Rae Woods:
From Advisory Board, we're bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. The last year has forced a reckoning with much of the way we provide healthcare. And as the state home economy has grown, there are very real questions about how much care can truly move into the home, especially when it comes to the elderly.

Rae Woods:
So to discuss the future of providing hospital level care inside the home, I've brought the co-founder and CEO of Contessa, Travis Messina. Hey, Travis. Welcome to Radio Advisory.

Travis Messina:
Hey, Rae. Thanks for having me, it's good to be here today.

Rae Woods:
Where are you dialing into the podcast from?

Travis Messina:
Today I'm actually in the office in Nashville, Tennessee. It's a nice fake spring day as we call it here.

Rae Woods:
Yes, I know. I feel like we're finally getting out of everyone having seasonal affectiveness disorder, and I truly believe that there's no more obvious moment where you go, "Wow, the winter has been hard." Than when it's suddenly 50 degrees in March and everybody wants to get outside.

Travis Messina:
And in Nashville we're oblivious to the fact that it is still a little chilly so everyone's wearing shorts and short-sleeved shirts. And so a little aggressive for me, but it's all right.

Rae Woods:
Because I'm speaking to a co-founder I kind of always liked to ask, what's kind of the inspiration behind this company? Why start something that's focused on hospital at home, and also, why Contessa? That's not really a healthcare name.

Travis Messina:
Yeah. My family members asked if I was a glutton for punishment because they'd say, "Why are you going to try and convince hospitals to not admit patients to their hospitals?" But the rationale was working at Vanguard Health, we were doing a number of things to prevent hospitalizations in our pop health initiatives, but no one ever focused on that highest cost encounter, and could we come up with a different way to render that level of care, because I thought if we can do that appropriately, and not jeopardize patient safety, we could go after a huge addressable market and really help bend the cost curve.

Travis Messina:
In terms of the name, so my family comes from a town in Sicily called Contessa Entellina, and it's not just about naming it after the town, but they immigrated to New Orleans where they started the Contessa Entellina Society of New Orleans, which helped the Contessioti get care in their home because they couldn't-

Rae Woods:
Oh, wow.

Travis Messina:
... access the American healthcare system. They didn't have money and they didn't speak English, and so it brought the care to their houses and I thought it was a nice homage to the motherland, if you will.

Rae Woods:
Yeah, I love that.

Travis Messina:
So Contessa was formed by myself and a number of my colleagues, and our main goal, Rae, was to partner with health systems to launch hospital at home programs. So taking patients that need to be admitted to the GinMed bed and rendering all that same level of care in the home.

Rae Woods:
And I do want to be careful about buzzwords, I think that semantics actually really matter here, especially when you just said the words hospital at home, what does that actually mean?

Travis Messina:
I can't thank you enough for asking that question, Rae, because there are so many companies and health systems and people out there that are talking about hospital level care at home, and it means a thousand different things to a thousand different people. When Contessa talks about hospital at home, we are talking about those patients that have failed ambulatory treatment and need to be admitted to a facility for several nights of care, typically for medical conditions.

Rae Woods:
So give me an example maybe about how that would work. What's a example, medical condition, can't be taken care of in the ambulatory space needs, hospital level care, but tell me how that actually works in the patient's home.

Travis Messina:
Yep. So, if you think about the admissions to health systems about 40-ish percent of them are for medical conditions, general medical complications. And so, let's take congestive heart failure, or COPD, or pneumonia, those are very frequent cases that we treat in our hospital at home programs. Many times those patients can be treated with ambulatory treatment plans, however, those plans often fail, and that's when those patients require to be admitted to a facility for several nights.

Travis Messina:
And so if we have, say for instance, a pneumonia patient, they've probably had oral antibiotics for a number of days and it's just not taking care of that pneumonia, and so they're going to need more continuous monitoring, oxygen treatments, infusion antibiotics, much higher acuity services, and we are able to replicate all the care they'd get in the hospital in their home.

Rae Woods:
How? I mean, when I think of hospital level care, I think that is cared that requires specialized equipment, specialized technology, specialized training and staff. How do you actually make that happen in someone's home?

