Latest / Anatomy Of Leadership / The Debate: Vertical Integration, Payvider, or World-Class Care—Which Path Forward? | Part One

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The Debate: Vertical Integration, Payvider, or World-Class Care—Which Path Forward? | Part One · Anatomy Of Leadership

• 0:00
  Jeff Haffner: Thank you, NetSmart, for sponsoring this podcast.
• 0:05
  Melody King: Everything rises and falls on leadership.
• 0:08
  Melody King: The ability to lead well is fueled by living your cause and purpose.
• 0:13
  Melody King: This podcast will equip you with the tools to do just that.
• 0:17
  Melody King: Live and lead with cause and purpose.
• 0:20
  Melody King: And now, author of the book The Anatomy of Leadership and our host, Chris Como.
• 0:28
  Chris Comeaux: Hello and welcome.
• 0:30
  Chris Comeaux: I'm excited today.
• 0:31
  Chris Comeaux: I'm also really nervous, and that'll be more apparent why in just a little bit.
• 0:36
  Chris Comeaux: So let's jump in.
• 0:38
  Chris Comeaux: What if the greatest threat to hospice is not that we fail?
• 0:43
  Chris Comeaux: What if that is that we would succeed but at the wrong strategy?
• 0:48
  Chris Comeaux: What if we became world-class at hospice, but someone else controls whether the patient ever reaches us?
• 0:55
  Chris Comeaux: What if we build the perfect continuum of care, but the complexity and the capital required pulls us away from the very mission that we're all trying to protect?
• 1:06
  Chris Comeaux: And what if we became the payer as well as the provider, align every financial incentive, and then we discover that the patient feels less free and not more cared for?
• 1:19
  Chris Comeaux: What if in our quest to innovate that we open up the space to every flavor of healthcare, including non-credentialed modalities?
• 1:29
  Chris Comeaux: Thus watering down the competencies that over these past 40 years have saved Medicare billions of dollars and has ensured that millions have passed from this earth having experienced love and dignity and great care.
• 1:45
  Chris Comeaux: What if we accidentally make that go away in our quest for innovation?
• 1:50
  Chris Comeaux: Today, I'm gonna debate those questions with three people who disagree with one another.
• 1:56
  Chris Comeaux: The complication, and thereby my nervousness, is that all three are me.
• 2:01
  Chris Comeaux: And we're gonna get to that in just a moment.
• 2:04
  Chris Comeaux: Before we jump in, I want to kind of do a little bit of a PSA.
• 2:07
  Chris Comeaux: First off, I want to thank you, our listeners.
• 2:09
  Chris Comeaux: Incredibly, we're gonna reach over a hundred thousand downloads before the end of this year, 2026.
• 2:16
  Chris Comeaux: That's because of you.
• 2:17
  Chris Comeaux: You guys have made this one of these most watched and listened to podcasts in the hospice and powered care world.
• 2:23
  Chris Comeaux: If you don't know, you can watch us on any of the platforms, Spotify, uh, and also Amazon.
• 2:32
  Chris Comeaux: Apple is my personal favorite, and of course, YouTube.
• 2:35
  Chris Comeaux: Now, YouTube was the OG for video.
• 2:37
  Chris Comeaux: Many of you already follow us on YouTube, but guess what?
• 2:40
  Chris Comeaux: You may not know this.
• 2:41
  Chris Comeaux: Going forward, Spotify and Apple are gonna have video as well.
• 2:45
  Chris Comeaux: And this is a show where you're gonna have a much more enhanced experience by utilizing the video and not just the audio.
• 2:52
  Chris Comeaux: So the great news is you absolutely can do that on YouTube, but you can also do that on Spotify and Apple also.
• 2:59
  Chris Comeaux: So pick your fave.
• 3:00
  Chris Comeaux: Mine is Apple Podcasts.
• 3:02
  Chris Comeaux: I love it.
• 3:02
  Chris Comeaux: Be sure whatever platform you subscribe and also hit the like button.
