Thursday, February 28, 2019

This is not financial advice, continued

House of cards?

These are the publicly-traded companies I've identified that are currently working the hospice space. You can read more about them at their respective websites.

I've decided to buy one (1) share in each of these companies.

I'm doing it in order to be able to obtain information and ask questions as a shareholder. This is not investment advice, and I'm not suggesting that anyone else go out and do this.

At the market close on February 28, 2019 I own AMED, EHC, and ENSG. I entered limit orders, and am waiting for my price on HUM, CHE, and LHCG.

Humana (NYSE: HUM) is 40% (minority) owner of a 3-way investment consortium whose other two (majority) owners split the remaining 60% - private equity firms Welsh, Carson, Anderson & Stowe and TPG Capital. They're trying to combine the hospice operations of three former companies: Kindred, Gentiva, and Curo.

It's also the story behind the amazing blog, Generic Hospice.

Amedisys (NSDQ: AMED) is pursuing "non-organic growth."

CHEMED Corporation (NYSE: CHE) has two divisions, Vitas and Roto Rooter.

Encompass Health (NYSE: EHC) is the re-branding of the scam and scandal-ridden HealthSouth, leveraging its 2015 acquisition of Encompass Home Health and Hospice based in Dallas.

LHC Group (NSDQ: LHCG) is one company where I haven't quite got a handle on their business model yet.

The Ensign Group (NSDQ: ENSG) is also a little difficult to figure out. It looks like they own a bunch of nursing homes and different sorts of rehab and retirement facilities, as well as a home care and hospice business of some kind. But they also refer to "affiliate entities" in a vague, unhelpful way (to me).

And, can someone please tell me what the 2:42 video on their main page (scroll) is supposed to mean?

meanwhile, back in 2005...

That's a screen snap of the abstracted results and conclusions from McCue,M. Thompson,J. (2005). Operational and Financial Performance of Publicly Traded Hospice Companies. Journal of Palliative Medicine,8(6),1196-1206. DOI: 10.1089/jpm.2005.8.1196

On PubMed.

The 2005 study by McCue and Thompson examined the performance of four publicly-traded hospice companies. 

Odyssey Healthcare - 65 hospices

VistaCare - 38 hospices

Heartland* - 89 hospices

Vitas Healthcare** - 22 hospices

Total: 214 hospices

* subsidiary of Manor Care 

** division, CHEMED Corporation (NYSE: CHE)

Since 2005, Odyssey bought VistaCare in 2009 for $147.1M, before itself being bought by Gentiva for $1B in 2010, which was subsequently bought by Kindred for $1.8B in 2015, which itself was sold to the Humana/TPG/WCAS consortium in 2017 for $4B, which had since gone on to also acquire Curo for $1.4B in 2018. 

Since 2005, Heartland/HCR Manor Care became privately-held, underwent various spinoffs, reorgs, and other financial transactions, entered bankruptcy protection in 2018, and was acquired in 2018 by ProMedica Health System.

Thanks for reading. See you next time.

Monday, February 25, 2019

Failing CMM-101

re-branding includes PhotoShop

I've been tracking down information on the companies maneuvering to dominate the hospice industry in the coming years, as Boomers get old, sick, and die. 

That's easy for the publicly-traded ones like Amedisys (NASDQ-AMED) - snag their annual reports.

Most of the reading is pretty tedious. I'm not a lawyer, accountant, or finance-type, which I think are the best skill sets to have for going over the fine numeric and related details.

The text is generally corporate weaselspeak - extraordinary claims surrounded by disclaimers.

But ya gotta start somewhere.

Anyway, I always manage to find a chuckle or two buried in the pile.

any alternatives to 'shiny happy people?'

I've spent almost half of my nursing practice in business roles, including marketing and marketing communication, but can't believe I'm the first person to notice this.

AMED annual reports - collect 'em all!

Also, too: My mother always said, "Follow the money. In the end, no matter what else they want you to believe, it's always about the money." (includes full video!)

Thanks for reading. See you next time.

Friday, February 22, 2019

This is not financial or investment advice

PowerPoint, the worst possible way to convey information

What the slide tells me, IMO

Get the full AMED roadshow at Seeking Apha.

Here's a their filing with the SEC.

Thursday, February 21, 2019

At least it's not a meat grinder

Blender cost is up to $5.4B +/-

Here's another index card graphic, or slide panel - I'm not sure what to call it - from the presentation or video I'm working on. Anyway, the text is from a press release available through the SEC or the online press room at TPG Capital.

Here's the full paragraph I used to pull the quote:

" The Consortium members partnered with the objective of investing in and building businesses that can help modernize, enhance and transform home healthcare in America. Curo brings a highly capable management team and a tech-enabled, centralized model for hospice care that presents the opportunity for Humana and its Consortium partners to be a leader in managing the continuum of home health, palliative care and hospice in an integrated fashion, creating a positive and differentiated experience for patients and their families – as well as their care providers. This integrated model will leverage data and analytics to measure and advance evidence-based clinical outcomes for patients and seamlessly coordinate the transition from home care, to in-home palliative care, and thoughtfully into hospice, as chronically ill patients’ disease burdens progress."

