Egregious Breaches at Vital Cheating

Strange Tony,

A judge ruled against two financial rapscallions and April Anthony, the former founder of Encompass Health, for "egregious breaches" of fiduciary duty.   As a CPA Mrs. Anthony clearly knew about fiduciary duties.  As a Christian she is supposed to have a basic moral code, one above "earthly desires."

April's partners in crime?  Vistria Group and Nautic Partners.  I imagine these firms are similar to the financial rapscallions that denigrated our once great hospice.

Welsh, Carson, Anderson & Stowe

TPG Group

Clayton, Dubilier & Rice

Anthony and her greedy co-conspirators did the following in their "building" of VitalCaring.  

At first she tried to buy the company (Encompass), in secret partnership with Nautic and Vistria, and then later chose to form a new, competitive company (VitalCaring) with her new PE partners.

Anthony served on the board of First Financial Bankshares, a regional bank based in Abilene, Texas.  Her board bio states:

... as a certified public accountant, Ms. Anthony brings strong accounting, management, strategic planning, technology and financial skills important to the oversight of our financial reporting, enterprise and operational risk management.

Her board bio indicates that she founded Homecare Homebase, the crappy hospice software WCAS and TPG pushed on us after their summer 2018 takeover.  Homecare Homebase made it nearly impossible for our hospice staff to receive fair pay for hours worked and miles driven.  April made $422 million from selling her equity in Homecare Homebase over a number of years.

It's never enough for the greedy.  All that knowledge, money and deep faith did not prevent April Anthony from acting unethically in the pursuit of even more money than the $740 million she had accumulated as of 2023.

I'm afraid this is the state of hospice, healthcare and more.  It is sad as it is a form of death, the extinction of ethical leaders.

Anonymous

Gentiva Settles False Claim Suits for $20 million

Strange Tony,

Having lots of names came in handy for Gentiva/Kindred/Curo in its settlement with the Justice Department for fraudulent billing.  The nearly $20 million settlement involved mostly Curo branded hospices.  The bad behavior began in early 2010 and went on until year end 2023 over various individual hospices.  The settlement agreement has the specific breakdowns.

That Curo hospices behaved unethically is no surprise and calls into question the judgement of Humana and its financial rapscallion partners (TPG and WCAS) as they chose to impose the Curo model on Kindred's hospices (which were generally much larger and greater in number than Curo's brands).

That decision destroyed our once nationally ranked hospice.  We went from a Kindred sized hospice of over 100 hospice patient census to half that (Curo sized).  It turns out referral sources expect someone to answer the phone and show up when needed.  Curo's technology and staffing model did not enable this level of service delivery.

Left out of this settlement were any of the company's owners whose financial practices encouraged, almost demanded, unethical behavior.  If the company can steal pay and mileage from employees, surely an enterprising branch manager can steal from Medicare/Medicaid/Tricare.  

Humana, TPG, CDR and WCAS  take a bow.  Bad behavior from June 2018 to December 2023 rests on your shoulders.  

I wonder how far Humana CEO Bruce Broussard's Washington, D.C. office is from the Justice Department and how many trips he made to Capital Hill to put this issue to bed.  Surely he and the boys from CDR/TPG/WCAS put a bug in someone's ear.

The latest Gentiva/Kindred settlement makes me realize how our legendary Medical Director kept the ethical wolves at bay for so long.  Our census stayed high due to his care and concern for patients and their families.  Money flow kept regional and national corporate parasites in check.  

He loved to tell our corporate visitors about the special closet in the national office where new recruits were taken in and had half their brains sucked out.  Their facial expressions were priceless.  Thank heaven he retired before Humana/TPG?WCAS trashed his baby.  Our legend was a hospice doc to the very end.  God rest his soul and God help those suffering under greedy fools.

 Anonymous

Greed Drives Hospice De-evolution

Strange Tony,

Financial rapscallions have caused widespread harm in healthcare.  Only a sycophant could refer to their impact as "elevate."  

Private equity and venture capital are the business version of iatrogenic disease.  