Travis Messina:
So the number one, I guess, misperception is that people think that you can do hospital at home without hospitals. And we partner with health systems and hospitals because when patients need that level of care, 80 to 85% of the time, they actually show up in the emergency departments. So we have team members that are based within the emergency departments of our partner health systems, they identify those patients as needing that level of care, we use admitting hospitalists, no differently than a hospitalist would admit to the floor, they admitted to our program, and we send that patient home.

Travis Messina:
If you think about a traditional general medical admission, they're getting rounding by a nurse every few hours, but they're not continuously monitored. If you need continuous monitoring, you're going to the ICU, send nurses to the home twice a day, and they render labs, plan film imaging, infusion services, and once a day, while they're there, a hospitalist rounds on that patient virtually using a remote patient monitoring kit.

Rae Woods:
Oh, interesting. Okay. And this, I think is top of mind for the entire healthcare industry right now because, as we know, COVID-19 has just put a spotlight on site of care shifts in general. I want to take a moment and talk about the role that Contessa has played when it comes to the COVID-19 crisis specifically, the direct impacts of battling this pandemic. What did you see as Contessa's role in the fight against this crisis?

Travis Messina:
There's been several instances in which contest has been leveraged throughout the pandemic. The one that immediately comes to mind is the work that we did in New York. So we are partnered with the Mount Sinai health system, and as everyone knows, New York was hit hardest and first by the surge. And so, I think it's okay to say this, but at one point in the spring, Mount Sinai had every single bed in their system filled by a COVID positive patient, and there were just simply not enough beds. They had tents and everybody knows that they were using the Javits Center, and all these things.

Rae Woods:
Patients were dying in urgent care centers. Yeah, absolutely.

Travis Messina:
And so we began using our model, A, to free up capacity, so they could use that bed for higher acuity patients first and foremost. And while we first were not planning to treat COVID positive patients, it became a necessity.

Rae Woods:
Oh, really?

Travis Messina:
Yep, the physicians came to us and said, "Look, I know that this is something that we haven't done, but we have to come up with a care plan. We have to come up with it quickly and make sure that we're not jeopardizing patient safety." And so that was probably the second use case, if you will, where we stepped in and started treating COVID positive patients at home.

Rae Woods:
To protect capacity, to stave off outbreaks, and ultimately to just treat more patients, obviously there are use cases beyond the surges, especially as, I'm going to knock on wood as I say this, since surges seem to finally be getting under control here in the United States. So beyond the kind of direct impacts of the pandemic, what are the other strategic reasons that an organization might want to partner with Contessa to invest in home based care?

Travis Messina:
Yeah. So, I mean, having come from a big integrated health system and having a... I'm more of a finance and accounting guy by training, I'm not a clinician, when we created the company, we were trying to think of the ways that we could satisfy, just as you said, strategic reasons why health system should offer this as part of their toolkit, for lack of a better description. Because if you're not at capacity, and you don't own the premium dollar risk, why on earth would you willingly take a patient you could send to the floor and get reimbursed for it and send them home.

Rae Woods:
Right.

Travis Messina:
And so those were the questions that we were really trying to solve when we started the company. And ultimately, I think before the pandemic, we came up with a couple of reasons. One, medical admissions typically have a very poor margin profile, from an economic perspective for health systems. And so we thought that if we could come up with the appropriate reimbursement structure, a system would be financially incentivized to do so, to admit to a hospital at home program, as opposed to admit to their floor.

Rae Woods:
Because it also means that opens up capacity for more profitable services for that hospital.

Travis Messina:
That's not exactly the argument that I would use because I would never say that you could guarantee you're going to backfill that bed. And more importantly, how do you know that you're not going to backfill that bed with a Medicaid patient or an OPA patient? And so we look at it, when we do the financial analysis, we always assume that you are not going to backfill that debt, and what would the financial impact be under our risk arrangement versus the traditional healthcare or hospital delivery system.

Rae Woods:
I do want to go deeper into the financial. So I think what I just heard you say is that you create the right reimbursement structure to make it make sense financially for this kind of medical care to exist in the home. How does that work? What is the reimbursement structure?

