TCN Talks
Welcome to TCN Talks. This podcast is designed to be a pithy, talk of relevant need to know to help you in your role in hospice palliative care serious illness care.
TCN Talks
The Need for Innovation with Meg Pekarske
What happens when you blend nearly 25 years of legal expertise with the rapidly changing landscape of healthcare? Join us as we welcome Meg Pekarske, head of the Hospice and Palliative Care Practice Group at Hush Blackwell, who shares her remarkable journey and insights into hospice law. From her early mentorship under Mary Michael to leading a dynamic team of 15 professionals, Meg's story is one of adaptability and growth. As we navigate the complexities of the evolving healthcare market, Meg's unique blend of analytical and creative skills provides invaluable perspectives on fostering resilience and innovation in hospice care.
Discover the strategies for financial sustainability in the hospice industry as we explore the significance of revenue diversification. With traditional Medicare reimbursement for palliative care falling short, there's a pressing need for creative financial strategies tailored to organizational needs. You'll learn about the potential of innovative care models and the increasing appeal of PACE (Program of All-Inclusive Care for the Elderly) as we discuss substantial investment and staffing requirements. This conversation emphasizes the urgency for leaders to be agile and inventive in meeting the needs of the community and patients effectively.
Our exploration doesn't stop there. We tackle the intricacies of legal structures in healthcare, the resurgence of Independent Practice Associations, and the active landscape of healthcare antitrust concerns. Meg's insights guide us through the potential future of Hospice care, advocating for a broader approach that prioritizes upstream interventions and interdisciplinary care. As we ponder the evolving role of professional skills in the age of AI, don't miss our reflection on the enduring importance of human empathy and emotional intelligence. This episode promises a thought-provoking journey that challenges conventional methods and inspires a broader vision for serving our communities.
Guest:
Meg Pekarske, Partner and Head of the Hospice and Palliative Care Practice Group at the Law Firm of Husch Blackwell
Host:
Chris Comeaux, President / CEO of TCN/TCG
https://www.teleioscn.org/tcntalkspodcast/meg-pekarske-on-model-considerations-for-the-future
Teleios Collaborative Network / https://www.teleioscn.org/tcntalkspodcast
Melody King: 0:01
Welcome to TCNtalks. The goal of our podcast is to provide concise and relevant information for busy hospice and palliative care leaders and staff. We understand your busy schedules and believe that brevity signals respect. And now here's our host, Chris Comeaux.
Chris Comeaux: 0:23
Hello and welcome to TCNtalks. I'm excited, our guest today is just a longtime friend and colleague and I always get excited when I get to just talk to her and I'm not actually calling her because I have a problem. So, our guest today is Meg Pekarske. She's a partner and head of the Hospice and Palliative Care Practice Group at the law firm of Hush and Blackwell. Meg welcome.
Meg Pekarske : 0:46
Awesome. I'm so happy to be here and I like, because I am usually the host and I like to. Now I get to be the guest and get to go on my long. You know what I actually think, instead of talking to other people about what they think. So, thank you for this opportunity.
Chris Comeaux: 1:03
Well, and I love the fact that you I love your podcast get a lot of. I listen to your podcast, probably as much as I listen to anybody else's, and, like you, I do get excited when I'm on other people's podcasts, but you're one I'm just so grateful to have today. So, before we jump in, Meg, there may be a few people that don't know about you, but what would you want them to know about you?
Meg Pekarske : 1:22
Yeah Well, I've been doing hospice work for now almost 25 years and I'm really so. I was 25 years old when I started doing you and I both oh my God, I did not know that yeah Well, and Mary Michael, who was my wonderful mentor, and you know, people come into your life and you never really know what that means. But she had joined the firm at the same time I did, and she had this crazy idea of starting to help hospice from a legal perspective and people thought like why would hospices ever need help? And so, I helped Mary from the very beginning, and then our practice has grown and now we have a core team of about 15 people here at Hush Blackwell that do hospice stuff day in, day out, and we really do everything from federal false claim work to audits to some of the things we're going to talk about today.
Meg Pekarske : 2:27
I think about how people can build something new together, and so it's been a really interesting ride and I think I've said many times, I feel like I've had to reinvent myself, like every five years, because I have to learn new stuff all the time at myself. Like every five years, because I have to learn new stuff all the time Because and thinking ahead of where we're going to be from a business planning standpoint, and then what people I need on my team, because, just like hospice, my team's very interdisciplinary, and so I grew up as a regulatory lawyer. But right, we do litigation, and we do transactions, and so I really needed to have a really broad team behind me too. So, it's interesting how that mirrors what my clients do.
