What is PDPM and How Will it Affect You? With Marc Zimmet of Zimmet Healthcare

00:04.137 --> 00:07.612

The problem with the system is that you almost have to provide

00:07.750 --> 00:11.272
an intense level therapy to keep your doors open.

00:11.380 --> 00:14.722
You have an aggressive treatment approach where the patient is

00:14.755 --> 00:18.567
taking therapy early in the morning before they go out to dialysis

00:18.702 --> 00:21.952
because they'll be too weak at the end of the day to receive it.

00:21.970 --> 00:26.012
So the new model, the patient driven payment model PDPM that starts October,

00:27.037 --> 00:30.457
enhances the reimbursement sensitivity to

00:30.460 --> 00:33.667
use that term, of all the different payment drivers and

00:33.715 --> 00:37.702
takes the focus away from therapy as the

00:37.720 --> 00:39.875
primary driver of payment.

00:44.362 --> 00:48.297
Welcome to The Nursing Home Podcast, your Goto source

00:48.342 --> 00:52.372
for professional insights in the long term care industry. Hear from

00:52.405 --> 00:55.927
leaders and experts as they share current and practical insights to

00:55.945 --> 00:59.607
help make the most of your day. I'm the longterm care financial specialist.

00:59.697 --> 01:03.622
What that means is I help people plan for the inevitable. Nobody wants

01:03.655 --> 01:06.682
to think about getting old, but it's possible that some day we might need a

01:06.685 --> 01:09.777
little bit of care. Here's your host. Nursing home Administrator

01:09.807 --> 01:12.737
Turnpodcaster Schmoel, Septimash.

01:13.687 --> 01:17.262
Welcome to this episode of the Nursing Home Podcast,

01:17.412 --> 01:21.052
the podcast which is becoming your Goto resource for the

01:21.070 --> 01:24.837
professionals in the nursing home industry. Today's guest

01:24.987 --> 01:28.677
is the President and CEO of Zimmer Healthcare

01:28.782 --> 01:32.377
Services Group and they offer innovative solutions for

01:32.395 --> 01:36.792
the post acute care industry. So today's guest is Mark Zimmetm.

01:36.852 --> 01:40.642
Welcome to the nursing home podcast. Thanks for having me. Well,

01:40.690 --> 01:44.602
thank you for coming on and I know how precious your time is and

01:44.620 --> 01:47.947
we're going to try to make sure that it's the most beneficial for

01:48.055 --> 01:50.772
both of us and of course for the listeners.

01:50.817 --> 01:53.977
So for those who just to paint a little bit of a

01:53.995 --> 01:57.652
picture, not to spend too much time on, this is for those who don't know

01:57.670 --> 02:02.162
who you are or not familiar with your company and some of the accomplishments

02:02.587 --> 02:05.812
that you've done professionally so far. Can you give us the short

02:05.875 --> 02:09.172
version of whom our Zimmet is and how

02:09.205 --> 02:12.500
Zimmet Health Care came to exist? Yes.

02:12.862 --> 02:16.357
Zimmer Healthcare is a consulting support

02:16.510 --> 02:20.457
firm specializing in skilled nursing facility reimbursement, compliance operations,

02:20.547 --> 02:24.247
strategic planning. We have been around just

02:24.280 --> 02:27.667
over 25 years, started out completing Medicare cost

02:27.715 --> 02:31.857
reports and appeals when Medicare was reimbursement,

02:31.872 --> 02:36.067
was based on allowable costs and have

02:36.115 --> 02:39.892
just expanded as the industry is matured and we now employ

02:39.940 --> 02:43.522
about 60 people servicing nearly 3000

02:43.705 --> 02:47.302
facilities and stakeholders across the country.

02:47.470 --> 02:51.187
Well, okay, so it's quite an expansion over

02:51.250 --> 02:54.742
a significant number of years. Now, obviously,

02:54.940 --> 02:58.527
your company definitely deals with clinical reimbursement for nursing

02:58.557 --> 03:02.002
homes. And this is kind of where the rubber hits the road when

03:02.020 --> 03:05.287
it comes to after speaking as an administrator, after all the

03:05.350 --> 03:08.772
care issues that we deal with and all the customer service and staffing

03:08.817 --> 03:13.212
and dealing with everything. The end of the day if we are not reimbursed appropriately

03:13.287 --> 03:17.827
or if we don't do the things to make sure that that happens so

03:17.845 --> 03:21.397
that we will not be successful. So before we even get

03:21.430 --> 03:24.962
into the weeds too much but on a global

03:25.462 --> 03:29.512
or more general way, do you see that there's been a very

03:29.575 --> 03:32.917
significant change in trend from

03:32.965 --> 03:36.427
25 years ago to today and the way the

03:36.445 --> 03:40.507
facility is getting reimbursed? Yeah, there's been

03:40.660 --> 03:44.172
a complete shift in S and F reimbursement.

03:44.217 --> 03:47.962
Again, when I started out, Medicare was cost based and

03:48.025 --> 03:51.657
the different Medicaid programs also for the most part reimbursed

03:51.672 --> 03:54.952
based on how much a facility spent. The hospitals used to

03:54.970 --> 03:59.212
be paid that way. They were the first to go into prospective payment to

03:59.275 --> 04:02.607
limit costs way back in the early eighty S and then skilled

04:02.622 --> 04:06.357
nursing followed and then home health care. So it's

04:06.372 --> 04:09.787
all an attempt to rein in program cost to provide

04:09.850 --> 04:14.082
reasonable incentives. So we have sort of the arc in skilled nursing

04:14.097 --> 04:17.997
reimbursement from cost based to some type of Acuity

04:18.042 --> 04:21.282
based system to then managed care. And we're

04:21.297 --> 04:24.657
seeing that in all aspects, medicaid programs switching

04:24.672 --> 04:28.087
over to managed care in some form, medicare being

04:28.150 --> 04:31.857
almost privatized by default with Medicare Advantage that's

04:31.872 --> 04:35.572
going to be a 50% pretty soon and is over 65%

04:35.605 --> 04:39.322
in some markets and then it's impacting even

04:39.355 --> 04:43.677
the long term care population through the institutional

04:43.707 --> 04:47.127
special needs platform. And on top of that we've

04:47.157 --> 04:50.632
got all the pressures from hospitals and health systems looking to

04:50.635 --> 04:52.700
reduce monthly pay as well. Okay,

04:54.712 --> 04:58.072
to be perfectly frank as an administrator, this is the piece,

04:58.105 --> 05:01.552
and I'm sure I'm not alone with this, this is the piece where it

05:01.570 --> 05:05.802
would be I did my job and now let the clinical reimbursement specialist

05:05.832 --> 05:09.402
do their piece. This is the part which although we're very involved

05:09.432 --> 05:12.922
in operations part, but the reimbursement part maybe not as much.

