We must remove partisanship from healthcare: Home care is a win-win for everyone, and should not be seen as a Republican- or Democrat-backed venture. 90% of Americans prefer to age at home, and it saves government money by keeping people out of costlier institutions. Regardless of party affiliation, we will all continue to get older, and most of us will need to continue to receive healthcare. Home care is something that we can all get behind.
The COVID-19 Pandemic taught all of us many things. One of the sectors that the pandemic put a spotlight on was the healthcare industry. The pandemic showed the resilience of the US healthcare system, but it also pointed out some important areas in need of improvement.
In our interview series called “In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System”, we are interviewing doctors, hospital administrators, nursing home administrators, and healthcare leaders who can share lessons they learned from the pandemic about how we need to improve the US Healthcare System.
As a part of this series, I had the pleasure to interview Dave Totaro, Chief Government Affairs Officer of BAYADA Home Health Care and chairman of the Partnership for Medicaid Home-based Care.
David Totaro joined BAYADA Home Health Care in June 2009 as chief government affairs officer. In this role, Mr. Totaro spearheaded the development of a far-reaching legislative advocacy program. His team of legislative professionals advocate daily for BAYADA clients and caregivers and regularly interact with legislative and regulatory officials at the state and federal levels. Mr. Totaro currently serves as founder and chairman of the Partnership for Medicaid Home-based Care (PMHC), a Washington, DC based alliance of Medicaid home care providers, managed care companies, national and state home care associations, and technology companies. He also serves as chairman of the Hospice Action Network (HAN). He is the Treasurer and a board member of the Partnership for Quality Home Healthcare and a board member of the National Association for Home Care & Hospice (NAHC).
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
Well, I got to this role of chief government affairs officer at one of the leading home health care companies in the country, through a series of very fortunate happenstances. The first one, back in 1970, was during the height of the Vietnam War, when I joined the Army National Guard and was sent to Ft. Knox, KY for my basic training and Advanced Infantry Training. At the reception station I was given #18. We stood in line according to our number all day long, getting our heads shaved, our uniforms, our equipment — and, so we spent a lot of that first day standing in line. I quickly struck up a friendship with #19, who also was a college graduate, going to grad school, like me, majoring in marketing. He turned out to be Mark Baiada, the eventual founder of BAYADA Home Health Care. If I had been #17 — who knows where life might have taken me.
Can you share the most interesting story that happened to you since you began leading your company?
I’m not sure I can limit this to just one. But, I can tell you that I have been lobbying for our home care issues and supporting our caregivers and our clients for more than a decade now. When I first started, there was not a lot of understanding of what home care was — many thought we were a house cleaning service. But, today, we now have legislators who have experienced home care for their own families — aunts, uncles, parents, spouses — and they can now tell me of the value of what we do. That, to me, is energizing and satisfying. Our work is taking root and the beneficiaries are our children with medically complex needs, our elderly and those who care for both of them.
One of the best memories I have is when a US congressional member came up to me in a busy hallway and thanked me for telling him about home care’s benefits a few years back. He said that he and his siblings recently had a meeting to discuss what they needed to do for their aging mother, and that it’s because of our meeting that they were able to keep her home with BAYADA’s services rather than putting her in a nursing home. It’s moments like that one that make me especially proud to do this important work, particularly for a company so focused on doing good.
Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?
Well, I can laugh now, but, at the time, I was mortified. This didn’t happen early on in my career, but maybe just a few years ago, which proves we all make mistakes at any point in our careers. Like many, I didn’t really pay close attention to who was included in an email distribution list and also didn’t pay attention to the fact that I replied “all” rather than just to the sender. Suffice it to say that I made a few comments about the lack of speed in getting work done on one of our pieces of legislation and copied the senator who was sponsoring the bill. Lesson learned. Another lesson learned was to act quickly, own up, apologize, accept responsibility, and admit that it was said out of frustration. And, look twice, or three times, at every email before hitting “send.”
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
My favorite quote is one I use often with my team of professional advocates. It’s an old African proverb. “If you want to go fast, go alone. If you want to go far, go together.” This inspiring message speaks directly to all I believe in — building teams and alliances and creating long-lasting, strong relationships, which is so important to achieving all goals, whether you are advocating for an important issue or just living your daily life within your community. I once had the wonderful opportunity to chat with Alan Kaye, the creator of the phrase, “If you see something, say something.” I asked him how I could be more effective in getting the message of the value of home care to critical decision makers. He responded quickly, “create a movement.” It’s crystal clear: Anyone who believes they can move mountains alone will always be disappointed. This has been the foundation of our very successful advocacy program at BAYADA and will remain so.
