Sunday, August 5, 2018

Broussard Talks Hospice in Humana's Q2 Earnings Call


Strange Tony,

Humana owns 40% of our hospice alongside two financial rapscallions.  CEO Bruce Broussard spoke of Humana's interest in caring for patients with terminal illness in the recent earnings call.

Over the last year, we've continued to make significant advances in our enterprise strategy, particularly in the past few months as demonstrated by our recent investments in both Kindred at Home and Curo Health Services. With a continued focus on helping seniors achieves their best health, we are striving to reshape healthcare by expanding access to high-quality, value-based care in both primary care and home health. 

Humana's CFO said the company used approximately $1.1 billion in parent cash to buy the 40% stake in Kindred at Home and Curo.  Parent cash could've bought 100% of Kindred at Home and had two divisions to spin off, LTAC hospitals and RebabCare.  Humana would've had $280 million leftover to invest in Curo.  Instead Humana did a squirrely deal with Welsh, Carson, Anderson and Stowe (WCAS) and TPG Capital, the employer of a Kindred board member.

In the call Humana's CFO added "we expect reasonable adjusted EBITDA growth in our healthcare services segment, as the Kindred results are annualized and our other businesses in the segment, particularly our own clinics, improve."

Broussard stated in his prepared remarks.

Turning to home, we recently announced the completion of the acquisition of a 40% interest in each of Kindred at Home and Curo Health Services, collectively the largest home health and hospice operator in the nation. As we previously indicated, we are striving to do something that has never been done before in home health -- transform the payment model into one that is value-based, encouraging a transition for maximizing volume to focusing on managing health and chronic conditions, such as COPD, congestive heart failure, and diabetes to prevent or slow disease progression. This movement to value-based care and aware from a predominantly therapy-based methodology, is aligned with the recent CMS proposal for changes to the home health payment methodology, which was anticipated when we entered into the transaction.
Broussard partnered with leveraged buyout firm WCAS, which employs ex-Medicare Chief Tom Scully.  WCAS is also Broussard's former employer and sponsor of his first fortune.

In that regard, we appreciate the model proposed by CMS and welcome change that aligns home health with pay-per-value and improved clinical outcomes, reducing preventable events. While the ultimate transformation will take many years, upon closing of the transaction, we immediately launched test-and-learn pilots aimed at both operational and clinical improvements in four markets: Richmond, Virginia; Charlotte, North Carolina; Virginia Beach, Virginia; and Dallas, Texas. These pilots incorporate a pay-per-value mechanism in addition to the traditional fee-for-service payment based on four quality measures: hospital admissions, hospital readmissions within 30 days, emergency room visits without hospitalization, and timely initiation of home care specifically within 48 hours of referral or an M.D. order.

In addition, in order to create differentiated home health model, we had the opportunity to weave the richness of Humana at Home telephonic and in-home engagements, as well as Humana pharmacy resources, into the skilled nursing provided by Kindred at Home clinicians. Over the next year, we plan to leverage Humana predictive modeling to identify additional clinical interventions, integrate Humana pharmacy resources to conduct comprehensive medication reviews, and extend our care management best practices from Humana at Home into the Kindred at Home homecare environment.

We will also reduce friction in the authorization process to ensure Kindred professionals are in the home within 48 hours of a referral or supplement the ordering physician through telehealth with a virtual M.D. to expedite the delivery of care. We expect the changes we are making in the home health space will not only benefit our Medicare Advantage members, but also our Medicaid members over time.

The continued development of our in-home capabilities, together with our demonstrated clinical capabilities in Medicare Advantage uniquely position us to serve the Medicaid population, giving us confidence that we'll be successful in growing our Medicare platform through procurements. Under our recent statewide award in Florida, we expect to serve an additional 141,000 members, an increase of 44% from our existing Medicaid membership.

The Florida contract was awarded based upon the ability of plans to achieve the Medicaid agency's goals. These goals included creating enhanced provider and member experience, the ability to reduce preventable inpatient and outpatient events, high-quality scores, innovative and effective methods to deliver integrated care, and integration with the community and support of Medicaid beneficiaries.

We've been successful in achieving strong results across these areas by leveraging the capabilities that have positioned us as a top Medicare Advantage plan, including our capabilities in chronic condition management, integrated care delivery, value-based provider relationships, and community programs designed to address social determinants of health, such as food and security, and social isolation. While we are confident in our capabilities and expect to be successful in the procurement process, consistent with our previous remarks, we will continue to assess length of time to scale and potential barriers to entry at the state level, while considering potential M&A opportunities in the Medicaid space. In that regard, we appreciate the model proposed by CMS and welcome change that aligns home health with pay-per-value and improved clinical outcomes, reducing preventable events.