05:13.030 --> 05:15.697
So there was just a lot of terms in there. I want to make sure

05:15.730 --> 05:20.087
that everyone understands what you just said. So initially

05:20.662 --> 05:24.277
you're saying that it was a cost base reimbursement and

05:24.295 --> 05:28.147
I know I'm going to be generalizing a lot of things. I just

05:28.180 --> 05:32.047
want to make sure that at least the listeners walk out of our

05:32.080 --> 05:35.512
conversation with a better big picture and the immediate changes

05:35.575 --> 05:38.752
that are coming. So that means that

05:38.770 --> 05:42.547
if I spent, let's say $1,000 caring for this patient so

05:42.580 --> 05:45.957
my reimbursement was spend plus x and telling

05:45.972 --> 05:49.297
me, correct me if I'm wrong because these are questions yes,

05:49.330 --> 05:53.002
spend plus x or spend minus x so we won't get

05:53.020 --> 05:56.677
too technical. I apologize for that. No, let's get what

05:56.695 --> 05:59.877
do you mean spend minus x? They put caps

05:59.907 --> 06:03.382
on. Again, I'll try to not get too specific

06:03.460 --> 06:06.802
here to accounting jargon. So if

06:06.820 --> 06:10.072
you spend $1,000 there'd be limits because the

06:10.105 --> 06:14.537
state or the Medicare system didn't want to reward inefficiency.

06:14.887 --> 06:18.397
So a lot of different ways they do this either cost plus or cost

06:18.430 --> 06:22.100
minus. But again, that is old

06:23.662 --> 06:27.472
models. Okay, but initially that's where

06:27.505 --> 06:30.967
the models were. The reimbursement was directly tied to

06:31.090 --> 06:34.732
either actual or expected or reasonable spend.

06:34.885 --> 06:38.257
Right? Because even what you said before, cost minus. So that's because

06:38.335 --> 06:42.200
to discourage in efficiency, meaning that you spent 1000. But we think

06:43.012 --> 06:45.517
for this type of carrier you should have spent 800. So we're going to pay

06:45.565 --> 06:49.147
900, right? Yeah, kind of.

06:49.255 --> 06:52.222
Okay, close enough.

06:52.330 --> 06:56.322
That's been the general approach

06:56.367 --> 06:59.772
to this. And now when you're saying that it's changed already significantly

06:59.817 --> 07:03.050
in all the specific applications you've already mentioned,

07:03.862 --> 07:07.822
again, on a general level,

07:07.930 --> 07:11.122
the 40,000 foot view is that changing from being based on

07:11.155 --> 07:14.827
cost to being based on what price I think is the

07:14.845 --> 07:18.522
best way to put it. And that's the prospective payment system. That's the Rug

07:18.567 --> 07:22.612
model, that's the new PDPM model and

07:22.750 --> 07:26.527
that's a model many states have adopted. So it

07:26.545 --> 07:29.900
has nothing to do with costs. They actually set a rate,

07:30.412 --> 07:34.942
a fixed rate that the facility has a little control over based

07:34.990 --> 07:38.727
on patient acuity and how we manage and capture

07:38.832 --> 07:42.877
the Acuity based on cost. It's based on a

07:42.895 --> 07:46.297
fixed fee per day and the fixed fee is based on

07:46.330 --> 07:50.422
diagnosis condition. It's based on a

07:50.455 --> 07:52.337
number of payment drivers,

07:53.137 --> 07:57.177
conditions, diagnosis services. One of the big criticisms

07:57.207 --> 08:00.972
about the current PPS, the Rugs model in Medicare,

08:01.092 --> 08:04.862
is that it's driven way too heavily by therapy

08:05.512 --> 08:08.902
a patient receives. So you have two patients, both receiving the

08:08.920 --> 08:13.087
same amount of therapy. One is non medically complex and one has

08:13.225 --> 08:16.792
three wounds and IV and has cognitive problems.

08:16.915 --> 08:20.302
If they both receive the same amount of therapy, you're getting the same

08:20.320 --> 08:23.467
reimbursement for both of those patients. And that's what Medicare is moving away

08:23.515 --> 08:27.102
from. So from a facility standpoint,

08:27.282 --> 08:30.997
if you have two residents that come in, they both are coming

08:31.030 --> 08:34.477
after knee replacement, they both need the same extensive therapy, but the

08:34.495 --> 08:37.747
other one has all these other issues going on at the same

08:37.780 --> 08:40.550
time. There's maybe advanced dementia, there might be,

08:41.137 --> 08:43.897
like you mentioned, the wounds and the other clinical piece.

08:44.005 --> 08:47.122
So the old model, they would both have the same amount, not the same,

08:47.155 --> 08:50.842
but very closely, pretty much the same amount of money.

08:51.040 --> 08:54.532
And that's not focusing. So I

08:54.535 --> 08:58.987
guess that's simply not fair from a nursing home perspective because either

08:59.050 --> 09:02.652
the one who has no issues other than the therapy

09:02.682 --> 09:06.447
is being overpaid or the other one that's more complex

09:06.492 --> 09:10.047
is being underpaid, but it's definitely not going to be consistent.

09:10.092 --> 09:13.627
The people that facilities providing care are getting

09:13.720 --> 09:17.287
reimbursed based on based on the

09:17.350 --> 09:20.962
care which they are providing. And again, this is not based on cost.

09:21.100 --> 09:24.652
So we're not discussing the

09:24.670 --> 09:27.792
amount of money it's going to cost for the additional staffing, equipment,

09:27.852 --> 09:31.242
time and all that. But even from a diagnosis standpoint,

09:31.377 --> 09:35.300
I'm processing this as we're speaking. So tell me if I'm getting this wrong,

09:35.737 --> 09:39.447
but that doesn't make sense. Let's just stick

09:39.492 --> 09:43.227
to Medicare short term rehab reimbursement.

09:43.332 --> 09:46.325
So where is that up to right now?

09:47.287 --> 09:50.587
You pretty much hit it right on the head there that

09:50.650 --> 09:54.082
it really wasn't fair. All those other clinical services that

09:54.085 --> 09:57.057
we mentioned beyond rehab weren't reimbursed.

09:57.072 --> 10:00.597
Insensitive is the term we use. So the most profitable

10:00.642 --> 10:03.792
patient under the Rugs model is the non medically

10:03.852 --> 10:07.527
complex, short term rehab, the heavy rehab which we can't

10:07.557 --> 10:10.962
get and everybody fights over. Yeah, they pretty much disappeared.

