Saturday, August 29, 2015

Making Sense of Performance Nonsense


StrangeTony,

I received my performance review yesterday.   It was plain and simple a character assassination, crudely crafted with no supporting information.  The harshest of words were not spoken but planted like a cluster bomblet to come across later.  A year's worth of hard work had been effectively reduced to two sentences.

"You are to check your mind at the door.  Your thoughts, opinions, knowledge and experience are expressly not wanted here."

Later that day a co-worker sent me a handwritten note.  It said:

"I received your thank-you note and words of appreciation.  Very thoughtful and kind of you, so freely given.  It is yet another example of the difference between Law and Spirit.  When extrinsic Law is twisted or absent, Spirit can still work its magic, welling up from within.

You are the one deserving of thanks, for noticing a need and building another bridge to facilitate the addressing of that need.  To me the process you fostered is the true supervision, the "epi-scopos" of early Christian communities.  It was to be a service, not a dominion.  As we've discussed many times, our society's companies are drunk on authoritarian pyramid which uses money and dismissal as its shackles and lashes.  All the more insidious today in its sheep's clothing of shiny websites and hollow mission statements.

Thank you for taking the lonely path of the Hero.  It doesn't matter whether it holds you in hospice or leads you elsewhere; it's golden and God-breathed, and it's in your blood and bones.  Peace, friend!"

My true performance feedback arose from someone I work alongside in the service of others.  That I will treasure in contrast to the nonsense from the person I report to in the organizational chart.  I cut their's into perforated strips with segments sized roughly four inches by four inches.  That way I can properly recycle the material.

Anonymous (from Gentiva a Kindred company)

Sunday, August 9, 2015

Uninspiring Leadership Highlights Business of Hospice

 StrangeTony,

In case you miss the language of business being used to describe hospice, here's what Kindred executives said in last week's earnings call with Wall Street analysts:

Moving now to Kindred at Home, which comprises our Home Health, Hospice, Community Care and Home-Based Primary Care businesses, we've had a terrific quarter. The leadership team in this division has really come together over the last six months, led by David Causby, the Division President. Revenue increased to $606 million this quarter and core EBITDAR contribution increased to $101 million. The integration of Gentiva and Kindred continues to proceed faster than our initial expectations and we remain on track to achieve our goal of $35 million of realized synergies in 2015.

For our Home Health operations, total episodic admissions grew 6.5% and revenue increased 7.6%, both over prior-year quarter on a pro forma basis. For the Hospice segment, ADC improved 2.3% sequentially over the first quarter of 2015. We believe we have successfully stabilized our census over the past several months and are returning this Hospice segment to growth in light of recent policy changes by CMS, providing more clarity on the importance of the hospice benefit to Medicare beneficiaries, our continued focus on highly-effective palliative care programs and a deep belief that hospice save the Medicare system money while aiding greatly with end-of-life care, we are bullish on the growth potential of this segment over the next few years.
 Several analysts asked questions about Kindred's hospice segment.  

Frank Morgan - RBC Capital Markets
Okay. And then you called out certainly how the hospice business is improving and we're certainly seeing a lot of other companies talk about that as well. But any high level thoughts on really what's driving this recovery that most people seem to be experiencing today?

Benjamin Breier - President and Chief Executive OfficerI think if you listen, Frank, to what's coming out of policy makers in Washington, as I said in prepared remarks, I think that there is this growing parallel path that started to come together on two specific ideas. On the one hand, I think that – and for anybody on the call and lots of Americans out there who have gone through the path of having a loved one who's had to deal with and received some form of palliative care hospice card – as a qualitative benefit at end of life, it really is, I think, one of the most powerful things societally that we can give to our loved ones around caring for them at end of life. So on the one hand there's this undebatable qualitative nature to it.

And on the other hand, Frank, I think what policy makers are seeing on the reimbursement side of the world is that what is clear is that if you can have discussions earlier with family members and loved ones about end of life care and if you can make some decisions on where those loved ones are around end of life treatment, there is the potential, if I may, to talk about significant savings to the Medicare system if you use these services appropriately.

