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

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

0:00
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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.
0:16
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 Comeaux.
0:28
Chris Comeaux: Hello and welcome.
0:29
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.
0:37
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?
1:18
Chris Comeaux: What if in our quest to innovate, that we open up the space to every flavor of healthcare, including non-credentialed modalities, 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.
1:44
Chris Comeaux: What if we accidentally make that go away in our quest for innovation?
1:49
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.
2:15
Chris Comeaux: That's because of you.
2:16
Chris Comeaux: You guys have made this one of these most watched and listened to podcasts in the hospice and paled 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.
2:31
Chris Comeaux: Apple is my personal favorite, and of course, YouTube.
2:34
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.
2:58
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 one.
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.
3:22
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 Telias.
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.
4:35
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.
4:44
Chris Comeaux: Now, around the country, some of the brightest leaders in hospice empowered 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: Now, 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 FES, 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 powder 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.
5:46
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 hypercompetition.
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.
6:35
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.
7:19
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.
8:46
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, 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.
9:24
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.
10:03
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.
10:12
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 LEED 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 powdered 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.
10:53
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, pallid 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 4: I'm glad to be here, Chris.
11:20
Speaker 4: I would say that you saved 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.
11:44
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 in an actual patient.
11:54
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
Chris Comeaux: Como it's good to have you as well.
12:10
Speaker 2: Well, thank you, Chris.
12:11
Speaker 2: I did bring the mission because somebody's got to keep it in the room.
12:15
Speaker 2: Well, mission without margin is a memory.
12:19
Speaker 2: 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.
12:36
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.
12:53
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.
13:12
Chris Comeaux: So let's go with round one.
13:14
Chris Comeaux: Now, Paul, take us inside your worldview.
13:17
Chris Comeaux: Why should a hospice move upstream into powder care and then into a frail elder practice?
13:24
Chris Comeaux: i.e., I call it vertical integration.
13:28
Speaker 4: Well, because the patient does not experience life in benefit categories.
13:32
Speaker 4: Patient does not wake up on Tuesday and say, well, yesterday I was a primary care person and today I'm a powdered care person, and next month perhaps I'll become a hospice person.
13:42
Speaker 4: That's how our payment architecture sees the person.
13:45
Speaker 4: It's not how the person experiences illness.
13:48
Speaker 4: A frail elder practice is not simply a primary care clinic for people who happen to be older.
13:54
Speaker 4: It's a model designed for people whose health, function, cognition, and support systems have become fragile.
14:00
Speaker 4: These patients don't just need more office visits, they need a longitudinal relationship and a team capable of caring for them wherever they live.
14:10
Speaker 4: Traditional primary care was not designed for that job.
14:14
Speaker 4: A 15-minute office visit cannot fully see the person with six chronic conditions, twelve medications, declining mobility, a frightened spouse, a daughter trying to coordinate care from another state, food insecurity in a home that may no longer be safe.
14:31
Speaker 4: You see, for this population, the home is not just a place of service, it's clinical information.
14:37
Speaker 4: The caregiver is not merely someone standing beside the patient.
14:41
Speaker 4: The caregiver is part of the care unit.
14:44
Speaker 4: Function, cognition, social isolation, spiritual distress, medication burden, and the capacity to remain safely at home.
14:52
Speaker 4: Well, all those things matter.
14:54
Speaker 4: So this vertical integration strategy is simple to describe, although not simple to execute.
15:00
Speaker 4: Begin with the strengths of hospice, extend those strengths upstream through powdered care, and then extend them further through home-based primary care designed for frail elders.
15:12
Speaker 4: The primary care team must be able to deliver primary powdered care from the beginning, symptom management, serious illness communication, advanced care planning, deprescribing, and care align with what matters most.
15:26
Speaker 4: Then specialty powdered care is layered in when the needs become more complex.
15:31
Speaker 4: And when hospice becomes the right service and the patient's goals align, well that transition should feel like the same trusted team adding additional support.
15:40
Speaker 4: Not like falling off one healthcare island and then having to swim to another.
15:46
Speaker 4: Paul, how does that strategy then answer the eight challenges?
15:51
Speaker 4: Okay.
15:52
Speaker 4: Well, let's start with hypercompetition.
15:55
Speaker 4: If we remain only at the end of the continuum, well then we depend upon other people to recognize that need and also to explain hospice accurately and also refer at the right time.
16:07
Speaker 4: Increasingly, those other people, they may be financially accountable for the patient.
16:12
Speaker 4: They may own also competing services, or they might view hospice only as a cost center.
16:17
Speaker 4: So moving upstream allows us to earn the relationship earlier rather than waiting for referral at the 11th hour.
16:25
Speaker 4: Now, on reimbursement, I'm not re pretending that the economics are easy.
16:30
Speaker 4: See, fee for service alone usually will not fund the interdisciplinary model that this population needs.
16:37
Speaker 4: You need expertise in the physician fee schedule and the disciplined use of appropriate care management codes and services.
16:44
Speaker 4: You also need contracts with accountable care organizations and Medicare Advantage plans, health systems, and other risk-bearing entities and partners.
16:53
Speaker 4: And you must quantify the downstream value created for Powder Care and for hospice.
16:59
Speaker 4: Now, on your workforce challenge, you know, this model can be attractive to physicians, advanced practice clinicians, nurses, social workers, and other professionals who entered healthcare for all the right reasons.
17:12
Speaker 4: They wanted to know their patients.
17:14
Speaker 4: They didn't want to be involved in a race through a scheduled day.
17:17
Speaker 4: Hospice organizations, they already understand teams, 24-7 responsiveness, family systems, goals of care, and also caring in the home.
17:26
Speaker 4: Those aren't small advantages.
17:28
Speaker 4: Now in the demographic challenge, this model meets baby boomers exactly where they are.
17:34
Speaker 4: It's home-based, it's personalized, it's relational, and it's also easier to navigate.
17:40
Speaker 4: The customer does not need to understand whether today's support is technically primary care or powdered care.
17:46
Speaker 4: They need to know whom to call and trust the team that knows them.
17:51
Speaker 4: On the regulation side, an integrated continuum can reduce the artificial cliff that's created by eligibility rules.
17:58
Speaker 4: Person who's not ready or eligible for hospice does not have to be abandoned.
18:03
Speaker 4: The care intensity can change without the relationship disappearing.
18:07
Speaker 4: On the technology side, things like remote monitoring, predictive analytics, the virtual check-ins, those become tools within a human relationship.