Are you working on any exciting new projects now? How do you think that will help people?
Yes! Over the last several years BAYADA has embarked on a strategy to form joint ventures with mission-aligned healthcare systems. We recently formed a joint venture with VCU Health System in Richmond, VA. We will be partnering to deliver home health and hospice services to area seniors and individuals with disabilities that need it. This is an ideal opportunity for us to increase access to care and to showcase how one’s own home will be the central location of health care delivery in the future.
Joint ventures have become increasingly important in our overall strategy for many reasons. Partnering with other mission-driven healthcare organizations helps us to learn from others who are leaders of what they do in their spaces. Additionally, partnering in joint ventures helps us maximize home health care’s reach in an environment where limited government funding makes it difficult for us to reach all the individuals who would benefit from our services. In short — as we invest in our JV strategy, we can help show state and federal governments how investing in home care is valuable for their own communities.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
Unfortunately, I’m not surprised by this poor ranking. Our healthcare system is totally not integrated. Instead, it’s a series of very separate and distinct entities — Medicare, Medicaid, Private Insurance, Hospice, etc. As a result, today we are often unable to choose what healthcare services we receive or who we get them from, and we hardly ever see how much they really cost or what’s being paid for them. That’s crazy! No other economic sector in America works like this, and the unavoidable result is that costs have exploded and we rank poorly amongst other high-income nations.
I believe legislators recognize that true correction of the healthcare system will require very drastic revisions to major healthcare laws, but competing priorities and the controlling interests of so many prevent drastic changes and favor slow steps. Consequently, it’s death by a thousand cuts — small, inconsequential steps that aren’t making healthcare better or more accessible for Americans. The Affordable Care Act (ACA) didn’t correct the healthcare system, it provided more insurance to more people. While this is admirable and we support it, it wasn’t a fix to the imploding healthcare cost crisis. And now, in DC, it’s the dominant healthcare issue that’s fought over, and it’s sucking to the air out of the larger healthcare conversation each time. For true change to occur, lawmakers will really need to buckle down and work together for an overarching solution.
Ok, thank you for that. Let’s now jump to the main focus of our interview. The COVID-19 pandemic has put intense pressure on the American healthcare system. Some healthcare systems were at a complete loss as to how to handle this crisis. Can you share with our readers a few examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these specific issues moving forward?
The pandemic shined a bright spotlight on the flaws of our current institution-dependent system. Nursing homes are a good, necessary part of the US healthcare system- but they are not the long-term solution for individuals’ long-term care needs. This is especially true as medical technologies advance and people with chronic conditions and multiple diagnoses can live more independent, healthy lives outside of such institutions. While we within the home care industry have known for a long time that home care is cost-effective, patient-preferred, and the future of healthcare, COVID made this clearer for the general public.
We can start to move beyond the facility-dependent system by leveling the playing field between home care and institutional care. This would involve making home care more accessible, first, by amending antiquated federal Medicaid laws that make nursing “rest” homes the default setting for aging adults. Second, we would need to make sure we have a reliable, trained caregiver workforce. Right now, nearly every state we operate in has a shortage of in-home caregivers, particularly home health aides. Inadequate state funding for home care programs prevents providers from being able to compete for the workforce. Home health aides are being drawn to retail, fast food, and other industries that can pay better wages. At the end of the day, home care can’t keep up. There aren’t enough aides in the workforce, and as a result, people that need care are forced to find it in ERs and long-term placements such as in nursing homes.
Of course the story was not entirely negative. Healthcare professionals were true heroes on the front lines of the crisis. The COVID vaccines are saving millions of lives. Can you share a few ways that our healthcare system really did well? If you can, please share a story or example.
