Conspiracy of Verticals: Rethinking Healthcare Models with Peter Benjamin

In this conversation, Peter Benjamin and Chris Comeaux discuss the impact of COVID-19 on mortality rates, particularly the concept of 'death pull forward' and its implications for hospice care. 

Peter highlights the significant role of assisted living facilities in hospice days and explores macro trends in healthcare, emphasizing the shift from vertical to horizontal care models. 

The discussion also covers the evolution of palliative care, frail elderly practices, and institutional special needs plans (iSNPs), while stressing the importance of measuring quality of care, particularly in pain management. 

The conversation concludes with reflections on the future of healthcare and the necessity of collaboration across various care models.

Guest:
Peter Benjamin, Partner, The Huntington Consulting Group

Host:
Chris Comeaux, President / CEO of TELEIOS

https://www.teleioscn.org/tcntalkspodcast/conspiracy-of-verticals-rethinking-healthcare-models-with-peter-benjamin

Teleios Collaborative Network   /   https://www.teleioscn.org/tcntalkspodcast

Transcript

Chris Comeaux: 0:00

Can you talk about the death pull forward? And my bottom-line question is, is it over?

Peter Benjamin: 0:05

Let's start with the data, which I think it's fair to say is unassailable. Predicting what will happen going forward becomes considerably more complicated. You know, we saw the first significant drop in life expectancy in our lifetimes during COVID. Part of what has modulated every epidemiology and demographic forecast of mortality has been the seemingly irreversible improvement in life expectancy.

Chris Comeaux: 0:37

But here's what I caught you saying. You said that um one half percent of our American population is in assisted living facilities. We call it senior living communities, but assisted living facilities. But yet it makes up 50% of our hospice days of care. Did I catch that right?

Peter Benjamin: 0:55

Mostly. So, a half, yeah, a half a percent of our population lives in assisted living or skilled nursing. In a quote unquote average nursing home, annual mortality is going to be 20 to 30 percent. I think when you have this genuine horizontal, inherently integrative experience for patients and families, it's better for them. And oh wow, it turns out that it's cheaper. I wish we could take care of more people for longer. We don't really have a healthcare system in the United States. We have a conspiracy of verticals.

Jeff Haffner: 1:28

And now our host, Chris Comeaux.

Chris Comeaux: 1:32

Hello, and welcome to TCNtalks. I'm excited today. Our guest today is Peter Benjamin. He's a well-known consultant and a partner of the Huntington Consulting Group. Welcome, Peter. It's been a while, man. It has.

Peter Benjamin: 1:43

Chris, it's great to be with you. Thanks for having me back.

Chris Comeaux: 1:46

It's really good to have you, man. Have you been? Or feel like I haven't talked to you in a while. I feel like we've been like ships passing in the night. I haven't been to the conference where you've been, so well, I think we may not have seen each other, but we live in the same increasingly tumultuous world. I think our clients wake up, our your partners, my clients, wake up trying to do the best they can every day. It just seems like that's getting a little bit harder, not easier. Yeah, well said. Well, there's so much I want to talk to you about. Um, you and I caught up to kind of prepare for today. And then there are so many things. You're always such a wealth of wisdom and knowledge. There are several things that you were basically um just talking about. That I'm like, oh, I want to make sure we talk about that, want to make sure we talk about that. But the first one, because it's popped up three different times since I last talked to you, can we talk about the COVID death pull forward? By the way, I think you were the person who coined that term. So just for our listeners, um, those of us in of life care, of course, we're dealing with people at the end of their life. And Peter was the first one to predict that because of COVID, we have pulled forward deaths into 2020, 2021. In fact, I'll let Peter talk about the stats. And interestingly, Peter, we have a state related to C O N. Let's just say those chickens came home to roost in this year because how the actual formula was actually working. And there's two other projects I've kind of bumped into recently. So, can you talk about the death poll forward? And and my my bottom line question is is it over? Or are we still dealing with it?

Peter Benjamin: 3:14

Let's start with the data, which I think it's fair to say is unassailable. Predicting what will happen going forward becomes considerably more complicated. But let's start historically, if we go back around a decade, if we go back to 2011 and take a look at the growth rate in Medicare decedence between 2011 and 2019, the compounded annual growth rate was 1.80. That reflects a bit of an uptick from the decade before, but not a demonstrable uptick. So we're not talking about huge numbers. I think there's often a misconception that as our country ages, oh my goodness, there must be 5 or 10% increases in Medicare mortality each year. And that's simply not the factual case. So again, just to repeat, 2011 to 2019, 1.80% compounded annual growth rate. So, if you had asked me in 2019, as many clients did, do, have over the decades, to make a projection for the next decade, I would have been highly confident. I would have looked at the prior eight years and probably done a little sensitivity analysis. So maybe it's conservative to say the death rate was only going to continue to increase 1.8%. But okay, even if you increase it dramatically, remember, 10% on 1.8 only gets you to 2.0. Meaning, you know, we're we're not talking about big numeric ranges here. So, for the sake of argument, let's say we just continued the trend forward. That would have suggested that in calendar year 2020, we would have had about 2.361 million deaths. It turns out we had 2.730 million deaths. And so, epidemiologists back then referred to excess deaths when they were trying to broadly gauge the impact of COVID. For me, as you mentioned, Chris, my instinctual reaction was slightly different, not out of any lack of respect for the broader epidemiology, but you know, you and I work in a marketplace and we have clients and this affects them. And so, I immediately started to play with the numbers thinking, wow, that dramatic increase in deaths, that 20% increase one year over the other, rather than the 1.8%, has to get reconciled somehow. And so, as the COVID years continued, I just started to more diligently track this data and share it with colleagues. And 2021 may feel like a long time ago, but when we close our eyes and think back to COVID, we realize 2021 was virtually no different than 2020 in terms of COVID mortality. Now it varied by county. So, if you take a look nationally, some places were hit more in 21 than 22, but you get my drift. So, if we took a look at calendar year 21, and I had done that same projection I would have in 19, you'd get 2.404 million deaths, and the number was 2.728. So, oh my goodness, in calendars 20 and 21, we had about 700,000 excess deaths outside of what we would have predicted. So, if we fast forward, I won't bore you with each year. Calendar 23 continued to have excess deaths. And by the end of calendar year 23, there were almost 900,000 Medicare deaths that I couldn't have otherwise accounted for.

Chris Comeaux: 6:40

So that was a cumulative impact of the year.