18:17
Speaker 4: Technology helps us identify decline, identify caregiver strain, medication problems, and emerging crises before the emergency department becomes the default.
18:28
Speaker 4: Now, in your speed of change, this strategy reframes the organization.
18:33
Speaker 4: We're no longer merely a hospice organization that just happened to add a clinic.
18:37
Speaker 4: We're a serious illness organization responsible for a population over time.
18:42
Speaker 4: And yes, that is a challenge.
18:44
Speaker 4: Now, on the mental health side, an interdisciplinary home-centered model, well, it can see loneliness, grief, and caregiver exhaustion, anxiety, and spiritual distress much earlier than episodic medicine can.
18:58
Speaker 4: So let me make this concrete.
19:01
Speaker 4: Imagine Mary, because I told you I was going to bring a patient.
19:03
Speaker 4: Imagine Mary, age 83.
19:06
Speaker 4: She has heart failure, COPD, mild cognitive impairment, and a husband who's quietly becoming overwhelmed.
19:13
Speaker 4: Under the current system, she may see multiple specialists visit the emergency department three times and receive a hospice referral only after that final hospitalization with only a week left to live.
19:26
Speaker 4: But in our model, the Frell Elder team knows Mary before the crisis ever occurred.
19:31
Speaker 4: We see her at home, it simplifies her medications, supports her husband, creates an escalation plan, answers after hours, brings in specialty powdered care, symptoms intensify, and introduces hospice, honestly, ever before that final emergency ER visit would occur.
19:50
Speaker 4: We prevent it.
19:51
Speaker 4: And when Mary elects hospice, she's not handed off to strangers.
19:55
Speaker 4: The circle of support expands.
19:58
Speaker 4: This is not empire building, this is continuity building.
20:03
Chris Comeaux: Now, Paul, you've made a really strong case.
20:05
Chris Comeaux: So I want to affirm what I'm hearing or affirm the things that I pretty much agree with.
20:10
Chris Comeaux: So you're designing around the person's journey rather than around Medicare's boxes.
20:15
Chris Comeaux: You're addressing the greatest structural weakness of hospice.
20:19
Chris Comeaux: We often arrive too late and we depend upon systems that are outside our control for access.
20:24
Chris Comeaux: You're taking our capabilities that hospice already possesses: home-based care, interdisciplinary teamwork, 24-7 response, caregiver support, goals of care conversations, and you're extending them to a population that really desperately needs them.
20:41
Chris Comeaux: I also think that you're correct that for the customer, the seams absolutely should disappear.
20:46
Chris Comeaux: The patient should feel one relationship, one plan of care, even if different disciplines, programs, and payment mechanisms sit behind it.
20:56
Chris Comeaux: Now, let me poke some holes a little bit in your worldview.
21:00
Chris Comeaux: First, this is not just a line extension.
21:03
Chris Comeaux: It's a new business.
21:04
Chris Comeaux: It really needs upfront capital, physician, billing expertise, different technology, and Lord knows the problems we've had in that area, different talent, data sophistication, contracting capability, and a true tolerance culture for experimentation.
21:23
Chris Comeaux: A hospice cannot fund it through what Dr.
21:25
Chris Comeaux: Bethany Snyder said in a podcast that we did earlier this year, death by a thousand cuts, quietly skimming a little resource from hospice each month and then hoping magically that a continuum appears.
21:38
Chris Comeaux: Second, fee for service does not naturally support the team that you just described.
21:43
Chris Comeaux: If the business model depends upon future shared savings, downstream hospice value, or contracts that have not yet materialized, the organization may spend years carrying a mission rich but a cash poor service.
21:57
Chris Comeaux: Now, third, culture, and this is a big one.
21:59
Chris Comeaux: Hospice teams operate inside a highly defined benefit with very familiar rules.
22:05
Chris Comeaux: Population health is much more ambiguous.
22:08
Chris Comeaux: Attribution, coding, quality measures, denials, network arrangements, and rapid iteration, those require different muscles.
22:18
Chris Comeaux: Some hospice organizations will really underestimate that gap.
22:23
Chris Comeaux: Let me say that again, as this might be the biggest one.
22:26
Chris Comeaux: Many hospice organizations really may underestimate that gap.
22:31
Chris Comeaux: Now, fourth, workforce.
22:33
Chris Comeaux: You said that this model can attract clinicians, and I believe you're right, it can, but it also competes for the same scarce clinicians hospice already is having a trouble filling.
22:44
Chris Comeaux: If expansion weakens the core, the continuum becomes broad, but maybe mediocre.
22:50
Chris Comeaux: In fact, let me share an example I grew up with, which is General Motors.
22:53
Chris Comeaux: I remember when I was a kid, maybe some of you do as well, depending upon your age, where my dad had a GM truck.
23:00
Chris Comeaux: He also had an AC Delco radio, and even the tires were made by GM.
23:05
Chris Comeaux: Perfect example, vertical integration.
23:08
Chris Comeaux: But General Motors was an adventure and mediocrity.
23:12
Chris Comeaux: And anybody remember who competed and kind of took out the king that was General Motors?
23:18
Chris Comeaux: Toyota.
23:19
Chris Comeaux: And you know what Toyota competed on?
23:21
Chris Comeaux: World-class quality.
23:23
Chris Comeaux: We're going to get to that a little bit later.
23:25
Chris Comeaux: So, fifth, the transition to hospice is not automatically timely simply because we own both sides.
23:32
Chris Comeaux: An upstream team may become attached to its own care plan, preserve fee for service revenue, or believe it can manage one more crisis.
23:41
Chris Comeaux: Vertical integration can prevent fragmentation, but it can also create internal substitution.
23:48
Chris Comeaux: You must measure timely hospice transitions and guard against replacing hospice with a diluted version of palative primary care.
23:56
Chris Comeaux: Sixth, local scale.
23:58
Chris Comeaux: 24-7 access, home visits, interdisciplinary staffing at technology, those are all really expensive.
24:05
Chris Comeaux: When the patient population is geographically scattered, the model that works in a dense metropolitan area may break down in rural America.
24:15
Chris Comeaux: And seventh, patient choice.
24:18
Chris Comeaux: You call it continuity.
24:20
Chris Comeaux: The patient may experience it actually as a closed ecosystem.
24:23
Chris Comeaux: If Mary prefers another hospice, your example, does your continuum make that easy?
24:30
Chris Comeaux: Or has every relationship, data feed, and incentive been designed to keep her inside your system?