"...a state of ill health or adverse effect caused by" management greed

Obscenely wealthy principals partner with executives to shovel money into their pockets from the work of hospice multidisciplinary teams.  Strict staffing models, combined with bad technology and high turnover, mean salaried nurses often work 70 hours a week for 40 hours pay.

That's a win for greedy management.  It's cheating and overworking staff.  

Elevate happened yesterday in Washington, D.C.  Did any members of the Federal Trade Commission attend?  I hope so.  They should be much smarter after months of public comment on healthcare consolidation (mostly by private equity).

Anonymous

CDR Monetizes Gentiva Personal Care

Strange Tony,

It took twenty months for Clayton, Dubilier and Rice to sell off Gentiva's personal care division to Addus for $350 million.  

Ownership genealogy for this division went from Kindred to Humana/WCAS/TPG to Humana to Humana/CDR.  It's now going to Addus with its $280 million in annual revenues.

Moody's is yet to weigh in on the impact of the deal on Gentiva's debt rating, if any.  The press release states Addus agreed to "acquire the personal care operations of Gentiva."  That reads 100%.  Currently Humana owns 40% of Gentiva and CDR 60%.  

How might the parties split the $350 million?  That's a financial rapscallion trade secret.  Charlotte Buyer-Gentiva debt holders should pay close attention.  Moving prize assets away from the parent company (debt issuer) is all the rage for financial tricksters.  

A Gentiva higher up that went on to run the Personal Care Division once visited our hospice site.  They called staff concerns about our hospice a "female dog" (bitching).  

The local Personal Care manager used our office for interviews and we ran across their staff in the field.  They were often college students pursuing nursing or physical therapy.  Our least paid hospice position was a big step up in pay for these folks.

I'm sure that has not changed given the miserly nature of Gentiva executives under financial rapscallion ownership.  Let's hope Addus is a bit more generous to the little people.

Anonymous

Public Comments on Healthcare Consolidation: Over 50% Cited Financial Rapscallions

Strange Tony,

Public comment closed two days ago on the impact of health care buyouts.  Over 6,000 comments were submitted and the FTC shared 2,142 on their website.  50.5% of the public comments cited the impact of private equity, aka financial rapscallion, consolidation.  

Thirty four comments mentioned hospice.  I submitted two, one from my experience with Gentiva/Kindred/Gentiva and the other based on how financial rapscallions have harmed society's most vulnerable, children and the elderly.

The National Hospice and Palliative Care Organization submitted a letter.  It avoided the consolidation that has gutted hospice care over the last decade.  NHPCO's board has many members from financial rapscallion owned hospice organizations (the ones doing the consolidating and gutting).  One is even a limited partner with 99% percent ownership of their hospice organization. It's no surprise they avoided the elephant in the room with their recommendation:

Bad actors and poor performing hospices can come in any shape, size, or ownership status; therefore, we strongly recommend the federal government better target program integrity efforts and supporting quality hospice providers to ensure beneficiaries have access to quality, affordable hospice services while promoting and protecting competition in healthcare markets.

A physician had a different take:

Private equity only exists in its current state as a leech on healthcare, reducing quality and patient safety and extracting healthcare dollars at the expense of the American public.

Gentiva CEO David Causby led our hospice through two financial rapscallion buyouts.  He likely doubled the value of his holdings in the consecutive sales, Kindred Hospice to Humana and then Humana to Clayton, Dubilier and Rice.  Trickle down is yet to happen.  

Causby is on the Transition Board for the merger between NHPCO and the National Association for Home Care and Hospice (NAHC).    Home care and hospice have not always been friends.  Our legendary Medical Director started providing care for terminally ill patients in our area in the 1980's.  Home Health fought against the establishment of hospice and lobbied against Medicare establishing the Hospice benefit.

NAHC's letter on healthcare consolidation refers to the benefits of "private interest ownership and consolidation."  I saw no benefits from TPG Capital and WCAS owning 60% of our hospice.

 

Letter writer Leslie Norwalk works for a healthcare venture capital firm (Epsilon Health Investors) and healthcare private equity firm (Peloton Equity) in addition to serving as strategic counsel for Epstein Becker Green.  Her EBG bio states:

Attorney Leslie Norwalk serves as an advisor to private equity investors, including three private equity firms, and to those seeking investment. 