Peter Benjamin: 6:42

Of those four years for 2021, 22, and 23. In calendar year 24, the actual Medicare deaths were a little bit lower than I would have predicted in 2019. Only by about 20,000, that's only 1% of the total. But here we are, and your question is the right one. Is it over? Well, that depends on what you mean. I don't think we continue to have excess deaths, although that's actually possible. In other words, there are some epidemiologists who speculate that if you got COVID in 2021-22 and didn't die, maybe your life expectancy has nonetheless been compromised because no one suggests COVID was good for you. Okay, so there are no epidemiologists suggesting, oh gee, if you got COVID, you're now a Superman. In addition, there clearly were folks who didn't get the normal treatment they might have in 21, 2, and 3. There again, hard to imagine that was good for you. So I think we have a tale of two problematic cases. If we don't rapidly adjust for the almost 900,000 deaths I can't account for, then we're going to see a temporary shrinkage or at least extraordinarily low, no growth in deaths, which I mean there's no nice way to talk about this, drives the potential for the hospice market. If we don't see that immediately, I think we're just confronting a steeper cliff a few years from now. Because if deaths stay elevated, it will be because, as I mentioned, those folks who either got COVID and didn't die, or didn't get COVID but missed out on treatment may have premature mortality. So, the bottom line is is it over? That's easy. No. Can I, with high confidence, explain exactly what's going to happen? Equally straightforward, no. But I'm very confident quantifying the number of deaths that have been pulled forward that we're going to have to account for over the next three, four, five, six years.

Chris Comeaux: 8:56

Is it possible? So, we had brought a gentleman, he did work for a lot of chambers, national chambers. He was kind of a data geek, and this is our early, early days of Teleios. And we asked him kind of project deaths into the future. Most importantly, we were looking for the baby boom impact. And he had pulled from five different databases and he created like these interesting trend lines. And so starting right about now, so this was all pre-COVID, this was actually 2019, 2018, maybe when we actually had brought him. And the trend line, Peter, you know, I wasn't all that good in math, but remember how to calculate the slope of a line. And the slope of the line between um about now, especially to about 2035, was very steep because of the baby boom population. It continued to increase, but it the uh there's a term, mathematical term I'm forgetting, but like the biggest part of the slope itself, um, the incline was the greatest between now and about 2035. So, when you were talking about how you looked at that past from 2011 to 2019, were you accounting for some something from the baby boomers that would maybe disrupt that prior trend? The simple answer to that is no.

Peter Benjamin: 10:07

If you went back and did a mortality curve from the 90s and the first decade of the 2000s, you'd have considerably lower growth than the 1.8 for 11 to 19. That's why I started our conversation by saying intelligent people could disagree and potentially suggest the forecast for this decade should have been higher than the compounded annual growth of the prior. That's why I started by saying that. But here again, even if you have a very dramatic jump, if you went from 1.8 to 2.8, just to be clear, that additional 1% delta is 25,000 deaths a year.

Chris Comeaux: 10:46

Not the 900,000. Because you know where my where I was going with my question is could the two net against each other, but it doesn't sound like mathematical. You're saying they won't.

Peter Benjamin: 10:55

In no world do they get close. To your point, might the 900,000 become 700? Sure, that's possible. The trickiest part about those projections relates to average life expectancy. And so, what we've seen, there's no way to know because we're not far enough out of COVID to see this. You know, we saw the first significant drop in life expectancy in our lifetimes during COVID. Part of what has modulated every epidemiology and demographic forecast of mortality has been the seemingly irreversible improvement in life expectancy. And that's been counterintuitive in America because it's reasonably clear that as a comorbid matter, we're not necessarily the healthiest people in the world. And we don't, in fact, live the longest. But it has been awkward for epidemiologists to connect our morbidity and lack of general health with a nonetheless empirical increase in life expectancy. So, again, too many complicating factors, I think, to get at all of that. I think for folks listening, the simplistic takeaway would be if we were counting on a strong tailwind for the rest of this decade in annual mortality growth, I think that's a flawed assumption. Might we experience some of what you were alluding a decade from now when all these things wash out? Sure. Now, part of me, of course, having attained a certain age, hopes that life expectancy continues to grow. Which would modulate even the most uh optimistic forecasts in terms of what our marketplace would look like. So again, simple, I think, for all of our careers, for the careers of everyone who has worked in the hospice movement. This was just a matter of how many more people would die each year and how much tailwind would there be. And that story has been interrupted. And I think it's just incumbent on leaders in our field to recognize this and just be cognizant that this is a unique period and they should temper their forecasts for market growth as a result of this conversation. So, there you go.

Chris Comeaux: 13:17

We don't need to chase us rabbit too far, Peter. But if you've been have you been called in on some interesting projects because of the death pull forward, um, states that still have certificate of need in place are now showing a need because it's not actually they're not serving the community. It actually is the death pull forward. And our friends in the acute care space, you know, they had much more of an immediate feedback loop because hospitals are full. Oh my God, you need more beds. No, wait a minute, that's actually because of COVID. Let's go ahead and and so then states have actually approved that on the acute care side. You would have think they would have actually made the D Doctor go, oh, wait a minute, we need to think downstream and post-acute. But now that's hitting. Have you bumped into that?

Peter Benjamin: 13:54

Yeah, the simple answer to your question is yes, I have been involved in a variety of CON dialogues in multiple states. And far be it from me to suggest that politics ever enters the fray. Never but I think it is straightforward in saying politics does enter the fray. And so, this gets more complicated than folks like me would like it to be because I just want to talk about the data. And that having been said, politicians clearly have views about CON, irrespective of what the data may or may not say. So, I'm just chuckling because of the obvious. I think what compounds the difficulty is for states that have a formulaic CON statute, that gets dicey because it isn't really the regulator's license to alter the formula. And that means they'd have to potentially go back to a legislature. And now you're really talking about politics, and do they want a temporary adjustment to the formula? You know, you can imagine all of that. So, I think you're raising a fact-based query about are all regulators sufficiently nuanced and nimble to accommodate once in a lifetime, hopefully once in a lifetime, phenomena like COVID. And I'll leave that to our listeners, but yeah, let's just move on.

Chris Comeaux: 15:23

Well, I'm with you and I'll move on, but one final comment. But they did actually do it without any type of statutory change for their acute care friends. So, there is precedent there. And so certainly we use that as kind of an interesting, um I mean a very factual basic on, well, you did it for them. Um wouldn't you apply it here? So well, here's my next question. You raised this, and I you are so brilliant and you're so damn smart and you like go through stuff. And I was like still processing this one that weekend after we talked. But here's what I caught you saying. You said that um one half percent of our American population is in assisted living facilities. You we call it senior living communities, but assisted living facilities. But yet it makes up 50% of our hospice days of care. Did I catch that right? Mostly.