That's the plan, as they say.

MOST IMPORTANT: Catch up on the story, or jump in at any point, over at Strange Tony's Generic Hospice blog.

Wednesday, February 20, 2019

Peeking up from the rabbit hole...

After getting that fateful call from a colleague (Part 1 Part 2) I've been researching what's happening here in the Commonwealth ("God save it!") with regards to hospice, and it's brought me into the murky world of private equity (PE) investing in corporate mergers and acquisitions (M&A), a place where MBA's armed with algorithms and hubris confidently predict to rich people and others with big money that they can become even richer and bigger by investing in their schemes.

They are masters of the universe.

Here's the most current list I could find of the one-hundred biggest US hospice corporations, companies, agencies, and other players. I've highlighted the first 10. Ranking by LexisNexis:

Yeah, that's not so helpful. Let's really focus on the ten biggest players in the nationwide hospice sandbox, based on their percentage share of a total national market:

I've crossed-off #9-Hospice of the Valley because as a tax-exempt not-for-profit agency, they're not relevant to our current discussion.

But, since they're non-profit we can easily review Hospice of the Valley's financial and operating information by looking up their IRS Form 990.  

The latest available for 2015 shows $131,481,031.00 ($131M) in service revenue. Their 2017 LexisNexis ranking shows their market share at less than 1% (0.81%).

I'm going to estimate each percent of market share at $150M, just because. You can go higher or lower.

Two significant deals have gone down since the LexisNexis list came out. Here's how they've shaken the board:

There's no reason to expect this to end anytime soon. The top player, either Vitas or Kindred/Curo, still has less than 5% of total national market share. 

Only seven players, or five, have more than 1%

We're looking at a classic "fragmented industry" as taught in business schools everywhere - one ripe for consolidation, with lots of money to be made buying and selling hospices. 


Boomers are getting old, sick, and dying. It's a demographic wave, and the surf is most definitely up.


Note: I developed these graphics as part of a project to present the overall story as a presentation or video. That's part of the rabbit hole. I'll get it done.

Also, too: be sure to follow Strange Tony's ongoing saga of corporate psychopathy at Generic Hospice, and the deeply personal reporting by Steve Lopez at the LA Times about how a hospice agency failed his mother and family

Thanks for reading. See you next time.

Monday, February 11, 2019

Reporting in pictures: Excellent brunch, people, connections, and contact hours made possible by End Game - FREE!

Gardens within gardens...

First things first. Yes, there is a garden at the Virginia Thurston Healing Garden Cancer Support Center in Harvard. It's everywhere.


And here, among other places.

"End Game isn’t an easy watch, but it’s a film America needs."

Shoshana is an executive producer on End Game, and joined us via video to introduce the film.

We watched Mitra



Pat, and the people who loved them. 

Brianne guided the post-film discussion track: "Facing loss, finding meaning, being human: the clinician’s challenge."

Jerry guided the post-film discussion track: "Tools and strategies to inform conversations about prognosis and goals."

Everyone viewed the film, actively participated in both discussion tracks, provided thoughtful evaluations, and acted on their personal commitment to lifelong learning, as evidenced by...


- Brianne Carter, LICSW, MTS, OSW-C
- Rachel Lucas
- Kelly Marchand
- Christine Zinke, LICSW

- Timothy Boon, RN
- Colleen Cusack
- Catherine Monoxelos, PT
- Jennifer Sax

- Linsey McNew



Facing loss, finding meaning, being human: the clinician’s challenge 
Brianne Carter, LICSW, MTS, OSW-C


1. Mitigate clinician burnout through increased awareness of the physical and emotional impact associated with working in a field where significant loss is a common experience. 
2. Discuss the effects on clinicians of working with suffering, loss, death, and grief.
3. Identify ways to improve clinician well-being, find meaning, and feel a sense of purpose.

While watching the film...

Notice what goes on in your body as you watch the film — see if you can stay present with what you are experiencing as the film moves you, especially in conversations or scenes about death. 

For Discussion

“There is nothing inherently medical about dying. It is much larger than medicine. Dying is purely human. Part of the mission is to keep all of this couched in humanity. Not medical science or social science but the full arch of humanity. Kindness. Total openness. Vulnerability.”

~ B.J. Miller, MD Zen Hospice Project

Question 1: What did you notice about what went on in your body while watching the film? Are these responses ones that you have to “turn off” or “ignore” when working as a provider? 

B.J. Miller at Zen Hospice Project said: “My interest in being a physician was learning to live with my own illness, trying to fashion life when shit goes wrong… When I stopped comparing my new body to my old body, when it wasn’t about what I lost, I stopped suffering. My identity had accommodated the facts of my life. I like to think of suffering as a gap, as a wedge between the world you get and the world you want… The basic principle of the Zen Hospice Project is you don’t run away from hard stuff, you don’t run away from suffering.”

Question 2: What has been your original and continued motivation to work in this field? 

What sustains you while you accompany others through relentless loss (death, ambiguous loss, traumatic loss) and suffering?