Travis Messina:
Yep. So we use a bundled payment approach for our hospital at home programs. All of our health plan contracts are risk-based arrangements for 30 or 60 day episodes of care. And so we're not just looking at what health plans reimburse the hospital, but we're looking at all the related spend over that 30 to 60 days. And that is what enables the health system to participate in economics that are outside of what is in their control, and that's where you make the financial benefit to a health system that's not at capacity.

Rae Woods:
When you're talking to health system executives, let's say, specifically the CFO, what are the biggest questions or pushback that they give you when it comes to this payment model?

Travis Messina:
So it's been funny because CFOs have actually become our biggest advocates for the program.

Rae Woods:
Oh, really? That is not usually the case.

Travis Messina:
Right, like you don't... And the CFO of Dignity Health in Arizona, Doug Watson, he always says, "You don't always hear about CFOs promoting new care models." But the biggest pushback rate that I would say is the, "Help me understand exactly this is going to benefit me if I leave that bed empty in my hospital." That's the number one question. And our head of analytics, Patrick Armentor, he's a cost accountant by training and he used to run decision support for a big health system, and so he speaks their language and he walks in and we lay it out very clearly, "This is what you make when the patient comes into your hospital, and this is what you will make in our program." And we show that margin accretion that is possible of a hospital at home program under our structure.

Rae Woods:
And does that value proposition change when you talk to other industry players? I'm thinking, does it change when you're speaking to, say, health plans?

Travis Messina:
The health plan value prop is always the same. We go in, we look at the historical spin, and we prospectively that new rate for us off of that old rate. And so every single time one of their members comes into a program, they know that they're saving on average, saying illustratively, 15% for a Medicare Advantage member or 30% for a Commercial member. So they know it's going to be the same value prop every single time.

Travis Messina:
Now it may vary by market depending upon utilization and rate, and Nashville is going to be very differently priced than New York city, for instance. And so you always have to account for those market nuances, but generally speaking, it is a pretty consistent value prop to a health plan.

Rae Woods:
So we've been talking about the value prop for the kind of classic industry stakeholders, the providers, the payers, but the other kind of big stakeholder here are the patients and the caregivers and the family members themselves. And this kind of brings me back to COVID-19. One of the most tragic kind of elements of this crisis has been what it has meant for post-acute facilities in general. Suddenly hospitals, skilled nursing facilities, they were seen as dangerous places, the last place that you would want grandma or grandpa to end up in. So there's an obvious preference for those patients and caregivers. How much has that changing patient preference influenced these kinds of site of care shifts?

Travis Messina:
It's really interesting. So before COVID, the biggest barrier to adoption for the model was the fact that CMS did not reimburse for hospital at home for Medicare fee for service beneficiaries. They implemented a waiver the day before Thanksgiving, an individual waiver that allowed hospitals to sign up for it, and if they could demonstrate efficacy and safety, they would get approved.

Travis Messina:
And one of their primary initiatives, Rae, was so that patients wouldn't be afraid of withholding care because that's what was going on in America. You had patients that were concerned about either going to a hospital or potentially having to get discharged to a skilled nursing facility where they would be exposed to others that had this horrible virus, and this created an alternative that previously didn't exist, and that has driven massive adoption from health systems as well as the patients themselves because they know it's an acceptable form of care.

Rae Woods:
That is super interesting to me because it's not patient preference in a vacuum, it's patient preference influencing policy that ultimately benefits, again, the patients and the providers, the payers, et cetera. But is that something that you expect to stick around? I mean, a lot of these waivers are crisis waivers alone, is that something that you're tracking for the future?

Travis Messina:
Absolutely, and advocating heavily to see sustained for the term. So to be very explicit, this waiver for acute hospital care at home is only allowed during the public health emergency. Various folks from CMS, in innovation center for CMS, CMMI, they've stated, "It's our goal to make this available long-term." But they never hesitate to mention at the end of every call, "This is only during the public health emergency."

Rae Woods:
Let's say it does go away, does that change anything for Contessa?