24:37
Chris Comeaux: Let's not forget the talking point that worked against Obamacare, you can keep your physician, and how that was touted over and over again as a way in many respects to ultimately unravel Paca that we all now know is Obamacare.
24:52
Chris Comeaux: So, Paul, maybe your greatest strength, the control of the continuum, could also be your greatest blind spot.
24:59
Chris Comeaux: What do you think?
25:00
Speaker 4: Those are fair challenges, but fragmentation is not freedom.
25:04
Speaker 4: Sending Mary into a maze and giving her a list of phone numbers, well, that's not patient choice.
25:09
Speaker 4: The answer is not to abandon integration.
25:12
Speaker 4: The answer is to build ethical integration, transparent options, warm handoffs, objective triggers for hospice assessment, open networks where possible, and measures that expose delayed transitions.
25:26
Speaker 4: And yes, this does require investment, but doing nothing?
25:30
Speaker 4: Well, that's also an investment decision.
25:32
Speaker 4: And invest our future in the hope that somebody else will keep referring those patients to us.
25:39
Chris Comeaux: Well, that's the strongest version of Paul's argument.
25:42
Chris Comeaux: Continuity without captivity and investment before irrelevance.
25:46
Chris Comeaux: Hmm.
25:47
Chris Comeaux: Let me say that again in defense of vertical integration.
25:50
Chris Comeaux: If the goal is continuity without captivity and investment before irrelevance, well, you really may be onto something with this strategy.
26:02
Chris Comeaux: All right, let's go to round two now.
26:04
Chris Comeaux: Christopher, you agree, I believe, with much of Paul's continuum, but you think he stops too soon.
26:12
Chris Comeaux: Why?
26:13
Chris Comeaux: Well, because Paul wants to redesign care while leaving someone else's incentive in charge.
26:19
Chris Comeaux: He is right about the clinical model though, but if another organization controls the premium dollar, the benchmark, the network, the attribution, and the rules by which value is measured, well, then Paul's beautiful continuum may remain a subcontractor.
26:35
Chris Comeaux: The pay vital thesis begins with an uncomfortable observation.
26:40
Chris Comeaux: The entity accountable for total cost of care increasingly determines what services are encouraged, delayed, substituted, or excluded.
26:50
Chris Comeaux: If hospice and palliative care organizations remain downstream vendors, they may create enormous value while someone else captures the economics and controls the access.
27:00
Chris Comeaux: So, yes, build hospice, palliative care, frail elderly, primary care, but also participate in the financing and risk of care.
27:08
Chris Comeaux: That can take several forms and they're not identical.
27:12
Chris Comeaux: An organization may participate in the Medicare Shared Savings Program, we call it MSSP, through an ACO.
27:19
Chris Comeaux: It may enter the LEAD model, which really succeeds the ACO reach beginning in 2027, and it's really designed as a 10-year accountable care pathway with options for professional or global risk.
27:33
Chris Comeaux: It may own or partner with special needs plans focused on defined high-need populations.
27:39
Chris Comeaux: It may operate or align with pays, where an interdisciplinary organization receives capitated Medicare and Medicaid payment to serve eligible older adults in the community.
27:50
Chris Comeaux: At the far end of the spectrum, it may even sponsor or acquire a Medicare Advantage plan.
27:56
Chris Comeaux: I'm not saying every hospice should become an insurance company, but I am saying every serious illness organization must decide where it will sit in the flow of risk, capital, data, and decision rights.
28:09
Chris Comeaux: Christopher, thank you for that.
28:11
Chris Comeaux: So how does that answer the challenges that I opened the show with?
28:15
Chris Comeaux: Okay, I accept your challenges.
28:18
Chris Comeaux: Well, let's take hypercompetition first.
28:21
Chris Comeaux: In a referral economy, competitors fight for episodes.
28:25
Chris Comeaux: In a population health economy, the organization with attributed lives, they can design the care model before the episode ever occurs.
28:34
Chris Comeaux: Attribution becomes strategic access.
28:37
Chris Comeaux: On reimbursement, the payvider model attacks the central mismatch in our field.
28:43
Chris Comeaux: We know interdisciplinary, proactive, home-based care can prevent crisis, but fee for service primarily pays for billable encounters.
28:52
Chris Comeaux: Under accountable payment, the organization can invest in a nurse call, social worker intervention, transportation, remote monitoring, or caregiver support, because avoiding the hospitalization has economic value.
29:06
Chris Comeaux: Now, on your workforce challenge, aligned payment can fund teams differently.
29:10
Chris Comeaux: Instead of forcing every professional activity through a billing code, we can deploy the right team member at the right time, and we can use technology and centralized resources to extend scarce clinicians.
29:23
Chris Comeaux: On demographics, baby boomers will demand convenience, coordination, transparency, and digital access.
29:30
Chris Comeaux: A payvider can create one front door, one navigation experience across settings.
29:36
Chris Comeaux: Now, in your regulation and politics, participating directly gives the organization a seat at the table.
29:43
Chris Comeaux: We become a model participant with data and experience, not merely a provider reacting to decisions that are made upstream.
29:52
Chris Comeaux: On technology, pair and provider data together are far more powerful, then neither one of them can be alone.
29:59
Chris Comeaux: Claims tell us where the patient has been, clinical data tells us what's happening now, and predictive models can identify rising risk, trigger outreach, and also match resources to need.
30:12
Chris Comeaux: On change in resilience, your reculture challenge, you know, a diversified organization is not really dependent upon one single benefit.
30:22
Chris Comeaux: It can move resources as a policy and patient needs do evolve.
30:27
Chris Comeaux: Then on your mental health challenge, financial flexibility permits us to address caregiver strain, loneliness, and behavioral health needs when they drive utilization, suffering, or both, even when there's not a neat fee-for-service code.
30:43
Chris Comeaux: Now let us return to Mary.
30:45
Chris Comeaux: Paul's team may care for Mary beautifully.
30:48
Chris Comeaux: But if Mary's Medicare Advantage plan denies or underfunds key services or directs her into a narrow network or evaluates the team only through short-term utilization, well, Paul's model remains constrained.
31:02
Chris Comeaux: In the PaveFider model, we hold responsibility for Mary's outcomes and her total cost.
31:08
Chris Comeaux: We can invest earlier because we receive the benefit of avoid a crises.
31:13
Chris Comeaux: We can create incentives for prevention, home-based care, medication simplification, and caregiver support.