Peter Benjamin: 16:13

So, a half okay. A half a percent of our population lives in assisted living or skilled nursing.

Chris Comeaux: 16:19

Okay, or all right.

Peter Benjamin: 16:20

It's about it's a little under a million in each, and we have a population of about 350 million. So, when you adjust for occupancy rates, yeah, about a half a percent of our population lives in a congregate-setting senior living environment, ALF or SNF. The mortality rates, not shockingly, are extraordinarily higher than you would find in the general community. So, just as a reference point, if you look at any state or Medicare Advantage plan, you're gonna find Medicare mortality rates between 3.5% and 4.5%. It's possible a startup MA plan might be lower than that because they attracted a bunch of healthy 65 to 70-year-olds. But the broader the senior population, the more you're gonna normalize between 3.5% and 4.5%. If you take a look at the nursing home population, and you can see this in state reported data, you can see this in institutional special needs plans, whose mortality rates we can report through Medicare claims data. In a quote-unquote average nursing home, annual mortality is gonna be 20 to 30 percent. Wow. Assisted living communities are considerably more variable. All of our listeners can relate to that because if we go back 25 years, for example, there were no hospice patients in assisted living because people didn't die there. It wasn't the business model for the assisted living community. That's demonstrably changed. There are many assisted living facilities whose mortality rates don't quite approach nursing facilities but are well into the teens and even high teens. Even in a PACE program where you have a self-selected initial nursing home population, you have mortality rates between 6-7 on the very low end, meaning a new PACE program, to 15-16% on the high-end mature PACE program, less affluent neighborhood, you know, higher comorbid conditions and greater mortality.

Chris Comeaux: 18:21

And is that their whole is that mortality across the whole PACE programs you're speaking to, Peter? Okay.

Peter Benjamin: 18:26

So the bottom line is if you're in our line of work and you just start to do a segmentation model, you very quickly conclude, wow, this half a percent of the population with this predictably but sometimes jarring to talk about high mortality rate, also has a higher likelihood to choose hospice and is the most likely to have a long length of stay. And so not only do we have the mortality data we're talking about, but nationally, about 42% of all hospice patients on any given day are in an assisted living or nursing facility. And in some states, that number is as high as 65 to 68%.

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Peter Benjamin: 20:03

So, there are many markets where senior housing is hospice. And I'm always a little uncomfortable, you know, making a conversation all about the money, but hey, we have a responsibility to follow the money. I don't think there's any contradicting the notion that congregate-setting environments are significantly more lucrative financially for any hospice, whether you're for-profit or nonprofit. Even in the most altruistically run nonprofit community-based hospices, while their percentage of senior housing patients may be lower than the big for-profits, their margins are high. That's not a criticism; it's just a fact. I mean, all our folks intuitively realize if you have 10 people living in a nursing home, your nurse and aide aren't driving to 10 different residences. And because they're largely non-cancer, their med costs are lower, and their HME and medical supplies are lower, and their after-hours costs are lower. You can just go through the financial model. It's no nefarious activity on anybody's part. It's why our for-profit friends so dramatically emphasize senior housing. You don't get to 20% margins by accident. And hey, we could have a long, rich conversation about what the literal service model looks like. I don't want to defend cost reports, but folks are quick to criticize senior housing-dominated hospice providers. They often make more visits than our not-for-profit colleagues. So this is a complicated conversation. But let's leave it at this strategically for our colleagues. If you work in the hospice space, if senior housing hospice catches a cold, you're going to get pneumonia. Any ripple effect that changes how end-of-life care is being provided in congregate settings is going to have, I don't think it's hyperbolic to use this word, existential impact on the hospice community. It is simply where all the margin dollars are. If hospice became what it started with, and some of our listeners don't remember back then.

Chris Comeaux: 22:10

Yeah, it was actually going to take us there, but if you want to go there, go for it. If you look interesting, right? Because I mean, originally it was about people dying in hospitals. That's why this whole thing came to fruition. And now you have this huge shift where they're dying in these facilities.

Peter Benjamin: 22:24

If we go back to the 80s, the hospice movement certainly had ambition beyond what I'm about to describe. But the hospice movement started by taking care of folks in their traditional residences, largely with cancer. In the late 80s, certainly by the early 90s, the first major change occurred, and we began to see unified rate legislation in almost all states. And by the late 80s and early 90s, the fastest growing part of the hospice market, even though the overall market was growing quite quickly, was skilled nursing. Because all of a sudden there was an opportunity to serve folks that just as a practical and financial matter couldn't readily be served by hospices. And that trajectory was significant through the 90s and early 2000s. And as that market began to mature, somewhat coincidentally and serendipitously, the assisted living community marketplace changed, having nothing to do with hospice. As assisted living communities began to be built at somewhat staggering rates by the 2008-9 financial crisis, they had a problem. And since you need to usually need to sell your primary residence to move into assisted living, when you have a housing crisis, financial crisis, 2008, 9, 10, all of a sudden assisted living communities have an occupancy problem. And, you know, I kiddingly use this phrase. I think it's a PG phrase. Back in the day, if you leaked, you left. If you were incontinent, they kicked you out of assisted living. They didn't want you there. And now you'll more frequently see challenges like if you talk to the activities director and the folks running an assisted living community, you'll hear them talk about how they have to partition their dining room because the able-bodied folks don't want to eat in the same room as the rollers. Because there's a big enough wheelchair walker community that the ALF needs to keep in their community that you have these visions around lifestyle and who wants to be seen with whom. And it's why in so many counties around the country there are more assisted living hospice patients than skilled nursing hospice patients. So, net net for our listeners, I think, on the one hand, there's never been broader, wider, higher quality access to hospice care, immaterial of where you live. And on the other hand, markets evolve, and skilled nursing providers and assisted living community owners are increasingly recognizing and embracing that they're in the healthcare business. They're not just in the residential business. And that I think is driving the beginning of what I predict will be profound change to end of life care in these communities.

Chris Comeaux: 25:08

All right, Peter, that's fascinating. Um, and in the very beginning, before you went off on that, you said if our facility friends catch a cold, uh, we might catch something much worse, like the flu. So, what are macro trends that maybe concern you, or just other macro trends you think that we need to be aware of?

