Protecting Patients at the End of Life: Why CON Still Matters | Part Two

In Part Two of Protecting Patients at the End of Life: Why CON Still Matters, host Chris Comeaux continues the conversation with two of the nation’s most respected hospice policy leaders—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.

This episode moves beyond regulatory theory and into the real-world patient and family experience—especially in states without hospice Certificate of Need (CON) laws. Drawing on decades of leadership, personal stories of loved ones in hospice, and data-informed insights, Paul and Tim explore what families actually face when hospice markets are oversaturated, fragmented, or poorly regulated.

The conversation examines how too many choices can overwhelm families, how small, unsustainable hospice programs can dilute quality, and how fraud and inappropriate enrollments disproportionately affect vulnerable populations—often stripping patients of access to Medicare benefits when they need them most.

Listeners also gain a deeper understanding of how Florida and North Carolina use CON to balance:

• Access to hospice care
• Program sustainability and scale
• Rural and underserved community coverage
• Inpatient hospice availability
• Protection against bad actors

The episode concludes with a forward-looking discussion on what principles—not politics—should guide states that are reconsidering or redesigning hospice CON laws today.

This is an essential conversation for healthcare leaders, policymakers, hospice executives, board members, and anyone committed to protecting quality end-of-life care.

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

Welcome And Topic Recap

Jeff Haffner 0:00

Welcome to TCN Talks and Anatomy of Leadership. Today we are continuing a conversation with Tim Rogers and Paul A. Ledford in part two of Protecting Patients at the End of Life and Why CON Still Matters. And now here's Chris Comeaux.

Chris Comeaux 0:19

Well, now we're going to move on to the next segment. And I kind of alluded to it in this question, but let me ask it in a different way. Put yourself in a patient family's shoes. What do you think their experience from their perspective, you know, all this CON versus non-CON state? What do you think they're experiencing from their perspective? And they don't have you guys' knowledge to probably describe it. So keep your knowledge, but their perspective. So, Tim, why don't you go first?

Tim Rogers 0:47

I have experience with the patient experience in hospice. Both of my parents died in hospice, two uncles and one aunt over the tenure of my career. And I will say, had great services in both types of entities, uh hospital-based, for-profit, and nonprofit hospices. North Carolina, the majority of hospices in North Carolina are nonprofit. But um, I think you've seen instances of greater hospitalization rates, hospitals wanting to keep on to those patients uh longer in other non-CON states. And what does that do? That drives the cost of health care up. You can't tell me that it doesn't. And um, I just think the patient experience suffers greatly. And we, I know in our state, and I'm sure Paul does too, works very, very hard to ensure that our member hospices give that best patient experience possible because they have to in order to continue to be competitive.

Chris Comeaux 1:43

That's well said. Tim, do you think that maybe because you you do have like the tale of two cities where there isn't no CON, do you see some bad stories or some bad experiences?

Tim Rogers 1:54

Uh I I love South Carolina. My father was born in South Carolina, and I'm so glad we manage that state. It has also some amazing hospices. But like Paul alluded to earlier, North Carolina's typical hospice is fairly large. It's pretty medium-sized or larger. A large in South Carolina, what we've been seeing over the last five or six years as growth has come in, South Carolina is one of the fastest growing states in the country, one of the best places to retire. You've seen now over 110 hospices, almost half that of North Carolina, and growing, and they're very small. 10 patients, 20 patients, 30 patients. You cannot be financially viable at that level of VET ADC. You just cannot do it. Um, I think Paul would agree with me.

Market Proliferation And Viability

Chris Comeaux 2:44

That's probably a good segue because Paul, again, with Florida is very unique with the size of their programs. So, Paul, speak from the patient experience from your perspective.

Paul A Ledford 2:53

You know, I I think that probably uh one of the things that would be overwhelming in a non-CON state is the sheer number of choices you have. Uh you know, how do you go about deciding who to call into your home? You know, most people don't know there's a state hospice association that probably has a helpline that you can call and ask questions. So you're sort of at the mercy of whoever your the uh referral agent is, you know, if it's if it's oncologist or cardiologist or whatever, uh and who they're gonna refer you to. And uh so I think that's one of the biggest dangers uh is people don't know how how to choose. That people don't and and I think CMS quality measures are marginal in terms of their usefulness. That's a whole show, I'm sure. Um and uh so how do you go about if you have a CLN state, pretty much anybody you call is going to deliver good service. I I think that's yeah, I think that's that's the bottom line.

