? Because if you do have a tail, everyone should have people that outlive and have the good fortune of outliving their 180 day prognosis. That's not bad. You're actually doing hospice. Someone who, like, doesn't ever have that. They're not doing things right. And they're going to have a life.
00;38;38;21 - 00;39;02;21
Meg Pekarske
I live discharge, right? Everyone knows that. Go look at the people with a high life discharge problem. Those are probably the people not like that easy like length of stay like this person was on service for five years. Well, sometimes that does happen because every story that someone was on for five years, like they are not like running marathons and doing stuff.
00;39;02;21 - 00;39;38;01
Meg Pekarske
It's like I'm contracted weighing £70, being fed by a syringe or something and it's like, I can't explain medically why this person is still alive, but they are. And, you know, I mean, so I just feel that there's just a lot of regulatory burden that is. And obviously now we're going to have a lot more survey scrutiny, which is going to bring double monetary penalties as well as, you know, all these overpayment audits that we're dealing with.
00;39;38;01 - 00;40;02;26
Meg Pekarske
And so I think there needs to hopefully we can crack open a discussion with the government about we're not saying don't audit, but what's in your magic box about data analytics? Because I think there is a here and this isn't really good or having that desired outcome really for anyone here.
00;40;03;10 - 00;40;25;09
Greg Grabowski
I'm a 100% there are there are really good hospice organizations that are caught in this doom loop that you said that they have to work through. It costs lots of money, lots of angst. People get very upset. Oh, my gosh. Yes, you are 100% correct. And it's the data piece of this is not working. You know, it's actually crazy.
00;40;25;09 - 00;40;51;03
Greg Grabowski
And I know this is going to sound way overly simplistic. But to your point, if you went into a specific community with all the smart hospice people, literally everybody would start point based on analytics, not just hearsay and stuff, but you could go into literally I mean, I go into towns to try to help clients and by the time I'm finished, I know who are the folks that are in.
00;40;51;03 - 00;41;21;13
Greg Grabowski
And by being on the ground, egregious, the ones that are those are the folks that the government needs to be paying attention. And the crazy thing is, is not only while you're in an ADR teepee, ze pig and all these other like that, there's your competitor who's doing all who is not on that. Who, by the way, is, you know, and this is a big this is on my you know, there are lots of Alzheimer's, dementia, Parkinson's patients that do not belong on hospice.
00;41;21;13 - 00;41;41;29
Greg Grabowski
We know it. We see it all the time. And we see conversations between hospice and referral sources. To your point, who want to age in place, going back to your other point of aging in place and needing resources and saying something like, well, if your hospice doesn't believe this patient's eligible, we know there's another hospice that will admit this patient in.
00;41;42;03 - 00;42;06;25
Greg Grabowski
And that's a huge and when we look at those cases from a clinical eligibility standpoint, it's not even in the gray area. I mean, we we take a deep dove on it because we want to make sure that the hospice isn't, quote unquote, being too conservative, which happens, by the way, right after you get the heck kicked out of it for a long period of time, everybody shifts over to this.
00;42;07;19 - 00;42;33;09
Greg Grabowski
You know, and the thing is, is it should be fairly you should say we do everything that we can to document eligibility. And to your point, sometimes patients live six months longer. And by the way, holy cow. I mean, there's patients who are 100 years old that don't fit into hospice eligibility, that could use the resources and want to stay at home.
00;42;33;16 - 00;42;53;12
Greg Grabowski
They understand they're 100 years old. They don't want to go to the hospital. They want to go to the emergency room and so on, so forth. But there are patients that are really old to your point, interactive and so on, so forth that don't meet eligibility. So yeah, we need to expand eligibility and the enforcement stop is out of control and not based.
00;42;53;18 - 00;43;15;15
Greg Grabowski
And by the way, the games that get played on the front end, shame on, shame on the contractors and and they just deny and stuff to deny stuff. And then to your point, you know, 99% eventually after you play the game, it shouldn't be a game. It should you're doing the job or you're not doing the job and that should be taken care of right on the front end.
00;43;15;15 - 00;43;18;14
Greg Grabowski
So, yeah, you're absolutely right. You're absolutely right.
00;43;19;07 - 00;43;46;20
Meg Pekarske
It's obviously we now there isn't going to be 100% agreement. But when you see such disparities between the beginning of the story and the end of the story like and 90% of the things you denied in Algiers saying, oh, yeah, no, I think that's right. And you have an outside expert saying, that's right, who's, you know, board certified in hospice and palliative medicine.
00;43;46;20 - 00;44;09;13
Meg Pekarske
I mean, it's just there's something that just it's it's not good for anyone because, again, the government's having to spend more money doing these audits than there is that money to recoup at the end of the day. And so somehow that that needs to be privatized. But what we have to keep going on and I could. Yes, but maybe.
00;44;09;13 - 00;44;23;29
Greg Grabowski
We're going to need we're going to be part two part way. Yeah. Audience, audience. If this was great sent by great comment. Yeah. And then it wasn't, don't tell me about it and we just won't do this again. So because I feel so I'm very supportive.
00;44;24;09 - 00;44;55;16
Meg Pekarske
That's good. Good conversation. And I do think all of this I think what's very clear from from all of this is like the good and bad, actually sort of birds together. And we had is an easy flip to it's like we have the right strength on our team and we can these are very solvable problems that we don't necessarily I mean, some of these we need legislative change to like meaningfully change the benefit.
