Bruce Greenstein, chief strategy and innovations officer for LHC Group (NASDAQ: LHCG). He leads the hospice and home health giant’s value-based contracting, accountable care organization management company, and alternative payment and delivery model strategies, while overseeing the technology and innovations business segments.
Prior to joining LHC Group, Greenstein was chief technology officer for the U.S. Department of Health and Human Services (HHS). He has also served as secretary of the Department of Health and Hospitals for the State of Louisiana.
LHC GroupGreenstein sat down with Hospice News and our sister site Home Health Care News to discuss the staffing pressures facing the industry, the market forces impacting hospice and home health, and where technology fits into these equations.
A recent study from tech company Forcura found that 70% of 97 health care leader respondents consider talent development their top investment and challenge, followed closely by interoperability technology at 51%. Where do you see staffing heading in 2022? Have we hit rock bottom? Is it only going to get better? Or do you think that things can actually get a little bit worse here?
It depends on the trajectory of the next wave of COVID. We’re all watching Omicron and how many hospitalizations could occur from that, but, obviously, we’re still battling the Delta variant in the biggest way. We have over 1,200 deaths per day. I just looked at the New York Times figures this morning. That’s devastating when you think about the death toll that’s occurring, and somehow — it’s not been dismissed from the national psyche — but it certainly doesn’t feel the same today, as it did last year at this time when we were still buckled down.
We’re really concerned about gathering for Christmas travel, masking, and it feels like as a nation we are undergoing COVID fatigue and letting people’s guards down. When you think about those that are jamming up hospitals across the country, they’re overwhelmingly the unvaccinated. So now we’re in this moral dilemma as a country. How far do we push? How much do we want to protect those who, at this point, have made decisions that they don’t want to protect themselves? I think that’s sort of the existential policy question moving forward.
Having said that, one of the best measures from is what percentage of either visits or staff today are contract labor versus [full-time employees]. At least we’re coming back down off of a high point that’s positive for our area, but it certainly doesn’t speak to the number of open positions that most of us have around the country. If you talk to hospital administrators, it has not gotten easier at all. The number of open positions there, and the number of contract staff that are being used are overwhelming, which pushes up the cost of providing the care.
This issue with contract labor, there’s been some price gouging out there. There’s been some super-inflated costs, because of the high demand, especially for those staffing agencies. Is that something that you guys have experienced?
I call caution for our experience to characterize it as “price gouging.” Prices have gone up, for sure, but you’ve got to look at it on both sides. The labor itself, the price that nurses are charging, or getting, depending on which way you look at it, has gone up dramatically as well. To some extent, maybe it’s just a market working efficiently in that we have massive excess demand for a limited supply. It’s not a regular commodity; it’s a piece of labor. We as a market are so desperate for that. Those that hold that high-demand asset, which are the nurses themselves, they get to really set their price.
I’ve heard what seems like touching stories of nurses — that have student loans and take care of a family working at a hospital and making ends meet — to making three times that amount, getting a chance to travel, retiring their student loans, saving some money. That’s what they can do, given that there’s so much demand for that service. I think that it’ll come down. This is transitory. But I also think that when it comes down, it’s not going to come back down. I think we’re in a period of heightened demand, excess demand, and we’ll not see the regular level of compensation that we did three years ago. But I don’t think it’s going to be 50% more. I think it’ll be single digits above where we were.
In addition to the pandemic, what are some of the other, less obvious factors complicating staffing for home health and hospice?
The pandemic has highlighted it, but there has been a current underlying this for a long time. From the level of wages, if you start at the bottom, people refer to home care workers as non-skilled, I think that’s an inappropriate term. It’s a non-clinical workforce that are taking care of people in their home, personal care services. Much of it is contracted under Medicaid, which has been paying low wages for a long time.
This is a market where workers may work at Target [NYSE: TGT] or fast food one week, and then in personal care services the next week. I think that this is an area that we need to focus on for the future of our nation, mainly because of the chronic disease burden and the aging of the population and the family dynamics. By that I mean, the percentage of elderly with chronic disease that don’t live near a family member makes it difficult — to be a caregiver when someone’s in New York and the other ones in Boca Raton [Fla.]. We need to bulk up on that part of the workforce.