10:11.037 --> 10:15.212
So the new model, the patient driven payment model, PDPM, that starts October,

10:16.237 --> 10:19.437
enhances the reimbursement sensitivity,

10:19.587 --> 10:22.867
use that term of all the different payment drivers and

10:22.915 --> 10:26.317
takes the focus away from therapy as

10:26.515 --> 10:30.067
the primary driver of payment. So to give you an idea

10:30.115 --> 10:33.627
how much more sensitive PDPM is than the Rugs

10:33.657 --> 10:37.597
model, we're going from 66 Rugs scores, and we really only use 20

10:37.630 --> 10:41.272
or so of them to PDPM, which technically has

10:41.380 --> 10:45.057
almost 290 rate composite possibilities.

10:45.147 --> 10:49.625
Now, some of those are mutually exclusive, but figure 15 to 20,000

10:49.987 --> 10:53.572
rate combinations will be used and that is all

10:53.605 --> 10:56.825
based on the conditions and the services

10:57.562 --> 11:01.182
and the diagnosis that a patient exhibits.

11:01.347 --> 11:04.552
So I mean, by definition, by having more words in the language you can be

11:04.570 --> 11:08.537
more precise. Exactly. And therefore the reimbursement

11:08.962 --> 11:12.792
can be that much more precise. Now what does this mean internally

11:12.852 --> 11:15.950
operationally for the nursing home?

11:17.137 --> 11:20.272
How does it affect the MDS process? Yeah,

11:20.380 --> 11:24.297
it reworks the MDS process considerably. First of all, we don't

11:24.342 --> 11:28.027
need as many assessments under PPS. We need at least five

11:28.120 --> 11:31.972
over 100 day period benefit period. Under the

11:32.005 --> 11:35.542
PDPM, we essentially only need one.

11:35.665 --> 11:39.337
And that's the initial assessment, which was called the five day.

11:39.475 --> 11:43.117
So that one assessment can set the

11:43.240 --> 11:46.947
rate or the base rate for the full benefit period.

11:47.067 --> 11:50.497
Now why is that? If it's more complex, why do we only need one

11:50.530 --> 11:53.977
assessment? Well, the system is more complex with

11:53.995 --> 11:57.697
respect to the rate sensitivity, but the

11:57.730 --> 12:01.042
administration of the system, the rate setting process is

12:01.090 --> 12:04.872
based on one assessment, so that limits the administrative burden.

12:04.992 --> 12:08.682
And Medicare will allow us to change the score

12:08.772 --> 12:12.717
if a patient's condition changes through something called an interim payment assessment.

12:12.852 --> 12:16.147
But the actual structure of the program is

12:16.180 --> 12:19.927
far more complex. But the administration of the program is

12:20.095 --> 12:23.322
designed to limit the administrative burden on the provider.

12:23.442 --> 12:27.327
Okay, so for them, the coordinators that are listening and the nursing home administrators

12:27.357 --> 12:30.772
are listening and they hear their MDS coding, is complaining about

12:30.805 --> 12:34.942
PDPM and what are we going to do? So basically

12:35.065 --> 12:38.502
it is a more complex system and there might be a learning curve

12:38.532 --> 12:41.782
or maybe even a steep learning curve, which is why we have all

12:41.785 --> 12:45.532
these training programs and the has their own training program

12:45.610 --> 12:49.447
coming up. But once the program is

12:49.480 --> 12:53.592
learnt and the facility learns how to appropriately

12:53.652 --> 12:57.277
set these assessments and so then it's set

12:57.295 --> 13:00.607
it and forget it type of thing, unless there is a significant change, like a

13:00.610 --> 13:03.575
change of therapy or change of, I don't know, a change of care.

13:04.087 --> 13:07.792
Well, not therapy that's poisoned by the definitely

13:07.840 --> 13:11.272
not therapy, but yeah, right, but that's what we used to,

13:11.305 --> 13:14.557
you know, it's all rehab based, I guess.

13:14.710 --> 13:18.102
Okay, but once again, let me just make sure that that's

13:18.132 --> 13:21.577
correct. Right. So for them coordinators, I was an

13:21.595 --> 13:24.922
active administrator until a few weeks ago,

13:24.955 --> 13:27.832
maybe a month and a half ago, and we were working on this with the

13:27.835 --> 13:31.447
MDS coordinators and getting them all ready and trained for

13:31.555 --> 13:35.452
PDPM while we were discussing it. What would

13:35.470 --> 13:38.532
it be? So now what is it actually going to be for them to coordinate?

13:38.547 --> 13:41.600
They're going to have to learn this new system,

13:42.187 --> 13:45.437
but once they learn it, they're going to be doing much less MDS.

13:46.537 --> 13:50.167
Yeah, it's different. The job description changes, so they'll be doing

13:50.215 --> 13:53.525
fewer assessments. I don't believe that we're going to be able

13:54.187 --> 13:58.617
to reduce the MDS staffing.

13:58.752 --> 14:02.752
So I don't think we're cutting any positions on MDS, but the job description changes.

14:02.920 --> 14:06.897
So the basic fact is that therapy drives reimbursement.

14:07.017 --> 14:10.357
Now under the Rugs model, under PDPM, there's a

14:10.360 --> 14:13.827
lot more moving parts. The way we explain it, far more moving parts.

14:13.857 --> 14:17.202
It's not just therapy and ADLs. You've got really a broad

14:17.232 --> 14:20.722
spectrum of disciplines that are

14:20.755 --> 14:24.052
now part of the reimbursement management team. So to give you an example,

14:24.145 --> 14:28.222
dietary dietitian impacts reimbursement for

14:28.255 --> 14:31.992
every single patient that comes in by way of mechanically

14:32.052 --> 14:35.877
altered diet. If the resident needs a mechanically altered diet,

14:35.982 --> 14:40.407
there's additional dollars. We have psychologists

14:40.497 --> 14:43.927
involved with respect to signs of depression and

14:43.945 --> 14:49.027
cognition being reimbursed in drivers. We have it

14:49.045 --> 14:52.767
goes on and on. Respiratory therapy, which many facilities

14:52.827 --> 14:56.427
provide, nebula treatments, but they're not reimbursement

14:56.457 --> 15:00.402
sensitive. Now we have the incentive to formalize the respiratory therapy

15:00.432 --> 15:03.725
program. Not more work. It's not a care issue. It's a capture issue.

15:04.087 --> 15:07.407
And respiratory therapy becomes a big reimbursement driver.

15:07.497 --> 15:11.762
So different disciplines I'm sorry and everything from admissions

15:12.262 --> 15:15.592
when the patient comes in, becomes critical to capture and take credit

15:15.640 --> 15:19.552
for. Got it. So the MDS coordinator is not making

15:19.645 --> 15:22.702
as many assessments and as they are.