Another bio states:

She serves as an advisor to private equity firms Warburg Pincus, Peleton Equity and Enhanced Equity Fund.

This obvious conflict of interest is not mentioned in Norwalk's letter to the FTC.  That is not unusual in a world where financial rapscallions work nearly unseen in our houses of power, drawing multiple massive salaries in their many roles.  Our Hospice Nurse Aides struggle to get paid 40 hours a week.

Norwalk worked alongside Tom Scully at the Center for Medicare/Medicaid.  Scully went on to financial rapscallion Welsh, Carson, Anderson and Stowe.  WCAS owned 30% of our hospice before flipping it for massive profits to Humana.  I worked for two WCAS affiliates in my career before retiring.  This blog details the many harms our hospice endured under greedy hands.

Our climb is a steep uphill to wrestle hospices away from financial rapscallions.  The deterioration has gone on for too long, enabled by the very people who were to protect us.  

At least some of the common people got to speak up.  Now, which side is taking note?

Anonymous

Financial Rapscallions in Healthcare: Comments Not Yet Closed

Strange Tony,

The public submitted over 1,600 comments on private equity's impact on healthcare.  The comment period was extended from May 6th to June 5th.  So the door remains open for those wishing to share their thoughts and experiences with financial rapscallion ownership.  A number have struck me to date.

Anonymous said:

Private equity's focus on short term profits before all is antithetical to providing quality, humane, sustainable healthcare. The industry's track record of extracting every bit of cash from companies they acquire at the expense of customers and employees before selling off a ruined husk unable to continue existing is horrifying, at best. Continuing to expose something as critical to the well-being of our citizens and whole society as healthcare to such predatory and self-destructive practices would be an absolute travesty and a self-inflicted cancer on the very fabric of our country.

 Another commenter provided the following:

Many of thepworst instances of a poorlygfunctioning corporate governance/economic incentive system have been through U.S. private equityafirms mismanaging investments in U.S. healthcare and technology companies -- are just the uniquely awful examples with broad public awareness. Private equity firmslcynically deny they have operational control of their portfolio companies when abuse is revealed, despite their effectiveicontrol through an interlocking directorate of board members, investors, and economic incentives. Some limited partner investors arevincentivized into complicity through access, equity co-investments, or fee breaks. Employees and management teams at these portfolio companies, like helots, are retaliated against if they speak out of line. 

The current governancepsystem in place for private equity is not effective and the DOJ, FTC, and Department of Health and Human Serviceseshould have a greater degree of oversight to stop this from happening again. This induced trauma is happening with full awareness from the wider private equity ecosystem. Many of the most resourced private equity firms in the world are right nowucolluding to ringfence their own liability and cover up the impact this misappropriation of resources is having on our healthcare system.

A physician from hell-hound (Cerberus) trained Steward Health offered:

My 2 partners and I sold our independent medical practice of 9 primary care providers to Steward health in 2019, then quit them in 2022. A long list of failed contract fulfillments includes: wouldn't pay vendors (credit holds precluding ordering flu shots, equipment), maintenance, cleaning (we often cleaned and fixed our own offices, did necessary yard work after hours, etc), and tried numerous times to extort us out of money owed contractually. Showed up to office with contract addendums asking us to sign with hidden language to relinquish bonuses or change pay formula. We started having serious management calls within 6 months, lawyer meetings within 1.5 years. We were collectively underpaid 100k each year because they failed to calculate this correctly, necessitating a battle to correct, even thought the factual data was easy to interpret. 

They hid financial metric data from us to facilitate their underpayments to us for which we were forced to go directly to insurers or individuals within Steward (off the books) to locate. Our group was never payed a large percent of Medicare earnings and multiple years and ACO shared savings (though SHCN) of which was another story in/of itself. Was told a legal judgement against Physician Group of Louisiana would be easy, but collecting would be impossible because of the many tiered LLCs and ZERO assets in any of the ones that contractually own the practices/employ physicians. We were watching our community hospital in West Monroe, LA, being sucked dry all while they were acquiring more hospitals in TX, AZ, FL, and individually pocketing an exorbitant "acquisition fee" when they sold the assets WAY above FMV to Medical Properties Trust (which is about as legitimate as Pablo Escobar's taxi business) then letting the operating side IMMEDIATELY suffer. 