Broussard's excitement over home health is clear in his remarks.  What about hospice?


David Windley -- Jefferies -- Analyst
Good morning. Thanks for taking my question. Going back to Kindred and Curo, and understood those are investments not full acquisitions. Integration is maybe not the right word, but how do you think about optimizing or harmonizing your workflow between those entities and your internal home health initiatives to drive more cost savings for the member base? I'm thinking about what could manifest as a trend-bender as we think into 2019 and what has to happen to make that a reality?

Bruce D. Broussard -- President and Chief Executive Officer 
At the time of close and pre-close, we had a lot of planning of what would be our top priorities in engaging with Kindred. I'll wrap around a few things. First is we're going to test and learn in a number of markets and be able to really focus more on just not about bringing our home health business over to Kindred, but more importantly, bringing the ability to prevent preventable events from happening. We have a number of things going on that are focused more on nursing-oriented patients that have chronic conditions that can be managed in the home.

First, we're just rerouting more effort nursing area as opposed to the therapy area. That's the first thing. As you mentioned, the trend-bender out of this is reduced admissions, readmission, our rates going down, ER visits going down. That's our measurement of success there, by focusing on these chronic conditions.

Part of that test will also be how we bring telehealth into the home. The telehealth platform will not only allow us to be more convenient in bringing care into the home, but the second thing is it also will help us with our star scores and other preventative measurements that that we can get into the home quicker, both in being able to do it more convenient as a result of not having to get people transported there and, in addition, working through the appointment schedule. So, we see two combinations here in our test-and-learn. One is around how do we reduce the preventable events from happening and then secondarily, how do we continue to increase our performance on our quality measurements.

David Windley -- Jefferies -- Analyst
Thank you. 

The following interchange showed CEO Bruce Broussard soft pedaling Humana's vision of being the largest hospice operator in the U.S.  Humana paid a huge premium for Curo relative to Kindred deal pricing.

Frank Morgan -- RBC Capital Markets -- Analyst
My second question, obviously with the Curo acquisition, you must like the hospice business. So, my question is, with hospice being carved out of the MA benefit today, what's your short term and your longer term view there and also just any thoughts in the context of the future for value-based purposing for hospice? Thanks.

Bruce D. Broussard -- President and Chief Executive Officer
Hospice for us is really, we look at that as a service we are participating in and providing to the healthcare community, and we leave it ultimately up to the caregiver, the family, and the physician to decide where is the proper place for an individual.

But once that decide that it moves from a restorative to pain management kind of treatment, then we are there to serve them and integrate that into offerings we have. In regard to is it in or outside of Medicare Advantage, we really look at it more is it the right thing to do for the family member and then ultimately be able to help them with the transition of quality of life.

We do believe, over time, that hospice and palliative care will continue to be more and more important parts of the care model as we see the need for it. We see people living longer and at the same time, treatment options at end of life become more intense or there are fewer of them and people make this choice that is probably one of the less used area of healthcare today that probably have a large, positive impact on people's life as they think about where they are in their stage of life.

 For us, we are more a recipient of it. We are believer it's the right thing to do and we are a believer that we will provide that service to our members if they choose to.\
The payment model is less of an issue for us and insignificant in our decision making.

Frank Morgan -- RBC Capital Markets -- Analyst
Thank you.

 
Broussard provided mixed messages to hospices in his call.  It's an important service for families and the payment model isn't important.  However, as people have less treatment options hospice has a role to play.  What if insurance denials result in more insureds having few to no treatment options?  In that case hospice would be a cost saving measure for Humana.

If payment were insignificant why would Humana's CFO talk about Kindred's contribution to reasonable EBDITA growth for the second half of 2018?  He went past EBDITA as a measure saying the company would only report adjusted EBDITA for Kindred at Home/Curo.  Adjusted EBDITA is a financial rapscallion measure. 

Cost control measures have already begun at our hospice.  WCAS, TPG and Humana have set clear financial performance expectations.  The only window into these is Humana's SEC filings.  Financial rapscallions don't disclose.  

Anonymous (from KAHtivacare Hospice managed by Curo Executives)

Sunday, July 29, 2018

Pushing Kindred Hospices into Curo's Management Structure

Strange Tony,

Kindred at Home (KAH) President David Causby welcomed a new hospice division executive in Curo Health's Larry Graham.  Together they are integrating Kindred's 178 hospices into Curo's 245.  Kindred at Home's hospices are much larger than Curo's, over twice the size on an average revenue basis.   Significant overlap exists in a number of hospice markets..

