Health Care Reform Implications: Home Health Care
I’m a tad behind where I hoped to be in terms of getting these posts out. Its been a bit busy over the last ten days or so but headed into the Holiday weekend, a break in the schedule affords me the opportunity to “maybe” get caught up.
Of all of the industry sectors touched by health care reform, the two most dramatically impacted from an operating perspective are DME and home care (see my earlier post on Medical Devices and DME). Over the last two years, home care or home health has become the target for payment reform, principally due to MedPac’s reports to Congress and CMS on the rising profitability of the industry, the year-over-year growth in agencies and utilization, and the percentage growth in Medicare spending. Justifiable or not, the Feds never like to see any sector perform well or grow rapidly whenever Medicare and Medicaid are the dominant payer sources. To this end, health care reform, those elements focused on home health, focused-in on realigning the trends of growing utilization, Medicare spending, and rising profitability.
- Beginning in 2011, cap outliers at 2.5% and impose a 10% outlier cap on individual agencies. The cap per agency is 10% of anticipated current year revenues.
- Reduce the market basket by 1% for fiscal years 2011, 2012, and 2013.
- Incorporate a productivity adjustment factor (offset) to the market basket beginning in 2015 (anticipated 1% average reduction).
- Rebase the PPS starting in 2014, fully phased in by 2017. Rebasing is meant to take into account the costs of treating more severely ill patients as found typically in efficient, high performing agencies. In so doing, the Secretary of HHS is charged to look at case mix, the number of visits per episode, the resources used in each visit, the cost of providing care, etc. The Secretary is also supposed to analyze the differences between agencies such as those that are free-standing, non-profit, and institution based (hospital typically). The Bill does provide that the Secretary cannot reduce or adjust (reduction is what is intended) reimbursement by more than 3.5% per year. MedPac is supposed to monitor this process and issue reports reflecting changes in utilization, changes in the number of agencies, changes in access, etc. NOTE: MedPac is the principal advocate for these changes so anticipate rebasing to mean “cuts” and MedPac to issue only favorable reports on the implications/outcomes of rebasing.
- Develop a voluntary system that seeks to create a bundled payment for certain post-acute episodes of care (yet unspecified). Under this system starting in 2013 and continuing for five years, CMS will pay one fee to hospitals, SNFs, physicians and home health agencies (as applicable) per a post-acute discharge, covering the care provided for a period of up to five days prior to hospital admission through the period ending thirty days post hospital discharge. Participation in the program is “voluntary” and the Secretary is charged with providing an analysis of the program’s impact and effectiveness in creating efficiency and improving care coordination to Congress by January 1, 2016. At such time, the Secretary shall also determine whether an expansion of the pilot is warranted. NOTE: In this pilot, the goal is to reduce costs nothing more. Hospitals and physicians are the only potential winners here and for home health agencies, the implications (negative) primarily impact fee-standing, non-hospital affiliated agencies.
- The Secretary is required to conduct a study and submit a report for possible legislative and administrative action on home health agency costs for providing care to low-income individuals, particularly those in under-served areas with high levels of disease complexity and/or disability. Medicare may conduct a pilot program worth $500 million to provide incentives to agencies in certain under-served areas, to expand services to care for these “targeted” individuals.
- 3% add-on for rural visits/episodes occurring during the period beginning April 1, 2010 and ending prior to January 1, 2016.
- Establish a center for Medicare/Medicaid Innovation in CMS that would provide some funding opportunities to agencies that implement chronic care management programs for targeted individuals.
- Require face-to-face encounter by the physician (or applicable extender such as NP, advance-practice nurse clinician, physician assistant) within a reasonable time-frame as determined by the Secretary.
- Physician must keep open records and documentation of Medicare home health referrals.
- Require that physicians participate in care plan certification.
- Require background screening and credentialing of provider, suppliers, owners and managers and require compliance plans. Also gives CMS the authority to place a moratorium on the creation of new agencies.
- Establishes spousal impoverishment protection for home care eligibility under Medicaid.
- Removes barriers for access for additional home health care under Home and Community Based waiver programs.
- Implements the Community First Choice program under Medicaid, expanding access to home care services.