Travis Messina:
It does. I mean, as I mentioned earlier, one of the hardest parts about Contessa and hospital at home is trying to create a reimbursement mechanism for a care model that previously didn't have reimbursement structures. So when you lose the biggest payer in the United States, it really makes it tough. And it's helped us in the interim because a number of health plans have started signing on very quickly and saying, "Hey, CMS set the precedent, we want to follow suit, but if they do reverse course, I can't deny the fact that it will create challenges, but they're not challenges that we weren't able to overcome previously because we had signed up a lot of health plans prior to COVID."

Rae Woods:
And it's a good reminder that as important as patient preference is for any site of care shift, you also can't rely on patient preference alone, feasibility does matter, payment does matter, regulation does matter.

Travis Messina:
Yeah, it's funny. So, I mean, it's no surprise that everyone is concerned about the solvency of the Medicare trust fund, I heard on your podcast where you guys talked about that interestingly, I think, becoming completely insolvent in the next election year.

Rae Woods:
That is correct. You are just feeding my ego, thank you.

Travis Messina:
So I will say that the feedback from CMS, a huge portion of it was, what impact will this model have on the Medicare trust fund? Because all of a sudden we are now paying rates for hospital level care that is being rendered in the home, and how do you prevent bad actors from all of a sudden dropping claims for hospital equivalent rates when the patient is not going into a hospital? We have suggested value-based payments, but completely recognized the fact that this is a pandemic and you can't let perfect get in the way of good, whatever the saying may be. And so, they opted just to pay the full DRG, it's our hope that they move to a value-based payment, I think that will solve that issue. But yeah, time will tell.

Rae Woods:
Absolutely.

Rae Woods:
I want to talk about one other constituency that really matters here. Again, we've talked about the patient kind of caregiver, we've talked about the incumbent organizations, we've even talked about payers, including government payers, but I want to talk about the actual workforce, the doctors, the nurses, the clinicians that are part of this program, let's start first with, how do you make the clinical workforce comfortable with the idea of sending patients home?

Travis Messina:
It's really hard. I'm not going to deny that fact. So we are asking hospitalists and nurses to take a patient that has always been admitted to the floor and now send them home. And it takes a while for some folks to wrap their head around that.

Rae Woods:
What makes the light bulb kind of go off for them? I mean, I imagine that COVID has helped a little bit, again, because hospitals, skilled nursing facilities seen as dangerous places, but how do you help them make that shift?

Travis Messina:
First of all, I'm nowhere near that conversation. It has to be led by our clinical team and we've got an amazing clinical team. Our chief medical officer is Mark Montoney, he's a geriatrician by training. He's been the CMO of three very large health systems, OhioHealth, Vanguard, and then Tenet Health.

Travis Messina:
And he walks in and he says, "Hey, let's just talk about what your care plan would be for this patient on the floor." And he has them describe what they would do, and he goes, "Now, what requires that they need to be in the building 20 feet away from a nurse that would preclude you from doing that in the home if we can guarantee that we can get them back into the health center if there is a complication, that we can get them all of those services and turnaround times that mirror what you would render on the floor?" And so when he talks through those elements, or a member of his team talks through those elements, that's where you start to see comfort.

Travis Messina:
And the last thing that I would state is we always talk about a crawl, walk, run approach. You have to start with, I don't want to say easier patients, but ones that is well within the comfort zone of those physicians. And over time, they begin to acclimate to higher levels of acuity for patients in the program.

Rae Woods:
And I think physician comfort or physician preference is one piece of this, but I also have to acknowledge the fact that the workforce in general is going through a crisis of their own. They are, I mean, unbelievably capacity constrained, overworked, dealing with trauma, headed towards burnout, turnover is the highest we've seen in many years, and all of those things are especially worse in the post acute space.

Travis Messina:
So I completely agree with the comment, Rae. And it's been a delicate balance because we do equity joint ventures with health systems and we're partners with those health systems. A lot of the hospitalists are getting extremely burnt out because their panel sizes are... Candidly they're pushing North of 20, 25 patients, and they haven't had a day off in a year. We were talking with the [inaudible 00:20:55] medical director that has been on since January 1st, and I said, "January 1st, 2020?" He goes, "That's right."

