Protecting Patients at the End of Life: Why CON Still Matters / Part ONE

Protecting Patients at the End of Life: Why CON Still Matters / Part ONE

Certificate of Need (CON) laws are among the most debated—and misunderstood—regulatory frameworks in healthcare. In this timely Part One conversation, host Chris Comeaux is joined by two of the most respected voices in hospice policy and advocacy: Paul A. Ledford, President & CEO of the Florida Hospice & Palliative Care Association, and Tim Rogers, President & CEO of the Association for Home & Hospice Care of North Carolina.

Together, they unpack why CON laws were originally created, what problems they were designed to solve, and why hospice continues to raise unique concerns that set it apart from other healthcare services. Drawing on decades of leadership and real-world experience, Paul and Tim explain why hospice does not function like a traditional free market—highlighting fixed reimbursement rates, demographic-driven demand, and the responsibility to serve entire communities, including rural and complex patient populations.

This episode explores what actually happens in states without hospice CON: oversaturation in urban markets, reduced access in rural areas, fragmented care, and increased vulnerability to fraud and abuse. The discussion challenges common assumptions about competition and access, using data, policy insight, and firsthand examples to illustrate the unintended consequences of deregulation.

Part One lays the foundation for a deeper conversation about quality, equity, and patient protection at the end of life—and why thoughtful oversight still matters in preserving the integrity of the hospice benefit.

👉 Don’t miss Part Two, where the conversation continues with a closer look at quality outcomes, bad actors, and what states can learn from one another moving forward.

Guest:

Paul A. Ledford, President & CEO of the Florida Hospice & Palliative Care Association

Tim Rogers, President & CEO of the Association for Home & Hospice Care of North Carolina

Host:

Chris Comeaux, President / CEO of TELEIOS

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

Transcript

Opening And Guest Introductions

Melody King 0:00

Everything rises and falls on leadership. The ability to lead well is fueled by living your cause and purpose. This podcast will equip you with the tools to do just that. Live and lead with cause and purpose. And now, author of the book The Anatomy of Leadership, and our host, Chris Comeaux.

Chris Comeaux 0:21

Hello and welcome. I'm excited. We have two incredible guests today. We have Tim Rogers, who's the president and CEO of Ock AHC, and Paul Ledford, the president and CEO of the Florida Hospice and Palliative Care Association. Welcome, gentlemen. It's so good to have both of you.

Tim Rogers 0:37

Great to be here. Thank you. Absolutely.

Chris Comeaux 0:39

Yeah, let me read from Paul's bio and then Tim's bio. So Paul Lepford grew up in Tallahassee, Florida as a graduate of FSU. Go Knowles, Paul, my wife's a graduate as well, and he was in the college of business there. His career includes service as a government administrator and regulator. And since 1995, as an association executive, he is a certified association executive and a designated professional lobbyist. In 2004, Paul joined the Florida Hospice and Powder Care Association as a president and CEO. He is a past member of NHPCO and the Hahn Board of Directors and past chair of NHPCO Council of States, and currently serves as the Alliance Assembly of State Associations. And Tim Rogers is the president and CEO of the Association for Home and Hospice Care of North Carolina and South Carolina Home Care and Hospice Association. And Tim has held this position since 2001. Tim served nine plus years in the home care and hospice industry, starting at Ockett 1992 as a director of government affairs. And he's also served in key C-suite positions for two large, duly certified Medicare, home health, and hospice agencies that were serving North Carolina and South Carolina from 1994 to 2001. And you look at him, you swear he's still 30 years old. Tim is a graduate of U UNC Chapel Hill with a BA in political science and history. And he has additional work experience and positions in State Employee Association of North Carolina, North Carolina Bankers Association, 1983 and 1992, and just a wealth of amazing position and experience throughout the country and a state and political level. So, gents, Paul, maybe you first. What did I leave out that maybe you'd want to?

Paul A. Ledford 2:16

Yeah, I think the bio pretty well covered it. Yeah, I've been involved in government affairs really since uh 1984. I'll put that on my resume, but uh got involved uh early in presidential campaigns and before, you know, well awesome.

Chris Comeaux 2:33

Tim, what about you? What would you want our audience to know about you besides all that great stuff in your bio?