One final note. The Bill provides for the creation of an Independent Payment Advisory Board tasked with submitting legislative proposals further limiting program growth and spending under Medicare if the per capita growth in Medicare exceeds targeted spending levels. Beginning in January of 2014, the Board’s proposals become law unless Congress has taken alternative action to curb program growth and spending. The Board cannot raise taxes, raise Part B premiums, change eligibility standards or increase beneficiary cost-share levels – essentially limiting the Board to relying on spending reductions. Hospitals and hospices are not subject to any Board proposals through 2019.
Strategies for Accomplishing New Development or Major Capital Projects
One of the focal areas of my consulting practice/work is assisting health care organizations in accessing sources of funding (securing financing basically) for major projects and/or new development. Given the state of the economy, most specifically the capital markets over the past eighteen months, getting funding for capital projects and/or development has been challenging, though not impossible. Terms are definitely not as good (rates, covenant restrictions, and length or term of the obligation) and lending sources are far more credit adverse than two years ago. Health care, although the defaults have been low, is an eclectic industry for most traditional lenders and their lack of specialization or knowledge makes them deal “shy”. Even lenders with health care technical experience are more cautious and requiring far more information and deal due-diligence than say, two years or so ago.
Approaching a major capital project (expansion, remodeling, equipment replacement, etc.) or a new development (addition or new facility) is a daunting task and if any of the cost involves securing financing, below are some strategies or tips for project analysis and due diligence that I have found are virtual necessities to secure financing. Obviously, this information does not supplant the credit worthiness of the organization doing the borrowing or in other words, bad financial ratios equals bad terms or today, no credit.
- Completion of an Internal Rate of Return analysis at “current” market cost’s of capital. The analysis needs to include sensitivity adjustments/tests as well. If the project is such that the expenditure will not add revenue (major equipment or even some remodeling projects), the Internal Rate of Return analysis uses assumptions of savings and depreciation expense as the source of “revenues”. In other words, you begin the first phase by using a life-cycle cost analysis as the means to produce the “net inflow” assumptions (savings, etc.) for the IRR.
- Much of health care, especially the reimbursed and clinical segments is very much a fixed-revenue prospect. I see providers get caught all the time trying to justify remodeling and even down-sizing projects as “revenue improvements” and it doesn’t fly. It is possible to produce or to generate new or improved “cash inflows” from these types of projects but creating assumptions for this improvement and the resulting new inflows requires careful thought and impartial analysis. Suffice to say that if the project involves remodeling or down-sizing, getting to the point of improved net inflows as a result of the project means something had to change on the expense side (especially again, if the bulk of the revenue related to the project is fixed reimbursement), efficiencies have to be clear and demonstrable, and/or the use of the remodeled or down-sized space is for a new product or service line that will generate incrementally higher revenues or reimbursements per patient day.
- On new developments or expansion projects, the largest mistake I see made is around the assumptions of occupancy and revenue generation. The assumptions used need careful analysis and should be weighed against comparable provider/market experiences whenever possible. This is critical in the sensitivity testing portion of the IRR – stressing and testing the new revenue assumptions. Some very important revenue assumptions cues are;
- Reimbursement rates and the corresponding revenue assumptions need to fit the current legislative and policy trends. For example, health care reform just passed and Medicare is looking at $500 plus billion in cuts. Medicaid is another issue and state budgets and forecasts of rate cuts or rate stability are an issue. Don’t use assumptions that don’t follow the present health policy issues.
- Dramatic changes in payer mix and product line mix are unlikely to occur as rapidly as I see providers try to project. If for example, your payer mix has been predominantly Medicare, some Medicaid and some private insurance (65/25/10), it may change dramatically for a new development in a new market location but not for an addition to an existing location. In reality, just by “building it”, they won’t “naturally come”. Marketing strategy is the key to this change but in the analysis, the assumptions of any major revenue changes as a result of a project need to be smoothed.
- Capital Budgeting techniques and analysis need to be performed for major equipment replacement or infrastructure improvements. Alternatives to the project need to be reviewed and financial analysis of the costs and operating impacts of each alternative need to be completed. Again, interest rate/cost of capital assumptions, even a cost of cash assumption (investments of internal cash v. cost of debt), need to be integrated into the analysis. Lenders want to see that the provider has thoroughly evaluated analytically, the alternatives for each proposed capital project.
- Benchmark your project against like projects and your numbers against industry ratios. There are a number of sources for industry ratios by health care segment from Fitch, to trade associations, Ziegler, BB&T, etc. I typically will add comments and a brief discussion of salient differences when the ratios and results are positive or negative to industry standards. I also like to incorporate a pre and post project re-cap.