Travis Messina:
And by design, hospital at home programs require smaller panel sizes. So we're talking 12-ish patients per hospitalist. They actually prefer it. So it's created this interesting dynamic with our health system partners because hospitalists and even nurses are saying, "Well, wait a second. I want to go to the hospital at home program." Because they can spend more time with their patients, they can be thoughtful in their care plan, but it's almost like a relief valve for them, if that makes sense.

Rae Woods:
Because they can deal with smaller patients, which helps with the fact that they are traveling from home to home so you almost can't see as many patients as if they're all on one floor. Are there other benefits? Again, I'm thinking about the fact that turnover in the post acute space is well above 100%, I think. And part of the challenge there is that a lot of those clinicians maybe are seen as kind of the bottom of the totem pole. Oftentimes they're not paid as well as some of the other clinicians. Beyond kind of panel size, what are the other benefits for the workforce specifically?

Travis Messina:
Absolutely. I think it's important to note that we have two key team members that are nurses. So we have a recovery care coordinator that is virtual, who is sort of a charge nurse of the virtual unit. And then we have the nurse that is actually in the home rendering the care to the patient and they're at the patient's bedside. And I think the number one benefit to those nurses is the reduction in the clerical or administrative work that takes place in a hospital at home program. And they are focused on rendering care to that patient and making sure that they have the appropriate care plan and they get back to their acts of daily living as quickly as possible. And I've seen massive fulfillment from nurses and their ability to just focus on the outcomes as opposed to documenting in EMR or making sure that they got the appropriate authorizations for health plans.

Travis Messina:
Contessa's mission is to make the healing experience enjoyable, not just for the patients, but also for the caregivers who render care. And we focus intently on how we enable them to really do what people over utilize or [inaudible 00:23:00] as practice at the top of their license, and doing clerical work does not enable them to do what they got into medicine for. So we created our workflows specifically to achieve that goal. It's a lofty goal, we're never going to get there, but we can continuously improve upon it.

Rae Woods:
Can I reveal to you my concern?

Travis Messina:
Of course.

Rae Woods:
I completely understand why this would be better care for grandma. They get to age in place, they get to be taken care of at their home. I also can see a world where this would be better for the clinician who is doing the rounding. They have a smaller panel size, a more manageable workload, they're working as a team. But my concern is, with capacity so strapped across the workforce, and with shortages, especially in the post acute space, what happens for the grandma that is at the sniff that's now down five nurses? What does it mean for kind of the rest of the industry?

Travis Messina:
Well, I think regulation is always going to play a role in ensuring that those institutional settings are always adequately staffed. They're never going to be to a point where they don't have the appropriate staff on their floor to take care of the patients that get admitted. I think if you do have those instances, it should tell you that there's probably an over bedding issue, with respect to those types of facilities. And that that facility probably shouldn't be there because I guarantee you there's an open bed at another facility where there is appropriate staffing. But if I'm totally candid, Rae, I mean, I'm competing against those skilled nursing facilities, and if I can offer a better service with a better outcome at a lower cost, I hate to say this, but that's what makes us attractive to health system partners because they are competing with those institutions and they want to continuously improve their market share and this is a vehicle then it can enable them to do so.

Rae Woods:
And let me ask you this, with shortages of clinicians, especially nurses, and I should say a shortage of nurse experience being top of mind for many, are you concerned at all about that for your clinicians through Contessa?

Travis Messina:
I'm obviously concerned about the ability to recruit high quality caregivers because it's the foundation of everything that we do. That being said, I do feel that we offer an amazing environment in which a nurse or a hospitalist or a nurse practitioner can advance their career. I think that they are overwhelmingly coming to us and saying, "Hey, I really want to work with this hospital at home program." We have nurses from each one of our partners that have come to us to say, "I would like to move to this type of care model." And so again, if you're offering a great service and you can offer a great environment where someone can be a part of a great team, that is going to enable us to attract the highest and best talent.

Rae Woods:
Which is especially important for you all because you probably need more nurses and more clinicians than the status quo model, because it's a smaller panel size, because they're going to be traveling from home.

Travis Messina:
Definitely. I mean, if you look at our staffing ratios, not to get really technical, but one nurse can probably take care of, call it, five to six patients a day.