Kindred at Home's new owners, TPG, WCAS and Humana, expect significant cost reductions in the hospice arena from combining Curo and Kindred at Home.  Causby oversaw the integration of Harden Hospice into Gentiva as a newly promoted Executive Vice President-Chief Operating Officer.  That integration came up $150 million short of revenue expectations.   That's a lot of business to drive away.

Moving Forward communications have avoided personnel reductions to date.  Early casualties can be found in the medical director arena.  Kindred's former Hospice National Medical Director now fills a regional position.

Cost control is the mantra under KAH's new National Medical Director.  Insurance like approvals are needed for a number of hospice interventions.  Board certified hospice physicians have to ask management for approval for certain medications or treatments to treat symptoms and/or manage pain.  It's not clear how this process might delay needed care for hospice patients or deny it altogether.  That will play out over time.

Very little has been shared locally about changes but our hospice managers seem distracted, even disconnected.  They may be trying to wrap their minds around new targets to meet, possibly Curo's staffing model.

The way work is done is important.  Hospice was founded on compassion, teamwork and collaboration.  Respect, integrity and openness are in short supply at the moment.  Win/lose competition has reared its ugly head at our site.  Management fomented chaos since the double KAH-Curo buyouts were executed.  

Gratitude, appreciation and raises disappeared long ago.  There are no signs of a pay increase.  Hospice has its own intrinsic rewards but the work carries an emotional toll.  Bad management adds an additional unnecessary burden that can drive employees away.

Financial rapscallions prefer a lower average wage.  This emphasis discounts the value of seasoned, experienced employees, something critical in the hospice arena.  Seasoned staff are integral to quality patient care/customer service and are necessary for mentoring/training new employees..

Massive change is underway.  It's mostly subterranean at this point.  To date leaders have been massively enriched while employees wrestle with stagnant pay and deteriorating benefits.  I'll write as more information arrives that illuminates executive priorities for our hospice. Hopefully it won't be years before my hospice co-workers get a real raise.

Anonymous (from KAHtivacare Hospice)  

Saturday, July 14, 2018

Kindred Sold Cheap, Curo Went for Far More


Strange Tony,

Brigade Capital sued to stop Kindred's breakup sellout to two private equity firms and Humana.  The investor claimed the deal severely undervalued Kindred. The court ruled in Kindred's favor on March 27, 2018.  Kindred shareholders voted March 29, 2018 to sell out.

Humana and its financial rapscallion partners announced the deal to buy hospice provider Curo Health on April 23, 2018. 

Both Kindred and Curo had leverage around 6 times EBITDA.  The two companies shared a similar capital structure.

Had the Curo deal been announced earlier Brigade Capital would have had a stronger case.  Kindred at Home sold for 0.78 times 2017 revenues while Curo went for 3.03 times 2017 revenues.  Buyers paid nearly four times more for Curo than they did for Kindred at Home.

Long term Kindred investors did not make out well.  Kindred's last 10-K showed a mere 1.87% return over a five year period for long term shareholders.


The end result is Kindred at Home will have $3 billion in revenues.  It will also have $3 billion in debt, a massive increase from pre-buyout levels of $1.1 billion.


This is the new face of Kindred at Home.  Despite buyout after buyout, legacy employees have never been in this precarious a position.  Pray for coworkers as management gets marching orders from executives and owners who vastly overpaid for Curo relative to Kindred..

Just as Brigade Capital received short shrift, so may Kindred Hospice employees under Curo's executive rule.

Anonymous (from KAHtivacareplus Hospice)

Wednesday, July 11, 2018

Humana, Financial Rapscallion Partners Close on Curo


Strange Tony,

The second leg of our hospice buyout happened today.  The first leg had Humana and two financial rapscallions purchase Kindred at Home.  That occurred on July 2nd.  Nine days later the same owners closed on Curo Health Services, another hospice provider with 245 locations.  Prior news reports indicated Curo's management would lead Kindred at Home's hospice division.

Curo settled with the Justice Department in April 2017 for $12.2 million to make an investigation go away.  Curo was accused of paying kickbacks for admissions. Curo's President Larry Graham has not publicly addressed the settlement. 

Our new owners have confidence that Mr. Graham is the right man to lead the hospice segment.  Graham does have a record of growing margins at Amedisys.  Employees asserted the company manipulated patient assessments, as well as treatment plans, to maximize Medicare reimbursement.