• 3:06
  Chris Comeaux: We don't want you to miss an episode.
• 3:09
  Chris Comeaux: And this is one we really think that you're gonna want to pay forward to at least one person, at least once.
• 3:15
  Chris Comeaux: Please make sure that you pay it forward to them.
• 3:18
  Chris Comeaux: Again, my fave is uh Apple.
• 3:20
  Chris Comeaux: All you have to do is hit that share button.
• 3:23
  Chris Comeaux: I do it probably five, six times a week with some of my own podcasts, but many of the other podcasts that I follow that help me be informed to do this show.
• 3:31
  Chris Comeaux: So please pay it forward.
• 3:33
  Chris Comeaux: This is gonna be one where you're really glad you did.
• 3:36
  Chris Comeaux: And again, thank you for making this the most listened to podcast.
• 3:39
  Chris Comeaux: We have some big goals next year within 2027, and it's all going to depend upon you, the listener.
• 3:45
  Chris Comeaux: We appreciate the great feedback.
• 3:47
  Chris Comeaux: Recently, I got an incredible, almost testimonial from a CEO and said, first off, thank you for the work that you guys are doing at Telios.
• 3:55
  Chris Comeaux: Pay that forward to my whole team, but also the work of this podcast because it gives the CEO and she pays it forward to all her team members almost like wind beneath their wings for this work that we do.
• 4:07
  Chris Comeaux: That was a blessing to us.
• 4:08
  Chris Comeaux: That's exactly why we do this podcast.
• 4:10
  Chris Comeaux: To be a blessing to all of you to know what's coming, and not only to know what's coming, but to be able to do the thinking and the strategizing and ultimately most importantly, the implementation, so we can navigate these incredible whitewater rapids of time that we're navigating in hospice powder care, healthcare as a whole, and you could even say our economy and our country as a whole as well.
• 4:32
  Chris Comeaux: So, again, welcome to TCN Talks Anatomy of Leadership.
• 4:36
  Chris Comeaux: I'm your host, Chris Como, and today this is going to be probably the most unusual show that we've ever recorded.
• 4:42
  Chris Comeaux: But the subject could not be more serious.
• 4:45
  Chris Comeaux: Now, around the country, some of the brightest leaders in hospice and powdered care see many of the same forces that are bearing down in our field.
• 4:53
  Chris Comeaux: Yet they're arriving at very different answers about what organizations their organizations should become.
• 5:01
  Chris Comeaux: Now, before we debate those answers, let me set the table with eight challenges.
• 5:07
  Chris Comeaux: You know, here at TELEAS, TCN, we used a great tool that is called a Future External Environmental Scan, the acronyms of FES.
• 5:15
  Chris Comeaux: If you ever hear use the word fees, that's what we're talking about.
• 5:18
  Chris Comeaux: We use this interesting tool.
• 5:20
  Chris Comeaux: We scanned the external environment.
• 5:22
  Chris Comeaux: And via that tool, and via some of the brightest leaders in hospice and powdered care utilizing that tool, we've come to the conclusion there are eight challenges that are facing all of us.
• 5:32
  Chris Comeaux: In fact, in April of 2026, Court Castor and I, in fact, Court turned the tables on me and we did a podcast and basically Court interviewed me around those challenges.
• 5:42
  Chris Comeaux: We'll include a link to that show if you need to delve a little bit deeper into it.
• 5:47
  Chris Comeaux: So here are those eight challenges now, just for a summary, because it's going to set the table well on this debate.
• 5:52
  Chris Comeaux: First is hyper competition.
• 5:54
  Chris Comeaux: We have more traditional competitors, more national platforms, and more private capital, and more substitute services, and more organizations trying to control the serious illness patient before hospice ever has entered the picture.
• 6:10
  Chris Comeaux: So that's the first hypercompetition.
• 6:13
  Chris Comeaux: The second is reimbursement and financial pressure, inflation, wage pressure, utilization patterns, payment limits, denials, and then the inadequacy of fee for service payment for interdisciplinary care all collide with an expectation that we have to do more with less.