Chris Comeaux: 3:12
Yeah, no, actually, I love that actually and I'm glad you just put words to it because I've always felt you're a bit of a unicorn from a lot of different perspectives. You're so creative. I mean, typical attorneys are very kind of left brain.
Chris Comeaux: 3:23
You are a left brain, right brain, human being. You're just a beautiful human being. I love your creativity, but now that I could actually listen to your story because I think I did meet you when you were first- working with Mary, but you've always struck me as someone in the learning mode and you were always willing to look at that circumstance from multiple dimensions, and that adds so much value to a conversation.
Meg Pekarske : 3:52
Well, that's so funny. You say that because I have taken, like the at the firm we use the Gala strength assessment thing. My number one thing is learner, and then the Enneagram or whatever. I've done that and I am like equally like analytical, and then equally like artistic and whatever. So, as you can see, the most creative thing I get to do every day is get dressed, so I'm wearing something colorful for you today, and I hope people are watching us and not just listening, because that's what I do love about.
Chris Comeaux: 4:20
Every time I see you too, it's like what is Meg wearing and what is her jewelry?
Meg Pekarske : 4:24
Yes, exactly, I had that fabulous pin the last time we met, exactly and just.
Chris Comeaux: 4:30
I think it was you and I and Bill Finn, and that was such a Bill's listening. Right now, he's probably blushing a little bit at that comment. Yes.
Chris Comeaux: 4:39
We want to tell our listeners. We can leave them in the mystery on that one, so we'll let's jump in, Meg, and so you and I do talk about this frequently. These are, these are really challenging times, and I totally forgot that you were 25. I was 25. So, we have a really interesting kind of rear view mirror to look back from. But it feels like these next five to seven are going to be pretty fascinating. So, from your perspective, I think it'd just be great. To start with, what do you see as the top challenges that you think are coming that just really make it necessary?
Meg Pekarske : 5:14
For people to be either changing, evolving, getting ready to change. Yeah Well, some of this I think is already here, but I think it's just going to continue to grow. I think competition is a big thing and I think competition not just from other hospice companies, but we have the whole payvider. You know, in healthcare we always have to have funny names for things, but you know payers who are also providers and have a lot of cash right and a lot of resources, and I mean we've also had, you know, really nontraditional folks enter healthcare to, like, I think, amazon and, you know, the Walgreens and, and some people are coming and going, not in necessarily the hospice space, but I just think there's competitors that are maybe different than we're used to seeing.
Meg Pekarske : 6:12
And I think that this is a real challenge is we have historically just done one thing and we've done hospice, and you do hospice really well, but you're sort of I always say the one trick, pony right, and you're really cutting yourself off from you know how can you be of service in the world and service your community if you really limit yourself to that silo?
Meg Pekarske : 6:38
So, I think that folks who aren't willing to pivot and you know, have a wider lens of how can answering that question, how can we be of service and what does our community need?
Meg Pekarske : 6:53
And so, another thing and I think you deal with this too is there has been a lot of my not-for-profit clients are really geographically limited, right, and when you're starting to think about working with non-Medicare payers or at least not traditional Medicare they really care about you know breadth and your geographic reach, and that matters. And so I think that that our community and maybe expanding who is our community that we serve, and so and I can't answer questions of challenge without talking about the enforcement environment is just so, so difficult for people. It's draining cash, it's casting a really wide net. I think we all know too wide of a net, and so but and maybe this is like my eternal optimism, but I think all these challenges and you too, so I'm like singing to the choir here these are opportunities, right, if we talk about all of these, because we have. So, we as an industry have so many strengths and skills that I think are unique to us that we can be of service in the greater world and overcome these challenges. So, but they're real.
Chris Comeaux: 8:18
Those are really good. Meg, you'd be fascinated by this. We got this really great process from a well-known she's actually in the National Speaker Hall of Fame, but she was probably one of the best strategic planners I've ever met and she had a really interesting tool that you do a 360 degree environmental scan. We started it when we started TCN seven years ago and we've now gotten down to eight challenges Very succinct.
Chris Comeaux: 8:44
It's a great presentation you just actually hit upon most of them which really which is why you're so darn good with you know, we've been using this tool with the CEOs within our network. We've been bringing their C-suite team, so we beat the heck out of the outcome and it was like this huge kind of like just brained up and we kept distilling it, kept distilling it and you just totally hit one of them.