Tim Rogers 4:00

That's what I see in the tale of two states. I see good service provided in both states, but I've had more issues, more problems, hospices over the caps, more complaints. Physicians, as I told you earlier, just throwing their heads up going, get out of my office. I don't want to see another hospice in here. There are 65 in this county, in Columbia, Charleston, Greenville, and growing and growing and growing. It diminishes that experience. And I go back and say it again. It's the best benefit of the Medicare program. And it's probably we have these type of people in states with no CON that are causing us a lot of trouble.

Choice Overload And Referral Influence

Paul A Ledford 4:36

Chris, can I add one more point? And this is how folks in non-CON states are affected, uh, particularly by fraud. When they go out and sign up people who aren't hospice eligible, you know, they give them a hundred dollar bill to sign here, that person has lost their Medicare benefit. Uh and so when they go back, so many of these people on the street actually do have Medicare because they had a career before they were on the street. And uh if they're elderly. And so they have a Medicare card that can go to the hospital and get service. But if their number is hijacked for a fraudulent Medicare hospice claim, they've lost access to health care. And good luck getting that back.

Chris Comeaux 5:22

Yeah, well said. You know, Paul, you alluded to the measures. It's almost like you knew this. Um, actually, the week after the airing of our podcast together, we're doing a whole podcast on measures that matter with Bob Taveries and members of his committee, measures that matter, and we poke on exactly what you talked about. And, you know, listening to both of you, you know, the word Kleenex has just become like we think, you know, there's all these different brands, but we just call it a Kleenex, right? Hospice, unfortunately, has been that for a good portion of the greatest generation. My hope is as we go forward with the baby boomers, because they've been so consumer focused, that we can change that. Because I think exactly what you're alluding to, and when you got 50-something hospices in a market, in fact, I have another family member, this exactly happened to it's a non-CON state. So he just went with what the um physician, who happened to also be a medical director of this for-profit agency. And uh my aunt was actually Alzheimer's patient dealing with dementia. They didn't have that clinical competency. They she wasn't on the right meds. She fell, hit her head, had a brain bleed, hit the hospital. Guess what they did? They discharged her, so they dumped her, so then now she's back on Medicare. And then they tried to pick her back up once she actually got back out of the hospital. It just broke my heart. And through my working with that family member, she ended up with actually a really good nonprofit hospice in that market and finally died in their inpatient unit. But just broke my heart just seeing that. And he was like overwhelmed. There were, you know, 20-something hospices, I guess, on the sheet. And he's like, what do I choose? And well, I think this one's really good. Well, yeah, because he was the medical director and he was a part-time medical director. It was kind of a moonlighting job, not really part of it. So, Paul, let me ask you this question, Tim. I want you to pick up on it. If removing CON truly improved access, we'd really expect to see higher hospice utilization rates in those non-CON states. Do we actually see that higher penetration, or do we see the opposite, or is it a bit of a mixed bag?

Fraud, Eligibility, And Medicare Harm

Paul A Ledford 7:20

Yeah, it's it's definitely a mixed bag with respect to overall utilization uh with some CON states uh falling below the national average. And it's difficult to generalize about CON. And Tim mentioned this earlier. When you've seen one state sealing law, you've seen one state sealing law. They're all different. Um and I I don't really know the origin of any of those CLN laws. Uh it's you would have thought they might have evolved similarly, but I don't think they did. I think they were mostly uh sort of organic according to their states. Um there is there are likely unique reasons for each of those CLN states that fall below the national average for utilization. And I think it would be a great doctoral research project for someone to tackle someday to look at that and see if they can ascertain why. Excellent.

Tim Rogers 8:14

Um, you know, driven utilization, I I'll just move a little bit off to uh states methodology, the ones I'm familiar with, like Paul said, others are different. North Carolina um for now, and we're getting ready to modernize and even improve upon it, um, you know, also as a utilization-driven situation because of the 90-patient threshold, and because um the current methodology uses the two-year trailing average growth average. I mean, it's like, Chris, you'll know, it's like a 20-step process with so many characteristics built into it that we're able to take it now and look at the current market and look what's happening in the market and look what's happening being what CMS is doing, how they're regulating us, and try to make a good methodology even better. And that's what I hope is going to happen in North Carolina.