B.J. Miller at the Zen Hospice Project gives one of his patients an assignment, “ have some sort of relationship with death… If we can’t change not knowing what it is like being dead, then getting used to holding the mystery.” 

Question 3: After watching this film, what would you say is the quality of your relationship with death? Give it one adjective: _____________________. 

What kind of relationship would you like to have with death?

“To live in this world, you must do three things:
To love what is mortal
To hold it against your bones knowing your own life depends on it
And when the time comes to let it go, to let it go.”

~Mary Oliver

Some suggested reading

Gawande, A. (2014). Being mortal: medicine and what matters in the end. New York, NY: MacMillan.

Kalanithi, P. (2016). When breath becomes air (First edition.). New York, NY: Random House.

Oliver, M. (2017). In Blackwater Woods. Devotions: the Selected Poems of Mary Oliver. Penguin Press.

Ostaseski, F. (2017). The five invitations: Discovering what death can teach us about living fully. New York, NY: MacMillan.


Tools and strategies to inform conversations about prognosis and goals for care
Jerry Soucy, RN, CHPN


1. Describe the key difference between palliative care and a hospice plan of care.

Palliative care may be appropriate with any diagnosis, prognosis, or age. A hospice plan of care may be appropriate for someone diagnosed with a serious illness with a prognosis of about 6 months or less.

2. Identify 4 aspects of the patient’s and family’s experience of serious illness and end of life that are important for clinicians to assess and address.

1. Their understanding of prognosis.
2. Their preferences for treatment at end of life.
3. The current, desired, and maximum symptom burden.
4. The current, minimum, and desired quality of life.

3. Describe the role of a surrogate for making decisions about medical treatment.

a) Ethical constructs: substituted judgement, informed consent, autonomy, self-determination.
b) Application in practice - Massachusetts Health Care Proxy.

Application to social work practice - Skills and strategies for assessing and supporting informed decision making in the context of serious illness and end of life.

Discussion questions

1. How can we provide a context to help patients, families, caregivers, and clinicians understand disease progression, symptom burden, functional decline, prognosis, and “What happens next?” 

Tool - The Palliative Performance Scale (PPS)

2. How can we guide a systematic assessment for symptom burden, quality of life, and patient/family-centered goals for care? 

Tool - The modified Mini Suffering State Exam (mMSSE).

3. What factors can contribute to optimal patient/family-centered outcomes?

a) Exploring their knowledge, understanding, values, and priorities;
b) Establishing meaningful and attainable goals for care;
c) Matching options for medical treatment to the goals.

Tool - Ask five questions, choose the goal, select the treatment.

Some suggested reading

Boucher, J, Bova, C, Sullivan-Bolyai, S., Theroux, R., Klar, R. Next-of-kin’s experiences in End-of-Life Care. Journal of Hospice and Palliative Care Nursing. 2010;12(1):41-50.

“Communication issues emerged as an important concern for the next-of-kin respondents. Specifically, they used both positive and negative terms to describe their concerns about receiving information on what to expect at the end of life, the how and when of dying, to whom they should communicate information, and healthcare providers’ styles of presenting sensitive information.”

El-Jawahri, A. et al Qualitative Study of Patients’ and Caregivers’ Perceptions and Information Preferences About Hospice. Journal Of Palliative Medicine. 2017;20(7):759-766.

“Study participants had misunderstandings about hospice and perceived end-of-life (EOL) concerns such as fear of suffering, loss of dignity, and death, as well as lack of knowledge as the main barriers to hospice utilization. Interventions are needed to educate patients and their families about hospice and to address their EOL concerns.”

Epstein, A. et al. Development of an advance care planning paradigm for advanced cancer: person-centered oncologic care and choices (P-COCC). Psychooncology. 2017;26(6):866–869.

“The discomfort reported by several participants in this study reflects the delicate nature of having advanced cancer and discussing values regarding advance care planning (ACP) in that context. Nonetheless, all these participants indicated that such questions were necessary and relevant. Additionally, approximately one third of patients who were eligible declined to participate in the study, which reflects known challenges in accruing patients with advanced cancer to behavioral research.”

O’Donnell, A. et al. Social Worker–Aided Palliative Care Intervention in High-risk Patients With Heart Failure (SWAP-HF): A Pilot Randomized Clinical Trial. JAMA Cardiol. 2018;3(6):516-519.

“Patients at high risk for mortality from heart failure (HF) frequently overestimate their life expectancy. Without an adverse impact on quality of life, prognostic understanding and patient-physician communication regarding goals of care may be enhanced by a focused, social worker–led palliative care intervention that begins in the hospital and continues in the outpatient setting.”

Whitehead, P. Carter, K. A Model for Meaningful Conversation in Serious Illness and the Patient Preferences About Serious Illness Instrument. Journal of Hospice & Palliative Nursing. 2017;19(1):49–58.

“Engaging the patient as a partner in their care decision making will yield care that is reflective of the patient’s wishes and consonant with best practice. The Patient Preferences About Serious Illness Instrument (PASI) is an option for healthcare providers to provide a structured, comprehensive methodology in eliciting dialogues with patients and their families.”


UPDATED 02/15/2019
- added images of Thelka, Bruce, and Pat from End Game.