Chris Comeaux: 9:04
Now it just brained up and we kept distilling it, kept distilling it and you just totally hit one of them. Now it's interesting, actually, one of them you actually hit four of the key ones out of the eight. You start with competition. The term that we struck upon is hyper competition, which I think will resonate with you very quickly because it's coming from so many different directions. It's not just your traditional yeah, there are a lot of hospices but then also substitution competition. You identified the pay viters, all of that stuff happening upstream, and so I think you're dead on. So, given those challenges, I think organizations are looking for solutions. I love how you framed it challenge and opportunity. So, whether that's them getting bigger via banding together, that could take many different forms, diversifying the revenue streams. Probably in many cases it needs to be both. But can you just talk about that? Let's take it from challenge more to how do they turn those opportunities and move them forward to solutions.
Meg Pekarske : 9:57
Yeah, but maybe not as often. That's one of the most fun things I get to do is when I meet with boards and we do some strategic planning kind of stuff, because I learn a lot. But also it gives me an opportunity to sit down and think about these sort of big questions and reflect, and I think the thing that I come back to is there are. I think the thing that I come back to is there are. I think the payer market is really opening up in meaningful ways. So, what was it? 15 years ago, people started providing palliative care and we were really stuck with the Part B revenue stream and these pretty limited E&M codes limited E&M codes and it was sort of round hole square peg because you know those palliative care visits, goals of care, conversations you know you're not maximizing reimbursement because they take an hour and a half to have that conversation or whatever. But I think things are really changing and I think we're on the precipice of different revenue streams opening up and allowing for creative ways to get paid for what we have to offer, and so I think it's absolutely essential to diversify your revenue stream. I don't know of any other provider in healthcare that is so dependent on traditional Medicare it's like 90 to 95%. So, when you link enforcement and audits, it's like those things have such an impact because we're not diversified right. If you're thinking about your investment portfolio, you wouldn't put all of your eggs in this basket. We need to think a little bit bigger, not only to be of service, but just from a financial stability going forward, and I think these it's been hard to grow this because even if you got to the table with an ACO or Medicare Advantage plan, maybe there was some hesitation or you didn't have the data to support what you wanted to do. But again, I think those conversations are starting to to change. So my big thing is you got to diversify.
Meg Pekarske : 12:12
And I really don't like it when people go to conferences and it's like they try to cookie cutter whatever they heard at the conference and it's like I'm gonna go do this and not that. Obviously, I love learning, I love hearing what other people are doing, but that thing might not be right for you. But use these things as opportunities for brainstorming about what might be the right thing for you and what your community needs. And I think sometimes boards, because, let's say, you went down the palliative care road and you didn't make any money or you lost a lot of money, there can be some hesitation to invest in new things, and I think now is the absolute wrong time to pull back and not invest in new things, because if you don't, I think it's sort of a death knell to a certain extent. And so, anyway, my big thing is service diversification, which will automatically mean pair diversification. But I'll stop. That's really good Because, again, I told you I can go on and on, because I never get to like talk about these things as much as I would like.
Chris Comeaux: 13:26
So, this is really good, Meg. In fact, you would love this. I'll pay this forward to you. Years ago, a friend of mine called and said Chris, you need to go visit Pals, and they're a fast food company in eastern Tennessee that won the Malcolm Baldrige Award, and I'm like oh really, you see those are your. Just saw the look on Meg's face.
Chris Comeaux: 13:44
I'm like what the heck?
Meg Pekarske : 13:46
Yeah.
Chris Comeaux: 13:47
But actually, so they had this great center of excellence. It was like a two day training. I went and I'm so glad my friend recommended it and what. There's so much stuff. I learned like the guy who actually created the Baldrige standards lived in Kingsport, Tennessee. He actually is almost like a friendly bet, like I'd help your organization. So, there's just so much cool wisdom that I learned.
Chris Comeaux: 14:06
But one of the adages when I was there that I've never forgotten is the concept of learn, adapt, implement. And it's what you're poking on. Like there is this fallacy go to a conference and just copy and paste. It's not, it's learn. You have to come back and adapt, you have to go okay, what is it about this that would make this work in our specific market? That's the whole adaptation and then the execution is the implementation. So, learn, adapt, implement. I never forgot that because I could think of examples in the past where I went to a hospice and like oh my God, that's a cool idea and tried to run back to my hospice and copy and paste and it never worked and copy and paste and it never worked.