31:20
Chris Comeaux: We can make hospice part of the care architecture rather than a last-minute referral.
31:25
Chris Comeaux: The core principle is alignment.
31:28
Chris Comeaux: Same organization that benefits when Mary stays safely at home is responsible for funding the care that keeps her there.
31:35
Chris Comeaux: Okay, Christopher, here's what I could affirm kind of listening and considering your position.
31:40
Chris Comeaux: You're exposing the real power structure.
31:43
Chris Comeaux: Clinical excellence does not automatically translate into strategic influence.
31:47
Chris Comeaux: I get that.
31:48
Chris Comeaux: The organization that controls payment, attribution data, and the network, well, they can shape the patient's path long before hospice ever receives a referral.
31:58
Chris Comeaux: I know that old adage often holds true in healthcare.
32:01
Chris Comeaux: He who has the gold makes the rules.
32:04
Chris Comeaux: You also seem to recognize that FIFA service often rewards activity while underfunding prevention, coordination, and caregiver support and the interdisciplinary work that frail elders really need the most.
32:17
Chris Comeaux: And risk-based payment can really create freedom to use resources much more intelligently.
32:22
Chris Comeaux: I'll definitely affirm that.
32:24
Chris Comeaux: And there's a defensive logic here.
32:26
Chris Comeaux: If health plans, health systems, primary care platforms, and national aggregators are moving into serious illness, hospice organizations cannot assume that they will always be invited into the model and even into the model in favorable terms.
32:41
Chris Comeaux: So now let me see if I can maybe poke some holes in your worldview or your strategy.
32:46
Chris Comeaux: First, risk is not just upside with a fashionable name.
32:51
Chris Comeaux: Depending upon the model, it includes downside losses, benchmark risk, coding, and risk adjustment complexity, utilization volatility, reserve needs, actuarial uncertainty, compliance exposure, and years in which excellent care may not even produce financial success.
33:10
Chris Comeaux: In fact, we just look recently in healthcare news, many hospitals who also thought that this was a great strategy for them are now exiting the insurance service line.
33:20
Chris Comeaux: So are we sure we're smarter and better equipped for this than they were?
33:25
Chris Comeaux: Second, and this is a key one, insurance and care delivery are totally different businesses.
33:31
Chris Comeaux: A world-class hospice does not automatically possess actuarial talent, network management, member services, claims operation, quality infrastructure, sales capability, capital reserves, or regulatory expertise, just to name a few.
33:47
Chris Comeaux: The leap from provider to payer may be a lot larger than the leap from hospice to frail elder practice.
33:55
Chris Comeaux: Third, in this world, this the strategy world of PayVider, scale really matters.
34:02
Chris Comeaux: Small or mid-sized nonprofit may not have enough attributed lives to manage the statistical variation, spread the infrastructure, or even negotiate effectively.
34:13
Chris Comeaux: A partnership can solve part of that problem, sure, but partnerships can also move control back to the larger payer or partner.
34:20
Chris Comeaux: Fourth, your greatest promise, aligned incentives, contains a potential conflict.
34:26
Chris Comeaux: When the same enterprise both authorizes care and bears its cost, every care decision has a financial shadow.
34:35
Chris Comeaux: Let that settle upon you just for a second.
34:38
Chris Comeaux: Hospice could be introduced earlier because it's appropriate, or because it's cheaper.
34:43
Chris Comeaux: It could also be delayed because the organization wants to retain revenue elsewhere.
34:49
Chris Comeaux: Palliative care could become a meaningful specialty or a utilization management strategy wearing a compassionate name.
34:57
Chris Comeaux: It was less than a year ago in this country that the head of United Healthcare was assassinated and on that bullet was engraved deny, depose, and defend.
35:05
Chris Comeaux: And it's crazy that half our country cheered.
35:08
Chris Comeaux: You know, it's easy for us to demonize the insurance companies, but what ensures that we don't become what we demonize?
35:15
Chris Comeaux: Fifth, the language of population health can depersonalize.
35:20
Chris Comeaux: Mary, well, she becomes an attributed life, a risk score, a benchmark opportunity, or a high cost claimant.
35:28
Chris Comeaux: Data can help us see her earlier, but can also persuade us that the model knows what she needs before anyone even asks her.
35:37
Chris Comeaux: And that is very antithetical to what's always the fine hospice.
35:42
Chris Comeaux: Everyone matters at an individual level.
35:45
Chris Comeaux: Let that sink in for a second.
35:47
Chris Comeaux: Sixth, consumer choice.
35:50
Chris Comeaux: A one front door?
35:51
Chris Comeaux: Man, that sounds convenient until it becomes the only door.
35:55
Chris Comeaux: Beneficiary alignment, incentives, preferred networks, and seamless internal referrals.
36:00
Chris Comeaux: Well, they can all be defensible, but together they can create a mousetrap, a system designed on the assumption that once Mary enters, she's gonna stay.
36:11
Chris Comeaux: And I'm not so sure that'll be the case.
36:13
Chris Comeaux: And we'll talk about that as we get towards the end.
36:16
Chris Comeaux: And seventh, hospice may still become a cost center inside the payvider.
36:21
Chris Comeaux: Ownership does not guarantee respect.
36:23
Chris Comeaux: A finance-led enterprise may pressure length of stay, eligibility decisions, staffing or service intensity in ways that erode the very model it claims to integrate.
36:35
Chris Comeaux: Again, my comments about United Healthcare.
36:38
Chris Comeaux: Christopher, you seem to want to align the financing with the care, but how do you keep the financing from swallowing the care?
36:45
Chris Comeaux: Well, by treating gourdrails as part of the operating model, not as a public relations language.
36:51
Chris Comeaux: We need independent clinical governance.
36:54
Chris Comeaux: We need transparent measures of access, disenrollment, complaints, hospice length of stay, live discharge, caregiver experience, equity, and out-of-network choice.
37:05
Chris Comeaux: And we need clear conflict of interest policies and board-level mission oversight.
37:10
Chris Comeaux: We need to publish whether we're improving quality of life, not merely lowering medical expense.
37:16
Chris Comeaux: And I agree, not every hospice should become a payer.
37:19
Chris Comeaux: Some should partner, some should take limited professional risk.
37:23
Chris Comeaux: Some should build capabilities first, but every hospice should understand who bears risk for its patient and how that entity's incentives affect access to care.
37:35
Chris Comeaux: If you do not understand the financing model around your patient, you do not fully understand your patient's care environment.
