For Chapters Health System President and CEO Andrew Molosky, the hospice model can lay a foundation for care delivery throughout the continuum with its emphasis on quality of life and person-centered interdisciplinary services.
The Florida-based nonprofit is applying this approach to a wider range of services across a growing footprint. The organization has secured three affiliations during the past 13 months, including Cornerstone Hospice & Palliative Care and Hope Healthcare in its home state of Florida, as well as Maryland-based Capital Caring Health.
The state has also awarded Chapters with a Certificate of Need (CON) to expand into a neighboring county.
The nonprofit Chapters Health System provides hospice, palliative and home health care, as well as durable medical equipment and pharmacy services, across 30 Florida counties and eight in Georgia. When the Capital Caring affiliation closes this year, Chapters will also have a presence in Maryland, Virginia and the District of Columbia, encompassing 14 counties and four independent cities.
Hospice News sat down with Molosky to discuss Chapters’ recent growth and future plans, as well as the headwinds and competitive environment the company will have to navigate.
Can you give some background on your new affiliations and how some of those discussions began?
By and large, the principles that lead to these types of dialogues, at least in the Chapters experience, is when you have a combination of several things — starting with active thought leaders in the space, those who embrace the future for its challenges and its opportunities. They’re not folks that are afraid of the future or are fighting for the status quo.
And then ultimately, you look for partners that bring value that neither individual partner could get by themselves. If you stick to those kinds of things, you start to immediately alleviate the usual cultural challenges, logistical challenges, ego challenges, because you can always default to the backbone of, “Listen, we all know the future’s coming, and we all want to embrace it.” That becomes your common language.
So with Cornerstone, with Hope, with Capital Caring, the leadership, the culture, the vision of the future aligned, and the rest sort of became about tactics as opposed to concepts. It is both an honor and a privilege to welcome them.
And I think it’s a testament to the fact that in affiliations, M&A, or whatever you want to call it, it’s a “big fish, little fish” scenario. But it doesn’t have to be that way. You can have very well-respected companies that, in the name of the greater good, find common ground.
Beyond the affiliations, Chapters also received a certificate of need in November for Pinellas County. What was attractive about that market? And are you pursuing more CONs for that kind of growth in 2023?
Specifically, Pinellas County from a very simple perspective was a corner of the map that — with a greater Tampa Bay presence — you didn’t want to leave friends and family on the other side of the bridge. And with the notion of being a seamless continuum in your community, whether horizontal or vertical, almost certainly warranted Pinellas County being part of our footprint.
We have staff who live there, referral sources who are from there, patients who traverse back and forth for their care. I made the joke to somebody that it’s like you could hang out in your front yard, but you couldn’t go in your backyard.
This made a great deal of sense for us as it pertains to other certificates of need or other geographic pursuits. Certainly, that’s always in the hopper. We take them on an opportunity-by-opportunity basis, as do most of the folks in the Florida hospice landscape.
We’re actually running a nice blend of de novo or organic growth through CON acquisition and then, of course, partnerships or affiliations. We don’t have an all-or-nothing type of approach. I would suspect we’ll continue over time to apply for select certificate-of-need spaces, but we’ll also look for those large partnerships that bring multiple geographies or states with them as well.
What are some of the key factors that you consider when you’re looking at new markets in which to expand?
In any line of work, whether it’s health care or retail or construction, you look at a saturation point. You look at an unmet need or look at the competitive landscape. And if you identify, in the old kind of lingo, the red water or blue water. If it’s more blue water, you can bring value to the space that may not be there.
And it’s not necessarily just competing in a hospice landscape, but a chronic illness landscape. That may be a home health sector. That may be a value-based sector. It may be hospitals. It may be a combination of all that — sometimes it’s joint ventures, sometimes it’s an acquisition.
So, we look at a market and say, “Okay, put all the chess pieces on the board, and what are you really trying to accomplish? Is it a map issue? Is it a size issue or a profitability issue? Is it a service line issue?” If you start to check more than one of those boxes, it starts to become more alluring.
If you’ve seen one market, then you’ve seen one market. Every one of them holds an allure or risk that you have to calibrate each time.
To your point about the other kind of services beyond hospice, what can you share about your plans or the opportunities you see in regard to that larger continuum of care that Chapters provides?
So this is something that we believe strongly in at the organization. Make no mistake: Our culture, our philosophy, our passion is rooted in the hospice approach to care. But I’m always clear with people that I didn’t say it actually was hospice, it’s the notion of interdisciplinary team-based, person-centered, low-cost, high-quality care.
That’s what drove hospice. But there’s a lot of the health care ecosystem that has never embraced that. So our ability to treat chronic illness also uses the hospice-like approach in a myriad other settings.