Meg Pekarske : 14:43
No, absolutely. And I think you need and I always talk about like law can be, like a creative endeavor it's not always, but like it can be in the sense of when you have a great team. It's about having ideas and like bouncing them off of each other to then get to a better place, and I feel like that's what reading books is about. That's what's going to conferences. You need input. It's not like manna is going to come down and like, oh, here's the right idea. You need to constantly be hearing and listening I mean podcasts, you know whatever it is to get new input, because I think the exciting thing about what we're on is we are going to develop a model of care that does not exist.
Chris Comeaux: 15:35
Yeah.
Meg Pekarske : 15:35
Yeah Right, and we might call it Chronic Care Management. We might. Who knows? There isn't even a licensure category for a lot of what I think is the solution to a lot of challenges in folks dealing with serious illness, and so we're building something that doesn't exist yet and but you're coming from. How can I be of service? What do people need? What do my community partners need? What do patients need?
Meg Pekarske : 16:05
And one thing I'd like to say, because I did a recent board presentation and another filter I think you have to have about what works for you is thinking about because PACE right now is super hot, right, everyone wants to do PACE. That is a huge investment. I mean, it's an amazing model of care, but super huge investment. You know lots of staff, lots of money, buildings, brick and mortar. You know all that stuff and not that people shouldn't do PACE, but thinking about what staff do I need to do this model of care because there's so much staffing shortage. So, if you're going to say I'm going to grow in this other area that needs tons of nurses and I don't even have enough nurses to staff my hospice, like maybe that's not the immediate right thing to grow into, and then I think technology. There's so many ways to use technology.
Meg Pekarske : 17:04
So thinking about, is this thing I'm going to grow into, how can I leverage technology to maybe make it, you know, more financially feasible, or whatever? But thinking about you know, more financially feasible or whatever, but thinking about you know practical things, I guess not only is what is the need, but to meet that need, what do I have to have on my team and is that even possible? And so, I think there's a lot of filters. I'm into filters, filtering down. I think the right thing is going to, you know, become apparent when you factor in all these different things, because not most people don't have endless sums of money to invest in stuff. And so, you know people are doing adult day centers. Well, that doesn't take a bunch of nurses, right? Like, how can you staff that, and so I think there's some exciting things, but, yeah, not the cookie cutter.
Chris Comeaux: 18:03
Oh, there's something so good and well, there's a lot of good and gosh, there's probably 10 different trails we could go in what you just said, but one I wanted to key on was you're talking about the pace. I was blessed because I worked in corporate America, KPMG, one of the largest CPA firms, and then a Fortune 50 company, before I fell into hospice at a young age. So luckily having that background. But I think some of us who maybe didn't have that kind of background and you just grew up in hospice, you've grown up in hospice in the heyday of the actual reimbursement and it almost could create this ethos of man. We could do anything.
Meg Pekarske : 18:36
Yeah.
Chris Comeaux: 18:36
But pace is a different animal. Like return on, investment of capital has not exactly been a discipline that most hospice leaders have grown up with, and so that is so capital intensive, the tail on where your ROI is, and et cetera. So that's one where you really want to make sure you have smart partners and they'll just jump off the deep end of the pool like, hey, pace is hot, it's like $16,000 a month or whatever the reimbursement is by state.
Chris Comeaux: 19:01
So that's a great kind of word of caution. So, Meg, I feel like you've given some good ideas around the diversification, but legal structures are kind of important. So, the models and legal structures that you're probably advising people because that's a bit of the core that you could go on the journey.
Meg Pekarske : 19:31
Like maybe you're going into a new structure that might be necessary to do. Some of nonprofits have like one legal entity that holds all of their real estate and holds all of their provider numbers and sort of trying to build something from. And this doesn't mean banding together necessarily, but even first starting with, if I'm going to do something new, I probably need to revisit this legal structure that I have and, like we always think in the nonprofit world, everything needs to be an ink and it can be an LLC and a disregarded entity and like for tax reasons and all this stuff. So, some people are first starting at home and thinking about you know what? Do I have the right structure, especially if you feel like you might be affiliating and having people come under your umbrella right and thinking about governance issues and other things. I think that. So obviously there's been a lot of member substitutions and combinations going on. So, you have a holding company and then you have different affiliates coming underneath that and you know, depending on you know the governance documents and bylaws. You know people could have equal voice at the hold co-level or they couldn't. I feel all of these things we're talking about unlike some regulatory things that maybe have more parameters around them.