Guys, Steward was not set up to operationally succeed, they were set up (likely by multiple closed door PE backer meetings - like ones with Cerberus) to provide immediate dividend/distributions on invested capital by selling WAY above any legitimate FMV (so...seemingly everything else in healthcare is regulated by not exceeding FMV, but this isn't???), signing ridiculous leaseback rates (precluding any entity from being able to purchase asset in future when the operating side INEVITABLY declines (because it was an afterthought, and not set up to succeed)), and distributing a stupidly high dividend to private investors. 

I personally am not against for-profit or even PE in healthcare, and absolutely see the premise of hawking a profit margin. But seeing this run from the inside (shutting down hospital profit centers, disallowing local decisions, stiffing community businesses accounts payable, routinely extorting from physicians.. the list goes on) it's very evident this is solely a real estate asset scheme. All Steward owned hospitals more than 1 year behind on accounts payable should be seized by the state government and resold to community after having 2 or 3 external FMV evaluations. You guys decide if MPT is illegal or not, but no question it's unethical. It will sink it anyway when you seize all the hospital assets back. But you should absolutely take back EVERY dollar of real estate acquisition fees that PE/Steward owners took out of the hospital property within 3mo of purchase.

They have raped our communities. And other companies are building business models similar to this. If I can be of assistance please reach out. I have kept a good bit of files, contract infractions related to our time at Steward (lots of lawyer meetings, were prepping to sue them, remember).

A nurse practitioner wrote:

I am a psychiatric nurse practitioner. I am not often privy to the administrative changes nor the financial machinations of the organization I work for. What I do know is that since being taken over four years ago by a private equity firm – an agency that works primarily with a Medicare and Medicaid population who has a high percentage of SMI patients (those with significant and serious mental illness) – the quality and availability of our services has significantly declined. We can not seem to recruit nor retain any counseling staff, let alone those with the skills needed to work with this population nor the required licensing that some insurances require in order to treat their patients. We are down to very few counseling hours and it is uncommon to hire staff, and even more uncommon to have them stay.

What is distressing is to sit with patients day after day and know that I can only prescribe medication, and give them at most 20 minutes of my time, and then send them on their way. I sat with three patients last week who all disclosed a history of incest, two of them discussing it only recently. So many of my patients have significant and debilitating Post-traumatic Stress Disorder from their traumatic life histories, and I have little to offer but medication and a little empathy. What they need is quality, ongoing, targeted therapy, but they can not access it. They can’t get it here because we have been starved of funds and therefore staff. As far as I can tell, they can’t access it anywhere in my county as there are few if any therapists accepting patients, let alone those on Medicare or Medicaid.

When I have a child or a teen who is struggling and has a potential for violence, we are being told that our local crisis won’t transport them to the ER. I am supposed to “fix” them with medication because not only do we not have therapists, but we have few if any services in the schools and almost none in the community. We talk and talk about increasing mental health services for kids due to a myriad of reasons – school shootings, increases of suicides, increases of drug use – but in the past four years, services have been in a steep decline.

Additionally, my father died a terrible death from ALS last year. He died alone because no one at the abysmal facility he was at which was two hours away from us had the heart to tell us he took a turn for the worse. He was on a ventilator as he deteriorated quickly. Due to a lack of adequate reimbursement, no facility anywhere close to us had a bed open for him. We tried to get hospice but it was too late, the facility stymied anything we tried to do. He died alone and suffering and that was after we did all we could to protect him. Our system is broken beyond repair, and I wish that anyone who is trying to profit off of patients could have seen my poor suffering father, and the grief of my mother, who tried everything she could to give him comfort and peace during a cruel and horrific illness.

For-profit heath care is an evil that must stop. People are making money off of the backs of people with schizophrenia, victims of incest, people with autism, and any number of other mental health concerns. Making money off of the back of my suffering father – why is this allowed to happen? I’m sick and tired and frustrated and I plan to leave health care as soon as I can.

Three of the four comments came from people on the inside.  The financial rapscallion cancer runs deep in our healthcare non-system.  It's a widespread harm, reaching from autism to nursing home care to hospitals to oncology.  It needs to be excised.