Our notion of going after payer strategies, after home health patients, after value-based design, the care modality that hospice has always known is sort of our approach.
Do you encounter challenges when applying that model, as you’ve said, to other services like home health and so forth, considering that the traditional care models and reimbursement models for those services aren’t necessarily designed to support that interdisciplinary approach?
Yes, there are challenges, and you can break them into a couple of buckets.
One is structural: Does the benefit you’re working within allow for innovation, allow for flexibility and creativity? There’s an educational or sort of a grassroots effort — just like hospice spent many years trying to show people that it wasn’t euthanasia; it’s a place to live and celebrate life. You have to educate people on a journey of why what you’re doing differently is actually innovative and wonderful.
And then the third piece, of course, is just financial and regulatory headwinds. You’ve got to find a way to fund some things. You have to find a way to legislate some things. You have to find a way to create your own path through the woods. So you put all that together.
That’s the hard part of doing it. It’s fun, but it’s hard. That’s where we have had and continue to put our emphasis on a lot of the value-based designs. If those who are paying the bills are open to getting something done differently, we’re that company that has demonstrated that we have a different approach that does work clinically and financially. So it’s equal parts reforming the system that already exists and blazing a path to create a system that isn’t in place today.
What are some of the headwinds or barriers that you’re steering around as you pursue this growth?
You can break them into a couple of key buckets. This is a service and a people-based industry, and so anytime I say industry, I mean health care in general. Without your people, there’s very little you can do. So labor headwinds are one — the cost of living inflation, talent acquisition, the great resignation — however you want to classify the challenge of getting, keeping and rewarding good staff. That’s a big one.
Secondarily, there certainly are legislative or political headwinds. Without making this a political conversation, you have a lot of infighting. It’s hard to find unifying subjects, and you don’t want to appear to be partisan in your pursuit of great clinical care.
The third piece becomes just functional access to capital. The markets aren’t great. Now, if you’re a nonprofit, margins are thin and getting thinner, and you’re in a fixed revenue environment. Unlike other organizations, we can’t raise our rates if you’re in hospice or home health or palliative medicine. The codes are the codes, and the rates are the rates. You’ve got to find a way to do more with less.
So you put all that in a stew, and it makes for an extra spicy dish. And I think that’s where the innovation has to happen. You’ve got to come up with a better clinical model, using the people that are available to you and rewarding them accordingly — and all the while hoping the payers say that’s a different way to do it.
How do you feel about the competitive landscape in Florida right now?
It’s interesting because I think it could be a forest-through-the-trees issue. And what I mean by that is, everyone feels that they’re in this hyper-competitive landscape that nobody else could possibly understand yet. If you go to the next city, town or state over, you’d hear the same story, and I think that hospice or end-of-life care really isn’t any different.
I think there are a lot of folks who have felt isolated from the rest of the health care continuum or ecosystem for many, many years. Now that it’s starting to blend and become one issue, some are challenging that, quite frankly.
I think Chapters takes it as a wonderful opportunity. Because if you talk to any hospice expert, what are the top complaints that they have? The stay is short. The education is not there. People don’t understand the benefit.
We believe that we’ll have our opportunity by virtue of being good at what we do. I think also really what people fail to capture is that we’re almost needing to stand arm-in-arm in lockstep because our real threats are not necessarily each other.
Our threats are the non-traditional folks, the ones that are circumventing the hospice benefit as it’s regulated, the ones that are kind of coming up with alternative delivery models that are based more on primary care, and acute care than they are traditional home- and community-based services.
I’ve told [other hospice leaders], “Why are you and I fighting over one patient when the notion of these other organizations could destroy the entire landscape and take away these patients from us?”
That’s where we really should put our efforts. Maybe it’s a unique look, but that’s how we view competition.
Can you say a little bit more about those organizations that you mentioned that you see?
I’ll avoid naming names, but, by concept, you look at a lot of primary care risk groups who view end-of-life services as extra cost inside of a capitated structure. So they decide to use it less.
You look at an acute care institution who say that they have got to keep billable days for our [diagnosis-related groups] up and high, so add a few more skilled days, cut out home health, or keep the patient for an extra day of observation and delay that hospice admission.
You look at some of the payers who might say they’d really like to embrace these third-party benefits administrators to cut down their spend. So you have a provider turning a home health visit from 60 days to 30, or a hospice length of stay from a month to two weeks, to try to cut costs. There’s a whole slew of avenues, but most of them center around what they perceive as unnecessary costs, because they’re sort of being penny smart and pound-foolish, not understanding the real benefits.