Meg Pekarske : 21:12
I feel like on some of this corporate stuff we're going to talk about, there's a lot of flexibility and, like you know, these acronyms people throw out, like one member substitution is sort of one member substitution. I mean the mechanics of how you do. That, you know, is like someone's, a new entity is going to be your sole member but all the governance stuff and bylaws and what power, you know, do you get board seats and all that stuff. That really can be very different and there's a lot of different models out there. So, there's the sort of internal restructuring, there's the member substitution. I think in talking with lots of boards there's still for some folks a hesitation. I want to be, you know, keep my independence, but I see a need to, you know, have administrative efficiencies and cost savings and whatever. And so, we've seen some management services, organizations, people, coming together and co-owning that and putting their back office functions into that, and then, you know, other people can contract with them to do that.
Meg Pekarske : 22:23
Obviously, TCN is it was an early adopter of clinically integrated networks, which you know. All of this stuff it's like it blends together because it can be financially integrated. And then so I really start with, not the label, but really what are you trying to achieve? Because I think that again, you go to a conference or you talk to someone and they start throwing around these acronyms and I think CEOs and lawyers and everyone else want to sound smart and it's like, oh, I'm doing, you know, you throw out all these acronyms. But it sort of comes back to well, tell me what your goal is and what you want to achieve, and then we can figure out what's the best way to do that and we can put a label on that later. That start with that conversation, because there's a lot of flexibility in all these different models of but there's a lot of coming together and I think there's a lot of value in coming together. But coming together can look 100 different ways.
Chris Comeaux: 23:30
Boy, that's so well said. I'm glad that you started there, because I do. I see that from my peers that maybe they get, because they start to get their minds wrapped around. Well, member substitution is how nonprofits come together, and because we don't really have an owner, we don't have shareholders, we don't have stockholders, and then they think, well then, that's kind of the thing.
Chris Comeaux: 23:50
So, Meg, do you have like almost like principles that you tell people like here are the things that think through? So, then you can, so I could come to an incredible attorney like you and your team and say, okay, these are the principles we've thought through, and now I have my answers for you, and then we can figure out the best modality, legal structure, etc yeah, so we have.
Meg Pekarske : 24:11
We developed this guiding questions document to help people as a starting point about what's important to you. What are you trying to achieve? Because sometimes there's multiple different objectives. I mean, if you want to come together for with payers like and you know, have a palliative care product, that's like, and you know, have a palliative care product, that's like you know one state or multiple states like you can't just be like a messenger model, kind of black box, like they help with payer contracting but no one knows anyone's rates and I mean there's a whole bunch of antitrust stuff with that you need to follow when you're doing an anti, just general anti-competitive stuff. But if you want to develop a new model of care, you probably need to be clinically integrated, right to deliver that meet those data objectives that are going to be the measure of is are you meeting, especially if you're going to take risk with payers right Upside, downside risk, like you got to deliver a product and you got to know that it's going to be consistent and you're going to be able to meet those outcomes. So, I think we do start with these guiding questions like what are you really trying to achieve?
Meg Pekarske : 25:35
Some people, if it's really, we just want administrative efficiency and you know we're all don't need an HR director and we all, you know whatever.
Meg Pekarske : 25:47
I think a simpler like management services organization can be really helpful if that's really the primary focus is. I got to reduce costs and maybe eliminate redundancies, and I'm going to do it with like-minded people. So, we do, because I've been down this road and I too get a little bit confused. I get pulled in these different directions because if I glom on to the label the client gives me, I feel like we're going to not end up in the right spot. That's why asking questions is better than like taking direction from your client saying I want an MSO, and then you're like okay, let me go do that. And then you get to the end and they're like well, but I really want to develop this other model of care with pairs. And then you're like it's and not that things can't morph, like it began as an MSO and things can change and morph. But I think a good place to start is always with questions. The questions will reveal, like, what you should do.
Chris Comeaux: 26:55
This might be an unfair question, Meg, but is there one, because there's a lot that you just covered. Is there one general problem that you find, like you know, 30% of the time now people are trying to solve. Or is it because you really just covered a lot, or is it really it runs the whole spectrum of what you just covered?
Meg Pekarske : 27:14
I think people are trying to achieve all of those things, but yet they have an open mind about what they want to achieve, but then they don't want to give up anything. I don't want to give up. No control, no independence, no, anything. And it's like, well, that doesn't, it's not going to add up, you’re not going to be able to achieve those. Well, that doesn't, it's not going to add up, you're not going to be able to achieve that.
