The home-based care landscape has changed considerably between Paul Kusserow’s time as chairman and CEO of Amedisys and his return to the field as board chair of Elara Caring.
Kusserow led Amedisys from 2014 to August 2025 when the company was acquired by the UnitedHealth Group (NYSE: UNH) subsidiary Optum for $3.3 billion. Last year, he published a book, “The Anatomy of a Turnaround: Transforming an Organization by Prioritizing People, Performance and Purpose.” He returned to the home health and hospice space earlier this year as board chair of Elara Caring.
Hospice News spoke with Kusserow about his return and how the industry has changed in the intervening years, as well as Elara Caring’s next steps and what hospices need to do to grow in 2026.
How did you first connect with Elara Caring to join the board? How did those discussions begin?
I’m an operating partner at Aries Management. Ares owns about 60% of the business. Ares is a big private equity and credit firm, very active in healthcare services, very interested in home care, and so we were looking at a variety of different deals. We saw Elara, and we liked it.
It took two years to get the deal done, though. It was a very difficult deal to get done because of the equity owners and the debt holders. It was very highly leveraged, so we went in and cleaned all that up.
Our co-investor is Davita [NYSE: DVA], which is a very interesting partner. They own about 40% of the business, and Davita is very interested in home health and very interested in hospice. So, we’re trying to figure out how we can partner with Davita and really help some of their patients.
We’re in three lines of business right now. Home health is our largest business by far. We have a good presence in hospice, but we want to grow that, and a relatively small personal care business, largely doing Medicaid.
The deal closed a couple months ago, so we’re kind of just figuring out what we want to do. I think it’s a remarkable opportunity now to come back into the home health and hospice space now, because you know the top three players all have different owners, and all these different owners have different strategies for it.
You’ve got Gentiva now being part of CenterWell, and now being part of Clayton, Dubilier & Rice, building up some hospice presence there. But the home health piece of Gentiva is at Humana [NYSE: HUM]. Then LHC Group and Amedisys were bought by Optum. So, the top three players are gone in the home care space. Enhabit [NYSE: EHAB] just got taken private. It’ll be interesting to see what happens.
What impact do you think those big transactions, those players being absorbed into larger organizations, have had on the industry at large?
I don’t think it’s over yet. There’s still some big players out there that I think are going to need home health and hospice assets. I don’t think CVS [NYSE: CVS] and Aetna has one. They say Signify, but that’s really a coding company.
I think Elevance [NYSE: ELV] has always been interested. I know at Amedisys we talked to Elevance. They’ve always been interested in home health. I don’t think CareBridge really answers that for them in the in the traditional way. It’s a good asset, but I don’t think it answers that question fully for a business that’s very heavily in Medicaid and Medicare. I think all of them will need something.
The two leading players, Humana and [UnitedHealth Group (NYSE: UNH)], understand the value of care in the home and understand what that means for their members. They were very strategic in how they went about doing it. As you may recall, I was at Humana and made the first acquisition for Humana in home health, and we found it was very beneficial for a Medicare Advantage population. That’s why Optum and Humana went heavily into the home care business.
I think there will be a lot of interest. Also, remember, there’s nothing left really in the public markets anymore, and the public wants to trade in home care. It’s a great service. And right now, where do you put your money if you’re a public investor and you want to buy home care stocks? It’s a harder place to find.
Investors like trading in home care. I think there’s going to be more opportunities in the public markets. The multiples aren’t as advantageous as they once were, but I think they will get back there. There’s been some really good hospice assets out there that have traded. There’s some good assets coming up. I think it’s going to be an interesting time for hospice. It’s very highly valued now. One of the concerns we have is the cost, the multiples that things are trading for. It’s expensive to buy a hospice asset now, unlike home health, which is much cheaper.
What are some of the other changes that have occurred in the industry between leaving Amedisys and coming to Elara Caring?
When you step back in the river again after a year-and-a-half or two years, one of the things you definitely notice is fraud, waste, and abuse. There’s a lot of emphasis on that. Obviously, there’s a moratorium on that that’s been created by [the U.S. Centers for Medicare & Medicaid Services (CMS)]. I really think there’s a relatively easy solution for that, and hopefully I’m going to get see my friends at CMS and talk to them about it.
There’s a lot of people who can start these businesses up and have mailboxes. We knew California was a big problem long before the government popped in and saw it. Before that it was Florida and parts of Texas. We know where these things in the industry where they’re coming up, but that doesn’t mean you have to condemn everybody.
I wish what they do at CMS is go to where it’s quite obvious fraud is, and then the other thing I think I think the answer to fixing fraud in home health and hospice is getting rid of the six-year look-back provision, which is when you buy an asset they come in and look at it and they say what did you just buy, and then they try to find fault with it. Then on top of the purchase price, you have to pay a penalty.