The US healthcare system was able to develop, create, and distribute a vaccine in less than a year. That’s an amazing feat and a testament to the ability of the US healthcare system to act efficiently and change course quickly in a crisis. The federal government in many ways reacted quickly to help individuals and families meet their needs. In terms of home care specifically, I applaud CMS’s expediency in approving waivers and granting flexibilities so that providers could care for many people as quickly as possible. Congress granted additional funding to states, many of which passed along as temporary relief to the home care sector. All in all, it was quickly realized how important staying home and recovering at home is. Now, this needs to be carried further by making home care a permanent staple in our healthcare system.
One point I want to make here: When the government realized the need for quick and innovative vaccine development, they passed along subsidies to private companies like Pfizer and Moderna. With government support, they in turn were able to create and test vaccines relatively quickly. This shows how innovative healthcare companies can be when the government invests in them. Home health care providers by and large rely on government funding — primarily Medicaid and Medicare — and struggle to create any innovations due to razor-thin margins. We need more resources and support to create more innovation within the system. This is especially needed now, with a dwindling caregiver workforce and an aging US population. Spurring innovation to solve this pending national workforce crisis will help more people access care where they want to: at home.
I am hopeful that the pandemic will shine a light on the importance of in-home care and that the federal and state governments will see the benefit of putting more resources and attention toward home-based, rather than institution-based, care.
Here is the primary question of our discussion. As a healthcare leader can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
In short, we need to change funding and regulatory policies at the state and federal levels.
- First, as I mentioned earlier, the original Medicaid policy language — which has been in place since the program’s inception in 1965 — needs to be updated to equalize access to home care. This would ensure that people who prefer to stay at home, rather than rely on facilities like hospitals and nursing homes, are able to do so.
- Second, policy changes at the state level would need to be made. Right now, there are 50 different Medicaid programs, and 50 different ways that states implement home care programs. Third, we would need better state funding for home care. One thing that just about all 50 states have in common is that home care programs are underfunded. Low funding makes it impossible for home care providers to compete for the workforce. The median home health aide wage is $13.02. At the same time, we see advertisements for McDonalds, Home Depot, Target, and Amazon hiring workers for $15 or more per hour. We must realize that we need home health aides now — and that the demand is only growing. Through the pandemic, at BAYADA, we had to decline as much as 50% of our referrals because we didn’t have the staff. We have to figure out how to recruit them into the industry, and wages play a huge role.
- But I must be clear: Funding and wages are not the only part of the system that needs to change. To care for our future seniors and individuals with disabilities, we need a workforce that is strong, trained, reliable, and proud of the work they do. If workforce shortage projections are correct (The home health aide workforce has increased by 145% from 2009–2019, and we will need nearly 4.5 million more home health aides to fill the gaps we will see by 2029), then we need to look at all opportunities to strengthen the caregiving workforce. These means addressing immigration laws, looking at our operating models, increasing innovation and use of technology within the industry, addressing childcare, developing career growth opportunities, and more — in order to make sure we have enough of the workforce in home care.
- Federal funding needs to change as well. The ACA was a landmark success in terms of getting reliable federal funding into states because the FMAP ensures that states get at least $1 from the federal government for every $1 they invest in their Medicaid programs. This enables states to invest in home care for their vulnerable populations because it’s patient-preferred and more cost-effective. More recently, states have invested temporary federal relief funds into home care, but that funding will soon run out, and we will see a sudden drop — a “funding cliff.” To prevent this, the federal government could make the temporary FMAP increases permanent. The pandemic has increased the public’s awareness of home care, and as more people see it as a viable and safer alternative to nursing homes, then the more people will want it for their own family’s long-term care needs. We need stable funding to ensure we have a robust, trained, and reliable workforce to keep up with growing demand.
- Lastly, we must remove partisanship from healthcare: Home care is a win-win for everyone, and should not be seen as a Republican- or Democrat-backed venture. 90% of Americans prefer to age at home, and it saves government money by keeping people out of costlier institutions. Regardless of party affiliation, we will all continue to get older, and most of us will need to continue to receive healthcare. Home care is something that we can all get behind.
Let’s zoom in on this a bit deeper. How do you think we can address the problem of home health aide shortages?
Home health aides have one of the highest growth outlooks in the coming years, yet also has the lowest average pay. This is a huge problem that the federal government needs to address, especially as our population continues to grow older and as more people want to age in their own homes.
To recruit and retain enough of the workforce into entering the caregiving workforce, we need to make home health aides’ wages more in line with the value of their role. Their work is physically- and emotionally-tolling, incredibly important and increasingly in-demand, and yet their pay indicates that they are not being valued as such. And, again, it’s multi-dimensional and goes beyond wages: We must address growth opportunities and upgrade the role and re-brand it to attract more talented individuals. Our education systems need to embrace this as a viable career opportunity.
Most home health aides are paid through states’ Medicaid programs, and in many instances, these funding formulas haven’t been updated in years. This is increasingly important as a federal minimum wage increase to $15 per hour is being discussed. Aides do important work and certainly deserve to be paid above minimum wage — but if state Medicaid funding doesn’t go up concurrently with minimum wage increases, then providers will only be fighting harder for the workforce that we already compete for. Many would say that home health aides provide a more compassionate and necessary service in our society than they would in the fast food and retail industries, and that they should be paid as such. And that’s got to be addressed too, by ensuring that funding for home care programs is regularly reviewed and updated, so that we’re not fighting this battle every year as wages in other industries rise.
What concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
Individuals can do so much by sharing their voice. We have so many clients, parents, and families that have been positively touched by home care that have been inspired to share their stories with legislators and the public through advocacy. Your lawmakers answer to you, their constituents. Make them understand that home care is important and that they should support those that need to access it now and in the future.
Corporations & communities: Organizations must remain cognizant and supportive of their employees’ time needs by encouraging their employees to vote and to advocate for their beliefs — and ensure they have the time to do so. When individuals know they are valued — and that their thoughts, voices, and opinions are valued — they will in turn value you and your organization.
In terms of the home care community specifically- we have been coming together much more cohesively in recent years because the stakes are dire and our priorities are aligned: We need to solve the workforce issue to ensure that there are enough caregivers to care for our aging and vulnerable populations. Right now, several leading industry organizations — including the National Association for Home Care and Hospice (NAHC), the Partnership for Medicaid Home-based Care (PMHC), and the Home Care Association of America (HCAOA) — are working together to develop actionable recommendations to state and federal governments on how to address the workforce crisis. Without action soon, our nation could see a different national emergency — one where there is no one to care for us and our loved ones in our time of need.
Legislators and other decision-makers play a crucial role in the future of the healthcare landscape. My message to them would be: Listen to your constituents, and think of the many that struggle to share their voice. We have families that don’t have a minute to do anything else because there isn’t a nurse or aide available to staff their case, so they’re responsible for a loved one’s health and safety. Don’t forget about them as you create and vote on legislation. Investing in home care will cost money now, but it will lead to cost savings in the future as our nation’s reliance on facilities lessens. We have an opportunity to make sure that long-term care is available for years to come, but we must act now.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
If I could inspire any movement, it would without a doubt be a national “Home First” reform policy. I chair the board of the Partnership for Medicaid Home-based Care (PMHC) — a Washington, DC based alliance of home care providers, associations, and other organizations dedicated to advancing and supporting public policies that strengthen and secure the Medicaid program for care recipients and taxpayers. PMHC has been advocating for “Home First” reform policy for several years.
As I mentioned previously, outdated Medicaid policies make nursing homes and institutions the default setting for long-term care in America. But this is contrary to our familial and cultural beliefs that “home is where the heart is” — a sentiment has only become truer throughout COVID. “Home First” encourages lawmakers to reform long-term care policies to remove the institutional bias that currently allows seniors and adults with disabilities to more easily access care in facilities. It also aims to secure reliable funding for home care programs, and inspire support and respect for the caregiving profession.
Our nation has taken a setting that is first in our hearts and essentially placed it last in our healthcare policies. That has never seemed right to me, and it’s why I’ve devoted so much of my career to strengthening home-based care and supporting those who deliver it. A true movement would have a groundswell of grassroots support behind it — which is why we believe now is the right time to push “Home First” federally, and we want to get every American resident behind it. After all, if long-term care doesn’t affect you now, it almost certainly will in the future.
How can our readers further follow your work online?
Readers are welcome to connect with me personally on LinkedIn. At BAYADA, we have hundreds of advocates enrolled in Hearts for Home Care, an advocacy program where we spotlight legislative home care issues and encourage individuals to get involved. You can connect with us via our Facebook, Twitter, and blog. If readers are interested in learning about BAYADA and our services, they can check out BAYADA.com, which will also link you to all our social media accounts.
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.