Meg Pekarske : 27:59
Then you end up spending lots and lots of time and you know you don't really get anywhere, right, because it gets so watered down and you're not really going to be able to meet those objectives anymore. And so, one of the other things we try to do is get to the hard questions first, if at all possible. Right, you need your dating. So, people, this is more in member substitutions, like you know, you got to get comfortable, but then an Adam Royal who's on my team, who works on a lot of our transactions, it's how can we get to those questions sooner? So, then people don't waste lots of legal dollars and all this stuff, because you know, with member substitutions in particular, it's all about, like those governance things. And you know, am I going to have membership on the hold code board and what are my powers and what's my say and all that stuff.
Meg Pekarske : 28:58
And I feel like sometimes in transactions we do that sort of at the end after, oh, we've done this diligence and we've done all this other stuff, and then it's like, okay, but you were never gonna give me any board seats, like you know. So, so I think that that and maybe all of this comes down with doing I'm calling it inner work, but before. So maybe you listen to all this stuff and read stuff, but then you really need to think about what you want to do before you start really having conversations with people, because I see people waste a lot of time, and I do think there's like a time is of the essence, like the runway here isn't forever, right, we got to make this pivot. And so, I see people waste a lot of time and money, like I mean years working on something and sort of dilly dallying around, and then you know you end up not really being anywhere at the end because it gets so watered down.
Chris Comeaux: 30:05
So, yeah, and then you waste a whole bunch of just legal dollars. I love that says so much about you and your firm that you would even because but hey, you're getting fees, but yet if you really are about making a difference, then you would think about well then, how do we get to those questions so you could unnerve some of that stuff, so you could really making a difference, than you would think about well then, how do we get to those questions so you could unnerve some of that stuff, so you could really make a difference? One thing, Meg, that I'm seeing, and it is so much that you've touched on and everything you've said so many little pearls.
Chris Comeaux: 30:32
I see people throwing about IPAs. They're starting to throw it out and I'm just start asking a couple of questions and you can tell. I mean, I get it as hospice leaders today there's so much coming at us and if you don't want to know what an IPA is and someone's like banning that about, like well, maybe I need to go do an IPA. So, the last time I saw it was, I think, was during Hillary Care. You know that in the mid-nineties is whenever I released the IPAs. So, what's that about? Why are people starting to throw that about. Is that really something that should be kind of dusted off and brought back to the forefront?
Meg Pekarske : 31:06
Yeah, I mean, I think it was a model that a lot of physician groups used, because sometimes it stands for Independent Practice Association, but also people will say physician, that P also is like physician association. So, it is in some ways sort of like management services, like you have people, you have all these independent networks or independent physician groups typically, and then you know there's some, you know, overhead sharing and whatever. I just I feel like that label and plus, when you're dealing with physicians there's a whole lot of licensing issues like who can own, yeah, physician practices and stuff that we don't necessarily, you know, have in the same way with hospice. And so again, I'm not. I mean I've talked to some folks about IPAs, but I think it's not. I think usually people are more in the MSO camp because it's sort of more about overhead and like how we're sharing this and its sort of maybe there is a messenger model aspect to that, but I don't see a lot of interest in that. In the hospice space. I feel like the times and you, and I have talked about this too is more like.
Meg Pekarske : 32:39
Again, I went to a conference, and someone said, oh, these IPAs or whatever. And I went and talked to my colleague, Noreen Viguera, who's fabulous and has really taught me a lot about all these different models because she has tremendous background on that. And you know, as we were, you know, banting around, you know that idea. I mean, I don't know, all this stuff ends up merging together and I was like, is this really different than, and I was like, is this really different than an MSO? Like all this stuff. So, I, you know, I just wouldn't really get attached to that label.
Chris Comeaux: 33:12
um, uh, all that much, uh, and yeah and we had a horrible example of this actually in the Western North Carolina region and this. This may have been a one-off and you could, however you want, to answer this question, but here's the deal is that they actually got challenged around antitrust and that IPA disintegrated, and so it seems like clinical integration is a little bit of a safer route than an IPA, and I don't know if it was just an isolated case, but it always left the bad taste in my mouth. It was a multi-specialty group that came together and they literally had to dissolve it because they didn't they? It was a legal challenge. I think it actually came from a payer and so.
Chris Comeaux: 33:54
I don't know if that was a one-off or you've seen a lot of that from a case.
Meg Pekarske : 33:57
Well, I think, from an antitrust landscape, things are changing quite a bit and so there was sort of a long-standing exception for clinically integrated networks from antitrust concerns that.