Measures That Matter And Competency Gaps

Chris Comeaux 9:07

Yeah, in fact, we're gonna have Paul kind of unpack his for a second. You know, it's fascinating that you said about kind of a research project, Paul. I bumped into this recently because Utah has always been one that's confounded me a little bit because it's a non-CON state, but it actually has some of the highest penetration in the country. Now, this is theory, this is not backed. Because I asked, because I've seen some of that huge proliferation, huge number of hospices. We've been working with a program there. You see, the market differentiation is so hard. And so I asked them, like, what do you guys think this penetration is about? Because you still see the cherry picking and the things you see in other non-CON states, but the penetration overall is really high. And this is what the person said, and I think it was really fascinating. The Church of Latter-day Saints is very prolific in Utah. We all know that. You know, obviously the state was founded in many respects from that. And the whole death and dying, the approach to death and dying is so ingrained in the culture, it's much more accepted. So it had nothing to do with the CON, and it was much more cultural at a family level. And I thought that makes a whole lot of sense.

Tim Rogers 10:12

I was can I just say I was going to add to that. I do think it's cultural. I think it also has religious implications, like you said. It also has the what if the percentage of the number of Medicare beneficiaries are in that state to the national average. I'm fascinated to look at the top 10 states in hospice. And Pennsylvania, a great state, is there, and they're what, seventh or sixth largest state in the country from population, but they have one of the highest numbers of people 65 and older, but they only they have 300 hospices. Not Texas or California are they have as they have the same number of hospices as Georgia does. And Georgia's a little bit smaller, but not a lot. It's just a lot of variables that play into this, but I do think it's the way culture, I think it's the way your ethnicity, I think it's your family upbringing, your church, everything plays a part in this.

Chris Comeaux 11:06

Tim, you kind of alluded to this. I'd love for you to talk more about North Carolina and then have Paul get into the specifics of Florida. So let me ask it to you this way, Tim. So from a North Carolina standpoint, in your opinion, how does CON help our state balance access to hospice services with maintaining quality and sustainability? And then, and we alluded to throughout the challenge of also rural communities getting the care that they need.

Utilization Rates And Cultural Factors

Tim Rogers 11:30

I've always described our hospice methodology as fairly progressive methodology. Methodology in general for the state medical facilities plan talks about population, demographics, growth of counties. You're not gonna see a move to put five home health or five hospice agencies or a new hospital operating room in a county with a 20,000 population. That defeats the whole purpose. And so I think North Carolina's done a pretty good job of that. We're gonna do an even better job, I hope, this year with hospice and try to um add some more characteristics into that. We've had a fairly decent amount of growth in hospice, not as much as some would like. But I take you back to hospice-inpatient facility. Uh, 15 years ago, North Carolina was woefully below the national average in hospice-inpatient facility access. I pushed really, really hard, even when I was in the hospice agency and then got to the association for some additional situations. And we now have special needs where you could do a special needs application in CON, but we jumped dramatically up in the hospice. Now, I know hospice inpatient situation is completely different today than it was 10 years ago, but we needed to become up. Whereas in my other state of South Carolina, who has some great inpatient facilities, they're few and far between. And it just goes another juxtaposing between North and South Carolina, CON and non-CON.

Chris Comeaux 13:02

I'm so glad you brought that up, Tim, because most of our conversation to date has been talking about CON for access for a hospice agency. There is a whole nother level, which is the CON for inpatient units. Um, I don't know of any states. Alabama, for a while, Paul, if I remember correctly, didn't have one for the hospice agency, but they did for the inpatient units. But I think that's no longer the case. But that's the only state I could remember.

Tim Rogers 13:25

South Carolina, South Carolina did too for a while.

Chris Comeaux 13:27

Oh, good point.

Tim Rogers 13:28

They had inpatient hospice, but never hospice home care. But now it's only nursing homes. And what people don't know, not to get on a side subject here, there is a home health statute that talks about CON. Home health CON does not fall in the South Carolina CON statute. It falls in its own statute. So when they went to repeal CON in South Carolina, they repealed it for everyone, basically, except nursing home and home health.