15:22.720 --> 15:25.927
Now, they could barely catch their breath, and they're just churning out those

15:25.945 --> 15:29.617
MDS. So now it might not be that,

15:29.740 --> 15:33.172
but at the same time, it's going to be more involved with the other

15:33.205 --> 15:37.072
disciplines, whereas whereas the current model, then the

15:37.105 --> 15:40.925
coordinator is doing most of it and getting their bits and pieces from

15:41.287 --> 15:44.977
the other disciplines. But now it won't just

15:44.995 --> 15:48.877
be MDS and rehab coordinator running most of

15:48.895 --> 15:52.677
the show as far as the reimbursement process is concerned,

15:52.707 --> 15:56.047
but taking everything else into consideration. Now,

15:56.080 --> 15:59.802
I'm just trying to think of this a little bit from the bigger

15:59.832 --> 16:03.777
picture, the drive to change this. I know we mentioned earlier

16:03.807 --> 16:07.992
that it's wrong to have two patients

16:08.052 --> 16:11.692
who are receiving the same level of therapy, but one of them is very

16:11.740 --> 16:15.922
clinically complex and the other one is not. But is this

16:16.030 --> 16:19.177
the push for this is coming from where it comes from the facilities is it

16:19.195 --> 16:23.347
financial? Is it clinical? It's coming from the

16:23.380 --> 16:27.592
federal government Med pack. The Medicare Payment Advisory Commission has

16:27.640 --> 16:31.942
been really almost begging congress and

16:32.065 --> 16:35.750
CMS to implement a more specific,

16:36.712 --> 16:40.175
patient specific payment model that does not

16:41.137 --> 16:45.012
recognize the frequency and duration of skilled therapy

16:45.162 --> 16:48.472
as the payment driver because it provides an incentive to

16:48.505 --> 16:51.937
overtreat. And that's what Medicare wants to get away from. Okay,

16:52.000 --> 16:55.122
so it's coming from to be frank,

16:55.242 --> 16:58.550
the government thinks it's going to be cost savings. It's true.

16:58.987 --> 17:02.937
No, it's supposed to be budget neutral.

17:03.087 --> 17:07.107
So it is a redistribution. Theoretically it's a redistribution

17:07.272 --> 17:10.752
from the heavy rehab provider for non

17:10.782 --> 17:13.872
medically complex, although we don't have many of those anymore.

17:13.992 --> 17:18.502
New facilities that don't focus

17:18.595 --> 17:22.467
on non medically complex rehab and take the sicker patients.

17:22.602 --> 17:26.922
So the biggest increase in revenue

17:26.967 --> 17:30.327
comes for higher Acuity patients, vent and tragic

17:30.357 --> 17:33.952
patients. Their reimbursement goes up considerably where

17:33.970 --> 17:37.357
that non medically complex rehab payment goes down.

17:37.435 --> 17:40.925
So theoretically it's supposed to be budget neutral. We expect

17:41.362 --> 17:44.887
based on history with changes,

17:44.950 --> 17:48.157
improved or behavior that facilities are going to

17:48.160 --> 17:52.002
get better at documenting, capturing formalizing programs

17:52.032 --> 17:55.627
that drive payment, taking credit for the care they provide. So we expect the

17:55.645 --> 17:59.197
first year Medicare to spend more than

17:59.230 --> 18:02.947
they budgeted. It won't be budget neutral. It will cost the feds more money in

18:02.980 --> 18:06.200
our opinion, for facilities that understand how to manage the system.

18:07.762 --> 18:11.377
The next year, very soon after we will have

18:11.395 --> 18:14.802
a repeat of 2012 where medicare changed

18:14.832 --> 18:18.757
and overspent and they recalibrated and basically

18:18.835 --> 18:22.775
implemented a rate reduction to compensate for

18:23.437 --> 18:27.547
the case mix creep, the changes in provider behavior, the fact that facilities got

18:27.580 --> 18:31.207
better at capturing the care, so long run it should

18:31.210 --> 18:33.350
be budget neutral. Wow.

18:35.062 --> 18:38.917
In other words, I am thinking about this from if

18:38.965 --> 18:42.832
you're one personal thank you, that was very, very clear and

18:42.985 --> 18:45.622
if it was clear for me, I'm sure it was clear for others as well.

18:45.730 --> 18:49.357
But if you're one which makes a

18:49.360 --> 18:53.802
lot of sense as nursing home administrator we get all these referrals

18:53.832 --> 18:56.962
and a lot of them are very clinically complex and you have a choice to

18:57.025 --> 19:01.572
pick someone who's pretty much alert

19:01.617 --> 19:05.572
oriented and independent going back to the community and support a family. Therefore a

19:05.605 --> 19:09.512
physical therapy issue versus someone else who's

19:10.387 --> 19:14.000
morbid obese and has no social

19:14.587 --> 19:18.362
support has a whole slew of psychological

19:19.387 --> 19:23.227
maybe in psychiatric issues and it's very difficult to

19:23.245 --> 19:26.827
care for such a resident. But knowing that basically

19:26.920 --> 19:30.502
it's almost if it works in practice as

19:30.520 --> 19:33.757
it sounds in theory, it should even out that

19:33.835 --> 19:37.702
facilitates should be getting reimbursed closer to the

19:37.720 --> 19:42.127
level of difficulty it is to manage the resident in

19:42.145 --> 19:44.482
a way that could be amazing. And you're right that there are going to be

19:44.485 --> 19:48.367
some facilities that are not going to manage this properly in the first year and

19:48.415 --> 19:51.502
as a result they might still be therapy and says I'm sure a lot will

19:51.520 --> 19:54.727
still be focused too much on therapy and they're going to lose out in the

19:54.745 --> 19:58.617
other areas. And there'll be facilities that are going to all these conferences

19:58.677 --> 20:01.477
and they're learning. And as soon as it hits, they can be doing it right

20:01.495 --> 20:04.637
and they're going to be doing it correctly.

20:06.487 --> 20:10.432
Those facilities will gain in year one, but then year two,

20:10.585 --> 20:13.782
it's going to balance it out with a rate reduction,

20:13.947 --> 20:17.592
which means that everyone's going to learn how to claim

20:17.727 --> 20:21.067
and be paid evenly. So really, in theory, it really

20:21.115 --> 20:25.302
should work. If the goal was that facilities

20:25.332 --> 20:29.312
were incentivized to provide too much therapy as opposed

20:30.037 --> 20:33.697
to push it on people who maybe didn't need it just in order

20:33.730 --> 20:37.107
to survive, in order for them to get reimbursed for the care that they're providing,

20:37.197 --> 20:40.867
because that's what matters too much. So it sounds like

20:40.990 --> 20:44.932
realistically, this could actually work for Facilitators to actually

20:45.085 --> 20:48.757
be able to provide the care the resident needs and

20:48.835 --> 20:52.387
still get reimbursed appropriately. Yeah, I think it's better

20:52.450 --> 20:56.197
for the resident. So I use the example of a

20:56.230 --> 21:00.072
dialysis patient, goes out three times a week facilities.