• 6:32
  Chris Comeaux: So that's the reimbursement and financial pressure challenge.
• 6:36
  Chris Comeaux: The third challenge is workforce.
• 6:38
  Chris Comeaux: The people that are called to do this work, they're scarce.
• 6:42
  Chris Comeaux: We're asking exhausted leaders and clinicians to absorb more complexity, learn new competencies, and somehow preserve the humanity of care.
• 6:52
  Chris Comeaux: So that's the third challenge, workforce.
• 6:55
  Chris Comeaux: The fourth challenge, and we're really going to get to this at the ultimate conclusion of our show, is the patient family demographic shifts.
• 7:03
  Chris Comeaux: The baby boomers are moving into serious illness and end-of-life care.
• 7:07
  Chris Comeaux: They are different customers.
• 7:09
  Chris Comeaux: They have challenged institutions at every stage of life, and we should assume that they're going to challenge health care as well.
• 7:16
  Chris Comeaux: So that's the patient-family demographic challenge.
• 7:20
  Chris Comeaux: The fifth challenge is regulatory and political uncertainty.
• 7:24
  Chris Comeaux: You know, hospice is highly regulated, closely scrutinized, and increasingly shaped by policy decisions that can change the rules of the game almost on a whim.
• 7:35
  Chris Comeaux: And we've seen this as we're taping the show in the fall of 2026.
• 7:39
  Chris Comeaux: So that's the fifth challenge: regulatory and political uncertainty.
• 7:43
  Chris Comeaux: The sixth challenge is technology, artificial intelligence, AI, predictive analytics, remote monitoring, interoperability, and consumer technology.
• 7:54
  Chris Comeaux: All of those things will expand our reach, but they may also enable substitutes, intensify surveillance, or turn our human care into transactions.
• 8:07
  Chris Comeaux: So that's the sixth challenge, technology.
• 8:10
  Chris Comeaux: The seventh is the speed of change and the need for resilience and reculturing.
• 8:16
  Chris Comeaux: You know, we're not managing one change initiative.
• 8:19
  Chris Comeaux: We're asking organizations built around a defined Medicare benefit to rethink who they are.
• 8:26
  Chris Comeaux: And books have been written about how the change curve takes out many industry leaders.
• 8:32
  Chris Comeaux: It's almost like literally trying to defy gravity.
• 8:35
  Chris Comeaux: That's why authors like Jim Collins have written about how the mighty fall, the risk is real, and this could be us.
• 8:42
  Chris Comeaux: So this show is not advocating stagnancy or complacency.
• 8:47
  Chris Comeaux: Don't mistake that.
• 8:48
  Chris Comeaux: So that's the seventh challenge: speed of change, reculture.
• 8:52
  Chris Comeaux: The eighth and final challenge, the mental health crisis affecting patients, families, and staff, loneliness, caregiver strain, grief, burnout, anxiety, and moral distress.
• 9:03
  Chris Comeaux: They're not side issues.
• 9:05
  Chris Comeaux: They're part of the care environment.
• 9:07
  Chris Comeaux: So those are the eight challenges.
• 9:09
  Chris Comeaux: And many of the best thought leaders in our space at state and national conferences that I pay attention, they lead off their presentations with very similar derivatives of these challenges.
• 9:20
  Chris Comeaux: So let them sink in, because they're pretty fairly daunting.
• 9:25
  Chris Comeaux: Therefore, I do believe that many of the leaders, we all agree on the diagnosis.
• 9:30
  Chris Comeaux: However, as I pay attention, what I see emerging are three major worldviews, almost like three macro strategies for how to respond to these major challenges.
• 9:42
  Chris Comeaux: It's almost a prescription, if you will, for navigating these challenges.
• 9:46
  Chris Comeaux: The first that I see, as I group these, says move upstream, start with hospice, add world-class powdered care, then build home-based primary care designed specifically for frail older adults.