- Discussion and information on Market and Industry Trends is important for lenders to understand how the project fits into the overall market, into your organization’s position within the market and where the organization views the project in light of current industry trends. Remember, the policy landscape is quite volatile and lenders are aware of the volatility. Explanations of a thorough understanding of this volatility and how the project and organization plan fits in light of this trend is imperative in order for lenders to have a grasp of the organization’s project management and financial and strategic management capacity.
- Market discussions should focus on where the organization ranks competitively within a market area, where the organization’s target market is, how that market is changing, and how the project responds to the market needs, its market position, and to the changing demands within the market location. I also like to incorporate sales advantages, competitive advantages, quality information (as pertinent), customer satisfaction information, and any commentary on competitors.
- Industry trend discussions focus on what is happening in the industry and how the project relates to these trends and why. If the project is for example, an infrastructure improvement (roofs, mechanical systems, etc.), it is entirely appropriate to discuss the average age of physical plants in the industry, deferred maintenance and or average capital spending trends, etc. If the project is an addition, the discussion should focus around meeting customer needs, new products and services that will be delivered and how completing the project either keeps the organization up-to-date with industry advances or propels it ahead of the pack. Other industry information that is important to discuss is;
- Major health policy trends such as reimbursement rates, new regulations or requirements (e.g., mandates for sprinkler systems in SNFs), and as applicable, changing patient/customer needs. It is important to relate these trends to the project and as much as possible, across the anticipated horizon that covers the length of the credit. For example, if reimbursement changes may positively or negatively impact the organization’s cash flow, a frank discussion of this impact is necessary along with how the organization is planning to address the impact. The impact, of course, plus the organization’s assumptions of impact on the project and the organization should be incorporated in the financial analysis.
- Industry information regarding payer mix trends, length of stay, service utilization, labor costs, etc. may or may not relate to the project but whenever it does, I like to point it out and moreover, discuss briefly the relevance and the distinctions.
- For New Developments market and demand studies are critical. I like to see demand studies that test demand at given prices, not just global demand. Global demand assumes price doesn’t matter or location and service-depth is less relevant and in reality, it may be the difference between success or lack of success. Although a bit esoteric, I am even in-favor of incorporating a bit of “central place” or “location” theory in my market and demand analyses. This type of analysis looks at key project characteristics or specifications and analyzes how strongly they are met or reinforced by the development location. For example, if proximity to a certain referral source is a key project specification, I’d analyze this in relationship to market size and perhaps, existing referral patterns. I’d then look at the cost of development and location (site) in relationship to the requirement that the location is proximal to a referral source. In some cases, the cost of development may be to such a degree greater that an alternative location actually becomes preferrable from a financial feasibility stand-point. Finally, market analysis needs to define the primary markets, the competitors within the markets, the socio-economic condition of the market location (population growth, income/wealth, age,education, etc.) and the market trend. I will also address factors that may positively or negatively affect the project’s completion and revenue assumptions (occupancy/lease-up, etc.).
As daunting as the above may sound, it is nearly a pre-requisite to access capital for large capital projects and/or new developments at acceptable terms (again, assuming the general financial profile of the organization is solid). While each project is different necessitating more analysis in one area and less in another and each organization is different, I’ve found that lenders today prefer more on-point discussions, even if they seem trivial, than less. Building a solid case, financially and strategically, for the project is critical in order to achieve success in the capital markets and frankly, in order for the project to achieve the organizational objectives.
CMS Releases Annual Report on Health Spending
Earlier today, CMS released its annual report on national health spending for the year 2008. In summary, health spending grew at a rate of 4.4% (over 2007), equating to a per capita cost of $7,681 and a total cost of $2.3 trillion. This rate of growth, per CMS, is the slowest increase since 1960 although still more than 1.5 times the rate of GDP growth for the year. As a percentage of total GDP, health care increased to 16.9% in 2008.
Like most industries, health care spending slowed due to the flagging economy. The general spending for all services across the health industry slowed with the greatest spending reduction occurring in hospital care. Inside the data, the percentage of spending for health care attributable to or paid for by private funds increased only 2.8%; a definite reflection of the slowing economy coupled with increasing job losses. Private health insurance spending increased by only 3.9%; another indicator of a slowing economy, job losses, and reduced insurance coverage across the workforce.