21:00.117 --> 21:03.367
And the problem with the system is that you almost have to

21:03.490 --> 21:06.922
provide an intense level therapy to keep

21:06.955 --> 21:10.567
your doors open to the current system. So there is that incentive to provide

21:10.615 --> 21:13.857
that ultra high level of care. So you take a dialysis patient.

21:13.947 --> 21:17.722
A dialysis patient without therapy today is

21:17.755 --> 21:21.642
a money loser. It's difficult. The rates are inadequate.

21:21.777 --> 21:23.912
So we have facilities.

21:25.387 --> 21:28.897
Theoretically, you have an aggressive treatment approach where

21:28.930 --> 21:32.677
the patient is taking therapy early in the morning before they go

21:32.695 --> 21:36.367
out to dialysis. Yes, because they'll be too weak at the end of the day

21:36.490 --> 21:40.522
to receive it. So that is probably not

21:40.555 --> 21:44.307
in the best interest of certain residents to have that approach.

21:44.397 --> 21:48.657
Now we're

21:48.672 --> 21:52.147
not incentivized to provide that level of therapy, and we

21:52.180 --> 21:55.837
get a reasonable rate for the dialysis patient without having

21:55.900 --> 21:59.197
to stray from a you'd be very

21:59.230 --> 22:01.250
politically correct, but I understand that.

22:03.337 --> 22:06.942
I've had family members complain to me about dialysis patients.

22:07.002 --> 22:10.507
Specifically, mom is so weak and dad is so weak. Why are

22:10.510 --> 22:13.072
we so busy focusing on the knee? We don't even care about the knee right

22:13.105 --> 22:16.147
now. We're not even sure how much longer he has left or she has left

22:16.180 --> 22:19.507
to live. And the goal is to make it day to day.

22:19.660 --> 22:23.647
And it's true that our job is to provide for the entire

22:23.830 --> 22:27.427
residence and for every facet, but if

22:27.445 --> 22:31.537
there was zero financial gain or if there's a better

22:31.600 --> 22:35.677
system, we would actually be allowed to be

22:35.695 --> 22:38.827
allowed to care for them the way that they should be cared for. So that

22:38.845 --> 22:42.852
is actually really sad. What about from a Medicaid perspective?

22:43.032 --> 22:46.597
What are the big changes that are coming or have already come?

22:46.780 --> 22:50.667
Okay, Medicaid is hard to talk about in a vacuum

22:50.727 --> 22:54.952
because we don't have a national industry. We have

22:55.120 --> 22:58.777
thousands of micro markets. But Medicaid is obviously a state specific

22:58.870 --> 23:02.367
or plus DC. They have their own Medicaid systems.

23:02.427 --> 23:05.932
Some are better than others, some are completely

23:06.010 --> 23:09.737
woefully inadequate and some are reasonable.

23:10.462 --> 23:15.207
But the overall arc of the Medicaid reimbursement

23:15.372 --> 23:18.952
maturity, I suppose, is we went early on

23:18.970 --> 23:22.737
from a similar cost based model. Based on the cost reports.

23:22.812 --> 23:26.472
Many states then adopted a case mix, an Acuity

23:26.517 --> 23:30.307
driven model using usually the Rug system

23:30.460 --> 23:34.567
and then switching over to a price based system which

23:34.615 --> 23:38.392
sets the rate and then managed care. So not

23:38.440 --> 23:41.427
every state obviously has followed that progression.

23:41.532 --> 23:45.125
But that seems to be the overall run of the

23:45.562 --> 23:49.657
maturity of a Medicaid system. So every single one is different,

23:49.810 --> 23:52.917
but it doesn't even necessarily

23:52.977 --> 23:56.617
matter. I'm not concerned with the revenue delivery system of a state.

23:56.815 --> 24:00.277
Simply put, a state has x number of dollars to

24:00.295 --> 24:04.162
spend on Medicaid. Most states have that budget and if they exceed it,

24:04.300 --> 24:08.097
they implement what's called a budget adjustment factor scale

24:08.142 --> 24:11.917
back. They reduce rates to back

24:11.965 --> 24:15.532
into their budget. So I'm more concerned when I look

24:15.535 --> 24:18.817
at the Medicaid system not about the revenue delivery system,

24:18.865 --> 24:21.812
but about the overall funding and is it adequate?

24:22.837 --> 24:26.092
Every state is different. Okay, so how many

24:26.140 --> 24:30.127
dollars are going into the Medicaid bucket period? Not what is

24:30.145 --> 24:34.107
the method of reimbursement? Because I'm

24:34.122 --> 24:36.817
putting words in my mouth and you'll tell me if this is incorrect, but because

24:36.865 --> 24:40.347
it's not as disproportionate

24:40.392 --> 24:42.950
as the Medicare reimbursement system was.

24:43.987 --> 24:47.352
Yes, because for the most part there are certain strategies

24:47.457 --> 24:50.847
a facility can implement in almost every Medicaid

24:50.892 --> 24:54.297
system to ensure that they are optimized,

24:54.342 --> 24:57.627
that they are as high as they should be based on their profile.

24:57.732 --> 24:58.400
Okay,

25:00.562 --> 25:04.132
theoretically you could exceed that profile, but your rate is still going

25:04.135 --> 25:08.677
to be inadequate. And that speaks to the overall funding as

25:08.695 --> 25:13.197
opposed to the sort of threshold

25:13.317 --> 25:17.152
or the corridor that a facility can manage their rate.

25:17.245 --> 25:20.452
At the end of the day, if a facility's Medicaid rate maxes out

25:20.470 --> 25:24.307
at $180 a day and

25:24.385 --> 25:27.802
their costs are $220 a day, there's nothing you can

25:27.820 --> 25:32.247
do to make that difference up. So I'm more concerned about the overall funding

25:32.442 --> 25:35.975
of the Medicaid program, skilled nursing as opposed to,

25:36.787 --> 25:40.932
again, the revenue delivery system, the way that's distributed

25:40.947 --> 25:43.992
to the states I'm sorry, to the facilities.

25:44.127 --> 25:47.952
Right. So for sure here in Massachusetts,

25:48.132 --> 25:52.167
the facility that I was enclosed and last year 20 facilities

25:52.227 --> 25:55.507
closed here and there's a few ready to close this year and quite

25:55.510 --> 25:59.167
a few more that are scheduled to close. And a lot of them I'm talking

25:59.215 --> 26:02.872
specifically for Massachusetts it has to do with the Medicaid rate.