Tim Rogers 2:38

Well, I'm gonna um congratulate and echo my friend Paul. We have a lot of similar background. I started in about uh 79 to 83 in politics at UNC Chapel Hill. I'm the son of a county sheriff, elected official. So I got really interested in that and uh started going into the home care and hospice industry, as you said, in 92. But I tell you, I tell you what also lately is it's been really great is uh I've been able to work with Paul and other state execs across the country, and I'm the coach of the Alliance for Care at Home, um Assembly of State Associations, and we've come a long way. And I just have the utmost respect for you, Chris, and the utmost respect for you too, Paul.

Hospice Is Not A Free Market

Chris Comeaux 3:22

Yeah, well, both of you just appreciate that. Hats off to both of you. In fact, I have to tell you where the idea of this podcast came from. I know Paul probably knows Mark Cohen. So Mark was long time worked for Vitas in Florida and has done a lot of consulting, and he shot me an email, said, You need to do a podcast on certificate of need. And I was already thinking about that concept, but it really kind of pushed me over the edge. And then immediately I thought, man, if I could get Paul Ledford and Tim Rogers on a podcast together, that would be incredible. So reached out to both of you. Tim was out of the country, and then it just all fell into play. So that's what we're gonna talk about today. Um, certificate of need. I think this is a really interesting time. Uh, states that still have certificate of need, there's a lot of opposition to try to get rid of it. Um, so why don't if you guys are okay, let's just go ahead and jump in. So there may be some listeners who may not live in CON states. We're gonna use that abbreviation throughout the rest of this podcast. What problem was certificate of need originally designed to solve in healthcare? And why does hospice still raise those same concerns today? Tim, why don't you take it first and then Paul?

Tim Rogers 4:23

So to me, I think it's kind of ironic that some of the rationale and the reasons for starting CON uh way back in the 60s and 70s, it actually was a concept that came out of UCLA in the late 50s. I read a great paper about that, um, is that it was started to control cost, duplication of services, um, ensure efficiency, control capacity, and improve access. Well, I argue those same reasons exist today in CON states. And I've got uh 30 years in my belt that knows that South North Carolina is a CON state. South Carolina is not. So I know the best of both worlds. It's a tale of two cities. But um, yeah, through the 70s and 80s, and we know it was repealed in 87 by the federal government and it was left up to the states. So now we find ourselves in the issues of who's eliminating what, when and where.

Chris Comeaux 5:19

Well, and we're gonna get to a lot of great discussion about differentiation. But Paul, how would you answer that?

Paul A. Ledford 5:24

Uh well, similar. Uh, you know, it's to address cost access and quality. Um and it it's also prudent for the government to control who they pay money to. Uh, if you look at managed care, um, in like in Florida, Medicaid is 100% managed care now. And they control how many uh providers there are. And it's the same thing with hospice. Um, 95 plus percent of funds come from Medicare or Medicaid. So it makes sense for them to control who's providing those services.

Chris Comeaux 5:58

That's well said. You know, I I've been involved in several CON fights and trying to help educate legislators of why it's a good thing. And quite often folks that may come from more a free market standpoint and say, well, CON is just, you know, anti-competitive and it's not in line with with free markets. So what's different about hospice, maybe compared to other parts of healthcare, when it comes to market forces? Why don't you take that first, Paul? Sure.

Paul A. Ledford 6:24

Well, the the first thing I think is the criteria. The six months are from death on the normal course of the disease, and and foregoing curative care. So that's completely unique to any other sector of health care. Also, the daily per diem that hospices are paid based on the level of care. I think that's another very unique feature. I I don't know of any other sector of healthcare that does that. And what sets it apart from lots of other sectors of healthcare is that the elements of the free market are not there. And let me expound on that a little bit. Price and rate are set by Medicare, and that applies to Medicaid as well. Uh, there are no copays or deductibles paid by the patient, also a very unique situation. And the other free market elements missing are the flexibility and demand based on price or supply. Uh and that's because demand is shaped by demographics of the area. So two of the three fundamentals of the free market, price and demand, are inflexible, and supply is the only part of that principle that is flexible. So it's designed to fail if you think the free market's going to control uh the factors.