Other information of note contained in the report is as follows.
- Hospital spending in 2008 grew 4.5 percent to $718.4 billion, compared to 5.9 percent in 2007, the slowest rate of increase since 1998.
- Physician and clinical services’ spending increased 5.0 percent in 2008, a deceleration from 5.8 percent in 2007.
- Retail prescription drug spending growth also decelerated to 3.2 percent in 2008 as per capita use of prescription medications declined slightly, mainly due to impacts of the recession, a low number of new product introductions, and safety and efficacy concerns.
- Spending growth for both nursing home and home health services decelerated in 2008. For nursing homes, spending grew 4.6 percent in 2008 compared to 5.8 percent in 2007. For home health, spending grew 9% in 2008 compared to 11.8% in 2007.
- Total health care spending by public programs, such as Medicare and Medicaid, grew 6.5 percent in 2008, the same rate as in 2007.
- Health care spending by private sources of funds grew only 2.6 percent in 2008 compared to 5.6 percent in 2007.
- Private health insurance premiums grew 3.1 percent in 2008, a deceleration from 4.4 percent in 2007.
Viewed in light of the present health reform discussions in Washington and the upcoming reconciliation activities between the House reform bill and the Senate reform bill, today’s information illuminates some rather disconcerting facts; facts that will undoubtedly be altered by the outcome of the final reform legislative process.
- Of all health expenditures in 2008, 52.7% were privately funded and 47.3% were funded by government (35% by the Federal government). Without question, these percentages will become inverted by the passage of reform legislation as government will become the predominant payer for health care in the U.S. over time. Also of interest is the relatively flat share of health expenditures funded by the states. The Federal government has been gradually increasing its funding, principally by expanding its share of funding for Medicaid, alleviating the states of an increasing benefit burden. With health reform foretelling a dramatic increase in Medicaid eligibility and enrollment, it will be interesting to see if more of the Medicaid burden is shifted back to the states.
- In 1960, 75.5% of all health expenditures were paid for privately. With the passage of Title 18 and Title 19 in the early 60′s, by 1967 the shift toward government payment had begun with private funds supporting 62.5% of health spending and government (and taxpayers) picking up the balance – 37.5%. Health care spending in 1960 represented 5.2% of GDP and total spending on health care was $27.5 billion.
- By 1970, total health spending had grown to $74.9 billion, a 172% increase since 1960 and up to 7.2% of GDP. Government was now paying for more than 1/3 of all health expenditures (37.5%) or an increase in total outlays (dollars) since 1960 of 268%.
- By 1980, total health spending eclipsed the trillion dollar level – $1.099 trillion, a 208% increase since 1970. Government’s share of this pie was now 42% and in real dollar outlays, government spending had increased since 1970 by 245% (a bit slower than the jump between 1960 and 1970 as both Medicare and Medicaid were now fully implemented). In 1982, health spending equated to 10% of GDP.
- By 1990, total health spending approached the three trillion level – $2.814 trillion, a 155% increase over 1980. Government’s percentage remained essentially flat at 40% but in terms of real dollar outlays, spending increased from 1980 by over 250%.
- By 2000, total health spending reached $4.788 trillion and accounted for 13.6% of GDP. Government’s percentage of this spending had crept up to 44% and real dollar outlays had increased 168% since 1990.
- In 2008, total health spending reached $7.681 trillion and accounted for 16.2% of GDP and 47 cents out of every dollar spent is by the government. Since 2000, total spending on health care has increased over 60% and in real dollar outlays, government spending has increased by 72%.
Perhaps of greatest concern to me as I reviewed the CMS release and the numbers today is how much health spending has exploded, particularly governmental health spending since 1970. I’m further concerned by the continued escalation of spending between 2000 and 2008, especially when viewed in comparison to the GDP growth for the same period – 18.5% GDP growth and 72% growth in real dollar government spending on health care. Frankly, I don’t see anything in the reform bills (House or Senate) and the likely compromise, final bill that will change this paradigm except perhaps, to a worse state.
CCRCs and Problems: Much Ado About Likely, Very Little
A product that has seen its share of struggles in the economic downturn is entry-fee CCRCs. To clarify, not all CCRC models are struggling and not even all entry-fee based CCRCs are struggling as certain regions have seen less housing market fall-out and concurrently, operators have done the right things to keep their census stable during the “down times”. Where problems have cropped-up is in new primarily new, unstabilized developments, CCRCs in markets where housing sales are significantly depressed, and in larger suburban and urban market locations where options within the price range are plentiful.