Meg Pekarske : 34:14
And I have a colleague, Wendy Ahrens, on my team who does antitrust stuff in the healthcare space, does antitrust stuff in the healthcare space, you know, and that formally isn't there in the same way now. But I do think the climate for antitrust it's now pretty active space and I mean you regularly read about in hospice news and stuff and healthcare, and I think hospice in particular is an area you know of concern. So, I think it's a really great point that you're making and it's not really about the IPA but more about you need to have counsel. When you're talking about like oh, I'm coming together and we're like competitors and we have overlapping markets and we want to talk about rates and like ding, ding, ding, like antitrust, these are pretty serious. And one might say like, oh, I'm that small, no one's going to care about me, and it's like I don't know, you just get the right, you know regulator, and it's like they want to make an example or tap something down or piss off the wrong people.
Chris Comeaux: 35:24
Yeah, yeah exactly because you're coming together is now competition to get someone else and they report you, which is a lot more apt now compared to the past absolutely well make look into your crystal ball five to seven years from now, because my sense is it's going to be kind of really interesting. So that puts us like 2029 to the early 2030s, which oh, by the way, that's actually when Medicare is predicted to be insolvent between that's just going to be a whole nother thing, so, what do you think the hospice and palliative care landscape looks like as you look through your crystal ball?
Meg Pekarske : 35:58
So, I like being bold, so I'm going to say something bold but it's not my normal shtick which is get rid of the six-month prognosis standard for hospice. I just think and Elizabeth Kubler-Ross, when I've done courses through her foundation, she was really like we're not going to need hospice in five years because we've changed health care. And so, I guess my bold statement is more the silo of hospice doesn't matter as much, not that it goes away, but that if we're doing things upstream and meeting people's needs, maybe it doesn't matter so much whether or not they ultimately choose hospice. Because right now I think people are maybe a little bit too small minded, that I'm only going to invest in things that feed me hospice patients and like that conversion really matters. And I'd like to like use like sharp elbows to say who cares, like start with a different question of how can I be of service to seriously ill people in my community. And so, I think if we diversify from a service perspective, maybe because right now if all we do is hospice, then that's all we can meet the needs for right, but if we have ways we can support people in 10 different ways, like maybe it doesn't matter so much.
Meg Pekarske : 37:30
So, I think that that is my hope, not that I don't think hospice is a fantastic model of care and one of my biggest fears is the interdisciplinary nature of it is going to go away and that that's like it's going to all be about nursing visits, you know, and the chaplain and the social worker maybe, you know, fall away. But I guess that's what I want to see is that we really make meaningful impact on service diversification and, you know, sharing our gifts more widely, with how we can manage to a budget, how we can have difficult conversations, how, you know, little check-ins with patients can make a big difference and like them not going to the ER, like having someone to call when you're dealing with difficult things, and so. So, anyway, that's sort of what I my bold, bold prediction is just that it doesn't become so much about hospice that it's because we've made meaningful impacts.
Chris Comeaux: 38:36
Being upstream, it is very bold, Meg so final thoughts,
Meg Pekarske : 38:41
Aspirational. Yeah
Chris Comeaux: 38:42
Final thoughts Meg.
Meg Pekarske : 38:46
Oh, final thoughts. I don't know. We talked about so much fun stuff.
Meg Pekarske : 38:50
Anyway, I just I love having this conversation with you and I love the opportunity to talk about these things because I really care about them deeply, like from a personal standpoint. But also, I feel like it's letting me live out my 25 years of like I love connecting dots and you know, being able to get out of my lane of like, oh, you're a lawyer, I can just ask you legal questions. So, I just think that I'm grateful that I could be on and also grateful for for clients that give me interesting work that I can like grow. I've been able to grow with the industry and learn new things because people have trusted me and so I'm. I'm really grateful for that. So, who knows? Who knows where the future lies? But I've had great clients who have trusted me with really important things for their business, and then I can get all these little nuggets from people. So, it's more like you know, is there an original idea? It's more just like you listen to things and then they ruminate and then they come out.
Meg Pekarske : 40:01
So, thanks for letting me be on the other side of the microphone. So, to speak?
Chris Comeaux: 40:05
No, absolutely, Meg. I can actually again think about our relationship, our working relationship over the years. Usually when I called you in the early days it's because the car was in the ditch and it's like help us get the car out of the ditch from a regulatory perspective. But then of course, my role is different now than when I was just a CEO but having more of a thought partner like you. I don't know if you've read the book A Whole New Mind by Daniel Pink. You will love that book because it really kind of encapsulates like where you just landed the plane. It basically Daniel Pink started the book and said you know, the left brain dominated world, lawyers, accountants that detailed analytical aspect through artificial intelligence is going to be disrupted.