Chris Comeaux 7:37

That's well said. You know, and also in many states that don't have a CON, the supply almost kind of far exceeds the demand in many cases. And I'd almost even maybe amend that statement I just said, because sometimes they will cherry pick the population they serve and they will not serve all the population. And so, and then you don't you don't end up with everybody, you know, the idea of free market is, well, then you're going to meet all the market demand. That's not the case. It's not 100% homogenous throughout the country. Tim, anything you want to add to that?

Cherry Picking And Oversaturation

Tim Rogers 8:09

I, my esteemed colleague described it well. And I I think the same along the same line. Um, it's not like having a Starbucks on every corner or a McDonald's in every corner. You don't need a hospital in every corner, and you surely don't need a hospice on every corner. And his theories and Paul, your your analogies are, I totally agree with, and you said it, uh said it wonderfully. I know um, you know, it's just in North Carolina, we we have all these things built into a CON process. And I should have started by saying my mantra is if you've seen one state CON program, you've seen one state CON program because we're all different in some ways. But in our state, uh it ensures competition. It demands that you talk about access in your application process. And your county is your service area. So you're not gonna be able to cherry pick as much because you've got to be able to serve and tell the state of North Carolina you're gonna serve that service area, that entire county, not a certain demographic or a certain uh way of life or uh certain assisted living communities. It's just pretty much cut and dry, and the fact that it's regulated, and that's what I like.

Chris Comeaux 9:22

You know, Timmy, you remind me just something in what you were just saying. Many years ago, we worked on a project. I'll leave the city unnamed, um, but it was a big city in South Carolina, which, as you said, has no COM. And one of the, so the hospital hired us because there are 55 hospices serving that region, and they asked us to take those 55 down to four preferred providers. And this is the story that kind of pushed them over the edge to do this project. Two hospice reps got in a fist fight on the hospital floor, trying to be the first one into the patient's home. And that was the moment the hospital said, we've got to do something. This is kind of beyond ridiculous. It just breaks your heart. Yeah. Wow. Yeah. Well, let me ask you guys another question. So, advocates for eliminating CON, they often argue that removing regulation just increases access and improves quality through competition. But then we look at states with no hospice CON. Do we actually see that being the outcome? So, Paul, why don't you take that one first? Sure.

Paul A. Ledford 10:21

I've recently seen data that shows there is a correlation between CON and access in rural areas. It's not as clear-cut generally. Um for example, Florida's number three in overall utilization according to 2024 Medicare data. But we have four times the utilization rate in rural counties than a state like Texas, which is number 12 in overall utilization. Um California is a perfect example with 40, they're number 41 in utilization. And they have 11 massive counties with zero hospitals. Um so and and then also uh Florida has the highest utilization by minority population, it's far above the national average, which I think is a great access indicator. Quality is is a different is a different animal, and it's a more difficult question because participating in quality measures is optional. And a state like Florida has a hundred percent participation in quality hospice measures, and many states, particularly those six states on the CMS special focus program, have a small fraction of their hospices participating. So it's not an apples to apples comparison uh on quality.

Chris Comeaux 11:37

That's well upset. We just taped a podcast with um uh Bob Taveris and Cord Castner around measures that matter, and 30% nationally actually report quality measures, patient family satisfaction, the CAP survey, 30%. So 70%, some choose it willfully, some are too small. And and the fact that you guys have 100% participation, that's pretty awesome. That's good.

Tim Rogers 11:59

That's great. That's really and

Access, Rural Care, And Quality Data

Chris Comeaux 12:01

and I was thinking whenever you said the um about California, 11 massive counties, you meant by like square miles, right? Very rural big, not necessarily like not LA you were referring to.

Paul A. Ledford 12:12

Yeah, no. If you look at the California uh, they actually have an association of rural counties. It's pretty much all those. Um they're big agricultural, uh the east side of the Sierra Nevadas, it's a it's the middle of nowhere, but square miles, they're massive counties, and people do live there.

Chris Comeaux 12:33

But they're not getting the care.

Tim Rogers 12:36

But but there's 2200 hospices in California and growing, and there's more hospices in LA County along than the state of North Carolina. So those are some contextual um things to put in your mind. Paul said it fantastically. I just want to say one thing about access, too. In North Carolina, we have 100 counties, Paul, and we have a hospice office in nearly all, if not all, one or more in each county. But however, those counties are served on average with by 10 to 20 different hospices. Well, some counties in North Carolina, large ones, Mecklenburg and Wake, have 28 and 30 providers of hospice andor home health services. But you look to South Carolina and Hory County in Myrtle Beach, 60 and growing. 60 hospices in that beach, growing beach community. And we've had tales of oncologists and other doctors say, Stop coming to my office. I don't want to hear about you anymore. And what that does is uh deflates the hospice beneficiary experience and the entrance into hospice.