Peter Benjamin: 25:26

The most exciting and challenging trend is one that few folks should understand better than our colleagues, and yet it becomes highly problematic. Here's what I mean by that. Hospice folks, the hospice movement, arguably, was a pioneer in providing horizontal rather than vertical care. We don't really have a healthcare system in the United States. We have a conspiracy of verticals. And that's not because anyone wakes up trying to do the wrong thing. It just means if you run a hospital, you are optimizing the economics of the hospital vertical. And I started with them because I think that in no small part explains why there are almost literally zero examples of hospital health systems that have succeeded in the payer warmth. Because they've grown up optimizing their vertical. Take this through the rest of healthcare. Historically, if you ran a skilled nursing facility, you optimized your vertical. You weren't really in the longitudinal horizontal patient experience business. You were in the business of if Mr. Benjamin fell on Friday afternoon, you sent him to the hospital with a sign that said, please don't return him for 72 hours, because the way you optimized your vertical, it was to get as many skilled days as you could. That's the underlying financial driver of SNFs. That's how you optimize the vertical. That's how the non-healthcare system has worked. Hospice was a revolution if you think about it as a horizontal versus vertical. We became a pioneer in assuring a horizontal experience for patients and families. There was no, oh gee, we need prior authors for a physician to see you. Oh, gee, no, no, I have to get approval for the aid to come. Oh, you need a special thing for spiritual care. Oh no, the social worker, that's somebody else's gig. We became the seamless guide and provider of your care. We have always been a pay violer. We get the money, and we also directly provide the care. Unfortunately, even all these years later, the median length of stay for this fabulous experience is two weeks. So, while I think we are genuinely doing something, not quite as revolutionary as 40 years ago, I'll get to that in a second. We are doing something fantastic in the non-healthcare system system. We've broken the verticals to provide this horizontal experience. Again, sadly, 50% of our patients only have that experience for 14 days. Interestingly, almost literally concurrent to the evolution of the hospice market has been the evolution of another horizontal care model, which is called PACE. So the program for all-inclusive care for the elderly actually has an 11-person interdisciplinary team. And they don't have the same, I don't mean to make fun of it, but they don't have the same opportunities for discharge the live and revocations. They're really a pay fighter. They're getting money from Medicare and Medicaid, and they're responsible, just like us, for everything that patient needs, except their average length of stay is two to three years. So they're providing a horizontal experience for people at end of life. It's interesting. While I may be a hospice insider, even if I say things that my friends don't like sometimes, I'm never going to be an insider in the pace world, even though I've worked in pace for 20 years. That's how hospice and pace are. And when I often say to my pace friends, well, you know, you're in the end-of-life care business. Often, they take offense and say, well, what do you mean? We're not in the end-of-life care business. People don't forego life prolonging care. I said, Well, what's the number one cause of discharge for a PACE provider? Oh, well, death. I said, well, I don't know. Sounds to me like you're in the end-of-life care business. I'm bringing these two examples to the forefront because I'm going to share a third one that's evolving and a fourth one that's a little more mature. But I want everyone to think about this horizontal model. If you're a patient or family member, the conspiracy of verticals is what makes healthcare so painful in America. This horizontal experience, the reason you have such incredible. Incredibly high satisfaction in the hospice space and the PACE space, I suggest, is because it's this horizontal experience patients and families want. Institutional special needs plans are another horizontal experience. So, if you're in a nursing home with an ISNP, you now have a nurse practitioner who's your navigator, your primary care provider, your confidant, your everything. And they come see you where you live in that nursing home. And when you need stuff, they don't say, oh, there's a prior off for this, and I'm going to hand you off to that, and I'm going to not what they do. So in a well-run iSNP, frankly, even in a poorly run iSNP, because it's what you're being compared to, not are you meeting the standard that perhaps you should and could, this horizontal experience is a lot better than what the average nursing home resident experiences, because the average nursing home resident has a quote-unquote attending, but they're not in the building every day. They're running in and out with roller skates on. So I think the ISNP experience is also a horizontal one. Newest to the horizontal party for folks in their last two to three years of life are frail elder physician practices who, on the one hand, have been around for some time. So, I'm not suggesting there's never been a history of dedicated physician practices that either take care of folks that are at home or that take care of folks that lived in assisted living. But we've seen a sea change for a couple of reasons. In assisted living, we're seeing a sea change for all the reasons we talked about a few minutes ago, meaning the patient population is changing. So, 25 years ago, you largely had a cohort that was able-bodied ambulatory and wanted to and was capable and did see their physician in that physician's office. For all the same reasons that you now have a whole bunch of hospice patients in assisted living, you now have a whole bunch of significantly more comorbid sick people. And as a result, assisted living communities are getting pressure from their community residents and family members to have on-site primary care. It so happens that the growth of the MSSP and REACH ACO models now provide more of a financial infrastructure for these practices to be profitable. And so, some of the most highest performing MSSP and REACH ACOs in the last three years are frail elder practices with reasonably low enrollments compared to multi-hundred,000 enrollment ACOs, but with very sick people who almost only live at home or in assisted living or in nursing homes. And I think what we're going to see is an evolution in these frail elder practices that are in value-based models. So, they get part of the savings by keeping you out of the hospital. We're going to see them start to look more like a PACE program, a hospice, and ISNP. And I think at a high level, this is all about a horizontal experience that we all want. And the reason I started my conversation by saying our colleagues are in the best position of anyone to understand this because it's what we've always done. But if it might disrupt what we're doing, sometimes denial overcomes logic and experience. And I think for a lot of our colleagues, we just don't want to change. Hey, nobody wakes up in the morning and says, wow, I can't get to work because I want to change everything I've been doing. I think the bottom line is the world is changing around us. And I'm not Pollyannish about it, but I think generally for the better. Meaning, I'm not much of a general defender for all things Medicare Advantage. I'm a big proponent, advocate, defender of institutional, institutional equivalent special needs plans, because I think they do a fabulous job of providing a different experience than that person would have otherwise had. There's all sorts of limitations about PACE, and you and I can have at it about how good or not they are at certain things. But if you're in your last two or three years of life and your other choice was to go to a nursing home, PACE is a godsend. And one of the interesting things about PACE, empirically, we can measure Medicare Advantage disenrollments because the government reports it. As a rule, in the general Medicare Advantage population, you see an escalation in disenrollment as folks get sicker. Sure, a network is easy to manage if you don't need any health care. So, if you're 65 and healthy, MA is beautiful because you don't need it and it costs less. No shock, and I'm not criticizing in general, but the data's the data. You see more disenrollment when people get sick. Pace has significantly less disenrollment than overall MA, and yet they have the population that within MA would be the most likely to disenroll.

Chris Comeaux: 35:17

Oh, that's interesting. What's the actual statistic on that, Peter? Do you know?