Anonymous

Comments Wanted! Financial Rapscallion Hospice Ownership

Strange Tony,

You are well aware that financial rapscallions have overrun various aspects of our healthcare delivery system.  The Federal Trade Commission is taking public comment on the impact of private equity ownership in healthcare.  There are over 1,400 comments to date.

I have perused a few of them.  Numerous emergency room physicians detail the damage done by private equity firms in their ceaseless pursuit of outsized returns.  Dentists, radiologists, dermatologists and nurses detail the specific ways financial rapscallions have harmed staff and patients.

There are a few comments that mention hospice as an area of consolidation by financial rapscallions.  I offered a comment detailing the harm done to our hospice after being majority acquired by WCAS and TPG Capital.  I encouraged the FTC to look at the real time harm being done as Gentiva "integrates" Heartland Hospices, once owned by Promedica.

Private equity industry insiders with a conscience have commented, well aware of the possibility of targeted retaliation.  Hats off to these people.

The door is open for anyone to comment.  Any comments must be submitted by May 6th.  

Healthcare workers have the opportunity to share their thoughts, experiences and recommendations on healthcare buyouts, the majority of which are done by private equity.  Please do so, as inspired.  

Anonymous

If you are interested in commenting:

Click on this link and look for the Navy Blue box that says "Comment."

If you are interested in reading the comments, click on the link above and look for the box that says "Browse Posted Comments"

Heartland Hospice Employee Calls Gentiva Heartless

Strange Tony,

Another Heartland Hospice staffer noted Gentiva's reducing staff, vacation and miserly approach to supplies.

A Gentiva employee noted executive management not listening to people in the field.

I'm sure Gentiva's Human Abuse Department will work overtime to identify and current employees raising legitimate concerns and target them for elimination.  It's the Causby way.

Anonymous

Gentiva: Indeed vs. Glassdoor

Strange Tony,

Gentiva executives are courting hospice clinicians on their Indeed site with promises of good work/life balance.  Glassdoor's Gentiva reviews reveal a broader picture, one less flattering to equity holding executives.  

 

A hospice nurse in Georgia said:  

"The corporate level cares little about the staff and will not hesitate to lay you off if the profit margin shifts for a quarter. They call you back to try to rehire you (saving on training a new person). Ridiculous. Job security is non existent even for top level branch management." 11-24-23

A North Carolina nurse offered in her pro statement "everyone is so ridiculously overworked."  Her con reply included:

This is a company that cares about profit, and little, if anything else. Just like with their patients-they will say anything to get you in the door, then leave you high and dry. Require you to care for patients over a huge service area, manage a ridiculous and unsafe number of patients, force you to work overtime, on call, do admissions. There is zero recognition for hard work and dedicated staff. Will lie to your face and cover for employees not doing their job. Benefits are a joke-worst coverage/highest cost I have ever paid for health insurance. Covers primary care preventative only unless you reach entire out of pocket deductible. No urgent cares “in network” within an hour of me. No one near me takes their dental-not even any of the people listed on their site.  6-6-23

Financial rapscallion Clayton, Dubilier and Rice closed on its majority Gentiva stake in August 2022.  They completed the Promedica Hospice buyout in November 2023.  New employees are often gobsmacked by things existing employee have been trained to accept (numbed).   

An employee new to Gentiva offered:

Recently bought out from Promedica Heartland. We we're told that nothing will change, however at least 10% of the staff have been laid off.  We are told we will never get a raise.  Our phones were taken away and basically everything is changing.  2-29-24

That has a familiar refrain.  When TPG/WCAS became our majority owners many dedicated employees lost their jobs.  The work did not go away.  We had to do it under new, crappy, unreliable technology and yes, they took away company provided phones, overtime pay and three holidays.  The new comprehensive hospice software stole hours and mileage from employees.    

Don't worry Promedica people, IT is there to supply you with hours of background music while you wait for a representative.  You might be lucky and reach an actual person.  HR is there to back management at every turn.  That generally works out poorly for clinicians.

