Gentiva Borrows More for Next Five Years

StrangeTony,

S&P Global noted that Gentiva is exchanging its debt for a new issuance due 2031.  It will borrow up to $3 billion to retire a debt package of $2.76 billion (that currently shows $2.43 billion owed).  

The borrowing subsidiary is Charlotte Buyer which is under the control of majority owner Clayton, Dubilier & Rice, a financial rapscallion.  CD&R Falcon Holdings is the entity that controls Gentiva.

I was able to find the interest rates paid on the current debt and estimate Gentiva Hospice pays over $200 million per year in interest expenses.  Total revenue is around $2 billion.  Interest expenses are roughly 10% of the money that comes in.

There is no way to see how much cash CDR has pulled out of Gentiva Hospice since they purchased the firm via a Cayman Islands subsidiary in 2022.  That information is not public.  I wonder if there is a special distribution/dividend to sponsor in this refinancing.  

S&P Global showed projected recovery on the debt if Gentiva declared bankruptcy under CDR.  They lowered the overall recovery rate from 55% to 50% and the rating dropped from a B to a B- in their new analysis.

Financial rapscallions need to keep Gentiva Hospice going until they can flip it for a major payday.  Debt refinancing is a critical step for that cash bonanza to occur.  

The big money boys still trust one another to make good on their debts.  Financial crises tend to change that.  Should that happen financial rapscallions are often on both sides of a company, the equity and debt.  Bankruptcies mean affiliates, like Gentiva Hospice, change hands.  The loaner of funds becomes the new owner.

The rapscallion game remains energized enough to keep Gentiva going.  When that cools further or even ices, watch out.  Chaos usually follows, which means the sorry hand given to employees gets far sorrier.

Anonymous

Humana to Jettison Gentiva in Final Cashout

StrangeTony,

Humana will finally discard its 35%  remnant of Gentiva Hospice for almost $1 billion.  I recall the hope our hospice staff had when Humana and two financial rapscallions (majority owners) bought Kindred Healthcare's hospice division in summer 2018.  Staff expected professional human resources where pay scales had integrity and local management showed likewise.

However, operating partner Humana proceeded to decimate our once nationally recognized hospice and did so in a far crueler way than Kindred's pinhead numbskulls.  

Let's just say the slide has been long and far more inhumane than any hospice employee could imagine.  

Humana exits Gentiva Hospice with a final cash bonanza.  $900 million for 35% of the company?  That values Gentiva at $2.6 billion.  

Humana SEC filings show Gentiva revenue to have risen from $1.85 billion in 2023 to $2.05 billion in 2025.  Operating losses for the last three years were $23 million, $92 million and $84 million.  The heavy interest expense burden must be weighing on the company's financials combined with ownership's ability to shrink Gentiva's overall revenues.  Note: Humana ingested the home health division and Gentiva's personal care services were sold off later.

Staff reviews on Glassdoor and Indeed show the same employee abuse themes that Humana, TPG and WCAS foisted on us in 2018.  I thought management was supposed to learn from their mistakes, not multiply them.

Nearly all the people I worked with at our local hospice site have left.  Many are with other hospices and say things are better outside Gentiva.  

The 35% is going to a consortium of investors.  That's a remarkable lack of detail.  Maybe a future Humana SEC filing will shed more light.  I doubt it.  Humana is not know for bringing light.

Anonymous

Ran into Former Co-Worker

Strange Tony,

I ran into a former hospice co-worker the other day.  This caregiver had just left Gentiva for another hospice.  I asked how things had been and what caused the change of employer.

They said that corporate axed all management and brought in temporaries who cared not about our site, its history and the care that employees hoped to continue giving to patients and their families (which already had been constrained by years of company decisions and policies).  

CDR and Gentiva executives drove out all the heart.  With completely heartless management this person had to leave.

Early hopes that pay and benefits would be harmonized to Humana (minority owner) never occurred.  Frequent criticisms on employee ratings (Glassdoor or Indeed) has lack of raises (a common financial rapscallion move, although executives are exempted from compensation caps) and corporate chintziness regarding supplies.  Another consistent theme is profits over people (staff or patients).

Only a few of my former co-workers stuck it out for eight years of majority financial rapscallion ownership (WCAS/TPG to Clayton, Dubilier & Rice, also know as CDR).  If I run into any of them I will provide an update.

Anyway, it was great to see a wonderful person, catch up and get a good hug.  