Curo's average hospice census is 40 patients.  Kindred at Home's average hospice census is 75 patients.  Gentiva's Justice Department settlement for fraudulent billing occurred in February 2012. 

Two have become one, under the ownership of three.  The smaller will lead the larger.  The more recently unethical hospice will head the division.  Kindred at Home has 245 new little hospices with a documented history of cheating in the Dallas-Fort Worth area. 

Something is moving.  Our hospice employees will find out what soon enough.

Anonymous (from KAHtivacareplus hospice)

Monday, July 9, 2018

VP Toad to Join Curo's Dubious Executives?


Strange Tony,

It's been one week since Humana and two financial rapscallions purchased Kindred at Home, the Old Gentiva plus Integracare and Professional Medical's home health and hospice agencies.  There's a slight unease at our hospice.  We've not seen hide nor hair of VP Toad.

With the Curo Health Services buyout looming I expect Kindred hospice area/regional managers are rather nervous.  Our new owners plan to put Kindred's hospice division under Curo, despite our having nearly twice the revenue and much larger hospices by volume.  Their rationale is Curo's management is more entrepreneurial.

Curo Health Services, Inc. have agreed to pay $12.21 million to resolve allegations that they violated the False Claims Act by paying kickbacks in exchange for patient referrals.

Curo's  leaders settled for $12.2 million with the U.S. Department of Justice in April 2017.

First, from 2007 through 2012, kickbacks were allegedly paid to American Physician Housecalls, a physician housecall company, in exchange for patient referrals to these hospice companies. The alleged kickbacks took the form of sham loans, a free equity interest in another entity, stock dividends, and free rental space. 

Second, from 2007 through 2014, kickbacks were allegedly paid to medical providers, including doctors and nurses as well as hospitals and long-term care facilities, in exchange for patient referrals to these hospice companies. The alleged kickbacks took the form of cash, gift cards, and other valuable items.

Hospice employees don't have the means to offer sham loans, free equity, stock dividends or free rental space.  Those are all the auspices of management.

Curo spent years under the ownership of financial rapscallions.  Their executives are well trained in giving sponsors what they want, steady streams of cash and a huge final payday.

What changes await our hospice?  Is Toad Curo material?  I sense they share the same distorted values but only so many area/regional managers are needed in the combined company.

Anonymous (from KAHtivacare Hospice)

Tuesday, July 3, 2018

Ben Breier's Day One Pay


Strange Tony,

Kindred CEO Ben Breier received over $8.5 million on Day One for selling Kindred to financial rapscallions so it could be carved into pieces.  Breier's piece got the lion's share of revenue and lightened its debt load.

Breier became President of Kindred's Rehab Division in 2005 when the stock hit nearly $40 a share.  As President/CEO of the whole company he drove the stock price down to the $9 sellout price.  During the last three years of under performance Breier received $5.4 million, $6.5 million and $11.4 million in executive compensation.  Add his $8.5 million DAY ONE payday and the total is $31.8 million.

For the last three years Kindred paid $18.1 million to fund retirement benefits company wide.  These numbers are a direct reflection of board and executive priorities.  Financial rapscallions tend to do even less for employees, a bad omen for either new Kindred company.

Ben Breier and other Kindred executives had a banner Day One.  The shiny, happy people in Employee Experience have yet to mention the gross inequity of already rich executives bringing home millions more on the first day of our new "journey together."  They also have been silent on stagnant pay and deteriorating benefits.

Kindred at Home has been saddled with a massive debt load and is highly leveraged. Add that Humana wants to use Kindred at Home's cash flow for acquisitions and a pittance might be left for employees.  That is if executives don't need that morsel more.  The lesson in all this is:  Their will be done.

Anonymous (from KAHtiva Hospice--soon to be Curoed)

Monday, July 2, 2018

Day One: Extremely Good for Executives

Strange Tony,

July 2 served as Day One for the two private companies formed by Kindred's buyout by two financial rapscallions.  The industry refers to such owners as sponsors but other employee populations experienced them more as tormentors. 

Kindred executives did very well on Day One.  Enriched executives informed employees right off not to expect raises as a result of the buyout.  That guidance has not changed.

I'll need to re-read the shiny, happy Day One message from the amorphous Employee Experience group.  I'll hold up graph showing executive proceeds on Day One as I read their missive.  It should be a stark contrast of executive words vs. deeds.  That's par for the course in management today.

Anonymous (from KAHtiva)