• 10:00
  Chris Comeaux: In other words, create one coordinated continuum.
• 10:04
  Chris Comeaux: Now I'm going to refer to this as vertical integration.
• 10:07
  Chris Comeaux: The second strategy I see says do all that, but don't stop there being the provider.
• 10:13
  Chris Comeaux: Become, partner with, or meaningfully participate in the financing and the risk as well.
• 10:19
  Chris Comeaux: Enter the payvider world through accountable care, special needs models, PACE, Medicare Advantage, or emerging CMMI models such as the LEAD model.
• 10:29
  Chris Comeaux: I refer to this strategy as the Pay Vider strategy.
• 10:33
  Chris Comeaux: The third strategy says be careful and be smart.
• 10:37
  Chris Comeaux: Hospice and powder care are profound specialties, not merely service lines in a larger machine.
• 10:44
  Chris Comeaux: Become indisputably world class at the work only that we can do, and let excellence, trust, outcomes, and mission be the strategy.
• 10:54
  Chris Comeaux: So to make the strongest version of each of these cases, I've invited three guests to join me today.
• 11:01
  Chris Comeaux: So welcome those three guests.
• 11:03
  Chris Comeaux: First, we have Paul.
• 11:05
  Chris Comeaux: Paul believes the answer is vertical integration through a frail elder practice, hospice, pallic care, and home based primary care working as one continuum.
• 11:15
  Chris Comeaux: Welcome, Paul.
• 11:16
  Chris Comeaux: It's good to have you.
• 11:19
  SPEAKER_03: I'm glad to be here, Chris.
• 11:20
  SPEAKER_03: I would say that you save the most practical character really for first.
• 11:25
  Chris Comeaux: Yeah, that confidence will become relevant later.
• 11:28
  Chris Comeaux: Next, we have Christopher.
• 11:30
  Chris Comeaux: Christopher believes providers of serious illness care must understand and increasingly participate in the financing of care.
• 11:38
  Chris Comeaux: His worldview is the payvider strategy.
• 11:41
  Chris Comeaux: Christopher, it's so good to have you.
• 11:43
  Chris Comeaux: Welcome as well.
• 11:45
  Chris Comeaux: Thank you, Chris.
• 11:46
  Chris Comeaux: I brought data, risk model, and three spreadsheets that, frankly, I'm not sure you could even understand them.
• 11:52
  Chris Comeaux: And I brought an actual patient.
• 11:55
  Chris Comeaux: Gentlemen, please, let's pace yourselves.
• 11:57
  Chris Comeaux: Finally, we have Como, who argues that the best future strategy is to build a world-class hospice and a world-class powder care organization.
• 12:07
  SPEAKER_01: Como it's good to have you as well.
• 12:10
  SPEAKER_01: Well, thank you, Chris.
• 12:12
  SPEAKER_01: I did bring the mission because somebody's got to keep it in the room.
• 12:15
  SPEAKER_01: Well, mission without margin is a memory.
• 12:19
  SPEAKER_01: Well, margin without mission is pretty much just an insurance company.
• 12:25
  Chris Comeaux: All right, we've officially started.
• 12:27
  Chris Comeaux: So here are the rules.
• 12:29
  Chris Comeaux: I'm going to ask each character to explain his worldview, his strategy, and how it responds to the eight challenges.
• 12:37
  Chris Comeaux: I will then affirm why the strategy makes sense, and then I'm going to poke some holes in it.
• 12:42
  Chris Comeaux: We will go in this order.
• 12:44
  Chris Comeaux: We're going to go with Paul first on vertical integration, then Christopher on the payvider, and then world-class hospice empowered care with Como.
• 12:54
  Chris Comeaux: Nobody gets to pretend that his strategy is risk-free, and nobody gets to win by capturing the other two.
• 13:01
  Chris Comeaux: The question is not which strategy sounds the smartest.
• 13:05
  Chris Comeaux: The question is which strategy best serves patients and families and under what conditions.