37:42
Chris Comeaux: Well, that might be Christopher's strongest point.
37:45
Chris Comeaux: The premium dollar may be invisible to the patient, but its incentives are present in the room.
37:51
Chris Comeaux: Let me say that again.
37:53
Chris Comeaux: The premium dollar may be invisible to the patient, but its incentives are present in the room.
37:59
Chris Comeaux: You know, my first mentor in healthcare had a very crass way of making that point.
38:04
Chris Comeaux: He would say to me, figure out how every provider or business in healthcare is paid, and that's going to tell you why they do what they do.
38:11
Chris Comeaux: Why do hospitals try to get people out quickly?
38:13
Chris Comeaux: Well, it's how the financing incentives of DRGs work.
38:16
Chris Comeaux: Why do skill facilities skill patients?
38:19
Chris Comeaux: Because that's where the margin is.
38:21
Chris Comeaux: I know there's so many incredible people throughout healthcare doing great work, but the guardrails that are built for them to operate within are often based on the financial model.
38:31
Chris Comeaux: Now, let's go to round three.
38:34
Chris Comeaux: Como both Paul and Christopher say that remaining focused on hospice and pouch care leaves the organization downstream and vulnerable.
38:44
Chris Comeaux: Why do you still defend that strategy?
38:47
Speaker 2: Well, because focus is not the same as passivity.
38:51
Speaker 2: You're kind of confluencing those two.
38:53
Speaker 2: There is an assumption creeping into our conversation here that bigger scopes makes a better strategy.
38:59
Speaker 2: It does not.
39:00
Speaker 2: Sometimes expansion is vision.
39:03
Speaker 2: Sometimes it's fear wearing a badge as strategy.
39:06
Speaker 2: You know, hospice is one of the most extraordinary care models ever created.
39:11
Speaker 2: When it's practice at its best, it treats the patient and family as the unit of care.
39:17
Speaker 2: It brings a disciplinary team into the home.
39:20
Speaker 2: It addresses physical, emotional, social, and spiritual suffering.
39:24
Speaker 2: It supports caregivers.
39:25
Speaker 2: It provides medications and equipment related to the terminal illness.
39:29
Speaker 2: It responds around the clock, and it continues through grief and bereavement.
39:34
Speaker 2: Hospice is an absolute true medical specialty.
39:38
Speaker 2: And that's why having board-certified physicians, CHPN nurses, and LCSWs all make it a true specialty care model that is not easily replaceable or like some interchangeable part.
39:53
Speaker 2: PalladCare also practices a true specialty.
39:57
Speaker 2: It brings expert symptom management, communication decision support, and whole person care alongside disease-directed treatment.
40:06
Speaker 2: It can serve patients much earlier and then not requiring them to surrender every curative option, which is one of the biggest challenges when hospice was brought into being.
40:15
Speaker 2: So those two together make a formidable care continuum.
40:19
Speaker 2: So my strategy is to dissect what makes each of those models special, then define the components of world-class performance, measure honestly where we're at today, and then build organizations that become unmistakably, unequivocally excellent.
40:37
Speaker 2: World class is not a marketing adjective.
40:40
Speaker 2: It means reliable and consistent access.
40:43
Speaker 2: It means clinicians with mastery, performing with mastery.
40:47
Speaker 2: It means symptom response measured in hours, not days.
40:51
Speaker 2: It means care plans that reflect the patient's true goals.
40:55
Speaker 2: It means the family knows whom to call at 2 o'clock in the morning and they trust that the right people are going to pick up the phone.
41:01
Speaker 2: It means excellent transitions, low unwanted hospitalizations, meaningful spiritual and psychosocial care, disciplined compliance, and superb caregiver experience, and a culture in which people can do the best work of their entire lives.
41:18
Speaker 2: It also means being clear about the difference between primary powdered care skills that every clinician should possess and specialty powder care for complex needs.
41:30
Speaker 2: If everything is called powdered care going forward, eventually nothing is.
41:35
Speaker 2: Let me say that again just to be absolutely make an emphasis on it.
41:39
Speaker 2: It means being clear about the difference between primary powders skills that every clinician in the care continuum should possess and specialty powded care for complex needs.
41:51
Speaker 2: If everything is called powder care, then eventually nothing will be.
41:55
Chris Comeaux: So, Como, how does excellence alone answer the eight challenges that I set the table with?
42:02
Speaker 2: Well, it's not excellence alone, it's strategic excellence.
42:06
Speaker 2: On hypercompetition, your first challenge.
42:09
Speaker 2: You know, mediocre organizations compete on relationships, geography, or price.
42:14
Speaker 2: But world-class organizations, they compete on trust and demonstratable outcomes, including decreases in total cost of care.
42:22
Speaker 2: Then hospital physicians, payers, and consumers, well, they will know exactly what becomes better when we're involved.
42:30
Speaker 2: That's why they're going to demand world class.
42:33
Speaker 2: On your reimbursement challenge, focus protects discipline.
42:37
Speaker 2: We know our unit economics, or we should, we better going forward.
42:41
Speaker 2: What's our staffing model?
42:42
Speaker 2: Our cost per patient day, our quality drivers, and the services that create genuine value.
42:48
Speaker 2: In fact, if you look at how Elon Musk did what he did at SpaceX and Tesla, he applied first principle thinking.
42:55
Speaker 2: And then basically, which is exactly that, is basically figuring out what are those services that create genuine genuine value, go deep on that, become world-class, throw the other stuff out.
43:06
Speaker 2: And then we advocate for payment that recognizes quality rather than launching business lines that we don't even know how to operate.
43:14
Speaker 2: On your workforce challenge, people want to belong to something excellent.
43:19
Speaker 2: A clear calling, superb leadership, manageable systems, professional development, in other words, pouring into your people and the chance to master meaningful work, those are competitive advantages.
43:32
Speaker 2: We should repair the work rather than continuously asking our people to absorb new ventures.
43:38
Speaker 2: On demographics, the baby boomers, they're not going to accept a generic commodity.
43:44
Speaker 2: They're going to research, they're going to compare, they're going to ask questions, they're going to demand responsiveness, and then they're going to expect care that's tailored to their values.
43:55
Speaker 2: A world-class provider earns active consumer preference.
43:59
Speaker 2: Rather than relying upon referral sources or a mousetrap that someone else built that's just expecting them to passively go along with the care flow that's been pre-mapped out for them.
44:11
Speaker 2: I think that's a key flaw in their thinking.