26:02.905 --> 26:06.322
There's a lot of advocacy issues to pressure to

26:06.355 --> 26:10.072
change some of that. I think the number, the average number they have is $37

26:10.105 --> 26:13.797
a day of a loss per Medicaid resident.

26:13.992 --> 26:17.727
You know, I'm not supposed to say this as an advocate

26:17.757 --> 26:21.147
of the skilled nursing industry, but I never liked those studies.

26:21.342 --> 26:23.762
The rates are inadequate but those studies,

26:26.662 --> 26:29.977
they don't recognize the cost allocation for more

26:29.995 --> 26:33.777
expensive Medicare patients and they don't include Medicare Part B revenue.

26:33.807 --> 26:36.777
So I don't love those studies, but the fact is the rates are inadequate.

26:36.882 --> 26:40.477
But it's a bigger picture. It's not only the rates. It's about the

26:40.495 --> 26:43.412
marketplace. It's about the position of a facility.

26:45.562 --> 26:49.057
What do you mean by that? Yeah, go ahead. We've had

26:49.060 --> 26:52.222
the movement over the last 20 years. When I started this business in the early

26:52.255 --> 26:55.902
90s, we had the proverbial little old ladies,

26:55.932 --> 26:59.497
nice little old ladies in the nurse home that were private bag. So many of

26:59.530 --> 27:02.782
those residents, so many of those patients, the beneficiaries do

27:02.785 --> 27:06.427
not go to the school, nursing school anymore. We have assisted living. We have a

27:06.445 --> 27:09.592
big push for home and community based services in the state.

27:09.715 --> 27:13.852
We have Medicare Advantage that tries to avoid or

27:13.870 --> 27:17.172
bypass the skilled nursing facility. We have Medicare innovation.

27:17.292 --> 27:19.550
Things like the bundling program.

27:19.912 --> 27:23.187
BPCI. We have accountable care organizations.

27:23.262 --> 27:27.522
So we have all these programs designed to limit

27:27.717 --> 27:31.167
the post acute spend, to limit utilization the facility.

27:31.302 --> 27:34.432
And as a result, we haven't had many more beds come online in

27:34.435 --> 27:37.700
the last 20 years. We have fewer beds now.

27:38.587 --> 27:42.702
We have lower census. And the Medicaid

27:42.732 --> 27:45.587
rate is only part of it because your typical facility,

27:46.237 --> 27:50.127
even in a state that is not known for reasonable Medicaid

27:50.157 --> 27:53.802
rate, if we're operating at a high census, 95% census

27:53.832 --> 27:57.137
for arguing, and we have a nice decent

27:57.487 --> 28:01.337
mix of patients with Medicare and even Medicare Advantage,

28:01.687 --> 28:05.047
the Medicaid rate is inadequate. But we

28:05.080 --> 28:09.052
can survive. Facilities get into trouble where they

28:09.145 --> 28:12.877
lose the short term care residents based on

28:13.045 --> 28:17.047
they go other places. The spotlight, facilities that

28:17.080 --> 28:21.287
open up, disrupt the market. And if we're at 70% occupied,

28:21.637 --> 28:24.412
then no, we're not going to be able to COVID our rate.

28:24.550 --> 28:27.997
So cover our expenses. So it's more than just the rate.

28:28.180 --> 28:31.567
It is about again,

28:31.615 --> 28:35.047
the overall sense is a big piece of it and then quality and everything else

28:35.080 --> 28:37.972
that goes into today's environment. Years ago,

28:38.080 --> 28:41.337
20 years ago when I started, we had three rates medicare, Medicaid and private.

28:41.487 --> 28:45.657
And facilities were 90 plus percent occupied

28:45.747 --> 28:49.732
and they were making money. So you've got almost a perfect storm of

28:49.885 --> 28:53.712
the downward pressure on utilization and emissions and episodic costs

28:53.787 --> 28:57.172
use that term. And overall census and the different

28:57.205 --> 29:01.452
rate pressures, losing Medicare to Medicare Advantage and Medicaid

29:01.482 --> 29:05.197
shortfalls, that if you miss out

29:05.230 --> 29:08.452
on all of those, if you check every box for those

29:08.470 --> 29:12.812
negative indicators, it's going to be very difficult for survive.

29:13.162 --> 29:16.882
Okay, well, that's a very complete answer.

29:17.035 --> 29:21.007
Let me make sure, just so I understand this, that the

29:21.085 --> 29:24.802
articles that I was quoting and a

29:24.820 --> 29:28.737
lot of the advocacy groups and they're talking to the general population

29:28.812 --> 29:31.625
and they're saying they're losing x number of dollars a day.

29:31.987 --> 29:35.647
That is like almost with the assumption that if you could run a

29:35.680 --> 29:38.877
nursing home just with Medicaid patients and be reimbursed appropriately,

29:38.982 --> 29:42.622
that that could work. And now that the rates are off so now it's not

29:42.655 --> 29:46.937
working. But really in order to be viable

29:47.887 --> 29:51.472
and profitable as a skilled nursing facility, it's expected that you

29:51.505 --> 29:54.822
need to have a healthy short term

29:54.867 --> 29:58.837
rehab churn and have those Medicare patients and

29:58.900 --> 30:02.737
Medicare Advantage insurance patients and

30:02.800 --> 30:05.977
private pay. If you can get any of those and if you

30:05.995 --> 30:09.897
have that and you're maximizing your Medicaid reimbursement

30:09.942 --> 30:13.302
even as is, then not only could it be survivable,

30:13.482 --> 30:16.325
you could really thrive. Yeah,

30:17.137 --> 30:20.812
really thrive. Yes, you can do well.

30:20.950 --> 30:23.922
But there's so much that goes into the equation that is lost.

30:23.967 --> 30:28.227
It doesn't matter what the Medicaid rates are. If a facility is 50% occupied,

30:28.407 --> 30:31.672
you're going to have a very hard time covering your

30:31.705 --> 30:35.202
cost. Right? So if a facility was 100% occupied

30:35.232 --> 30:38.767
with Medicaid and everybody had Medicare Part B and

30:38.890 --> 30:42.212
you had the right patient mix, acuity mix,

30:42.712 --> 30:47.052
you wouldn't be losing $37 a day. But it's

30:47.082 --> 30:50.227
a lot of variables going to that equation. It's just

30:50.245 --> 30:54.352
not that simple. So a

30:54.370 --> 30:57.802
lot of dynamics that have to be considered and also you

30:57.820 --> 31:01.977
have the difference between operating costs and debt

31:02.007 --> 31:06.232
service. So what I mean by that is if

31:06.385 --> 31:10.522
a facility is sold, somebody comes in and buys the facility or

31:10.705 --> 31:14.612
an overstated price and they've got a mortgage on that facility,

31:14.962 --> 31:18.082
you might take a look at the operating piece, how much it costs you to

31:18.085 --> 31:21.417
care for that patient and still have a margin.