Peter Benjamin: 35:20

Yeah, I'll get it for you. It's a little all over the board, but trust me, on a macro level, the trend is so significant it's sort of unassailable. And we don't even have the real data because the real data would be if you could match cohorts, right? If you could take the PACE population with HCC scores of two and a half and higher and just match that inside MA to see disenrollment. We don't see that much, you know, quote unquote disenrollment or revocation, even when you allow for the two-week median. Why is that? I think because it's this horizontal experience. ISNP disenrollment is lower than MA disenrollment. How come? Because again, I think when you have this genuine horizontal, inherently integrative experience for patients and families, it's better for them. And oh wow, it turns out that it's cheaper.

Chris Comeaux: 36:19

Wow. Let's um I think that our listeners know about pace, but let's unpack, let's go to the frail elderly practices first. Can you put more descriptors? Like, what is a frail elderly practice?

Peter Benjamin: 36:30

Is this what used to be like sniffish groups or unfortunately, if you Google frail elder practice, there's no accepted industry-wide definition. So, here, let's break some ground. There's lots of us throwing that phrase around. When I define a frail elder practice, I'm talking in a practice that targets and is largely comprised of providers caring for patients that live at home, live in assisted living, or live in nursing homes. It doesn't mean they don't have an office, it just means that a very high percentage of their patients live in these other settings. And when I say they live at home, it's not that they're necessarily homebound in parallel to the Medicare home health definition of homebound, but they think of themselves as largely homebound. It's hard for them to get to the clinic. If they can get to the clinic, they can't do it regularly. And so that's that definition. And there's an increasing number of largely private equity-backed practices that are consolidating these types of practices around the country. So, for listeners, this would be companies like Kirana or Sound or Bluestone or Theoria or Harmony Cares. These organizations also almost literally to the organization have ACOs of their own.

Chris Comeaux: 37:47

Okay, I was going to ask about that. So, they have an ACO, they might be getting some MA funds.

Peter Benjamin: 37:52

So, they almost all continue to work with MA, and their MA offer is evolving because, and first, just to be clear, we have some colleagues that have these practices, whether you're in Responsive Care Solutions ACO or Advanced Illness Partners ACO or Surety DCE. There are a number of our colleagues, traditional hospices, that have started or bought frail elder practices and either started or found a sympathetic ACO with whom they can participate to be in the ACO world. I think what's so important, particularly for our listeners and colleagues, is even if the words are a little awkward, we don't want the Humanis in United to think we've suddenly decided we're in the primary care business or even the geriatric primary care business. We're not competing with them. And so these organizations I mentioned, and again, a bunch of our colleagues and my clients, your colleagues, are realizing part of this offer is to go to a Center Well Humana in Optimum United and say, you know, if you guys ran a little algorithm, if anybody in your clinic has an HCC score of over 1.5 or 1.8 and hasn't been in to see you in 120 or 150 days, that's probably bad. Because if you're not seeing them, they're statistically likely to use the ERN hospital. So, test our hypothesis. Why don't you run a slightly more complicated algorithm and match up folks with HCC scores of X, Y, or Z who haven't been in the clinic and their claims costs. And what you see is the obvious. That's the group that moved to an ALF and the clinic didn't know that. It's the patient that moved into a nursing home and the clinic didn't know that. It's the patient who just can't get out of their house and come see them. And so, to your point about MA, these practices have a multi-segment strategy where for traditional Medicare fee for service, they attribute the patients to their ACO, they get shared savings. In the MA world, they're increasingly pitching the big MA plants. Hey, we can be your partner because after all, your clinic business is a machine. You know, if you're a primary care doc in a clinic, you better be seeing, even when it's Medicare folks, 30 plus a day. You don't have time to go drive and see someone home or go drive and see someone in an ALF. So, sure, the jury's out. Let's see where this evolution goes. But I think it is instructive that we see not a couple, not dozens, but over a dozen traditional hospices that have started or bought these practices, participate in ACOs. Uh, at last week's NPHI conference, two of them, you know, self-serving plug, because my friend Bob and I were facilitating a panel, and Rebecca from House Calls in Oregon and Sean from Midland Care Connection in Kansas actually presented about their experiences in this space. And I think both offer opportunity. So if we take a step back, the world evolves. And generally speaking, to better things. I think that the notion that if you're a frail elder, a horizontal experience is better than a vertical one is unassailable. Well said. We've seen that in our own 45-year experience. Its why folks say to us, wow, I wish I'd had this kind of care. Wow, I wish someone could have been in charge. It's super cool that I can call you and you take care of things. We're talking about, I'm talking about the single thing I've heard the most from healthcare professionals in the hospice space for 40 years. I wish we could take care of more people for longer.

Chris Comeaux: 41:41

So, Peter, um, three, four or five years ago, especially with the uh independence at home demonstration, home-based primary care was kind of evolving as a thing. Is frail elderly practices just better packaging of home-based primary care? I almost say better marketing of what it is, or would you say that differently?

Peter Benjamin: 42:02

I think that the economics are important. And as a result, home-based primary care simply has more challenging economics than congregate setting frail elder care.

Chris Comeaux: 42:16

Okay.

Peter Benjamin: 42:17

Much like we once again experience in our hospice lives. If we take a look at the margins and caring for 20 people in their individual residences versus 20 people in one assisted living community, doesn't require a doctorate in finance to quickly recognize the differences. So, my suspicion is while ACOs have been a godsend for home-based primary care practices, they're an even bigger godsend for congregate setting practices. And I think that some of the private equity-backed companies will probably be more inclined to emphasize congregate setting. I think some of them are more mission-driven colleagues will want to do it all because I think that's what distinguishes us. But I think the opportunities are significant in each segment. It's just the math is a little more straightforward in congregate setting.

Chris Comeaux: 43:10

Gotcha. Um, and so let's go to the SNP I SNP plan. And so, can you talk about that? Because there may be a lot of listeners who are like, ISNP? Well, what is an ISNP?

