Changemakers: Todd Stern, CEO, Seasons Hospice & Palliative Care; EVC for AccentCare

Todd Stern came to Seasons Hospice & Palliative Care, now an AccentCare company, in 2001 as the company’s CFO and managing principal. In 2005 he ascended to the CEO spot. In the intervening years, the company has expanded in size and scale to become the fifth largest hospice provider in the nation with a footprint spanning more than 20 states.

Seasons is looking forward to further growth following its 2020 merger with post-acute company AccentCare, a portfolio company of the private equity firm Advent International. Via the merger Stern became executive vice chair of AccentCare in addition to his CEO role.

The combined company provides a full continuum of home-based health care services, including hospice, palliative care, home health care and personal care.

Stern recently sat down with Hospice News to talk about the forces that are reshaping the industry and the ways Seasons-AccentCare is evolving along with it.

I thought we could start by talking a little bit about your recent merger. How did that come together and what was the impetus?

Seasons is a 24-year-old provider of primarily hospice and palliative care. We happened to own two other complementary organizations. One was a home health provider, HRS Regional in the Midwest, and a Chicago-based personal care services organization, Gareda Services. These are much smaller pieces of our overall puzzle, and we’re continuing to grow those organizations.

AccentCare had been knocking on our door to see if there was a way to combine forces, and they really had the reverse dominant skill sets. The complementary expertise, coupled with wonderfully complementary geographic footprints really positioned our organizations together to be something quite unique, versus how we were operating focused on all three parts, but from different areas of strength. Our ability to integrate allows us to be a much greater force of good in a large percentage of the major open markets that we both share, as opposed to achieving that as competitors.

Philosophically, we saw the world very similarly about needing these various parts and how they will ultimately get coordinated, with commitments to quality and patient and family satisfaction. It was also about being a true partner to health systems, which both of us have been highly focused on. Seasons has a much lower length of stay, and a much more acute hospice care practice than some of our peers. We were all focused on the same directions with complementary yet opposite areas of maturity.

You alluded to one the goals of the merger was to create this seamless continuum of care. Is that indicative of changes you see taking place in the industry?

That depends who the provider is. The benefits have not changed. Seasons was an early adopter of innovation. We launched Seasons Medical Group more than 10 years ago, where we got credentialed by the payers and Medicare and Medicaid to provide pre-hospice services. Then we started to collaborate in our communities with home health providers to provide palliative care as a bridge. I think to some organizations hospice is just hospice, but I think they need to be very attuned because I don’t think that’s where the fiscal policy and value-based winds are going.

We certainly don’t believe that hospice will stay hospice, as pure as it is. Having the ability to support patients and families in a most seamless way — and at the right points — is key. We see a a longer term vision.

Everybody wants high quality care. Everybody wants to avoid exacerbation of illness, the patient and family as well as the payer or health system. The world is aligning incentives around value and quality. Everybody’s getting aligned around preventing patients from having to go through an unmanaged episode, and a health system is not going to see that favorably from a reimbursement perspective.

There are many different avenues of reimbursement. Seasons recognized that while it would need to play an upward role, and AccentCare thought the same way. Now as an integrated organization we’re looking to maximize our ability to provide the most seamless delivery of care experience for patients and families, and secondarily, health systems and payer partners as we look at the world going forward.

What are some of the most significant changes that you’ve seen impact end-of-life and serious illness care in recent years?

I’ve been at the helm of seasons for 20 years, and what drove the growth of hospice over those years is in part demographics, but the biggest piece was acceptance. It was the adoption of eligible hospice utilization. I’m not sure that the next 20 years are going to be penetrating the adoption rate as much. There will be incremental improvements, but we’ve made a lot of strides there. We’re at over 50% hospice utilization [among Medicare decedents], but I think we’re going to see more of the demographic growth increase than we are the adoption rate. But that’s been a significant driver of the last 10 years of our experience.

During the last five years, we’ve seen more appreciation for good end-of-life care experiences. The fiscal policy has engaged quality and value in a way that the whole health care continuum thinks of hospice as a complement to quality and cost. That’s allowing us to do things more strategically than we were able to do before.

Technology is rapidly growing. Regulation is sometimes lagging, but we see even more opportunities as regulation catches up. What we have seen over the last couple several years is readmission sensitivity, growth of [Medicare Advantage (MA)] and delegated risk providers of care for MA plans. These changes are robust. They are active in our communities. We are building connections and communication, bridges and coordination around those benefits.

Can you add some color about how regulation needs to catch up with technology?

We have an interdisciplinary team component, and historically regulation didn’t prohibit it from being virtual — but also didn’t explicitly allow it to be virtual. There are certain things that are best practices that have sort of become expected in the eyes of surveyors and others, and to take risks on that is a challenge.