Anonymous

Enhabit Returning to the Dark Side

StrangeTony,

Financial rapscallion Kinderhook Industries LLC is buying Enhabit, a home health and hospice provider in a $1.1 billion deal.  Hospice News reported:

At about $13.80 per share, the all-cash transaction represents about 24.4% of Enhabit’s closing stock price. The valuation implies that Enhabit has a roughly 10.3x EBITDA multiple for the Fiscal Year 2025, according to a report from Jefferies LLC.

That's far cheaper than hospice multiples in 2019-2020.

Multiples in the hospice and home care space reached a record 26x during 2020, according to a research report by PwC’s Health Research Institute.

Enhabit was spun off from Encompass in early 2022.  Encompass has financial rapscallion roots as it was once owned by Cressey & Company.  

Flashback to 2017 when our hospice was part of Kindred Healthcare:

Financial sharks circle Kindred Healthcare and some are inside the company. Take former CEO Paul Diaz, who received a $6 million cash bonus in May 2015 for closing the deal on Gentiva. Diaz went on to become an operating partner with Cressey and Company. Oddly, his bio on Cressey's website makes no mention of his current Kindred board service. Diaz is Vice Chairman of Kindred's Board of Directors.

We were sold down the river in summer 2018 to TPG Capital, Welsh, Carson, Anderson & Stowe (combined 60% owners) and Humana (40%).  Our new owners cut everything, including quality of care.

Humana kept the home health division but flipped Gentiva's hospice and personal care divisions to another rapscallion, Clayton, Dubilier & Rice

CDR just put affiliate Multicolor into bankruptcy and somehow will retain majority ownership.  That only happens if the rapscallion is on both sides of the deal, equity and debt.

Arm's length agreements and ethics are so yesterday.  I imagine Enhabit's hospices will funnel huge sums to Kinderhook, its executives and limited partners.  That is the way of the world today.  

Hospice deals with the eternal but must endure the greedy on our earthly plane.  I lived it and it was brutal.  Never again, Lord willing.

An attorney wrote a law review article titled "The Dark Side of Private Equity."  The anonymous author: 

"argues that the core tools of PE value creation—high leverage, cash extraction, and short-term exit incentives—externalize predictable risks to third parties including workers, healthcare patients, consumers, unsecured creditors, communities and the environment."

Sounds about right.

Anonymous   (yes, there are a lot of us)

Moody's Gentiva/Charlotte Buyer Rating Update

Strange Tony,

2026 is upon us.  Moody's debt rating for Gentiva is under the corporate entity, Charlotte Buyer.  After the sale of Gentiva's personal care division the company is primarily a hospice company.  

Financial rapscallion Clayton, Dubilier & Rice bumped up their ownership percentage from 60 to 65%.  Humana pulled back from 40 to 35%.

I joined you in retirement and what a relief it has been.  I haven't been back to the office since then so my view of the company is reduced to major news and what little financial information I am able to track down.

It was a privilege working with a great hospice team for so many years, one that struggled to stay good as executives eviscerated everything around us, all for their eventual, obscenely-excessive payday.  

Financial rapscallions are the anti-thesis of what hospice is all about.  They prize greed vs. love/support, taking vs. giving, earthly vs. eternal and power vs. service.  This too shall pass. 

Anonymous

The Financial Rapscallion Way

Strange Tony,

A former Director of Human Resources, Governance and Policy said the following on a Glassdoor review:

• Abrupt mass layoffs without notice or transparency 
• Severance packages offered and then rescinded without explanation 
• WARN Act compliance appears to be ignored, affecting hundreds of employees 
• Income not properly reported to unemployment systems, delaying benefits.
• Poor internal communication and lack of support for terminated employees 
• Senior leadership avoids accountability when legal or ethical concerns are raised 
• High turnover in HR and leadership — toxic cycle of “fixers” brought in, then removed 

Advice to Management 

If you expect loyalty, transparency, and compassion from your employees, they deserve the same in return. Executing mass layoffs at a company that provides hospice care — without even the basic decency of notice or severance — is not just unethical, it's possibly illegal under the WARN Act. Stop hiding behind silence. The values you market to patients and families should extend to your own workforce. Review your compliance processes, honor your legal obligations, and do right by the people who helped carry your mission — even when it's no longer convenient.

Financial rapscallions continue to eviscerate hospice services.  It began under TPG/WCAS/Humana and continues under CDR/Humana.  Executives actually win by canning large numbers of employees given their significant equity stakes and absurd incentive compensation.  

Financial rapscallions are happy to pay 10.4% interest on their 2nd tier loans but loathe to pay staff fairly, much less commit to keeping them employed.  The first wave of crappy Curo Hospice technology caused serious harm to service quality with its assumption that software could replace people.  