Peter Benjamin: 43:19

Yeah, the history is really cool, much like the history of PACE or the history of hospice. This was not a venture capital-driven entrepreneur with a business plan, the real origin of what became a company called Evercare. Was two nurse practitioners in Minnesota in the mid-90s who thought, you know what, there's just got to be a better way to provide care for folks in nursing homes. And they envisioned, they wouldn't have used this phrase, they envisioned a horizontal model. They happened to be in Minneapolis. I'm giving you the short version of the history. They got connected with some folks at United. And to United's credit, they really pushed this forward. And the formalization of the institutional special needs plan, as we know it, was really part of the Medicare Modernization Act of 2003. And United was a pioneer through their organization Evercare. In the last, let me just describe the model. So, the model is okay, if you run an institutional special needs plan, it enables you, with the permission and blessing of Medicare, to only target folks that live in a nursing home. The reason special needs plans are called that and regulated in a certain way is because they are meant to enable what would otherwise be called enrollment discrimination. In a regular Medicare Advantage plan, you can't discriminate against niches. You need to take all comers that are interested in your plan. And as a result, your plan design is pretty broad. So contextually, our listeners should know there are three types of special needs plans: dual eligible special needs plans, chronic care condition special needs plans called C SNPs, and institutional special needs plans that have a hybrid variety called institutional equivalent special needs plans. So in the traditional ISNP, you're allowed to only target folks that live in nursing facilities. If you have an institutional equivalent special needs plan, you can also target folks that live in assisted living communities but meet the same care burden as if someone were being enrolled in a nursing home. And as we just finished talking about 20 years ago, there would have been exactly zero such folks in assisted living. But if we have a bunch of hospice patients, we certainly have a bunch of folks that are nursing home level of care. So, you now have this dual opportunity. So, the way the business model works in the institutional special needs plan, the plan comes to the nursing home and says, okay, Chris, owner, operator, administrator, we want to collaborate with you and exclusively partner, where you're going to help promote our plan. We're going to send a nurse practitioner into your building on a ratio basis of about one to 75. For every 75 enrollees in this ISNP, we're going to send a nurse practitioner five days a week. If we get 150 enrollees, we're going to send two nurse practitioners, and that might be Monday to Friday, and the other one Tuesday to Saturday. And of course, they're the quarterback. They have a team behind them. They're going to collaborate with your medical director. And here's how the money's going to work. We're going to pay you a monthly capitation fee in return for you not billing us fee for service for Medicare skilled for the people who enroll on this plan. So the nursing home gets a capitation payment of $500 to $700 a month per enrollee. That's real money. Start hitting your calculator. And the nursing home has a gain share. So when the iSNP successfully keeps costs below its revenue, the nursing home further shares in that revenue. So that's the high-level clinical model, financial model. The most recent successes in the iSNP space, the folks that have challenged United and taken away market share, are called provider-sponsored iSNPs. What that means is you have entrepreneurial companies, two in particular, one called American Health Plans out of Tennessee, one called PPHP out of Maryland. They not only do what I just described, but they also have nursing homes as part owners of their health plan. And so you have a very tight, interwoven financial and clinical relationship between the nursing home and the iSNP. Now, at the moment, of course, hospice is carved out of Medicare Advantage. And most ISNPs are very high utilizers of hospice. Their death service ratios are often in the high 70s and even low 80s. Oftentimes their lengths of stay are 70, 80, 90 days. They're not fans of 200 and 300 day lengths of stay because they think they can manage that patient. But iSNPs have been very good hospice partners as long as the hospice isn't going behind their back and trying to get two, three, four-hundred-day length of stay patients. The same phenomena holds in assisted living. But if hospice were to be carved in, I think this is the first place you'd see very demonstrable impact. Because this would be the easiest environment for the MA plan, meaning the iSNP MA plan, to create its own hospice-like offering embedded inside the team. So again, my hair's not on fire. I don't think to carve in is on anybody's radar, particularly after the current congressperson from Arizona seems to have gone away on this topic, at least for the short term. There you go. Mind you, in the frail elder ACO world, this is quite different. Hospice is carved in. And so if you're a frail elder practice and you're in an ACO and you now have a hundred primary care patients in an assisted living community, and 10 or 15 of them are on hospice, those are your costs. Right.

Chris Comeaux: 49:19

They're carved in terms of it's calculating the total cost of care. So, they may not be opposed to having a good hospice partner with an ideal length of stay, theoretically.

Peter Benjamin: 49:30

Uh not theoretically, yes. Okay. I don't think that's theory. I think that's fact. I think what remains to be seen is how much some of those organizations may insource something like what we might characterize as palliative care because they completely recognize the increase, the needs of persons in their last two, three, four, five months of life. But when they look at hospice at 200 bucks a day, maybe to your point, the ideal old school hospice length of stay is a month or two with more palliative care for a longer period of time. And that having been said, maybe they'll call it palliative care, maybe they won't, maybe they'll call it supportive care, maybe they won't. I think in PACE programs and ISNPs, they don't call it anything. They call it good primary care. And so here again, I think while jarring to some of our colleagues, in no small part hospice started because of failures elsewhere. And I don't think the ideal long-term solution to the conspiracy of verticals is more verticals. And so I don't view it as treason to think: hey, if a PACE program can provide a horizontal experience, if a frail elder practice can provide a horizontal experience, if an ISNP can provide a horizontal experience, personally, professionally, I'm much more driven by how do we measure that quality? How do we know if that's better or worse than a traditional quote-unquote hospice experience? And Chris, you and I are gonna live to see these conversations play out because horizontal isn't a conceptual thing anymore. It's a thing. And if you're the patient in family, it's a real thing.

Chris Comeaux: 51:27

I want to make some comments about kind of the I love your framing this way. I've never actually heard you frame it like this. Um, so these horizontals versus verticals. But on the i-SNP side, Peter, so effectively they're like an MA plan. So, they apply like any other MA plan. So basically, the government is giving them the money as an i-SNP. Like, where does the money come from?

Peter Benjamin: 51:49

They're not like an MA plan, they are an INAP plan. It's a special MA plan. Exactly. They are paid exactly like the traditional MA plans. And the differences plural are plan design. So, if you have an i-SNP, unlike a regular Medicare Advantage plan, you probably don't include a gym membership. Because why would you? And one of the rationales on CMS's part for the creation and support of special needs plans was to enable the plans to do unique benefit design. The the even more crystallizing example would be the chronic care condition special needs plans are very focused. So, you might have a C SNP solely focused on diabetes, which you would never do in a regular MA plan because that doesn't work. The other difference is that in the traditional MA world, you have limited open enrollment unless you're a five-star plan. And in the special needs plans, you can have year-round enrollment. So, in the i-SNPs, they're enrolling folks every month, partly because of the compromised life expectancy and unique nuances of these targeted populations. So i-SNPs are enrolling folks all 12 months of the year.