Rae Woods:
Okay, wow.

Travis Messina:
Because if you think about it, they've got drive time that's included in that, and so if they work a standard shift, they can probably make it to five or six patients. If patients are kind of later in their hospital at home experience, maybe they can get to seven and that's kind of pushing it, and we can still do so in an economic manner.

Travis Messina:
If you look at hospitals, obviously they've got kind of eight to one staffing ratios. They're on the floor and they can see a lot more patients in a day given that staffing ratio and the shifts that they work. So we do need high quality nurses, we need more nurses, but again, we work hard to create an environment that makes it attractive to them.

Travis Messina:
And I think, ultimately, when our partners look to us and the need or the demand that we have for nurses, they view us no differently than a new hospital that they're building, the CFO of Mount Sinai always says, "Hey, we've got eight brick and mortar hospitals and our hospital at home program with Contessa is our ninth hospital." And so he's got to staff that appropriately.

Rae Woods:
We've been talking about how a lot of the headwinds that were previously against this kind of home-based care have changed. Many of those kind of classic barriers have come down, especially when it comes to things like regulation, reimbursement, et cetera. When it's all said and done, how much shift to the home do you actually think is possible? I mean, is this just a slice of the total care, moderate, significant, all of it, what are you thinking?

Travis Messina:
Oh, we're definitely not even at the bottom of the first inning. Sorry, I'm a big baseball fan, and so I'm going to use a baseball analogy.

Rae Woods:
Wait, hold on. What's your team of choice?

Travis Messina:
Cardinals.

Rae Woods:
Okay.

Travis Messina:
Sorry.

Rae Woods:
I live in a very strong Red Sox household, but I will let that go.

Travis Messina:
Yeah, boo that one. I went to the Red Sox-Cardinals World Series game in 2013 game one, and it was not good for my team. So congrats on that one.

Rae Woods:
So we're not even at the beginning of the first inning?

Travis Messina:
We're not even at the beginning of the inning. And I would use two analogies of new care models to substantiate where hospital at home is on its maturity curve, if you will. So the first analogy that I will utilize is ambulatory surgery centers. If you go back to the mid... I believe it was in the mid '70s when the first physicians established an ambulatory surgery center in Phoenix, and then in the late '70s, CMS approved specific codes. And then in the early '80s they approved several hundred codes to reimburse services rendered in an ASC.

Travis Messina:
If you look at surgical volume on an outpatient basis in the early '80s, it was about six or 7% of all surgical volume in the United States, and in the early 2000s, it was about two thirds of all surgical volume, either an HOPD, hospital outpatient department, or in an ambulatory surgery center. And I think that's the growth curve that you'll see with hospital at home.

Rae Woods:
Okay. Travis, what's next for Contessa?

Travis Messina:
So you asked about what other surfaces can be rendered at home. Obviously there is a rate limiting factor on that, you're never going to do cabbage in the home, you're never going to treat patients that are in the throes of an acute EMI in the home, we're not that naive at Contessa.

Travis Messina:
However, we will and are starting to expand the services that we offer in the home for other high acuity patients. We just announced a home-based palliative care program with Mount Sinai, which we're really excited about. And ultimately, we will offer everything from primary care, to end of life care in the home.

Rae Woods:
Oh, wow.

Travis Messina:
Yeah. We started with the highest acuity and most emergent encounter with hospital level care, we then went to SNF at home, now we have palliative at home, and we'll continue to expand those services.

Rae Woods:
So maybe healthcare goes full circle back to the olden days.

Travis Messina:
Yeah. I completely see that happening. I mean, it's kind of a lame analogy or story, but I grew up in Louisiana and my father was an orthopedic surgeon. I used to round with him as a kid on Saturdays when he would go see his patients. And that hospital had two floors.

Rae Woods:
Wow.

Travis Messina:
And Baton Rouge did not experience some massive growth in the last 40 years, but that hospital is now 10 or 12 stories and has several wings. There's not that much demand for that type of service. And I think like everything else in our economy, people are desiring more services in their home and you'll continue to see that adoption, especially in healthcare.