As you move up and you think about [licensed practical nurses, registered nurses, nurse practitioners], etc., we’ve just kept the production of those professions in a fairly limited way. A lot has to do with what kind of opportunities, the kind of specializations and how mobile is that workforce.
As we watched the nation age, certainly we’ve not sent a message that everyone has to take care of themselves for health care. Instead, we’re building new hospitals and making investments in bricks and mortar and the infrastructure. But the piece that has to get developed more fulsomely is the parts of the labor force that make everything work. That’s the nurse, again, whether it’s LPN, RN, NP, and I think this ought to be a focus in the next 10 years of being able to catch up with the production of the clinical workforce to match what the demand is going forward.
In terms of collaborating across settings, it’s something that providers have been talking about for a while now. What are you doing on that front, in terms of interoperability and making sure that everyone is in alignment with each other on the continuum?
When I was reading the [Forcura] report, I was thinking about the shift that’s occurred. I was CIO for LHC for a while and got to get deep in our infrastructure, and what I think about is, we approached technology three years ago as a growth lever. That’s how we justified making these investments. It’ll help us grow referrals, grow centers.
Today, that is still true. That’s the way to do your [return on investment] calculations, Now we’re looking at technology to help us improve productivity. Can we get more visits from the same workforce? As we’re trying to hire, we can’t hire as fast as the demand on our services are going, so we are looking to technology to help us develop that.
So start to think about what that means: Can we use technology to shorten the documentation time that’s required? Can we use technology to make that flow of information from acute to post acute, more seamless, so that more information is captured, and we’re able to do a visit? So almost all of the time is spent on clinical care rather than administrative tasks, because our goal is to fit more visits with the nurses that we have in.
That wasn’t quite as much the goal when we started out three years ago. Now, it definitely has shifted priorities. If you look at how we’ll use remote patient monitoring, and video and television, it’s the same goal. We want to do the same number of visits. We want to do them more efficiently with the use of technology, and remotely when possible, so that we can do more visits for the same number of nurses.
In terms of LFC group’s plans in 2022, you have indicated that your emphasis will be on home health probably a little bit more than hospice in 2022. Is that still the case?
Yes, you saw 2021 be a great year for both the acquisitive side of hospice for us, as well as working on our internal operation for integration of the new assets. We’re extremely pleased with the outcomes of those efforts. The way we look at our pipeline and our priorities 2022 is going to be back to a more traditional set of home health activities. It’ll be both on the [joint venture] side as well as the freestanding side.
We have put a lot on the board in 2021, including [Brookdale Senior Living (NYSE: BKD)] for a number of new locations, new markets. We’re in a steady march to trying to cover the entire nation. We think that’s important for patients and physicians and hospitals and we want to be sure that we can be the high quality provider of choice across the nation.
What do providers need to accomplish in order to remain nimble in the face of the constantly shifting conditions brought on by the pandemic and other market forces?
So it’s interesting. This [Forcura] report is about technology and how to deploy it. But when I read the report, I also recognized the importance of high quality staff. The success of the agency is dependent on that, more generally meaning nurses. Do we have enough nurses to carry out the job in front of us? All of us are struggling to get enough nurses to meet demand, but as you know, executives in provider organizations think about that all day long.
I say that we cannot take our eye off the ball, to continue to develop and evolve our technology infrastructure, to push ahead with the productivity gains that come along with the proper implementation of technology, and really cultivating, hiring or developing staff that are both home health and hospice business savvy, but also are really able to master the technology.
That has been a challenge for small agencies that don’t have the resources and the deep bench to have so much staff that can be focused on [electronic health records] and [enterprise resource planning] and [customer relationship management], and an interrupt platform or multiple interrupt platforms. That’s where I would tell my colleagues in the industry to focus every day on what the most pressing needs are with your agency.
But don’t neglect those medium-term goals, which are about developing the infrastructure, developing talent within your agency, and keep your eye on what the future goal is, which is much better integration within your own company and within the context of post-acute, and then within the context of the entire health care system.
Home Health Care News Reporter Andrew Donlan contributed to this report.
Companies featured in this article:
