The Role of Long-Term Acute Care Hospitals During COVID-19 and Beyond with Ben Breier
Long-term acute care (LTAC) hospitals are caring for the some of the most medically complex patients during the COVID-19 pandemic. As a post-acute care provider, Kindred Healthcare has been right in the middle of the battle to defeat COVID-19 by partnering with short-term acute care hospitals to help treat patients and ease overcrowding in hot spots across the country. Kindred CEO Ben Breier spoke to Chip about how the company relied on its network of hospitals to ensure its staff were always prepared to provide patients with the highest quality of care.
Breier also discusses a recent report from the consulting firm ATI Advisory that highlights how LTAC providers have been able to bridge gaps and extend care within the care continuum during the pandemic. Based on the COVID experience, the report also recommends key considerations for LTAC hospitals as part of future health policy development. See the full report here.
Speaker 1 (00:05):
Welcome to Hospitals In Focus, from the Federation of American Hospitals, here’s your host Chip Kahn.
Chip Kahn (00:15):
COVID-19 has significantly disrupted so much in our nation over this last year, particularly the delivery of healthcare, but it has also created an opportunity for some of our providers to demonstrate the great good they can do for their patients. The pandemic is highlighting the extraordinary ways our caregivers are meeting the unprecedented challenges of caring for patients in all settings, across the care continuum, including post-acute care.
A recent report from the research from ATI Advisory, highlights the vital role of long-term care hospitals, LTCHs, in caring for many of the nation’s most medically complex patients. These facilities are saving lives during the COVID crisis and cementing their unique contribution to patient care and placing a spotlight on the critical role they can play.
Ben Breier is the CEO of Kindred Healthcare, a major post-acute care provider. In our conversation today, he is lending us his expertise and discussing the role of LTCHs in the care continuum, the care of COVID patients specifically, and the highlights of the new ATI Advisory report. Thanks for joining us today, Ben.
Ben Breier (01:30):
Chip, thanks. Great to be with you. Thanks for having me.
Chip Kahn (01:32):
Ben, to get started, will you tell us a bit about Kindred Healthcare, your vision and aspirations for the company, and your role as the CEO?
Ben Breier (01:43):
Sure. I’ll be happy to Chip. Thank you again. Chip, for those that haven’t paid close attention to Kindred over the last couple of years or followed our story, we’ve gone through quite an evolution, a number of different changes in our organization. We’ve gone from a publicly traded company to a private company. We’ve sold a number of assets over the years, including our large home-health and hospice business to our friends over at Humana. We’ve exited the skilled nursing business and some other things. And we’ve really, I would say, established a foothold now as what we like to call ourselves, the nation’s leading specialty care hospital company. Simply put, I think for us Chip, our mission is to try and help our patients reach their highest potential for health, with what we call intensive rehabilitation and intensive medical care.
We today at Kindred operate hundreds of hospitals across the country. I think we do business in 35 states or so, we run, as you said, long-term acute care hospitals, LTCHs, we run inpatient rehab facilities, we run hospital-based rehab units, we run acute behavioral hospitals and we also run hospital-based behavioral health units.
Kindred I think today Chip, is primarily known for not only the care of these very medically complex patients that we take care of, but really for our ties and our relationships with large health systems across the country, in the form of our joint venture model that we have with many of these folks. We have today nearly 150 joint ventures with some of the nation’s leading academic medical centers, as well as many other regional and national health systems across the country as well. And we prioritize, as I said earlier, delivering clinical solutions and reducing costs to what we always talk about, this 10% of the medically complex patient population that in many ways, account for 60 or 70% of the total cost of healthcare in our country today.
Chip Kahn (04:10):
Thanks Ben for that review of Kindred Healthcare, our focus today is going to be on long-term care acute hospitals, LTCHs. We’re going to drill down there. Will you tell us more about the unique role of LTCHs in the patient care continuum?
Ben Breier (04:27):
Sure. I’d Be happy to. Thank you again. So long-term acute care hospitals are, as we’ve said, LTCHs, I think some don’t know, they are actually certified Chip, as acute care hospital. So we have the same joint commission, the same accreditation, the same certification as any other acute care hospital does. But these are, as I said earlier, specialized hospitals that are really for patients who have a couple of different criteria. One, they might have been in an ICU, in an intensive care unit for at least three days. Two, they may have been on some prolonged mechanical ventilation under a ventilator. And typically our average length of stay is somewhere around about 25 days in these hospitals. Where you might stay two or three or four days in an acute care hospital, you’re staying for a longer period of time in a long-term acute care hospitals.
LTCHs primarily take care of a very medically complex higher acuity patient. It’s a very unique population. Our patients have, for example, multiple systems failures, our patients have organ failures. Our patients have what has become known particularly in a post-COVID world, post-intensive care syndrome. LTCHs are today really playing a vital role, I would say, in helping to achieve a more efficient recovery, if you will, of patients who are at these higher risk levels, that if they weren’t cared for, in our kind of higher acuity setting, they would likely get readmitted back to a short-term acute care hospital or even worse.
I know you probably talked to a lot of CEOs in the healthcare space, particularly on the provider side that get to say this, but I am just honored and humbled every day, when I think about walking the floors of our LTCHs as I try and do often and witnessing, I don’t know, Chip, that there’s any better way to say it, just some of these miraculous recovery stories for patients who have come into these long-term acute care hospitals, gotten this specialized care and honestly might not have recovered had they not wound up in that setting. So that’s really what an LTCH does today.
Chip Kahn (06:51):
Ben, I know considering that COVID is one of the areas that you’ve focused on, and COVID has appended the way many patients are receiving care, including the treatment of severely ill patients, how have LTCHs stepped up in the treatment of COVID patients in the hotspot areas when the acute care hospitals have reached their capacity.
Ben Breier (07:15):
Well, first I’m sure like most people, you and I are sitting here today, I’m sure you find it just as unbelievable as I do that, I think we’re probably almost exactly a year out since the US healthcare system was basically turned upside down on its head because of the COVID-19 pandemic. It’s amazing to reflect on the year that we’ve all had.
And LTCHs, I think like other hospitals, particularly in the early stages of the pandemic Chip, we had to first determine what we knew and what we didn’t know about this virus. Things like transmissibility, the severe medical impact it had on other parts of our patient population. It like most took us a minute to figure out really what we were dealing with in this COVID environment. And when the surge began to really overwhelm hospitals across the country, I thought one of the things that our policymakers and regulators did a really good job of, in a really tough environment, CMS, Congress, et cetera, they took very swift action at a very early stage around providing regulatory relief, waiver relief, and this allowed for, and I think really encouraged if you will, LTCHs to effectively become, if you will, an extension of the short-term acute hospital and particularly of those ICU’s that were filling up so rapidly.
And so initially again, in the early stages of COVID LTCHs really began trying to that extension. And we did it by admitting many of the people who were medically complex, many of the people who were severely ill, that were sitting in ICUs and hospitals, that the hospitals needed to move out, to create more capacity to take this COVID surge. That was really the initial stages.
But I would say that by the end of April into early May, as we at Kindred and others learned more about the virus, specifically our hospital and payer sources, I think really began to realize that LTCHs had in many ways, the exact clinical expertise, that if you think about what a COVID patient is, that is specifically required to treat one of those patients. We also, I think in the early stages, if you remember, as I know you must, we had already in place, the safety measures, the PPE, the protective equipment, and many other things that many of our friends in the post-acute space did not have. And so we were able to respond, I think very quickly to the course.
And so at that point, we actually started dedicating quite a bit Chip, of our LTCH capacity towards helping with the COVID surge. We created COVID specific units where we isolated off and had COVID specific units in some of our hospitals. And in a number of hospitals, and in a number of communities across the country, we actually Chip, had COVID specific hospitals whose only job was to take people who were infected with the disease. It was remarkable to watch our LTCHs and action in the early stages, and now, as a long-term partner dealing with this pandemic
Chip Kahn (10:45):
Stepping in the way you did to alleviate some of this burden on acute care capacity, you mentioned some of them, but what kind of accommodations for your existing patients and those other patients coming online without COVID, did you have to make, to make the whole thing work both for the COVID patients and for your other patient population?
Ben Breier (11:07):
Well, we’ve always had very deep relationships with our referral sources, but I think the burden on hospital bed in ICU capacity was really a unique experience for all of us. Our LTCHs are accustomed, as I said earlier, to treating these medically complex patients who have unusual and different sort of viral presentations, we’ve seen all kinds of different diseases and bugs and different things that have gone through our hospitals. It is what we know, it’s what we do, it’s what we do regularly. And I think Chip, to your question specifically, it’s actually what made us kind of uniquely prepared and qualified to care for these very severely ill COVID-19 patients. I think that once we knew what we were dealing with, we knew that the things we did well, like isolation of patients, disinfection of rooms, and of the surrounding area of patients and the various different cohorting protocols that we’ve gotten very good at over the years, that these were actually going to be ideal for this patient setting. And we just worked hard to apply all that to this pandemic crisis.
Chip Kahn (12:20):
Kindred has a care settings across the country. How has this national footprint and the breadth of these settings allowed you to respond to hotspots more effectively?
Ben Breier (12:32):
Yeah, it’s an interesting question. I think about that a lot, we’ll be better off being across the country nationally, or would we have been better off in one local market? I’m not sure I know the exact answer, but I do think that having a national presence, I think in retrospect, I’ll give you a couple of specific examples. I think it turned out to be a real asset in this emergency.
The first thing that I really reflect on and remember was I remember watching the map early on in the pandemic and seeing the various hotspots across the country sort of pop up. And I’m sure if we all remember back and we think about what happened in the Pacific Northwest right up in Seattle, and then obviously the New York and New Jersey experience, and then how it moved to the Midwest and then down to Texas and Florida. And in many ways we were living it in real time in each of these markets.
So the things we learned in real time about how to handle some of these incredible challenges in Seattle, we were able to very quickly transpose and put to work when we had to face those in the Northeast corridor or other parts of the country. So that I think was the first thing, a better way to say it, it really allowed us to kind of prepare for the surges in the markets, as we sort of saw them coming. But I think there were other tangible examples where having some national presence was compelling for us as an advantage as well.
The first thing I was thinking about was just from an equipment perspective. Obviously, as we’ve talked earlier, we take care of a lot of folks with respiratory disease. We use a lot of mechanical ventilation ventilators, obviously COVID-19 particularly in the early stages, created a need for that. You’ll remember there was a shortage right across the country. People couldn’t find a ventilator. “How are we going to get a ventilator? What are we going to do?” We had car companies that were producing ventilators, and we were able because of our national presence to move equipment from markets that had not been hit by a surge, into other markets that really desperately needed them.
We actually, in many cases, Chip, took ventilators out from other parts of the country and we put them on loan to not just Kindred hospitals, but to other hospitals were in desperate need of them. So we were able to move equipment around that. I think having a national presence helped us in that regard.
PPE was another example of that, I think. We stockpiled it and had it in certain areas and we ran out of it and others, you remember when we couldn’t get gowns and masks and gloves and various things, particularly in the early stages, we were able to put things on planes and in boxes and get them to our hospitals so that we never ran out, never were really in jeopardy of running out.
And I think the last thing, and it’s an important point that I want to make, particularly as it relates to our Kindred teammates, we on a number of occasions actually had Kindred personnel nurses, clinicians, the respiratory therapists, radiologists, et cetera, that were willing to get on a plane and go to a hotspot and help provide care where we might’ve had a number of clinical personnel that were down with the disease or affected or where they had to take on because of surge activity. So yeah, I think having a national presence and national scale was probably incredibly helpful to our ability to provide care during the time.
Chip Kahn (15:55):
As I mentioned in the beginning of our podcast, ATI Advisory recently released a report about the role of LTCHs during the COVID 19 pandemic. What did the report find and what did you particularly think was important in their results?
Ben Breier (16:13):
First, let me just say, I think that this ATI study is a pretty critical one, and I hope policy makers and folks out there that care about our issues will get a chance to read it. I expect that they’re going to be an enormous number of studies done over time, over the next weeks and months and years to come about what we did and what we didn’t get right in our nation’s health care delivery system during this emergency. But I think this is one of the first sort of look backs if you will, to kind of do so.
And the study Chip, that you’re referring to, I think it’s called the role of LTCHs hospitals in the COVID-19 pandemic. I think it demonstrates, I would argue on unequivocally, the critical role that as you and I have just been talking about, that LTCHs played during the pandemic. I think it also, I thought interestingly proposed some considerations for future healthcare policy development, which I think it’s important that we not only learn about what went right, what went wrong, but what we can do differently in the future. But I think in the end that the study essentially points in many ways to the important role that LTCHs played over the last year.
I’ll give you a couple of examples if I could. LTCHs, I think according to the study, were uniquely prepared for the clinical complexities of some of the most severe and challenging COVID 19 patients. The study clearly states that. The study, I think codifies that LTCHs have become in many ways, even more clinically complex during the COVID crisis than they were before the COVID crisis. And we already were operating with very high CMI score, very high Apache score, very high case-mix comorbidity, if you will, around the patients we take. And now our CMI in these hospitals is through the roof, in terms of the clinical complexity.
I think the study, Chip, in many ways validated that LTCHs have the clinical capabilities to take care and be a valuable partner, that when we need to flex ICU capacity, that LTCHs are appropriate to do so. And in many ways, that not everyone in post-acute care is able to do that.
I think, as I said also, Chip importantly, the study, it talks about sort of future policy considerations. So maybe if I could, I’ll just mention a couple of those as it relates to the study. First, I think it clearly states the short-term acute hospitals STCHs, as we call them, that they should continue to take the lead on communicating and they use the word institutionalizing, effective communication around what surge capacity and what plans should look like in a public health emergency. In many ways, it was the short-term acute regional hospital system that had to figure out how they’re going to scale up and size up their ICU capacity.
That federal policy makers should develop, I think in the study’s view payment policy that supports physician driven site of care decisions. And I think this is a really important thing that we’ve talked about a lot in the past Chip, but it gets lost, I think a little bit of the noise, and the study clearly, I think talks about that. When doctors decide where a patient should go, in most instances that patient gets to the right place. When policy makers are dictating because of certain presumed and perceived criteria, they don’t always wind up in the right place. I think the study show that LTCHs should further promote the education of our unique capabilities, that we should take care of mental health type of issues, that there’s a huge need for that, et cetera. So I think we’ll see, but I encourage people to read the study and I thought that it shown a pretty good light on LTCHs and on what they did in the pandemic.
Chip Kahn (20:08):
Great. That’s so helpful in terms of understanding what they did and then going back and taking this snapshot of what happened over the last many months, looking at that period and thinking about the pandemic and its disruptive nature of the care continuum. Do you see permanent changes in its wake and the relationship between acute and post-acute care?
Ben Breier (20:34):
Well, the short answer is yes, absolutely. I do. I’ll dig into it a little bit, but I would say clearly there has been this enhanced recognition, if you will, that if you can have transparent communication and collaboration between hospitals, payers and certain aspects of post-acute care, you’re going to succeed better in this kind of an environment. And that has to become more permanent. It can’t just be because we had this, we’re going to do that, but that has to become more permanent. I think it will.
I’d also argue in terms of permanent changes that long-term acute care hospitals, and I would say IRFs, inpatient rehab facilities, and I would throw acute behavioral hospitals in as well, that they have proven in this pandemic that they are key counterparties and partners to this capacity need and to health systems across the country. The services that were provided, the capabilities that were shown clearly, I think are going to, I hope permanently create an environment where referral sources really understand the capabilities.
And my sense, one of the fun things I get to do in my job, Chip, is I talk to lots and lots of different hospitals CEOs because of all of our joint ventures across the country that are running big health systems. I think COVID has changed them forever, in a couple of specific ways. If you think about it, we are never as a provider group going to run out a PPE again, right? We are never going to let ourselves do that. We used to have just-in-time inventories and let’s keep our balance sheets clean. We’re going to always have inventory and we’re not ever going back to that. We’re not going to risk our balance sheets, and not that we would pre-pandemic, but certainly I think keeping a closer eye on our balance sheets going forward.
And I think that these same partners are never going to forget who stood with them in this crisis, like LTCHs and IRFs and behavioral hospitals, and really delivered the goods on helping them to extend their capacity needs when they needed it. And I don’t think that those relationships are going to change. I think in many ways, it’s going to make those relationships stronger and stronger than they ever were before.
Chip Kahn (22:50):
Ben, the ATI Advisory study set out a policy agenda that you have given us some sense for. Are there additional policy items you would recommend for Congress and the new administration to consider in order to provide the support for LTCH patients and the frontline staff who care for them?
Ben Breier (23:11):
First, this is a simple one. We should be extending the PHE, the public health emergency declaration until we know the full effects and the extent of the pandemic and all of its aftereffects. Our sense, looking at COVID recovery type patients and looking at where the pandemic is still today and the numbers that we still have around the country, that while we’re obviously enthusiastic about the vaccine distribution and about where we’re at, we’ve unfortunately got a long way to go. We’re all exhausted by it, but the facts are, we have a long way to go. And the PHE just simply must get extended. So that’s the first thing. And I suspect Congress and the policymakers will do that and the Biden administration will do that.
We also think more broadly that Congress and I would argue the Biden administration should try to understand if they don’t already the lessons of what we’ve all just lived with, with regards to post-acute care. And there are a couple of components of that Chip. The first is that, as I’ve said now, a couple of different times, not all post-acute settings are created equally, that has clearly been shown in this pandemic to be true. Not all settings should be viewed under one policy or reimbursement blanket umbrella. Just saying that out loud, I think is a good first place for policy makers and regulators to start.
Policymakers, I think should continue to recognize the lessons learned around the care capabilities that we’ve talked about and they should apply a payment and regulatory structure accordingly. And I think that if we can do that along with extending the public health emergency, that’s a good place for policymakers to start, vis-a-vis our industry.
Chip Kahn (24:50):
Ben, thank you for joining me today. And where can our listeners go to learn more about Kindred and the ATI Advisory report?
Ben Breier (24:59):
Well, Chip, thanks for having me. I enjoyed being with you today and getting a chance to chat about what we do here at Kindred. For those interested, we’d encourage you to go to our website, that’s kindred.com. And I know for the ATI study, if you go to atiadvisory.com and you can pick up that study, and I know there’s a lot of other research available there as well. So thanks again Chip.
Chip Kahn (25:18):
Speaker 1 (25:24):
Thanks for listening to Hospitals In Focus, from the Federation of American Hospitals. Learn more at fah.org. Follow the federation on social media @FAHhospitals and follow Chip @chipkahn. Please rate, review and subscribe to Hospitals In Focus. Join us next time for more in-depth conversations with health care leaders.
Ben Breier, CEO, Kindred Healthcare
Benjamin A. Breier is the Chief Executive Officer of Kindred Healthcare, LLC, one of the largest providers of healthcare services in the United States. He became CEO in March of 2015, after having been named President in 2012.
Kindred operates a diverse blend of health care services including long-term acute care hospitals and inpatient rehabilitation hospitals in approximately 300 locations across the country. Kindred was named one of Fortune magazine’s Most Admired Companies nine times.
In July 2018, Mr. Breier led a consortium of buyers, including Humana, TPG Capital and Welsh, Carson, Anderson & Stowe in a successful leveraged buyout of previously publicly traded Kindred Healthcare (KND:NYSE). Prior to taking the company private, Kindred had revenues in excess of $7.5 Billion, 110,000 employees, operations in 47 states, and served more than one million patients per year.
Throughout Mr. Breier’s tenure at Kindred, he has strategically deployed capital to create leading scaled businesses in a variety of areas. Acquiring and integrating publicly traded RehabCare in 2011 made Kindred the largest rehabilitation provider in the United States. Acquiring and integrating Gentiva Health Services in 2015 made Kindred the largest provider of Home Health and Hospice in the country. In December 2020, Kindred completed the sale of its RehabCare business to Select Rehabilitation, solidifying the Company’s position as a leading provider of hospital-level, patient-driven solutions for the nation’s most challenging patients, while successfully transforming its portfolio for long-term success. In 2017 Mr. Breier completed the divestiture of one of the largest skilled nursing facility platforms, completely exiting the skilled nursing industry. Mr. Breier also acquired Centerre in 2015 creating one of the nation’s largest inpatient rehabilitation facility platforms.
Mr. Breier received his Bachelor’s degree in Economics from the Wharton School of Business at the University of Pennsylvania. He received both an MBA and an MHA from the University of Miami (Fla.).
Mr. Breier serves on the Board of Kindred Healthcare, the Federation of American Hospitals, InnovaCare Health and is a member of the Wall Street Journal CEO Council. He also serves on the Board of the University of Miami’s School of Business, the Board of Overseers at the University of Pennsylvania and the University of Louisville Health Board of Directors. He chairs the Louisville Healthcare CEO Council.
Modern Healthcare magazine named Mr. Breier one of the 100 Most Influential People in Healthcare on three occasions and in 2010 recognized him as one of the young leaders aged 40 and under making a difference in healthcare. Louisville’s Business First named Mr. Breier one of the top Power50 in 2021, the Health Care Leader of the Year in 2015 and in 2018 named him the Excellence in Business Leadership honoree.