And so here you have a qualitative issue with a financial issue coming together and I think policy makers at CMS and others have looked at this and finally said, you know, this is a benefit that we probably ought to think about expanding, not contracting, and if you see some of the recent comments that came out of CMS around Medicare beneficiaries who are going to have the opportunity to participate in hospice at an earlier stage than what they might otherwise have been able to do, if you see what came out in the new payment policy around this U-shaped curve of – in terms of the way we manage hospice patients, and if we just watch ourselves what's happening from a patient day admission ADC trend, I think you have to be nothing but pretty bullish on what the future of the hospice delivery is and for us, we have almost a $700 million, $800 million Hospice business here at Kindred. It was, I think, one of the hidden jewels if you will, as part of the Gentiva integration and acquisition.

We're running the business very well and we're, as I said earlier, we're pretty bullish about our growth prospects in line.

Frank Morgan - RBC Capital MarketsOkay, and just one final one on the Hospice business, you mentioned the U-shaped curve, what's your assessment right now in terms of if you look at your length of stays, median length of stays, how do you think the U-shaped curve will impact that business in and ad hoc? Thank you.

Benjamin Breier - President and Chief Executive OfficerOur length of stay has historically been a little bit higher than others mostly because we're like 98%, 99% into the Routine Care business. We don't do much inpatient or continuous hospice care in our Hospice branches. I would say we're starting to see our lengths of stay come down slightly, irrespective of any payment changes that are happening and my general comment to the U-shaped curve is it will be net-neutral to slightly positive for us, although I would not be surprised if, Frank to your question specifically, lengths of stay come down a bit.

Frank Morgan - RBC Capital MarketsOkay. Thanks.

Josh Rashkin - Barclays
Hey. Thanks. First question just on the hospice segment; it sounds like, Ben; you're obviously excited about that. I'm curious what your perspectives are if and when the hospice benefit actually moves into Medicare Advantage. Clearly, currently not part of that. Do you think that's a risk in the sense that the health plans manage those patients to a lower length of stay, or do you think potentially there's an opportunity because MA's been avoiding hospice costs because obviously they don't manage it right now. So I'm just curious what your perspectives are, if that actually occurs?

Benjamin Breier - President and Chief Executive OfficerWell, I'll go back to my thesis, and or my hypothesis I guess, back to what I was talking about a few minutes ago. I understand your question and I think you're right to be – and all of us are right to be a little bit curious and concerned as patient benefits move from Medicare fee-for-service to Medicare Advantage, primarily because the MA plans have different thoughts in terms of how they manage utilizations. But Josh, if you go back to my hypothesis, which I think is right, that the hospice benefit is actually a net saver to the Medicare beneficiary and to the payer. I actually think that smart companies like Medicare Advantage that are looking to both be qualitative to their patients and their customers and managed costs, I think they're going to run to the hospice benefit, not away from it. I think.

Josh Rashkin - BarclaysYeah. No. I mean, you've seen a lot of this movement towards slower side of care and clearly hospice is cheaper than any of the inpatient options. So I get that. I'm just – it's just you always worry about the way they manage the patient I guess. Second question around these duals moving into Managed Care on the hospital division, is there a way to contract? I mean have you guys reached out to some of these Medicaid health plans, particularly in California that are getting all of these duals assigned and try and be sort of proactive around the contracting and seeing how you can help and maybe get a case rate to your point as opposed to length of stay mattering, et cetera?

Benjamin Breier - President and Chief Executive OfficerOh, absolutely, Josh. You should know. I mean, for the last 18 months as we were heading towards these demonstrations in California, as the state of California was picking who their Medicaid providers were going to be, our Managed Care folks, Franke Elliott, whose our Chief Managed Care Officer and his team of provider relations and contracting folks, I think we have something like 65 full time Managed Care folks now in our organization. They've worked collectively very hard to garner contract participation with; I think virtually all of the Medicaid managed providers out there, including negotiated rates, including a very good relationship with those payers in the state of California. And I think one of the reasons why we've been able to achieve so much of the movement into the Medicaid managed population is because of the work and the foundation we laid.

Provider relations and contract relations is always sort of an ongoing effort. You have to continually go back and talk about your value proposition, why rates should be what they should be. I think having the diverse market offering that we have in Southern California helps us in that regard. So we're on it. We're on it in a very meaningful way and we'll continue to pursue every path towards having good relationships with those payers as we can.