I think one of the things when you have conversations with people at CMS is that they want this industry to consolidate. They want home health, personal care, hospice to consolidate, but they make it almost impossible to do that to take riskier bets on things if there’s a six-year provision where you’re responsible for someone’s behavior six years ago. That’s brutal, and that means you also have to do tremendous diligence.
Often smaller players can’t survive the scrutiny of the diligence that you have to bring in if you’re a larger player. It’s really halted what I think would be much more consolidation in the industry, and I think it would also clean up the industry. The big players know they’re going to get looked at, and the big players do not play the games that these fly-by-night people do. I think it would be a good way to solve a lot of the problems of a huge industry in terms of the number of players in it.
Why would CMS want the industry to consolidate?
I’ve been talking with CMS ever since the Obama days, and I think there’s a there’s a long been a perception that fraud is rampant. There’s an opportunity to use scale. If you have fewer players operating at a higher scale, you can monitor their performance from a compliance perspective. When you have in home health — I think it’s around 10,000 players — that’s impossible to monitor. If there was much more consolidation, you could go to fewer sources and make sure everybody’s behaving properly.
When you build a business at scale, you want to make sure everybody’s behaving in exactly the right way because you don’t want to put your business at risk. Whereas, if you can go under the radar screen, which a lot of these small mom-and-pops can do, you can act any way you want. That’s a big concern.
What are some of your priorities for Elara Caring right now, if you could speak broadly and then maybe drill it down to hospice?
Our priorities now are to start to figure out how we can integrate home care with dialysis, with kidney care, because Davita has about a 40% share of the company. We have tremendous opportunity. These folks buy a lot of home health.
Hospice is much more difficult. You have to have a waiver, and the waiver is pretty narrow to have people get simultaneous dialysis plus hospice. I think that’s ridiculous because a lot of these people then have to pass away in the hospital. We want to try to change CMS’ thinking on that front and widen that aperture so that more dialysis patients can be treated when it comes time for hospice.
What’s interesting about Elara is they do high-acuity home care in about 18 states, about 60,000 patients. They like high-acuity patients, and they do well with it. That often means we need to work hand in hand with hospice.
In hospice, we’re in about 10 states. We have a census of about 2,800, and but up to 20% of our referrals come from home health, which is really unheard of. We want to continue to drive that. So that’s what we are going to do when the moratorium lifts, or we’re going to go out and buy assets.
We like the fact that when we do high acuity care, we can move people into hospice very effectively and easily. There’s not a culture of trying to skill people, where you just try to keep them as long as possible in home health or whatever venue they’re in and not get them into hospice. The key thing, obviously, for a good hospice experience is to get them into hospice as soon as possible, particularly if we’re taking care of high-acuity patients.
This is where Elara really has a unique capability, and so the more overlay and overlap we have will be great. Once we once we figure out how to start working in the home health and hospice arena with Davita, particularly where they’re at full risk, I think there will be tremendous opportunities to work within the Davita footprint, and to once the moratorium is lifted, to build de novos in both home health and in hospice. We’re very sanguine and optimistic about what that opportunity will do.
What are some of the most important things that hospices can do now in 2026 to foster growth?
The thing to do right now, particularly with the baby boom population, is to continue to educate people about the benefits of hospice. The most paradoxical thing about hospice is if you go early enough you’re going to the benefits are so much better than what you get if you pass away in an institution.
I think the the attitude is changing significantly, particularly as the baby boomers start to move into the era of hospice. One thing we’ve seen about in the baby boomers — and I wrote a book on this that came out about a year-and-a-half ago — is that they really like they really believe they can control their destiny, particularly in utilizing healthcare. They want to do more curation in healthcare, and I think hospice allows them to do that in a much better way.
The reason why I think hospice is trading at such good multiples now is because I think when people do the demographic work and the psychographic work with the baby boomers, it invariably comes back very favorable for hospice, very favorable.
One of the significant challenges, though, is still with staffing. It’s very difficult to get the right staff. It’s a very tough time to be taking care of people, and you need skilled staff much more than you do in almost any other type of home care.
At Amedisys, we spent time playing with our mix a little, trying to understand how we could lever skilled care versus unskilled care. There’s a lot of things that you can do in a holistic way, taking care of people in hospice that doesn’t demand pure clinical work, and I think therefore I think I think the model needs to be relooked at in terms of what the criteria are for purely skilled care coming in. There’s elements of other types of care that I think could benefit and provide a better experience. And I’m starting to see people come to that realization, which I didn’t see when I left the business.
Companies featured in this article:
Amedisys, Elara Caring, Gentiva, Humana Inc., Optum, UnitedHealth Group