Chris Comeaux 13:56

Oh, interesting. Well, Paul, I really want to get into Florida. And it just occurred to me how cool. Um, of course, now I work with hospices all over the country, but most of my career in the C-suite position was in Florida and North Carolina, and I have the two gurus from both of those states. And so I'm pretty fond of Florida CON, Paul. Yeah, I grew up at Covenant Hospice and the intricacies of that. So can you walk us through maybe high level, but a little bit detailed level, how Florida determines their need for a hospice? Sure.

North Carolina’s Methodology And Inpatient Access

Tim Rogers 14:23

So Florida Hospice CON is based on projected need in each of the state's 27 service areas. And these service areas roughly correspond with core-based statistical areas to get, you know, that's nerd speak, I guess. Uh the publication is called the Hospice Needs Projection, and it contemplates a planning horizon. So projected need, that's the key. So every six months, the agency runs an Excel spreadsheet with a formula containing data points uh about existing levels of service coupled with Department of Health demographics and the projected population growth. And if the number of projected of uh projected unserved deaths is 350 or higher, then numerical need is demonstrated and and it opens the process for applicants to compete for a CON. Um and then of course people throw their applications in in this competitive process. They they try to demonstrate that they're gonna best serve the service area uh based on the needs of the service area. Uh the agency picks the best one. Um there's also a second less commonly used path that we refer to as special circumstances, where an applicant petitions the agency to demonstrate an underserved geographic area or a uh within the service area or an underserved disease condition. Um and so those are the two primary ways uh that people can get in. And I'll talk more about uh the 350 uh in a bit.

Chris Comeaux 16:00

Yeah, actually, well let's go there now, Paul, actually, because I do think it's it's kind of a unique feature about Florida that your minimum threshold being 350 is like Tim alluded to, is it you said 90 for North Carolina earlier, I believe, Tim. And so 350, do you think that has to do with creating these larger programs? And was that by design? It was absolutely by design.

Paul A Ledford 16:22

Uh scale is built into the system. And and let me explain that a little bit. So that 350 number they came up with probably 30 years ago, and uh it assured that uh when you had a new program come into a service area that they would have enough ADC to be successful. And the calculation was uh it would take 350 annual admissions to have a ADC to be successful and robust. Um the rule even gives new entries into the marketplace two years after licensure to ramp up in the service area without threat of showing numerical need again during that same period.

Chris Comeaux 17:03

That's great. Tim, um, Tim, do you think that there are any aspects of that of Florida's approach that maybe might inform where as North Carolina thinks about where it's going to go in the future?

Tim Rogers 17:11

Well, I requested the Florida data to the state when we first started our hospice work group, and I know they have it, and I know we we would definitely look. There's there's some nuanced differences in the state and demographics, but there's some absolute wonderful things in that that can be looked at. There's wonderful things, I think, in ours. It's just that I we've just surpassed the projected death rate over 50%, I think, for this in hospice uh of all deaths in North Carolina. So, I mean, we're doing something right. I just think we can do something better that's doing something right. And um, the idea is not to underproduce a need and not overproduce a need. And what we had last year was an overproduction of nine needs, and we were able to know why with the COVID deaths and things like that. But I just think our committee, um, you wrote great comments, others wrote some comments. I think the committee is charged. I'm an appointee by the governor to this council, and I think we are gonna we take this position, this job very seriously in how we can make hospice methodology in North Carolina modern, today's time frame, and even better than it was.

Chris Comeaux 18:26

Well said. Well, I love this question, so I want both of you to respond. So if another state, let's say, let's say the new state of Greenland, ha ha ha, right? If if another state uh that doesn't have CON today was starting from scratch and they called Paul or Tim and they wanted principles, no politics, what should guide them in how they develop that CON?