The demand curve for virtually all senior housing that is not low or moderate cost is very elastic; many options exist for seniors when it comes to housing. Perhaps the most elastic of all demand pertains to entry-fee CCRCs, especially those whose pricing is above the median housing price within a geographic region. As median housing prices fell in virtually every major metropolitan real-estate market, unless CCRCs recast their entry prices to coincide, their new resident markets may have all but dried up. Certainly, slow housing turnover via sales would chaste the market regardless but all things being equal, pricing would be considered the icing on the cake. An entry-fee CCRC seeking a premium price (twenty or so percentage points above median housing prices) in a market where housing values were falling and sales were slow should anticipate significant new sales problems and possibly, few to no new sales at all.
Sales/marketing strategy for an entry-fee based CCRC requires a value proposition to be solidly in-place. The most common entry-fee CCRC includes some form of healthcare coverage (nursing care, assisted living, etc.) for either a period certain or as use to be the most common, for the remaining life of the resident. Ideally, the balance of the fee (the non-healthcare portion) was set aside as a capital reserve or a combination of capital reserve and debt reserve. This set-aside allowed for monthly rental prices to remain more stable, reflective of truly the economic costs of occupancy (the market rate philosophy). If in fact, a CCRC has held to this formulaic standard and is a stabilized community, it should not be too difficult to continue to create a value proposition attractive to new residents. Healthcare for example, is a hot topic and one that should easily be leveraged for most senior consumers.
Alas, problems have arisen in the sector, most notably with Erickson – one of the largest CCRC developers nationally. On a case by case basis, there have also been a few other headliners – the Franciscan Sisters in Chicago who built a high-rise CCRC in high rent downtown and a CCRC in Pennsylvania (bankruptcy) sponsored by B’nai B’rith. The “wind” of these problems has prompted the GAO to conduct an investigative study on the industry and report the same to the Senate Committee on Aging (see my related post on the GAO and CCRCs). In Erickson’s case, the issues of insolvency have not cost any resident any funds, at least to my knowledge. While investors and debt holders will take a hair-cut, there appears to be no drastic consumer issue that will arise. Erickson’s fate occurred as a result of being overstretched on new development, a bit upside down in pricing (see paragraph above), and locked into some management agreements in locations that were heavily impacted by the economic downturn. The Franciscan Sister”s issue in Chicago mostly involves an expensive, rather upscale project that has struggled making its value proposition clear to potential residents. This project was an enormously expensive undertaking and as such, pricing is at the premium end of the market in an environment that has seen drastic slow-downs in real estate sales and a large fall-back in property values.
With the GAO taking a look at the CCRC industry, there’s bound to be a bit of fall-out and perhaps, a few calls for added regulations and/or consumer protection activity on a state to state basis. In my opinion, the Feds, busy with other matters more pressing, will do nothing in the form of federal regulation. The reality in this situation is that the economy was bound to create a few setbacks for a few providers and developers. CCRCs require a reasonably stable economy and a solid real estate market in order to flourish and prosper. As such as has been the case across the last two plus decades more often than not, the track record for the industry has been solid. For those operators in stabilized projects, well-known and priced accordingly, better times are soon ahead. For developers of new projects, it will likely take another couple of years before the market is ready to assimilate more units, especially those that are priced at a bit of a premium – or higher.
Why Quality Matters
In the past month or so I have had a lot of conversations with various entities ranging from providers to investors about the financial state of the industry. The majority of the discussions have been around all things financial – reimbursement in particular and as this topic goes, so goes expenses. Understandably the economic and policy landscape tends to drive conversations and what with healthcare reform, Medicare cuts, state budgets and Medicaid, stimulus (or lack thereof) and now Cap and Trade in the headlines, much of the industry is focused on the “metrics” or the numbers. Being a numbers and a policy guy, all of this talk has been pretty good for business but I have this foreboding sense that too much discussion may diminish another set of metrics that need to be tied to the financial metrics – the quality metrics.