44:13
Speaker 2: Now on your regulation challenge, the strongest defense is operational integrity.
44:19
Speaker 2: We should be the field standard bearers for eligibility, documentation, quality, stewardship, transparency, and we should have, as Dr.
44:28
Speaker 2: Bayak has reminded us many times on the TCN Talks podcast, zero tolerance for fraud, waste, and abuse.
44:36
Speaker 2: Now, on your technology challenge, we should use that as an accelerator for excellence, not a strategy itself.
44:43
Speaker 2: AI can absolutely remove clerical burden and should.
44:47
Speaker 2: It should also help us detect symptoms sooner, should help us personalize education, and it should also help us make meaningful data available.
44:55
Speaker 2: And or technology must give time back to the bedside.
45:01
Speaker 2: That's how we should apply technology as an accelerator, not as some panacea.
45:06
Speaker 2: And it's critical to be world class.
45:08
Speaker 2: Now, in your speed of change challenge, a strong identity as an organization absolutely creates resilience.
45:15
Speaker 2: If an organization does not know what it must preserve, then every new trend becomes some strategic identity crisis.
45:22
Speaker 2: And then on your last challenge on mental health, hospice and powered care already possess the interdisciplinary DNA to address grief, isolation, and distress and caregiver burden.
45:34
Speaker 2: So let's become exceptional at deploying that.
45:37
Speaker 2: So let's return to your example earlier about Mary.
45:41
Speaker 2: She doesn't need us to own every part of her life.
45:44
Speaker 2: She needs us to be extraordinary when she needs pouch care.
45:48
Speaker 2: She needs us to be there and be extraordinary when she chooses hospice.
45:53
Speaker 2: She needs a specialist she can absolutely trust, not a corporation trying to turn every stage of her aging into a service line.
46:01
Speaker 2: You know, there's humility in saying this is what we do and we do it as well as anyone else in the world.
46:10
Speaker 2: We can build strong partnerships upstream to ensure against the upstream risk without owning everything upstream.
46:18
Speaker 2: We can create preferred relationships with primary care, ACO, hospitals, plans, and community organizations.
46:25
Speaker 2: We've done that most of our careers, many of us that have been around a long time.
46:29
Speaker 2: We can make our value so measurable and our reputation so powerful that excluding us would be absolutely irrational.
46:37
Speaker 2: The future does not belong to the organization with the most boxes on the organization short.
46:43
Speaker 2: It's gonna belong to the organization that patients insist upon.
46:48
Chris Comeaux: Okay, Como here's what I could affirm in your worldview.
46:51
Chris Comeaux: You're protecting something the other strategies could accidentally dilute or maybe even destroy.
46:57
Chris Comeaux: Hospice and special deep outcare, they require deep competence.
47:01
Chris Comeaux: Expansion creates managerial complexity, and complexity can turn excellence into inconsistency.
47:08
Chris Comeaux: There is wisdom and mastery, a clear identity, and a refusal to chase every adjacent opportunity.
47:15
Chris Comeaux: As I shared earlier, there are cautionary tales hospice leaders can learn from other industries who've tried to become all things to all people, and they did none of them well.
47:25
Chris Comeaux: That General Motors' example is the one that I alluded to earlier.
47:29
Chris Comeaux: Again, how did Toyota compete and ultimately win?
47:32
Chris Comeaux: They did it on world-class quality.
47:35
Chris Comeaux: Exactly, I think, the point that you're making.
47:37
Chris Comeaux: You're also placing a bet on brand and consumer preference.
47:41
Chris Comeaux: If the baby boomers become more active choosers of serious illness care, a trusted world-class organization really could have power that traditional referral models really underestimate.
47:53
Chris Comeaux: And you also remind us integration is not synonymous with ownership.
47:57
Chris Comeaux: Partnerships, open networks, shared protocols, data exchange, and warm handoffs can create continuity without requiring one enterprise to employ every clinician and bear every risk.
48:10
Chris Comeaux: So I love those key points that you make.
48:12
Chris Comeaux: Now, let me poke holes.
48:15
Chris Comeaux: First, the patient cannot choose a hospice she never ever hears about.
48:20
Chris Comeaux: Excellence at the end of the funnel does not guarantee access to the funnel.
48:24
Chris Comeaux: If payers, ACOs, health systems, and primary care platforms control the relationship upstream, well, your world-class program may receive Mary with only three days left, or not at all.
48:36
Chris Comeaux: Second, Powder Care economics really remain difficult.
48:40
Chris Comeaux: Calling the service world-class does not fund the interdisciplinary team.
48:45
Chris Comeaux: Without risk contract, philanthropy, health system support, new codes with payment attached, or downstream value, a superb community powder care program may be financially still fragile.
48:57
Chris Comeaux: Third, referral partners do not always act on value.
49:01
Chris Comeaux: Unfortunately, they act on convenience, contracts, network design, habit, ownership, and incentives.
49:08
Chris Comeaux: You may be objectively better, but still be outside the preferred pathway.
49:14
Chris Comeaux: Fourth, hypercompetition includes substitutes, hospital at home, advanced illness management, home-based primary care, Medicare Advantage Care Management, and technology-enabled platforms may perform pieces of what hospice and bad care do.
49:29
Chris Comeaux: If consumers can't distinguish the difference or the expertise, well, that excellence is invisible.
49:36
Chris Comeaux: It's invisible to the one who maybe matters the most.
49:39
Chris Comeaux: Fifth, focus can become dignified word for strategic inertia, where protecting the mission can really conceal fear of investment, unwillingness to build new capabilities, or nostalgia for a referral environment that is disappearing.
49:55
Chris Comeaux: Sixth, the demographic change cuts both ways.
49:59
Chris Comeaux: Baby boomers may seek a world-class specialist.
50:02
Chris Comeaux: I agree with you on that.
50:03
Chris Comeaux: But they may also prefer one seamless platform that already knows them.
50:08
Chris Comeaux: You're betting they will interrupt an established relationship to choose you at the hardest moment of their lives.
50:14
Chris Comeaux: And seventh, you depend on others to create continuity.
50:18
Chris Comeaux: Partnerships are often celebrated at the signing ceremony, and they fail in the daily work, the different records, different incentives, no shared accountability, and nobody answering after hours.
50:30
Chris Comeaux: So, Como, how do you keep focus from becoming, well, irrelevance?