Chris Comeaux: 40:45
And then people like wringing their hands and like, well, what am I going to do? But what he basically paints the picture is the future is the right brain, which is much more that creative side. You can't replace that with artificial intelligence. In fact, I was on a call with you. I did not tell you this. I was on a call with you and Noreen and it was awesome.
Chris Comeaux: 41:07
And what I did for the first time ever is I had artificial intelligence up and I asked the legal questions so then I could get that download. So, I had a good idea of the basic. So, then I asked you a much better question so we got to the creative part much quicker and that to me was a perfect little encapsulation of what Daniel Pink is poking on in that book of like that's the future. It's like you know, the typical transactional left brain. What does the reg say, which again I could kind of look back and see our, that's kind of been our metamorphosis with each other. Now I love talking to you because we're not getting the car out of the ditch. In most cases it's like how do we actually get the car in a whole new highway going forward in the?
Meg Pekarske : 41:40
Future? Yeah, absolutely, and I agree. And the other thing I think is important to the future is just emotional intelligence, and maybe that goes with the right brain. We're all still humans and I guess one thing that I've really built my practice on and I think I've gotten more comfortable over time of just like being myself and like I might not be everyone's cup of tea or whatever you want to say, but like bringing your authentic self and like my curiosity and I really like learning people's stories and all that stuff. That's the package. Like that I don't want to say you're selling, but that's what you're bringing to the table.
Meg Pekarske : 42:26
It's not like I can recite this regulation and whatever, and so I do really think that who's going to thrive in the future are people that you can bring you know more to the table. But I think there is a challenge is how do you train young lawyers or young accountants if AI is doing all? Because, like I had to start there 25 years ago to be where I am now, you know, and how do you get that experience? But, yeah, it's an exciting and challenging and but I still believe, and you, I think, my first podcast guest six years ago, I was actually, it was.
Meg Pekarske : 43:08
Yeah, and when I was having these conversations I always ended with are we ever going to take the human out of the dying experience or whatever, and I still go back to I was like, oh wow, that was actually sort of a good question, because now, even more so than six years ago, technology is so talked about as a solution to so many problems. But I still think like human connection and human I mean it's what you know stirs me and so and I think it's what makes a difference really at the bedside with patients too, because I've been a hospice volunteer for like a year and a half so I have had the bedside experience and I think that human connection and is still really important. So those are great final thoughts Meg.
Chris Comeaux: 44:06
Well, I appreciate you, Meg. Thank you for you and your firm. I do think that's what makes you unique, is that I know I could you know, anyone can call and get a great legal answer. But that future is really kind of how do we, how do we redesign where we need to go? And that's where you and your team are just great thought partners. So, appreciate you.
Meg Pekarske : 44:29
Yeah, I want to give my quote. Can I give my quote?
Chris Comeaux: 44:31
Actually, I was going to read it, but did you want to read it?
Meg Pekarske : 44:31
Oh no, no, you read it. Oh, I didn't know, because this quote means a lot to me and so I'm going to lead it up. So, tee it up. So, Georgia O'Keeffe like for people who don't know, I live in Madison, Wisconsin, and Georgia O'Keeffe is originally from Sun Prairie, Wisconsin, which is right outside of Wisconsin, but people don't think of her as a Wisconsinite. But, so this is a quote by Georgia O'Keeffe, who was I think pretty much everyone knows a pretty cool and revolutionary woman.
Chris Comeaux: 45:08
Well said.
Meg Pekarske : 45:08
With that said.
Chris Comeaux: 45:09
Which is similar, cut from a very similar cloth as Meg. So, our listeners, we always want to thank you. Thank you for listening to TCN Talks, and we always leave you with a quote, and this one was chosen by Meg, which is from Georgia O'Keeffe, and it's "I've been absolutely terrified every moment of my life and I've never let it keep me from doing a single thing that I wanted to do. Great words for us to live by Great words to end this podcast with Meg. Meg, thank you, and to our listeners, thank you for listening to TCNtalks.
Jeff Haffner: 45:58
Thank you to our TCNtalks sponsor Dragonfly Health. Dragonfly Health is also the title sponsor for April and November 2024 Leadership Immersion Courses. Dragonfly Health is a leading care-at-home data technology and service platform with a 20-year history. Dragonfly Health uses advanced technology and robust analytics to manage durable medical equipment and pharmaceutical services as part of a single, efficient solution for caregivers, patients and their families. The company serves millions of patients annually across all 50 states. Thank you, Dragonfly Health, for all the great work that you do.