Josh Rashkin - BarclaysOkay. And then just last question on M&A and I know you guys have had a particularly busy year. But I'm curious what the appetite is today to continue to roll up sort of tuck ins in your markets and then maybe which segments are most attractive. And maybe lastly, how do you weigh that against debt repayment?

Benjamin Breier - President and Chief Executive OfficerWell, I think we're always trying to be opportunistic as we manage our investor's capital and as we think about our balance sheet. De-levering this company and paying down debt remains our number one priority. We have said that and focused on the idea that we want to integrate Gentiva. We want to gain all of the synergies that we think are available in that integration and acquisition. As Stephen mentioned, we're off to a great start this year, and we think that we'll meet and, we hope, exceed the expectations of what $70 million-plus that we laid out. Nothing helps de-lever our company more than getting those synergies and driving EBITDAR higher. So that's our first focus.

But I think, Josh, to your question more broadly, there are a lot of markets, particularly our integrated markets, where there are tuck-in opportunities and we have to continue to remain nimble and opportunistic. We have markets for instance where we might have a very significant home health presence and there may be a hospice branch that may be for sale. We'll certainly be on top of that. 

Unidentified Analyst
Hi, this is Frank on for Chris. Thanks for taking my question. I see you touched on this a bit earlier, but it looks like there was some lumpiness in the Hospice segment in the quarter. Can you just provide a little more color about how we should think about stabilization in that business going forward? Thanks a lot.

Benjamin Breier - President and Chief Executive OfficerWell, I think – as I've commented a couple times, I think we've seen now five – I think it's five consecutive months or five out of the last six months, we've seen patient day and admission growth in this business. The trend after sort of stabilizing and flattening, I think, towards the back half of 2014, has really been the arrow I think pointing up.

Our operations are well intact, our sales teams are well intact, I think we have a really good sense of how we're managing the hospice patients. I think having some stability now in what the reimbursement environment looks like is going to be very helpful, and there is a little bit of seasonality in the Hospice business. I mean, certainly you'll see Hospice trends probably continue to go up, then flatten and probably a little bit down in Q4 before they return back to growth in Q1 of next year. But I would just generally say, the arrow, as I've said now a couple of times, is clearly pointed up in this business, and we remain very confident that we'll continue to show incremental performance there. Thank you.

Valued hospice employee, are you still there?

Nope.  I hung up long ago.

Anonymous (from Gentiva:  a Kindred at Home company)


Wednesday, August 5, 2015

Kindred Continues Crushing Heart of Hospice

StrangeTony,

Kindred's failed to turn Gentiva's tide of sick management, instead bolstering local leaders who don't listen, don't plan, don't communicate and don't improve.  There's no word yet on the PwC employee survey.  Rumors at our site suggest staff hammered the company and it's sorry leadership.

The very trends you felt before you retired have not abated.  I'll venture tomorrow's earnings call will scream the language of finance, but it will be heartless.  EBITDAR and leverage ratios will be the altar that Wall Street analysts worship.

You retired having experienced Generic Hospice's decimation of much that was good in hospice leadership.  I'm not sure I will get that luxury.  Kindred is at home with abysmal management, taking great offense at anyone who dare point out the simplest of management inabilities.  The reaction, in many cases vastly overemphasized, reveals an underlying insecurity, damage, limited ability to see and/or hear.

Kindred's propensity is to rely on local leaders it can micromanage.  Therefore, it will have to micromanage them.  That leaves everyone in a precarious spot, as decisions will be made on partial information by leaders without knowledge of their site, it's history, it's local market and people who've come and gone from the site.  One arbitrary move from layers above and careers are jeopardized.  Spin rules while truths told go unheard.  Truth's messenger is however eviscerated.

Anonymous (from Gentiva-a Kindred at Home company)

Saturday, July 18, 2015

ALS Patient's Sad Situation at Vitas Hospice


Hospice facility to take breathing machine from ALS patient photo

Atlanta media reported contention between Vitas Hospice and ALS patient Hector Torres.  AJC's article offered:

An Atlanta man battling ALS is fighting a hospice care facility to keep machines he needs to live.  Hector Torres has to live his life hooked up to two machines that help keep him alive.  "I'm dying. I'm suffocating, because I can't breathe," Torres said. He suffers from ALS, a disease that affects nerve cells in his brain and spinal cord.