I imagine AI is defecating all over the floors of various Gentiva Hospices and executives are nowhere to be seen for the cleanup.  It's their nature to make a mess and make workers wallow in it while they lounge in their offices counting cash.

Anonymous

Hospice Crapification Hits Federal Government

Strange Tony,

Financial rapscallion majority ownership turned our nationally recognized hospice into a shell of its former self.  

• Office headcount reductions of 50%
• Over-reliance on "new" (but unreliable and incapable) technology that wasted staff time
• Cutting the number of holidays and holiday pay 
• Not giving raises for years
• Reducing office square footage (to meet C-suite spreadsheet expectations)
• Put in phone system that enabled calls to be overheard without worker knowledge
• Hospice office/clinical system robbed staff of fair reimbursement for miles driven
• Made nurses salaried, then overworked them horribly
• Reduced work to 30 hours for some positions - 25% pay cut

Training on these new systems was poor to nonexistent.  Dedicated hospice staff did not have the time to properly care for patients and do the checking needed to make sure they were paid fairly for hours worked and miles driven.  The company effectively stole hours and mileage from workers.

These very things are occurring in the federal government under Elon Musk.  Musk's henchpeople are rapidly seeking headcount reductions, square foot eliminations and implementing crappy technology.  It's not clear if Musk's henchpeople have multiple full time, well paying gigs (like many insiders in our Age of Sponsorship).

Financial rapscallions have no problem ordering physicians around, negatively impacting the practice of medicine with hard spreadsheet targets.  This has been seen across multiple medical specialties.  

The greed imposed on our hospice resulted in significant and immediate disintegration.  Our census never returned to pre-rapscallion levels.  I expect that very thing is happening across the federal government as Musk's team crapifies operations.  Dang. it sure brings back bad memories.

Anonymous

Gentiva vs. Bristol Hospice: Glove Up

Strange Tony,

Clayton, Dubilier and Rice's Gentiva Hospice sued Webster Equity Partner's Bristol Hospice and a former Gentiva nurse administrator for damages resulting from the nurse violating a non-compete agreement and revealing Gentiva trade secrets.  

Bristol Hospice entered the Brewer, Maine market, hired Gentiva's nurse administrator who then tried to hire other Gentiva employees.  

Gentiva requested a jury trial.  I would love for Gentiva CEO David Causby to testify under oath as to the company's practices when they enter a new market.  I'd love to hear which Gentiva trade secrets the nurse administrator spilled to Bristol.  It it's to rob fair pay for hours worked by making nurses salaried or having a crappy software product that shorts staff for miles travelled, then I hope someone from the Department of Labor is in the courtroom for the whole trial.

I'm sure Bristol is just as abusive to staff as Gentiva.  Financial rapscallions require their numbers be met and that excrement flows downhill and downhill and further downhill. 

I expect a settlement as neither rapscallion wants to reveal their trade secrets in a public court of law.

Anonymous

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

Gentiva Targets Palliative Care

Strange Tony,

Gentiva CEO David Causby is targeting palliative care for service expansion.  He plans to take a low volume, loss leader program and turn it into 10,000 palliative care patients through a focused effort.  It would have to include increasing reimbursement for palliative care for that strategy to make sense.

Aveanna Healthcare took a similar approach to pediatric home services for medically complex patients.  Former CEO Tony Strange, a former boss of David Causby's, lobbied state legislatures for increased reimbursement for that service.  Aveanna's current CEO Jeff Shaner was a peer of Causby's, or should I say rival?

The U.S. Senate set up a committee to explore the impact of private equity ownership on healthcare.  Aveanna had Bain Capital as a sponsor.  Bain remains the majority shareholder for Aveanna.  Shaner may have his work cut out for him in refinancing Aveanna's billions in debt.

Gentiva is majority owned by Clayton, Dubilier and Rice and had two other financial rapscallion owners in TPG and Welsh, Carson, Anderson and Stowe.  

Senators asked Gentiva for information in 2021 but nothing has come from that inquiry to date.  WCAS, TPG and Humana already decimated our once nationally ranked hospice by 2021.  It has only gotten worse.  Regulators may finally pay attention to the damage done by financial rapscallions.

Aveanna was rated a "sell" and given a $1.50 price target by UBS.  Their report cited the company's high leverage.  I imagine Gentiva is in a similar position.  

Causby's goal is to increase the value of his equity holdings by several orders of magnitude.  I've seen the harm his greed caused at the local hospice level.  He and his financial rapscallion sponsors remain unchecked and for that we suffer.  

Anonymous