50:36
Speaker 2: Well, by refusing to define focus as sitting around and waiting, a world-class strategy must include absolutely these things market intelligence, consumer education, data interoperability, measurable outcomes, surely preferred partnerships, rapid access, speed to care, deliberate upstream presence.
50:58
Speaker 2: We should teach primary care teams embed pilot care expertise and support ACO partners and create open doors for patients and families long before hospice eligibility.
51:09
Speaker 2: But we don't have to own the patient's primary care or the insurance product to matter.
51:14
Speaker 2: We need enough strategic reach to ensure access and enough discipline to preserve and advance mastery.
51:22
Speaker 2: And let me challenge both of my colleagues Chris Christopher and Paul.
51:25
Speaker 2: Ownership is not going to automatically equal loyalty.
51:29
Speaker 2: Patients do not owe our enterprise their next episode of care.
51:33
Speaker 2: The only way our continuum or our risk model succeed is by keeping the patient from choosing someone else.
51:39
Speaker 2: That's not truly succeeding.
51:42
Chris Comeaux: Well, that might be Como's strongest case.
51:45
Chris Comeaux: Mastery without passivity, partnerships without captivity, and a brand the patient actively chooses.
51:53
Chris Comeaux: Let me say that again.
51:55
Chris Comeaux: Mastery without passivity, partnership without captivity, and a brand the patient actively chooses.
52:03
Chris Comeaux: Well done, Como.
52:03
Chris Comeaux: So let me do some cross-examination where each strategy potentially can fail.
52:09
Chris Comeaux: So I'm going to do one short cross-examination.
52:13
Chris Comeaux: Each of you gets one question for another of the other characters.
52:17
Chris Comeaux: Paul, you go first.
52:19
Speaker 4: Well, Christopher, if your financial model shows that a shorter hospice length of stay reduces total cost in a particular year, what protects the patient from your spreadsheet?
52:30
Chris Comeaux: Well, independent clinical governance, for one, transparent outcomes, and a payment model that measures quality over a meaningful time horizon.
52:39
Chris Comeaux: But I will turn it back.
52:40
Chris Comeaux: If your frail elderly practice keeps managing crisis and delays hospice because the team believes it can do everything, who protects the patient from your clinical pride?
52:51
Speaker 4: Objective transition triggers, external review, and patient goal measures.
52:56
Speaker 4: The danger is real.
52:57
Speaker 4: That's why timely hospice transition must be a key performance indicator.
53:02
Speaker 4: I would absolutely agree and indicate that.
53:05
Speaker 4: All right.
53:06
Speaker 4: Christopher, your question.
53:08
Chris Comeaux: Well, okay.
53:09
Chris Comeaux: Como if a payer controls 10,000 high-need lives in your market and selects a lower quality owned provider, what exactly does your world-class strategy do next?
53:20
Speaker 2: Well, because it produces evidence, it activates consumer demand, and that's a key one.
53:26
Speaker 2: It makes exclusion reputationally and clinically costly, and it creates alternative partnerships and it advocates for choice.
53:35
Speaker 2: But I do concede my central weakness in my thesis.
53:38
Speaker 2: Quality without access is not enough.
53:41
Speaker 2: But that's why world class must also include a market access strategy, not merely clinical operations.
53:48
Speaker 2: All right.
53:49
Speaker 2: Como your question.
53:51
Speaker 2: Well, Paul, when your organization is operating hospice, special deep house care, home-based primary care, after hours response, care management, technology, contracting, and multiple billing models, what are you willing to stop doing so that it all remains excellent?
54:07
Speaker 2: Because that's a huge challenge.
54:10
Speaker 4: That may be the most important implementation question.
54:13
Speaker 4: The continuum cannot become a collection of under-resourced mediocre programs.
54:18
Speaker 4: Totally agree.
54:19
Speaker 4: We would stage the build, establish readiness gates, and centralize only what truly creates leverage, and absolutely refuse to launch the next layer till the previous one meets defined clinical, cultural, and financial standards.
54:34
Speaker 4: That's how.
54:36
Chris Comeaux: All right, good job, gentlemen.
54:38
Chris Comeaux: Each strategy is now admitted its Achilles' heel.
54:41
Chris Comeaux: For Paul, it's complexity and the possibility that continuity becomes internal substitution.
54:48
Chris Comeaux: For Christopher, it's conflict of interest and the possibility that alignment becomes financial domination.
54:56
Chris Comeaux: And for Como, it's access and the possibility that mastery becomes irrelevance.
55:02
Chris Comeaux: So, gentlemen, thank you.
55:04
Chris Comeaux: There is so much wisdom in what you shared.
55:07
Chris Comeaux: Here's where I land after hearing all three of your strategies or your worldviews.
55:12
Chris Comeaux: These strategies are distinct, but they're not always mutually exclusive.
55:17
Chris Comeaux: In fact, the wisest path may be a sequence rather than a single leap.
55:22
Chris Comeaux: An organization might first establish world-class hospice empowered care.
55:26
Chris Comeaux: That's foundational.
55:27
Chris Comeaux: Without excellence at the core, expansion magnifies weakness.
55:32
Chris Comeaux: Let me say that again.
55:33
Chris Comeaux: Without excellence at the core, expansion magnifies weakness.
55:38
Chris Comeaux: It might then build our partner into a frail elder continuum where market conditions, capital talent, and mission support it.
55:46
Chris Comeaux: That creates an earlier relationship and a better journey.
55:50
Chris Comeaux: And it might then choose an appropriate level of financial participation, contracted value-based payment, limited professional risk, ACO participation, a joint venture, or for a small number of organizations with the scale, capabilities, and capital ownership of a plan or other risk-bearing structure.
56:10
Chris Comeaux: The strategic question is not simply, hey, which box do we select?
56:15
Chris Comeaux: It's these key questions.
56:18
Chris Comeaux: What problem are we solving for the patient?
56:21
Chris Comeaux: What capabilities do we genuinely possess?
56:24
Chris Comeaux: What capabilities can we build without weakening our core?
56:28
Chris Comeaux: Where do incentives help or harm the patient?
56:32
Chris Comeaux: And how will the patient exercise meaningful choice?
56:36
Chris Comeaux: And what evidence will tell us that the model is making life better, not merely making the organization larger?
56:45
Chris Comeaux: So let me land the plane with these three points.
56:49
Chris Comeaux: The patient and family absolutely have to remain at the center.
56:54
Chris Comeaux: Every strategy says that, but the test is going to be whether the operating model really proves it out.