00;44;55;16 - 00;45;36;26
Meg Pekarske
But some of this other stuff of getting people here, conversion rate and like your mission, I think people are focused on like how many hours does it take to admit a patient that like, well, even if it took two or three days, that's still meaningful. But I'm not saying we should take three days to get out and see a patient, but, you know, I think that there are very solvable things here that but in terms of our first point of agreement utilization, I still think there's an opportunity for a lot of of growth.
00;45;36;26 - 00;46;03;17
Meg Pekarske
And I think that there's a lot of people that need our skills and we can change the world. Right. So there's opportunities, you know, change the world. I mean, I don't think there's anything more meaningful that people could do with their lives than like this, this really important work in our and so many of my clients talk about you only have one shot to get this right.
00;46;03;29 - 00;46;42;20
Meg Pekarske
We as hospices and so it's it's really important to be part of this and journey and obviously passionate about sharing our mission and being able to serve more people and doing it the right way. And because I think of I mean, I always say this, but hospice people are my people. I mean, the people that when you say you ask those are like, as you said, with a dinner party, like, okay, I don't want to talk about death, but those of us crazy enough to do this like we are really passionate about what we do and like that, I don't think there's as much passion and health care as there is at first.
00;46;42;20 - 00;47;12;08
Meg Pekarske
Like, I think we're unique breed and like beating with our strength and, and our strength is also our interdisciplinary nature. Like it's going back to our roots about what makes us special and what makes us passionate and like, we can't lose that. So we have to like, lead with that as we transform and grow in different ways. But, but I think that what struck me in this conversation was just there's a lot to do within the construct that we have.
00;47;12;08 - 00;47;42;16
Meg Pekarske
And it doesn't require endless amounts of money. And because I think people are feeling strapped for cash and it's just like fresh eye perspective, and that's sometimes like if it's calling you Greg and like getting a fresh perspective because I think even in our own personal lives, right, you get in a rut and you get in these habits and it's like sometimes you just need an outside glance, you need something to change it up right?
00;47;42;16 - 00;48;00;06
Meg Pekarske
And to provide a different perspective. And I think that that's what all of this is about, is how can we, you know, get better and get different people's perspectives and unfortunately, we're still going to die and there are services. So this.
00;48;00;06 - 00;48;00;25
Greg Grabowski
Is true.
00;48;00;28 - 00;48;24;01
Meg Pekarske
This is true. I'm not I didn't put in more in mortality on my list of anything in the near term. So I think they're all problems we need to solve because we're all going to keep dying. And I know that I want, but that comes for me to be able to be served by an interdisciplinary team who takes the time to meet with Mariana.
00;48;24;01 - 00;48;43;11
Greg Grabowski
But yeah, I totally agree. And so I just really quick closing comment, I will say to, you know, investors, private equity, all these other folks, the one thing you could take away from this is, is there should be somebody sitting on your board or in the leadership position, not necessarily the president or whatever, because I get that there's this business stuff.
00;48;43;11 - 00;49;11;15
Greg Grabowski
But somebody that has this path to our point here, this can be all this can all coexist. But you should have somebody who really knows the business from this passion perspective. And then how do you balance out all the competing needs, whether you're a nonprofit or for profit, everybody still has to have some kind of bottom line, whether you have investors and stockholders or whether you have donors and so on and so forth and so choose wisely.
00;49;11;15 - 00;49;29;17
Greg Grabowski
And your leaders ought to. If you don't know the business, then you have to like be a study of meeting other people that that are known can even help you do lack because leadership now is couldn't be more important than it ever has been. So that's my last little.
00;49;29;25 - 00;49;30;16
Meg Pekarske
Absolute little.
00;49;30;16 - 00;49;31;02
Greg Grabowski
Piece there.
00;49;31;06 - 00;49;42;19
Meg Pekarske
So that's a good point. So while you and I both have passion, compassion, like everything, and so because you and I are just going solve all the world's problems.
00;49;43;13 - 00;49;43;27
Greg Grabowski
You get the.
00;49;43;27 - 00;49;45;13
Meg Pekarske
Last month of life.
00;49;45;24 - 00;49;49;06
Greg Grabowski
Correct. And I didn't even get all the way down our list. So we may have to do part.
00;49;49;19 - 00;50;00;06
Meg Pekarske
B to do round two and maybe that's 2025. We can kick off 2020. Okay. I'd like with our wish list for 2025. So there.
00;50;00;06 - 00;50;01;01
Greg Grabowski
You go. Yeah.
00;50;01;10 - 00;50;26;04
Meg Pekarske
Anyway, well, I still love talking to you. This is so much fun and it invigorates me because you know, obviously we all get it, you know, deep into problems. But like I've been doing this for 25 years and it's fun to talk to other people who are passionate and want to, because I think there's burnout that happens and like this invigorates me.
00;50;26;04 - 00;50;28;00
Meg Pekarske
So thanks for invigorating me, Greg.
00;50;28;21 - 00;50;32;12
Greg Grabowski
It is my pleasure. Thank you. It was a pleasure to be here. Thank you very much.
00;50;32;13 - 00;50;58;26
Meg Pekarske
Thank you. Well, that's it for today's episode of Hospice Insights: The Law and Beyond. Thank you for joining the conversation. To subscribe to our podcast, visit our website at huschblackwell.com or sign up wherever you get your podcasts. Until next time, may the wind be at your back.