ALS patients face a certain outcome, death.  When the diaphragm weakens patients are unable to expel carbon dioxide in their lungs.

Torres told Channel 2's Tyisha Fernandes he needs two machines to breath, a ventilator and another to supply oxygen.
 
Vitas Hospice's medical team determined Torres needed assistance expelling carbon dioxide from his lungs and would benefit from prescribing oxygen.    

Vitas Hospice officials were letting him use the machines in his home, but now that the location is under new management the hospice is taking back one of the machines.

The machines were prescribed as part of Mr. Torres hospice treatment, provided by Vitas, likely through a contract arrangement.  New management should have nothing to do with giving Mr. Torres what he needs to treat his symptoms and keep him comfortable. The article gave this response from Vitas:










Sunday, June 28, 2015

Listening Means Suspending Judgment

 Anonymous,

I pondered your question about management not listening and offer the following:  For one to listen they must stop talking, verbally and non-verbally.  That includes suspending whatever agenda, perceptions, preconceived notions, desires, repulsions or judgements they may have.  Their aim should be to fully and completely understand the person.  Any notion of helping or problem solving should come after communication has been completed.

You also asked for "advice for hospice employees working for managers who say they believe in teamwork but act autocratically, who say they're open to input but never seek it, who hold it against employees finally fed up enough to take the risk to speak out."  I offer several observations for those who must find their way in such circumstances.

There are ways of managing that appreciate the depth and complexity of life, that honor whole people in the workplace, that focus on the most important things (which is not numbers or money), that foster teamwork, trust and achieving great things.  This cannot be done by control from above, whether it be edicts from senior executives, regional managers or local site leaders.  "Doing to" people may achieve the illusion of success on shallow measures.  This is as fleeting as the house built on sand.

"Doing with" is the only way to achieve success over time.  Your company and site leader are limited in their vision.  They obsess over measures that are not primary.  They are not able to suspend their talking to hear. 

People experiencing this form of management obtuseness and control are naturally frustrated.  Yet, this is an opportunity for growth.  I encourage you to observe that which is going on.  Try to observe the whole room, including your reactions as situations unfold.  What is being triggered in me?  Why do I have this reaction at this time?  If you can monitor and learn from your self-talk you can become a better listener. 

The challenge is for you to become a better listener.  What you learn from yourself and others will guide your future.

StrangeTony (from retirement)

Sunday, June 21, 2015

Anti-Teamwork: Management Doesn't Listen


StrangeTony,

Do you have any advice for hospice employees working for managers who say they believe in teamwork but act autocratically, who say they're open to input but never seek it, who hold it against employees finally fed up enough to take the risk to speak out? 

This is all the more jarring in hospice with its interdisciplinary team emphasis.  How can hospice be a team when management views us as a collection of individual parts that must be controlled, directed,, externally motivated, kept in the dark, even micromanaged?   

My company lets anything go management wise as long as census and admissions are fine.  They believe our Branch Manager is solely responsible for good volumes and positive budget performance, as opposed to the sixty seven non-management employees busting their backside to provide great service on a daily basis.

Should volumes drop our Branch Manager delegates blame to anyone but them.  Corporate nits suddenly start hovering around looking for who to pressure, reduce or eliminate.  They offer exhortations like "pick up the pace."

A wise physician's message to corporate types:  Take care of patients and employees and census will follow. Nobody's listening.

Anonymous (from Gentiva, a Kindred at Home company)

Friday, June 5, 2015

Kindred Registers 200,000 Shares for Directors

StrangeTony,

Swirl this around in your mint julep.  Kindred filed a stock registration with the SEC for 200,000 shares to be used in non-employee Board member compensation.  Kindred employees lack a stock purchase plan, something Gentiva employees once had as a benefit.  It's better together for Board members.  For employees, no evidence yet.

Anonymous (from Gentiva, rebranded Kindred at Home)