57:00
Chris Comeaux: Does the patient experience fewer handoffs or merely more services carrying the same logo?
57:06
Chris Comeaux: Let me say that again.
57:07
Chris Comeaux: Does the patient experience fewer handoffs or merely more services that just happen to carry the same logo?
57:14
Chris Comeaux: Does the caregiver receive real support or appear as a data field in an assessment?
57:20
Chris Comeaux: Do we measure quality of life, goal concordance, trust, and the ability to remain safely at home, or only utilization and margin?
57:30
Chris Comeaux: Do we introduce hospice when it becomes the right choice, even when another part of our organization could keep billing?
57:37
Chris Comeaux: And do we help a patient choose another provider when that provider is the better fit?
57:44
Chris Comeaux: Patient-centeredness is not a sentence in the strategic plan.
57:48
Chris Comeaux: It's the willingness to design incentives, measures, governance, and daily behavior around the interests of the patient and family, even when those interests do not maximize our own enterprise.
58:01
Chris Comeaux: Second key point: the customer is changing.
58:04
Chris Comeaux: I alluded to this in the opening of the show.
58:06
Chris Comeaux: We're entering the age of the baby boom serious illness customer, and too many strategies or strategists treat that as a volume forecast rather than a transformation and expectations.
58:19
Chris Comeaux: Baby boomers have advocated for themselves and created disruption as they've moved through education, work, finance, travel, media, retail, and retirement.
58:30
Chris Comeaux: Why would healthcare be the one industry they quietly accept it as it is?
58:35
Chris Comeaux: They will ask, why is care fragmented?
58:38
Chris Comeaux: They're going to research quality.
58:40
Chris Comeaux: They will expect technology that makes access easier.
58:44
Chris Comeaux: They're going to challenge paternalism.
58:47
Chris Comeaux: They will want honest conversations earlier, and they will expect services to adapt to their lives rather than forcing their lives into our programs.
58:56
Chris Comeaux: The winners will not merely manage a large elderly population.
59:01
Chris Comeaux: They're going to understand that they're a different customer.
59:05
Chris Comeaux: Number three, the patient wants choice, not a mousetrap.
59:09
Chris Comeaux: This may be the point our field is most at risk of missing.
59:12
Chris Comeaux: In fact, many in healthcare, I think, are missing this.
59:15
Chris Comeaux: Many strategies are built around the assumption that once a patient enters our clinic, our continuum, our ACO, our network, or our health plan, that the patient will remain inside the system that we designed.
59:29
Chris Comeaux: But the patient is not a captured life.
59:32
Chris Comeaux: The patient is a person with agency.
59:34
Chris Comeaux: Continuity, no doubt, is valuable.
59:37
Chris Comeaux: Simplicity, that's valuable as well.
59:39
Chris Comeaux: Trusted relationships are valuable, but none of those should become an excuse to limit meaningful choice or quietly steer someone towards the option that's most profitable to us.
59:52
Chris Comeaux: The best model will not be the slickest or stickiest mousetrap.
59:56
Chris Comeaux: It will be the model patients and families choose to remain in because it has earned their trust, and the model confident enough to help them leave when another choice serves them better.
1:00:08
Chris Comeaux: So, should the future belong to world-class hospice and palliative care?
1:00:12
Chris Comeaux: Yeah, because no strategy can compensate for mediocre care.
1:00:16
Chris Comeaux: Should hospice organizations vertically integrate into palliative care and then frail elderly primary care?
1:00:22
Chris Comeaux: For many, the answer is yes, because patients need continuity before the final chapter, and hospice cannot assume that access will take care of itself.
1:00:32
Chris Comeaux: Should some organizations also become payviders or participate meaningfully in risk?
1:00:38
Chris Comeaux: Yeah, because incentives shape care and the field cannot afford to be financially illiterate or permanently downstream.
1:00:46
Chris Comeaux: But each yes comes with a warning.
1:00:48
Chris Comeaux: Do not let excellence become isolation.
1:00:51
Chris Comeaux: Do not let integration become captivity.
1:00:55
Chris Comeaux: Do not let financial alignment become financial domination.
1:00:59
Chris Comeaux: Keep the patient and the family at the center.
1:01:02
Chris Comeaux: Build for the baby boomer customer who is arriving.
1:01:06
Chris Comeaux: Preserve real choice.
1:01:08
Chris Comeaux: If we do those three things, this debate will really have served its purpose.
1:01:13
Chris Comeaux: Because the ultimate goal is not for Chris, Paul, Christopher, or Como to win, which, if you've not figured it out by now, my name is Christopher Paul Como, and I go by Chris.
1:01:24
Chris Comeaux: The goal is for Mary and her family to win.
1:01:27
Chris Comeaux: Thank you for joining me for this special edition of TCN Talks Anatomy of Leadership.
1:01:32
Chris Comeaux: And thank you to our listeners.
1:01:34
Chris Comeaux: In many respects, you can embirth today's episode as I listened to many of you and the things that you're wrestling with.
1:01:41
Chris Comeaux: It really gave me a vision for this, which is probably the most complicated podcast that we ever pulled off.
1:01:48
Chris Comeaux: Note in our show notes, we'll have the entire script because I have a feeling this is a document that you're going to want access to.
1:01:54
Chris Comeaux: And as always, at the end of each episode, we always share a quote, a visual.
1:01:58
Chris Comeaux: The idea is to create a brain bookmark, a thought prodder about our podcast subject to further your learning and growth and thereby your leadership.
1:02:06
Chris Comeaux: We're hoping it sticks, like a brain tattoo.
1:02:08
Chris Comeaux: Again, be sure to subscribe to our channel.
1:02:10
Chris Comeaux: We don't want you to miss an episode.
1:02:12
Chris Comeaux: Please, if you're interested, check out the book, The Anatomy of Leadership, on Amazon.
1:02:16
Chris Comeaux: Tell your friends and your co-workers about this podcast.
1:02:19
Chris Comeaux: You know it's easy for us to reel against the world and be frustrated by things.
1:02:23
Chris Comeaux: Let's be the change that we wish to see in this world.
1:02:26
Chris Comeaux: So thanks for listening to TCN Talks Anatomy of Leadership.
1:02:29
Chris Comeaux: And here's our brain bookmarked to close today's show.
1:02:32
Dragonfly Health Ad: The future does not only belong to the organization with the most popular organizational talk.
1:02:41
Dragonfly Health Ad: It may belong to the organization of agents and like a lot of people.