Chris Comeaux 13:51

That's well said. Tim, one of my board members in a board meeting, he we were we were talking about some of these challenges. And he kind of said, Oh, it's the Willie Sutton rule. And I said, Excuse me. He goes, You've never heard the Willie Sutton rule. I said, No, sir, I'm sorry. And then he educated me that apparently Willie Sutton was a bank robber. And they asked him why did he go to the banks to rob the banks? And he said, Well, that's where the money is. Unfortunately, why do these metropolitan areas get all the conglomeration? It's easier pickings to try to get those patients. And then the rural patients, it is much harder to reach them. So they kind of go where it's easy, if you will, and creates an oversaturation when you don't have a CON in place. Would you guys push back on that um or say it maybe slightly differently?

Paul A. Ledford 14:33

No, they're definitely going to go to the urb uh urban populations uh with where there's people. And if they're engaging in fraud, they need to come up with Medicare numbers from somewhere. And so if you're if you have a large homeless population where you can go literally buy Medicare numbers from people, um, that's how they do it. You you can't do that in a rural community. But the local sheriff will throw you out.

Tim Rogers 14:57

Or it's harder to do it in a CON state.

Paul A. Ledford 15:00

Right.

Chris Comeaux 15:01

Well, another area, most states that don't have a hospice CON, um, you see more providers, but for fewer patients are per provider, which is what we're kind of saying here. So from you guys' perspective, why is that a problem from a quality care perspective?

Tim Rogers 15:17

Well, I'll I'll just say this. I mean, there are more states without hospice CON than with hospice CON. In fact, 86% of hospices in the United States are in non-CON states. I don't think that's good. And um, you know, I think the research does say that it translates that fewer patients can be served. And in fact, data also says there are lower utilizations and challenges with the fragmentation in these states. And does that equate to quality of care? No. And actually, I'm gonna quote my friend here. My good friend Paul was interviewed in hospice news. I read, I read it, Paul. And you said a lot of things about um ways to safeguard bad actors and malfeasance in the hospice space, and the absence of such policies like CON and licensure heighten those risks around fraud, waste, and abuse. And I concur with you that the states without CON are seeing the majority, not all, the majority of unscrupulous people trying to get into the space, the sanctity, the best benefit in the Medicare program, the hospice benefit. And that's troublesome.

Fraud Risks And Safeguards

Paul A. Ledford 16:26

I think economies of scale are important. Uh like in Florida, we have big hospices. I think the average hospice in Florida is roughly 10 times the size of the average hospice nationally, and that's an old number too. It's probably more than that now. Um and you know, if if a hospice is at the break you know, hovering near the break-even point, they're gonna be struggling to keep the doors open. So they're not gonna provide as uh as wide a scope of services or be as flexible with staff. And then the other piece is the larger hospice program is gonna be able to you're gonna have a lot higher capacity to train and mentor their team members. They're gonna have significant technological and community support advantages. And you lose all that. If you have 70 or 80 or 100 hospices or 350 hospices in a town, there's no way you have those elements present.

Tim Rogers 17:21

I I just want to add to that, Chris, if I could. Uh Paul, you're that's another one you're exactly right. Uh, you know, in North Carolina, we're fortunate, like you are, in your association, to represent nearly every hospice. We represent 98% of the hospices in home health agencies. So I get a lot of feedback data from that. And also the, you know, just the fact that in those non-sealing states, you're going to see um really, really more problems than cherry picking. And I know we've talked about that before, but everything you said earlier was was just on target. Um I think there's a lot of similarities in some ways to Florida, North Carolina. I know our methodologies are a little bit different, and our methodology is evolving. Chris can tell you that. It's changing thanks to he, I, and others. So uh be interested to see what happens.