Rae Woods:
Absolutely. Well, Travis, I want to ask you one final question. It's the question that I ask at the end of every episode, and it's kind of a moment for you to speak directly to the industry and to our listeners. When it comes to site of care shifts, when it comes to hospital at home, what's the one thing that you want our listeners to focus on right now?

Travis Messina:
I think it's most important for your listeners, and I know that they are health system, health plan leaders across the industry that listen to this podcast for obvious reasons. The one thing that they have to remember that it is a gradual shift. We are not going to talk about massive out migration of patients from institutional settings to the home overnight because it will take time for the industry to adopt, it's going to take time for the clinicians to adopt, it's going to take time for the payers to adopt, and it's going to take time for the patients to adopt.

Travis Messina:
And so there shouldn't be this fear that there's going to be this giant vacuum sucking all the patients out of their facilities and thus the corresponding financials that go along with it. It takes time, and just like tele-health took time, and every health system has a tele-health strategy, hospital at home will take time, and every health system should have a tele-health, or I'm sorry, a hospital at home strategy. So I think that that's the one thing that they have to [crosstalk 00:31:55].

Rae Woods:
Every health system should also have a tele-health... [inaudible 00:31:57] be focused on tele-health, but that's a conversation for another day.

Travis Messina:
That's absolutely right. But I mean, I think that there is this massive fear that if you take patients that historically resided in a bed and now you start rendering them care in the home that you're going to go out of business, and that's not the case. These institutions have been in their towns for hundreds of years and they will continue to be in their towns for hundreds of years for good reason. But we do have to adapt with change, and that change is often led by the consumer. And I think that there's an overwhelming voice coming from the consumer right now that says, "Hey, we want this service." And so I think there needs to be that adoption with appropriate delivery, or deliberate speed, I should say.

Rae Woods:
Well, thanks, Travis.

Travis Messina:
Thanks for having me, I appreciated the opportunity.

Rae Woods:
We'll be right back with what our research team is watching this week.

Rae Woods:
This week, we're actually going to revisit some of the things we've discussed on the podcast before and check in on how they're progressing. Pressure is growing among Democrats to reform the filibuster. We talked about this in episode 58, much of the democratic healthcare agenda will be impossible to achieve if the Senate filibuster remains in place.

Rae Woods:
Senator Joe Manchin of West Virginia, and President Joe Biden, two lawmakers who have traditionally supported keeping the filibuster, have recently come out in favor of a talking filibuster, which would actually require the minority party to speak for the duration of the filibuster. Think like we might see in TV shows and movies.

Rae Woods:
Now there is no guarantee that the reform will happen, and even if it does, the minority can still override the legislation, but it would make the process a lot more tiresome, which would potentially create an opening for Democrats to pass some of their legislative agenda.

Rae Woods:
Meanwhile, hospitals are slow to comply with policies enacted by the last administration. We talked about this in this segment before, there's a new hospital price transparency rule that took effect in January, but a new analysis published in health affairs found that almost two thirds of large hospitals are not yet meeting the transparency requirements. Non-compliance results in a fine, but it's just $300 per facility per day so it might not be enough motivation in the short term, particularly as hospitals continue to respond to COVID-19. We'll keep watch to see if more hospitals comply under the current rules, or if CMS ultimately decides to increase the penalties.

Rae Woods:
We're also continuing to follow influential partnerships and big moves in the technology sector. Patient navigation company, Grand Rounds, and tele-health provider, Doctor on Demand, announced plans to merge last week. The plan is to pair Grand Rounds' navigation tools with Doctor on Demand's virtual care services, ultimately creating more longitudinal digital care. This is, of course, following in the footsteps of Teledoc's acquisition of Livongo last year.

Rae Woods:
That job may have gotten a little bit harder because Amazon just revealed its own virtual care first offering. It's called Amazon Care, the app based service previously only available to Amazon employees in Washington state, will soon be offered to employees nationwide, and the company is inviting other employers to participate as well. Just like we said, in episode 60, Haven Healthcare was never the only plan for Amazon, and the recent acquisitions are proof that the potential to disrupt healthcare isn't going away anytime soon.

Rae Woods:
And as always, remember, we're here to help.