31:21.477 --> 31:25.387
The revenue covers the operating cost. But then because

31:25.450 --> 31:29.225
debt service is so high, because the facilities were so expensive and

31:29.737 --> 31:33.622
we can't make our debt payments and that's where facilities have gotten into

31:33.655 --> 31:37.872
trouble or operating got into trouble. It's not that the overhead,

31:38.067 --> 31:41.887
the revenue doesn't necessarily cover the cost of care in all

31:42.025 --> 31:46.342
matters. But the debt service is what

31:46.390 --> 31:50.497
causes some problems. They can't make the mortgage payments. That's pretty

31:50.530 --> 31:54.097
much it. Again, that's certainly not

31:54.130 --> 31:57.327
universal. But that unfortunately has gotten all the attention,

31:57.507 --> 32:00.847
all the quality facilities that are doing well in serving the community and doing

32:00.880 --> 32:04.722
excellent, providing excellent patient care, the 90% of those facilities

32:04.842 --> 32:09.372
are not getting all the attention that the few problem facilities

32:09.417 --> 32:12.867
are getting. And that makes a very good sound bite to say the Medicaid rates

32:12.927 --> 32:16.402
are inadequate, which they are. But that is

32:16.420 --> 32:20.150
only part of the story. Wow. So the general

32:20.587 --> 32:24.500
notion the guy in the street thinks that 2025 years ago

32:25.012 --> 32:28.762
owning and operating nursing homes was a very profitable business

32:28.825 --> 32:32.052
and now the media is doing a good job about showing everybody how nursing

32:32.082 --> 32:35.847
homes are closing. And like we just discussed, blaming it on the Medicaid

32:35.892 --> 32:39.277
rate. And as you pointed out, that's only a piece of the

32:39.295 --> 32:42.357
pie. But as an operator

32:42.447 --> 32:45.817
or as an owner, is it still a

32:45.865 --> 32:49.492
good business opportunity for someone who is really

32:49.540 --> 32:52.957
on top of his game and is educating his.

32:53.035 --> 32:56.912
Team to operate appropriately and capture whatever they can capture.

32:58.912 --> 33:02.107
Is it a tougher game that's more difficult or do you

33:02.110 --> 33:05.902
think that leveraged properly, it could still be as exciting as

33:05.920 --> 33:09.022
it was 25 years ago when you started. Okay,

33:09.130 --> 33:12.817
what I'll say is that looking back 25 years,

33:12.940 --> 33:16.402
I can honestly say that that's not because I'm getting old here, but I can

33:16.420 --> 33:19.492
honestly say that in the early ninety s, it seemed to be a very easy,

33:19.615 --> 33:23.152
straightforward business. It is a complex business now, so I

33:23.170 --> 33:26.767
always put it in these terms. I have a son that's looking at college.

33:26.890 --> 33:30.402
So if this was five years from now and he was thinking about a career

33:30.432 --> 33:33.447
and he said, dad, should I go into the nursing home business? I would encourage

33:33.492 --> 33:37.002
him to go into that business. Not because I'm

33:37.032 --> 33:40.552
in it, but because there is tremendous potential not only in

33:40.720 --> 33:44.422
owning, operating, or whether or

33:44.455 --> 33:47.802
working for a nursing home company, a skilled nursing

33:47.832 --> 33:52.152
company, but the entire post acute care continuum,

33:52.332 --> 33:56.557
which skilled nursing is such a big part of. That's where the opportunity is

33:56.635 --> 34:00.922
for care management and quality

34:01.030 --> 34:05.367
incentives and risk management and solutions that improve

34:05.427 --> 34:09.057
the entire postcute care continuum.

34:09.222 --> 34:13.027
And that's where the opportunity is. So we shouldn't be thinking necessarily in

34:13.045 --> 34:16.602
terms of the nursing home industry, skilled nursing industry,

34:16.707 --> 34:20.217
let's look at it in terms of postcute care management.

34:20.352 --> 34:24.307
And that provides a wonderful opportunity for skilled nursing facility providers as

34:24.310 --> 34:28.327
well to expand their reach into the

34:28.345 --> 34:31.992
care continuum, take some risk with respect

34:32.052 --> 34:36.252
to payment and care management

34:36.282 --> 34:39.817
and quality. That's where the opportunities really

34:39.865 --> 34:43.902
lie. But yes, a skilled nursing facility, standalone skilled nursing facility that's

34:43.932 --> 34:47.887
well positioned and well managed can absolutely be

34:48.025 --> 34:52.497
a very profitable and strong and honorable

34:52.692 --> 34:56.287
position and serve the community

34:56.350 --> 34:59.977
very well. Okay, that's very encouraging to

34:59.995 --> 35:04.002
hear that. And it's important that this should be broadcasted

35:04.032 --> 35:07.522
and people should it's not all gloom and doom. It might be

35:07.555 --> 35:11.467
change, and we don't like change and means. People have to adapt and

35:11.515 --> 35:15.500
innovate and like you said, expand beyond just

35:16.087 --> 35:20.122
it's not a nursing home world. We're caring for seniors in

35:20.155 --> 35:23.722
this post acute space and there's more

35:23.755 --> 35:27.352
to it than just skilled nursing. Now, do you

35:27.370 --> 35:30.800
mean to say that nursing homes should experiment with

35:31.612 --> 35:35.017
home care companies or other solutions other

35:35.065 --> 35:38.272
than just skilled nursing care? Well,

35:38.305 --> 35:41.817
I'm not saying that. No, by no means am I suggesting that skilled nursing facility

35:41.877 --> 35:45.367
should be getting into home care. That's not necessarily it. Some of my clients are.

35:45.490 --> 35:49.227
But looking beyond the walls of the skilled nursing facility

35:49.407 --> 35:53.547
to identify needs in the community, to identify

35:53.667 --> 35:58.112
partners in care management, to consider innovative approaches

35:58.462 --> 36:03.282
to the financial limitations

36:03.372 --> 36:07.477
and possibilities of caring for seniors and

36:07.570 --> 36:11.082
longterm care patients, we get into the dynamics going to change. We don't

36:11.097 --> 36:14.487
have the quote unquote, little old ladies in our facility.