Chris Comeaux 18:15

You know, you both just reminded me. So, two personal experiences. Um, I love my godfather. He is a serial entrepreneur, and we hadn't seen each other in quite a while. Um, and I was working in Texas, so we went to dinner, and you know, we were catching up. We hadn't seen each other again, probably maybe a 20 plus years. And I was explaining to what hospice was and how I'd been, you know, this is my career. And he sat back for a second and he goes, hmm, a lot of people dying. That's a great business. I need to look into that. I'm like, no, no, it's exactly kind of part of the problem, is that, and the other example is uh I'll leave the state unnamed, but we were working with a very large home health and hospice program, and the CEO asked me if I would do due diligence with them. And we went and did due diligence of this hospice. And I kid you not, this you were interviewing the owner, and he was an elk hunter, and that was his qualifications, and his grandma had gone through hospice, and he thought, hey, this is a great business. And within two hours, the compliance risk, it was awful. And then what his expectation was for the sales price. And and this is one of many that were in that community. And I just thought, man, this is what's wrong with hospice. It's there's nothing wrong with an elk hunter. But I mean, this is a very complex modality of care, the regulations, and and then someone's like, oh, well, just a lot of people dying. It's it's like a car wash or like Tim Eulutor, like a gas station or something.

Consequences Of Deregulation

Tim Rogers 19:38

I was gonna say that about a gas station. And I was gonna say, you're exactly right. We have those people now in hospice. People with no health care experience, no knowledge whatsoever. And I used the analogy, it's not perfect, but I used the analogy in North Carolina with Medicaid home care. Years ago, we have licensure every facility starts with home care licensure and home care, home health, hospice. We always had strong licensure, but not strong enough. We had agencies that were had oxygen in the gas stations and wrecker services. And people did not have owner qualifications, didn't have this, didn't have that. And in North Carolina where CON is regulating this and requiring that, finally North Carolina licensure has done something similar to Medicaid except a moratorium or certificate of need. We have 246 hospices. We have 3100 licensed home care agencies. Wow. With no moratorium, no C O N. That's just a little bit of an analogy of where I think another aspect of where CON can work and has worked.

Chris Comeaux 20:51

Well said well let me ask you guys this question. What do deregulated states teach us about the unintended consequences? Such, we allude to this earlier cher cherry picking market driven admissions or reduce investment in those rural complex patients? Paul, why don't you take that one first?

Paul A. Ledford 21:09

Sure. Well I think diminished service to rural areas is probably uh top of the list. Uh and it well frauds probably top of the list, but that doesn't happen everywhere. So uh we'll start with rural service. Uh CL in Florida requires the hospice serve the entire service area. So it's the it's some of our service areas are multiple counties. So you may have an urban area and some very rural areas around it. That's the way it is in Tallahassee. We have the Big Band, if you will is uh a city with a bunch of rural counties around it. And and if you get a C O N in this service area you have to serve it all. Uh it gives you the patient mix. In a C O N state every unserved death essentially counts against the entire service area when the agency runs the formula. So chronically ignoring an area or a disease state if you will will have an effect. And then the last piece I would mention is in a non-CON state there's no requirement and no incentive to serve a remote or complex patient. There's also no consequence for not serving a remote or complex patient. And I think those are those are huge.

Chris Comeaux 22:25

That's very well said Tim

Serving Entire Service Areas

Tim Rogers 22:26

yeah same here Paul we have to serve the entire service area. You have to make that known in your application our service areas are our county but you can serve more than one county typically contiguous counties but you have to serve the whole area that you're in the whole the county you have to be available for those referrals. And that doesn't happen we know in places and we and let me just back up and say we know we have some good providers in California and Nevada and Arizona and Texas. There's no doubt but we have a lot and a growing number of unscrupulous providers who are targeting certain demographics and only trying to see those demographics. And that's giving us a black eye and I also put a little bit of blame to the state of California and others who didn't regulate this fast enough to allow that many Medicare certification numbers to come out of one building or one address over 100 or 200 shame on that state. That would not have happened in my state and it would not have happened in Florida.

Chris Comeaux 23:28

Yeah that's well said Tim you know our mutual friend Dr. Ira Byock I love this phrase that he has kind of coined because we're we're so collegial you know hospice is such a caring um field and so we have good hearted people but he said collegiality ends at criminality and I think that's a very sticky way to kind of call that out and um I've repeated it over and over again for Cordt Kassner and I quoted frequently.

Jeff Haffner 23:53

Don't miss Part Two of Protecting Patients at the end of life why CON still matter with our guests Paul A. Ledford and Tim Rogers.