A Pennsylvania hospice nurse wrote:

Salary position, no increases, no bonuses. Not paid for extra hours you work. No availability for nurses to work part time. It’s FT only. The work is independent which can be a bad thing if you need support or your superior to back you up on a decision you made.  You are promised one thing then management does the opposite, acting like that conversation never happened

Over and over I saw HR work against employees with legitimate concerns.

Under financial rapscallion ownership our clinicians learned that patients only became ineligible for hospice as a new certification period approached.  Area Medical Directors indicated there was no need to discharge a patient who no longer met hospice criteria because of our good care.  They said the certification is still good for however long.  Our hospice medical director disagreed but had no power. The TPG/WCAS/Humana way meant weeks of fraudulent billing.  

Promedica employees should know accessing the Compliance Department generally involves a quick exit from Gentiva.  Principled people are not appreciated.  

Gentiva cares for its clinicians?  Indeed, they don't and haven't for quite some time.

Anonymous

Gentiva Debt, Humana Trophy Office: Not Cheap

Strange Tony,

Gentiva Hospice's debt has several tiers.  Its first lien senior secured debt pays holders 10.1% annual interest, while the second lien senior secured debt pays 13.08%.  Both are floating rate and mature in 2028.  

This debt is far more expensive than prior issuances.  Interest expenses are up by 50 to 80% from prior debt offerings.  That means less money for staff or more important, patient care.

Humana and financial rapscallion Clayton, Dubilier and Rice issued Gentiva's debt via another corporate entity, Charlotte Buyer.  It's address is 500 W. Main Street in downtown Louisville.  Founder David Jones felt strongly about Louisville and built Humana's distinctive headquarters building in 1980's at that very address.

WDRB reported

Humana, the only Fortune 500 company headquartered in Kentucky, plans to vacate its iconic, 27-story headquarters building at 500 W. Main St. in a cost-cutting move, leaving a massive structure to fill in a downtown already struggling with a glut of empty office space.

As WDRB documented in 2022, many of Humana's top executives are based in a newer office outside Washington. And for the first time in company history, the CEO's job no longer requires living in Louisville.

It turns out Humana CEO Bruce Broussard was playing a confidential switch game, leaving Louisville for Washington, D.C., the center of power and influence.  Consider this report:

About the same time the Broussards sold their Louisville condo, Humana finished work on a new "trophy" office space for "executive leadership" in a high-rise building in the Rosslyn neighborhood of Arlington, Virginia, just across the Potomac River from the nation's capital. 

In May 2019, a trust in the name of Broussard's wife, Janine, purchased a $4.4 million home in the ritzy Kalorama neighborhood of Washington, where former President Barack Obama, Ivanka Trump and Jared Kushner, and Amazon CEO Jeff Bezos have had homes, according to public real estate records.

Humana's one-floor office in the Washington area represents a tiny fraction of its presence in Louisville, and no one close to the company knew of any plan to move its headquarters.

Humana made $1.3 billion in profit from flipping our hospice numerous times.  Those funds may have gone to Broussard's trophy office.  

Broussard is Chair of the Trust for the National Mall and Humana sponsored pickleball there in Fall 2023.  One doesn't get that opportunity from Louisville.

Douglas Edwards, Humana's senior vice president for enterprise associate and business solutions, and his wife sold their Louisville home in July and moved to Charlotte, North Carolina in summer 2022.  Is that the event that inspired the name "Charlotte Buyer?"

Only the executives know.  

Anonymous

KKR's BrightSpring IPO

Strange Tony,

Financial rapscallions hoped to get nearly $1 billion from taking BrightSpring Healthcare public.  Their take fell far short as investors were skeptical of the company's debt load, its valuation and KKR's dual role as sponsor and IPO underwriter.

The stock is yet to trade on NASDAQ.  Their website indicates bids around $12 for the stock, which IPO'd at $13.  

Abode Hospice is part of BrightSpring and former CEO Mike McMaude is the President of BrightSpring's Home Health Division.  

Working in hospice is hard enough.  Working for greedy executives and senior management jilted by the investment community adds a significant level of stress.  

BTSG will eventually trade at some market clearing price.  How low that is remains to be seen, but I expect an executive tirade to follow.  

Anonymous