36:14.562 --> 36:18.447
We have sick patients. We have an Alzheimer's pandemic

36:18.492 --> 36:22.027
that is going to sweep the nation more so than

36:22.045 --> 36:25.257
Nerdy has and in my opinion, create a shortage of nursing home beds

36:25.272 --> 36:28.777
in 15 years. And we're going to have to meet those needs,

36:28.945 --> 36:32.382
and the care is going to have to be paid for. But it's

36:32.397 --> 36:35.622
not going to be that straight line $100 a day versus

36:35.667 --> 36:39.727
$90 a day cost. It is going to require integration and

36:39.820 --> 36:43.237
creativity and quality. Wow. Okay,

36:43.300 --> 36:46.522
excellent. One last question, if you don't mind,

36:46.555 --> 36:50.722
is before we wrap up there's the

36:50.755 --> 36:54.652
notion everyone keeps on saying that the baby boomers are coming of

36:54.670 --> 36:58.047
age and nursing home beds are going to be more scarce

36:58.092 --> 37:01.237
and we have to meet the need. But as we've mentioned

37:01.300 --> 37:05.032
a couple of times here already, that's certainly not the case. And there are

37:05.110 --> 37:08.032
variables for that. Like you mentioned home care companies,

37:08.110 --> 37:11.542
and there's encouragement to find

37:11.590 --> 37:14.825
community based resources to provide for their care.

37:15.412 --> 37:19.392
But now you mentioned that with Alzheimer's increasing

37:19.527 --> 37:23.482
that we do expect to see that. Why hasn't that already happened

37:23.560 --> 37:25.100
or has it already happened?

37:26.737 --> 37:30.247
It's interesting. I was just working on something about this,

37:30.430 --> 37:33.802
something on this today. I'm looking at a map right now that shows the

37:33.820 --> 37:37.447
expected increase in Alzheimer's over

37:37.480 --> 37:41.007
the next 20 years I'm sorry, not 20 years, the increase

37:41.022 --> 37:45.067
in Alzheimer's of diagnosis for the 65

37:45.115 --> 37:48.952
plus age population growth between 2017

37:48.970 --> 37:52.647
and 2025. What the expansion

37:52.692 --> 37:55.902
is, and just taking a look at these, we have Florida,

37:55.932 --> 37:59.727
an increase of 39%, texas, 36%, vermont,

37:59.757 --> 38:03.462
42%. Every single state in the nation

38:03.612 --> 38:08.772
is expecting a large increase as the aging population grows.

38:08.817 --> 38:12.772
That's really it. I mean, the only market in the entire country that

38:12.805 --> 38:16.227
is expecting no change in Alzheimer's dementia is Washington,

38:16.257 --> 38:19.642
DC. And I joke around because saying everybody down there is dementia anyway,

38:19.690 --> 38:23.952
dementia anyway. Already there's no there's no room for expansion, but it's

38:23.982 --> 38:27.687
really tied into the growth of the population.

38:27.837 --> 38:32.127
And statistically, of the population 80

38:32.157 --> 38:36.607
years old and above, 4% of

38:36.760 --> 38:40.447
the population will need to be admitted to a skilled nursing facility by age

38:40.480 --> 38:44.300
80 with that overall. But 75%

38:44.662 --> 38:48.102
of the population with Alzheimer's disease will need to be admitted to a Smith

38:48.132 --> 38:51.575
by age 80. So the utilization is much higher. Got it.

38:52.387 --> 38:55.850
So in short, you're saying it's coming. It hasn't come yet,

38:56.662 --> 39:00.275
but in the very near future, it is coming where

39:01.012 --> 39:04.297
the residents won't be able to be cared for in the community with

39:04.330 --> 39:07.777
any of the resources that are available. They're going to need to be a

39:07.795 --> 39:11.842
skilled nursing facility, which well, one final point is that we know

39:11.890 --> 39:15.582
that nursing homes care for many people that don't belong in nursing homes,

39:15.672 --> 39:19.167
and hopefully some of these reimbursement

39:19.302 --> 39:22.402
changes can help take credit for what

39:22.420 --> 39:25.175
we're doing for them. And at the same time,

39:26.062 --> 39:28.627
the seniors that belong the nursing home should be in the nursing home. Those who

39:28.645 --> 39:31.957
can really receive adequate and

39:32.110 --> 39:34.550
sufficient care in the community receive it there as well.

39:35.587 --> 39:39.027
Mark, it's been a pleasure having you on the show. I know you're

39:39.057 --> 39:42.262
busy schedule and I really am very grateful for you making

39:42.325 --> 39:46.222
some time for us today for listeners. Want to learn more

39:46.255 --> 39:50.127
about some of the innovative solutions that your company is offering

39:50.232 --> 39:53.947
and to know some of upcoming events. Where's the best place for us to send

39:53.980 --> 39:58.447
them? Zhealtealthcare.com. Just the letter Zhealthcare.com.

39:58.480 --> 40:02.047
Okay, this is great. I appreciate the opportunity and

40:02.230 --> 40:05.112
it's great that you're doing this. Okay, well, it's been a pleasure,

40:05.187 --> 40:08.757
Mark. I really appreciate you coming on the show and sharing.

40:08.922 --> 40:12.717
Really, you have the national

40:12.777 --> 40:16.572
picture from all the different states and the wide perspective

40:16.617 --> 40:20.242
and the specifics and I'm sure our listeners are really going to enjoy

40:20.290 --> 40:23.602
this. I certainly have enjoyed it. It doesn't say much. My wife

40:23.620 --> 40:25.412
says I can talk to a stick,

40:27.112 --> 40:30.402
but this really was honestly, as an administrator,

40:30.507 --> 40:34.272
there's a certain anxiety sometimes when ownership pushes

40:34.317 --> 40:38.022
down too much on the financial side and pushes.

40:38.217 --> 40:42.087
I'm not saying they push to do certain things, but they're expecting

40:42.237 --> 40:46.117
sometimes from administration to understand some of the complexities that

40:46.165 --> 40:49.447
we never really need to deal with on a daily basis. And for me,

40:49.480 --> 40:53.077
this was very helpful and I'm sure there are other professionals in the field who

40:53.095 --> 40:55.597
will find this helpful as well. So thank you so much for your time.

40:55.780 --> 40:57.050
Okay, thank you.

41:01.837 --> 41:05.622
I hope you've enjoyed this episode of the nursing home podcast.

41:05.742 --> 41:08.877
Be sure to share this episode with all of your friends in the nursing

41:08.907 --> 41:14.437
home industry and just tell them to head on over to the nursinghomepodcast.com.

41:14.500 --> 41:17.932
In the meantime, head on over to itunes. Leave me an honest,

41:18.010 --> 41:21.442
wonderful review, take a screenshot of it, and I will send

41:21.490 --> 41:24.472
you a gift straight and special for you.

41:24.505 --> 41:27.877
Again, head on over to itunes. Leave me an honest

41:28.045 --> 41:31.252
review, take a screenshot of it and send it on over to

41:31.270 --> 41:34.852
me on LinkedIn and I'll be sure that we send something out special

41:35.020 --> 41:38.975
just for you. Have an awesome day.

41:52.387 --> 41:52.800
Subscribe our channel.