Chris Comeaux: 53:03

Gotcha. So, one thing that um so thinking about your framing about horizontals, um, you know, you and I have had a wonderful debate about, you know, hospice as a as a special modality. I would say that there are clinical competencies embedded in hospice. Maybe a full moment I pick on that we probably would agree on. I actually managed home health, and there's some great people doing great work in home health, but it's it is a vertical and it is very monocular, monofocus, basically, in terms of their approach. Whereas hospice people they think more holistically, and then you chassis onto that incredible clinical competencies, pain control, symptom management, thinking holistically, communication skills, care planning skills, what matters most, et cetera. I wonder, because I I'm not obviously that's what I'm familiar with. Well, when you look at PACE and some of these other vertical ISNPs, like the fact that it is nurse practitioner driven, um, I think there are some competencies that help hospice, which really infused into the powder of care movement, especially the community-based palliative care movement. And I think that it's why you get such beautiful outcomes. A high performing hospice chassis to a high performing community-based palliative care program creates a beautiful horizontal with great outcomes. So, I'd love to see if you want to take me to task on any of that.

Peter Benjamin: 54:24

I'm going to amplify our agreement and then posit some other things. So, I think your home health example is a really powerful one. It is often the case that the home health nurse visits Mr. Benjamin on a Monday and his or her job was to change the wound dressing. And they do. And they take a picture of it and they send it to their boss, and they get in the car and they call their spouse and they say, wow, I really feel bad for Mr. Benjamin. I bet he's going to go to the ER tonight. Now, did the nurse do anything bad? No. I mean, they did their job because their job is to optimize their vertical. They're getting paid to change the wound dressing. So, not so surprisingly, that's what they did. So, I think you're right. I think to try to transform the vertical home health industry into a horizontal will be really hard because you just have decades of this incredible vertical focus.

Chris Comeaux: 55:37

Systems, processes, EMR systems, all of that reinforces it.

Peter Benjamin: 55:41

All of the above. I think your example of hospice completely resonates for me. Palliative care is a lot more interesting to me because I think if number one, you've seen one palliative care program, you've seen one palliative care program. And in some respects, there are often examples of a palliative care person who goes to do a consult because that's what they got paid for. And they do their consult, and they send a beautiful note, and they too call their spouse on the way home and say, I really feel bad for Mr. Benjamin because I bet, he's gonna go to the hospital. So, depending on how a palliative care program is contracting with its payer, I'm sad to say oftentimes they are closer to the home health nurse than they are to their hospice colleagues who would never do that because they didn't get paid to do a visit. They're part of a team, to your point, who knows, hey, our mission with Mr. Benjamin started the day we agreed, he wants to die at home. That's our job, damn it. And we're gonna help do that. So, I'm not criticizing any of our palliative care colleagues. I'm just suggesting palliative care can and often does exist as its own vertical, divorced from that horizontal experience. Now, to your point about will iSNPs for elder practices and PACE programs fulfill my fantastical hope? Who knows the jury's out? I wouldn't jump up and down and suggest otherwise. I think in the case of PACE, there's at least a multi-decade history. Now, the numbers have gotten a lot bigger. So, you know, I hate small ends for all the obvious reasons. Um, but there's at least a you know, four-to-five-decade history. With ISNPs, in all fairness, there's a three-decade history, and the numbers have only gotten big in the last 10 years, so the jury's out. The frail elder word, to your point, if you go back to independence at home back in 2012, really small ends. But even in the non-economic home care world, Rebecca at House Calls in Oregon, you know, a plug for her, they did great early on on small volumes. I mean, there's clearly home-based programs with great management teams and providers who are able to work it out in a value-based program. When it was pure fee for service, you know, you couldn't stay those extra two hours to keep Mr. Benjamin out of the hospital because you'd end up in the hospital. So, I'm guardedly optimistic about all of these, but clearly, they each have different histories and fact patterns. I think the important thing for our colleagues is try to lean forward and not cross your arms and understand this stuff rather than lean back and cross your arms and reflexively defend what we have.

Chris Comeaux: 58:49

Gotcha.

Peter Benjamin: 58:50

I I think you're right. We have some magic. But we don't have the only magic. And two things can be true at the same time. We can have genuine magic and not the only magic. And we gotta be really, I think, a little more forceful and open-minded about, as you suggested, figuring out how we can apply the magic we have to do. But let's not reflexively react to anyone who seems to be playing in our sandbox by saying they can't do it as well as we do. Maybe they can. I just think we didn't do what they do.

Chris Comeaux: 59:35

It is, right? Like I think I'd share with you the first time um physician who's well known was one of the major Macs, his father and uh stepdad was in a PACE program and horrible pain crisis, and he had to advocate for hospice, and he had to f and he did get it in the last couple days, and really family was up multiple days with this pain crisis. And so I I think here's my takeaway listening. To you. Number one, because of your prodding, it's really made me to go to school of because I think one of our early debates on the podcast is, well, well, what really measures quality, Chris? How do you really know it's special and different? Which has been great because that's the journey of ours as a CIN is what are the real measures of success? But even more than that, what is the meat on the bone that that because actually one of our board members, you would love this, actually took us to task because we qualified it as the magic. And like, well, you know, good luck if that's what you're hanging your hat on, right? How do you create a true organization that is becoming masterful at that magic? Where are you putting the competencies, et cetera? So my takeaway listening to you, it's not an either or, it's really a both and. So, like, how do we either do like our 12 colleagues, you know, either create those verticals or those horizontals ourselves, or those that don't have the wherewithal, how do we collaborate with them? How do you become how do you partner with them? Because you've done something so amazing. I think it was actually um one of Warren Buffett's mentees would talk about great businesses have a moat around their castle. If you have a moat around your castle, it's going to be hard for them to replicate that. So, to be better, they could partner with you. So how do you think that that savvy but also know that you got a damn good moat around your castle because you've worked so hard on the model, systems, the processes, the people that make it incredible, that other people might look at and go, wow, that is magic. Well, it's really not, but it's a hell of a lot of years of work of making it incredible and high performing.

Peter Benjamin: 1:01:29

Yeah, you used an example that resonates for me, and I think is worthy of a challenge for all our listeners. We get an F at demonstrating we manage pain better than others. F. There is no data. Hard stop. There is no data in the hospice world after 50 years, other than we talk louder and have case studies. And hope isn't gonna change that, and hope isn't a savior. I respectfully push back on our colleagues who think this is some magical differentiator. Start with your premise. I'll bet you if you interviewed consumers, their immediate association with hospice is pain management. And yet, hey, I invite all listeners, send me an email. Let me know the data that your organization presents to everyone in the community, payers, providers, patients, and families, about exactly how we measure pain and what our offer is. Because we'd be in a lot better stead with a PACE program if we were able to say, hey, feature benefit value. We have pain management protocols that, according to our data, enable 80% of patients to have their pain managed to their satisfaction within 48 hours. And here's our data.