The governing organizations, surveyors, auditors, they expect services to be delivered in a certain way. Without explicit guidance it would be very risky to engage in change of practice that could result in a negative response from the overseeing bodies. Things like virtual visits for our face-to-faces [recertification encounters] were not allowed in a non-COVID world.

COVID precipitated a lot of change in hospice space and throughout health care. How did Seasons fare during the pandemic?

We’ve had to adapt a lot of our care delivery. When we have different levels of infection control sensitivity — as the world became better at understanding the risks of COVID-19 — the world slowly adapted in terms of how we were able to interact in care-delivery environments. We had to shift in a variety of ways, such as how to deliver telehealth visits, how to care for folks in long term care, or assisted living facilities. This required a lot of creativity, leveraging of technology, and prioritizing infection risk with care and also bereavement support.

It challenged the entire way we operate, and we tried to find the right balance to meet the need. We didn’t see any reduction in volume, because fortunately our adaptations worked. But I will say we’ve seen a lower length of stay associated with care. That’s probably a function of two things. Folks who needed care were delaying seeking it out, and so they found hospice later in their disease process. Also, we’ve seen an erosion in occupancy in facility environments. There were just more patients coming from hospitals and physician practice offices than from facilities.

What are some of the long term impacts of the pandemic that you foresee?

Hard to say. We’ll have to see what waivers become permanent on a regulatory level and what standards of practice become accepted. I believe that our entire country has a renewed appreciation for what a good care experience looks like relative to some of the challenges COVID presented. That provides a greater recognition of what death ought to look like, versus what it had to look like given the pandemic and its challenges.

I’m somewhat optimistic that appreciating a high quality of life will last as we become a little bit more normalized. We can appreciate what that means to have emotional support for both the patient and for the family. That’s going to be elastic change at least for a while.

Many providers are doing some soul searching in regards to demographic and socioeconomic disparities within the health care system. Seasons-AccentCare recently appointed a new vice president, Nicole McCann-Davis, to address those issues. Can you speak about why such a leadership position was necessary, and what kind of change you think is needed to address those disparities?

A large portion of our presence is in urban areas, and we have long worked with very diverse communities. We have been focused on that consistently. What you’ve seen in Nicole’s role is an evolutionary investment in that direction. I wouldn’t say that this is a new priority; it is an evolving priority.

We have long looked at the percentage mix of our employee base. We’ve long wanted to see our employee base mirror our patient and family composition. We have had different initiatives at different points, one of which was community advisory boards. We are as committed as always to serving the diversity that exists within our various communities, and that diversity.

Nicole’s role is really a next level investment in a rapidly growing organization. As you get bigger, you make bigger investments. At this point, we are focusing on the next level. We’re looking at each marketplace and making sure that not only are we looking at catering to certain disease processes or certain continuum of care partners, but we’re also making sure that every one of our markets has a diversity-specific marketing effort. Over time, we are ensuring that we are continuing to engage in and build support for unique communities across every market where we operate. They have to have a market-specific diversity plan.

What are some of the ways that hospice and palliative care providers need to adapt to the changing health care environment?

Hospice is very much a part of the solution. Hospice is the first value-based care model. Sometimes that gets lost somewhere in the conversation, and I have a hard time trying to reconcile that. When I started in hospice 20 years ago, we were celebrated for our holistic approach and our largely capitated reimbursement model.

We have different folks in the mix now than we did perhaps 20 or 30 years ago, so we have to educate and we have to collaborate in different ways. We have risk providers of all types that need communication and need coordination in new ways.

When it comes to palliative care specifically, we’re still part of that solution. There’s a lack of formalization of those benefits. The only thing that’s out there is the Medicare fee-for-service mechanisms and lookalike structures with payers. We had attempted to be part of [the Primary Care First Serious Illness Population] model. We’ll see where the government ultimately lands on that. Right now, it’s somewhat paused. But we did apply in almost every state in which we overlapped with the contemplated pilot. We hope that that does become more formalized.

We actually think that that is more important than the [value-based insurance design demonstration]. From our standpoint, the relationship with Medicare Advantage works very well. We’re not having problems, as long as you build the communication and coordination tools.

The reimbursement model isn’t a problem with MA. We think the bigger opportunity is palliative care — to actually have a formalized palliative care benefit that sets the table for all payers.

The only other thing I would say is staffing is an industry-wide problem. Our country is going through a number of challenges. COVID was a variable that. People were caregiving for their loved ones, children and elderly, and there were concerns about safe environments. You’ve also got wages changing. There are a lot of industries that are competing for talent.

The health care environment is expanding, putting more pressure on a pool of staff, and the age of the health care workforce is much older than the country’s average age. We’re navigating increased demand with a shrinking health care workforce. Without stability of wages, we’re not attracting younger entrants into that workforce.

We are very much focused on being the employer of choice. We believe that we are market leaders in terms of being the care providers of choice, but that is only sustainable if you can fuel it with the best staff.