The crazy thing about the SNF industry (and frankly, any healthcare segment where patients receive direct care) is that quality both makes and costs money. There is an interdependent relationship between the financial results of the business and the quality results the patient receives. With the present upward pitch of regulators yammering about “resident centered this and that” and five star ratings published on the internet, the push is on, at least by the Feds, to force the industry to promote more quality in the care residents receive. Arguably, the regulatory process is bereft with insanity and ill-conceived standards impossible to fully comply with but that has frankly, always been the case. What is at the heart of the issue is that financial performance via any long-term measurement and quality of care are inseparable – conjoined in such a manner that were quality eliminated from the picture, the other would surely suffer and perhaps die.
Why does quality matter? If at the simplest level one believes in two types of money, smart and stupid, then focusing on quality is the antidote to spending stupid money. Smart money is therefore, the dollars (and I don’t mean enormous) that are invested in, at a minimum, promoting and doing the “right” things. When smart money is spent in a rational and proportionate manner, the avoidance of spending stupid money (incrementally far greater in volume and dollars) is the minimal return expected. The return that comes longer term from smart money investments in quality is typified by higher Medicare, private pay and other census, lower Medicaid census and resultant, higher revenue and better margins.
To understand how quickly stupid money can rack up is to understand some of the basic pitfalls that exist in the industry today. Things like fines, lawsuits, worker’s comp claims, denials of payment for new admissions, billing probes, etc. are all current industry woes and excellent examples of stupid money spending. With each of these problems comes more stupid money spending on top of the base cost each presents in the form of lawyer bills, public relations headaches, higher insurance premiums, loss of reputation that leads to loss of census and eroding payer mix, etc. As the cycle continues, staffing problems can arise compounded by the need for external pool costs to fill positions, unionization activities (if no union is present) and recurring survey and enforcement issues that never seem to go away without spending additional money on consultants to aid in remediation of the initial problem.
Smart money and a continued focus on quality is a hedge, an inoculation if you will, against the disease of “stupid money”. Oddly enough, smart money need not be typified by exorbitant spending on “capital furnishings and equipment” – the bulk of which rarely does much for a resident outcome and only temporarily, gives the viewer the illusion that “this is a nice place”. Nice surroundings are important but opulence and expansiveness should never be confused with quality that is experienced by a resident or his/her loved ones. In fact, a bad experience with care in a very nice setting typically gives the customer a bigger gripe (“they can spend all this money on furniture but they can’t spend it where it counts” attitude).
The best smart money investments I have seen are in people, management and systems. Staff are critical to the outcomes residents receive and making sure staff are engaged, involved, variably compensated for performance and part of the decision-making process is not expensive and in all cases, an extremely important investment. With a solid staffing and human resource investment, staff make fewer mistakes, are engaged in improving the delivery, care about the organization, resist turnover, and resist costing the operator and owner stupid money by not giving a darn about the mission, vision and results of the business.
Bad management is the leading cause of stupid money spending. Management that is incapable of demonstrating solid human relations skills, active listening, agressive confrontation with poor performance and good performance (correcting the bad and rewarding the good) and problem solving should be eliminated from the picture. These managers, incapable of understanding how important outcomes and spending tied together are, will cost lots of stupid money over the short and long run.
System investments are frankly the easiest and the least expensive investments there are. Investing in common sense systems that seek complaints and errors, addresses them quickly, and educates both staff and residents in quality, topical issues doesn’t cost much and delivers enormous returns. The age old addage of “work expands to fill the time paid” applies; quality sytems make sure that the work is focused and measurable as opposed to confusing and time wasting. Most important, systems investments don’t need to come in the form of computers and software – good old fashioned paper, telephones, and meetings work just as well and sometimes, far better.
Not too surprising, when I encounter organizations that truly focus on quality they all tend to share a set of enviable statistics that many in the industry “wish” they could attain.
- Higher census and better payer mix
- Staff retention and low to no use of external pool staff
- Law suit free
- Low liability and worker’s comp premiums
- Limited regulatory involvement (no complaints, no regulators)
- Lower marketing costs – reputation delivers admissions
- Limited position openings – lower recruitment costs
- Stable, long-term management
- Generally, no unions and no costs associated with defending against a union organizing campaign
- Solid survey results and in all cases, results that don’t breed fines, forfeitures, and/or other regulatory (adverse) actions
- Limited use of “outside” consultants to assist with “fixing” problems
- A positive reputation in the community and definitely, within the desired referral sources.
In short, quality does in fact matter, if for no other reason than it produces results such as those above and more importantly, reduces dramatically, the resources wasted in the form of stupid money.
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