Chris Comeaux: 1:02:52

I like the way you frame it.

Peter Benjamin: 1:02:54

Well, we what we usually say is we're expert at it. Gotcha.

Chris Comeaux: 1:02:59

Gotcha, got your point. Now, do you not think that the hope will bring some sort to lay some tracks to make that I love the way again you framed it, that well, it won't perfectly push people in that direction, but it's certainly laying some tracks in that direction, no?

Peter Benjamin: 1:03:15

You're probably more optimistic than I am. So, we can leave that at that. What I'd like to see is a way to get a broader recognition that whether you're an oncology practice, a PACE program, an ISNP, a hospice, how could we identify a patient likely, so not an eligibility thing, but a patient likely to be 12 months or less? And how would everyone who gets a penny from Medicare have to measure pain? Because then it isn't just, oh, hope is gonna be X. It would be, wait a minute, we don't exist on an island. If we're really better, there has to be a comparator. And I think that as an advocacy matter, I'd like to see our colleagues advocate for more universal measures that won't be perfect. But again, this isn't an eligibility thing that won't be perfect. But this holds for our oncology partners as well. I mean, I say deferentially and with as much respect as I can, they don't get an A at managing pain. And maybe I can't empirically demonstrate that, but you and I could share enough stories that you know. So I'd like everyone, whether they think they're in the end of life care business or not, to come to the table and say we should recognize this stuff. I'd like to believe as a country that would extend to seemingly touchy-feely measures like loneliness and spiritual vacuums. I'd like to think that as a country, forget whether you're in a hospice. If you're in your last year or two of life, we should embrace measures that compare the experience you get from whom you get it.

Chris Comeaux: 1:05:16

Yeah. Well said.

Peter Benjamin: 1:05:17

You know, because then, Chris, you could say, dang it, Peter, I really was right. And here it is.

Chris Comeaux: 1:05:25

Here's the data.

Peter Benjamin: 1:05:26

And I would be ecstatic because what I really want to be right about is some level of advocacy for this conversation, some level of advocacy that everybody in their last two to three years of life should have the most horizontal experience possible from folks who are measuring how that experience plays out and are willing and desirous of being compared to others. If that's our legacy, brother, then we will have done really good work.

Chris Comeaux: 1:05:57

Well, I was going to give you the last word. It almost felt like that's an awesome last word, but I'm still gonna give you the last word.

Peter Benjamin: 1:06:03

Any anything else you'd like to share? No, I just appreciate you uh inviting all the very interesting people. So, I guess that was a little cocky to put myself in that group, but I I enjoy the very interesting assortment of folks you bring on your podcast, and I think it really benefits listeners, and I think we could use even more of open dialogue and discussion because that's what makes us all better. So, I appreciate you for doing it.

Chris Comeaux: 1:06:31

Thanks for that, Peter. Obviously, I'm always trying to learn. That's what I love about you. I learn every time, and I love this. There's so many takeaways. I mean, starting with the COVID um data, which has been interesting because it's been poking its head in some interesting projects, but then this whole thing about the congregate living and the impacts of that, and then these interesting models of for elderly practices and I-SNPs. I think this added great value. So, I appreciate you. I did want to ask you, please be sure to go and listen to the podcast we did with Rita Numerof because uh your conspiracy verticals. I don't know if you've ever thought about writing a book. My guess is you probably have. That would be a great book. I've never heard it framed that way, but damn, that's so accurate. That is just so accurate.

Peter Benjamin: 1:07:14

Well, I appreciate we mean to sign off officially, but last summer I gave myself a little reading project, which was a handful, turned out to be more than a handful, of histories of hospitals in the United States, nursing homes in the United States, the history of physician practice in the United States, the history of insurance in the United States. Because I was just imagining a slide deck, which I'll happily send you if you're interested, that would try to show an abbreviated form of this thing I had in my mind, which was this conspiracy of verticals. And of course, that is what you get. If you really do the homework, it was no one's intention to create a conspiracy of verticals. And interestingly, not unlike pace, not unlike hospice, not unlike iSNP, very little that was genuinely transformative in healthcare started as a business. If we really take a look at the history of hospitals and nursing homes, home health, the same thing, this was not entrepreneurs with investment and investors trying to make money. This was social entrepreneurs trying to improve their communities. And I think the more we can revisit those efforts and missions, and accept that we live in a mercantile economy, which I'm proud to be a part of. I'm proud to be an American. I don't get into the, oh my God, we need to socialize medicine to make it better. But I think we do need to revisit the origins of what have become these verticals, and then revisit what we lost along the way and might reclaim. And how ironic that as much as Kaiser is struggling at the moment, and as much as no one ever uses the phrase staff model HMO, what have United and Humana become? Right, exactly. I bumped into this yesterday. They've become staff model HMOs without hospitals. And I think the economics suggest, well, that's just a very interesting business model. That hasn't stopped United, by the way, from being one of the five biggest owners of ambulatory surgery centers. But the capex involved in that is demonstrably different than hospitals. But nonetheless, it isn't just to game the PPACA. There's a part of that, you know, the whole medical loss ratio cap on health insurers has led to some gaming around what you in-source. But I think it's a much more profound recognition that if you really want to provide as close to that horizontal experience as you can, you probably need to control at least primary care, probably multi-specialty.

Chris Comeaux: 1:10:04

It's just a fascinating historical remote. I'm going to take you up. I'm going to get that uh deck and I'm going to make sure I share that podcast with you about it, Rita Numerof, and how she would kind of redesign the system. And I think that'll create a great back and forth. Always appreciate you, Peter. Thank you.

Peter Benjamin: 1:10:21

Pleasure.

Chris Comeaux: 1:10:22

To our listeners, always appreciate you as well. Thank you for listening to TCNtalks. We always want you to hit the subscribe button. This is one I want you to pay forward. A lot of your friends, your coworkers, other leaders in hospice empowered care. I think they will very much benefit from listening to Peter and I go back and forth in his podcast, mostly Peter. And as always, we always want to leave you with a quote. This one I think I cleared through Peter, but I think he's going to like it because I've actually quoted it quite frequently. And so here's it goes. President Kennedy quoted the historian Arnold Toynbee. Toynbee said he had studied all the civilizations of the world and concluded that you could predict the longevity of each nation and its place in history by applying a common yardstick. This yardstick was the manner in which societies cared for their vulnerable populations, the aged, the infirm, and the disabled. Those who endured, most notably the ancient Greeks, the Chinese, not only cared for it, but they venerated the elderly among them. Thanks for listening to TCNtalks