Florida’s 350-Admission Standard

Paul A Ledford 18:48

Well, I I think using Flor the Florida rule as sort of a frame of reference, uh, I would reconsider the 350 threshold. Uh when that number was calculated in the early 1990s, uh it was based on uh based on annual admissions to run a robust program. But since then, uh we've had shortening length of stay in a in dramatic fashion. So if you ran that same calculation today, the number would be higher than 350. Uh you know, because it you're basing it on uh length of stay and and average daily census and those sorts of things. Um another thing would be to use current causes of death. So the Florida rule, when it was written, you know, cancer was the preval the pre predominant form of uh cause of death, AIDS was prevalent, dementions and dementia and Alzheimer's were hardly on the radar. So I think connecting to the modern causes of death uh would be the factors.

Chris Comeaux 19:52

Well said. Tim, what about you?

Tim Rogers 19:54

An interesting proposition. I wish more states would consider hospicity. C O N and I wish more states would call Tim and Paul because we would be able to give them those principles of our own methodologies, the things that have worked. Sadly, I don't know of any off the top of my head right now. Um if I did, I would hope that CON would be thoughtfully grandfathered and not to disrupt existing hospices, and that CON need would be determined with a combination hand in hand with robust licensure, the survey process, the accreditation process, in order that people could get to the right place with respect to balancing the market and promoting quality and compliance. That's what I would say as a chief cheerleader for CON.

Chris Comeaux 20:44

Well, I hope after this podcast you guys do get calls and people are like, hey, let's call Paul and Tim. Well, guys, this has been awesome. So let's go and land the plane. I want to give you both the final word, just final thoughts you'd like to share with our listeners. Paul, why don't you go first and Tim, you could close us out.

Paul A Ledford 20:59

Sure. Well, I I would say if you live in a CON state, uh recognize what a privilege it is to operate hospice in that sort of regulatory environment. Um know that the experience in many of the states without CON is that free market principles will not check uh bad players. Um you'll have bad, and only differentiate this as well. Bad players are in my mind are people who delivered poor service. And then you have criminal enterprises, and those are separate. You'll have both uh if you have big urban markets. Uh and there's almost no regulatory door that's gonna kick them out uh without CON. Well said.

Chris Comeaux 21:43

Tim

Designing Better CON Principles

Tim Rogers 21:43

Eloquently said, um you should feel lucky. Um I know that we all know that CON theoretically is not the panacea or not the the mar the the the do-all to be all for everything about stable compliant hospice industry, but data will show in CON states and will refute some of those critics, like some of these nonprofit foundations that I'll go unnamed in North Carolina and elsewhere that are publishing these wonderful white papers and citing all types of statistics to do away with CON. They have twisted those statistics and they've applied it in the uniformity, not to a hospice ish, not to the hospice chapter, or why home health is different than hospice, or why nursing homes is are different than adult care homes. It's not a one size fits all. I just know for a fact, in dealing with 33 years under my belt in this state, I am thankful we've had hospice CON. And I don't think, knock on wood, that I can count one OIG investigation or one serious fraud investigation in the state of North Carolina as I can in some other states. Thank you.

Chris Comeaux 22:55

Well, I want to thank you both for your leadership. I think it's no accident that you have an amazing state of Florida with amazing hospices and an amazing, amazing state of North Carolina. Carolina is where you have amazing hospices. Everything rises and falls in leadership. It's something I believe, and I think you both provide great leadership. So thank you for that. Appreciate that. Thank you. Thank you.

Tim Rogers 23:14

Good to see you too, Paul and Chris.

Paul A Ledford 23:16

Thank you for staying here.

Chris Comeaux 23:17

And to our listeners, we want to thank you. At the end of each episode, we share a quote, a visual. We call it a brain bookmark. The idea is to create a thought prodder, almost like a brain tattoo, just to further your learning and just your thought about our podcast subject. We want it to stick. Be sure to subscribe to our channel. We don't want you to miss an episode. Pay this one forward, especially to the leaders in your organization, maybe even the board of directors, because certificate of need is the states where we still have it. It's a lot of legislators are looking at, hey, we want to look at C O M. Um, you know it's easy to rail against the world and be frustrated by things. Let's be the change that we wish to see in the world. So thanks for listening to today's podcast. And today's here is our bookmark to close today's show.

Jeff Haffner 23:57

You don't need a hospice on every corner, but you do need one that serves everyone. By Tim Rogers. Hospice is the best benefit in Medicare, and it deserves thoughtful stewardship by Paul A. Ledford.