The Future of Healthcare: “First and foremost, reprioritize long-term care into the home setting” with David Totaro of BAYADA Home Health Care

First and foremost: Reprioritize long-term care into the home setting. It’s well-known that caring for a person in their own home costs much less than a nursing home — approximately $30,000 less per resident per year — but little is being done to reinvest healthcare dollars to encourage these savings. In fact, the exact opposite […]

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First and foremost: Reprioritize long-term care into the home setting. It’s well-known that caring for a person in their own home costs much less than a nursing home — approximately $30,000 less per resident per year — but little is being done to reinvest healthcare dollars to encourage these savings. In fact, the exact opposite is true. Since the Medicaid program’s creation in 1965, there has been a “default” policy in place which directs vulnerable individuals to nursing homes for care, even if they would prefer to be cared for at home. This archaic policy separates people from their families and communities, it puts them in institutional settings where they may face infection, neglect, and other risks, and it imposes avoidable costs upon federal and state budgets. This is wrong, but there is an available solution: “Home First” is a reform initiative that would involve screening individuals up front to determine their suitability for home care. If it is a sensible and realistic option, and if they prefer it to institutional care, their right to be treated there would be preserved. This would be incredibly beneficial for our nation’s most vulnerable populations, their families, and for Medicaid budgets.

Asa part of my interview series with leaders in healthcare, I had the pleasure to interview David Totaro. 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. Prior to joining BAYADA, Mr. Totaro was chief marketing officer at RehabCare Group, Inc., a national rehabilitation therapy management company headquartered in St. Louis, MO. Mr. Totaro currently serves as 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 a board member of the Partnership for Quality Home Health (PQHH), the Home Care Association of America (HCAOA), the Hospice Action Network (HAN), and the Pennsylvania Homecare Association (PHA), as well as on the Public Policy committee of the National Home Care and Hospice Association (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.”

What do you think makes your company stand out? Can you share a story?

What sets BAYADA apart is our employees’ commitment to being involved. I’ve never worked for another company where employees are so eager to say, “What can I do to help your team accomplish your legislative goals?” We have an Ambassador program where each office has one volunteer serve as the liaison to the government affairs office. We often ask them to help spread a message or meet with their local legislators, but I’m always surprised at how far our employees often take it. I just found out the other day that one of our Ambassador now serves as chair on a state-appointed task force designed to recommend health care policy changes to the governor. Generally, as you climb up the ladder, people tend to have less and less time to do much more than what their role specifies. But at BAYADA, I’m always shocked to see countless people step out of the box and take control. Half of the time leading starts by just getting involved.

In terms of a story, this is one example of many where one of our Ambassadors threw us for a (very pleasantly surprising) loop. The Ambassador took her state representative on a home visit — a trip to a local client’s home so that the legislator can witness home care and its effects on constituents “in action.” Our office was pleased to hear that the legislator subsequently assisted the family with home modification so their medically-complex son and his caregivers could more easily navigate around the home. But we were floored when a week later, the legislator reached out unexpectedly with draft bill language to change state newborn screening list requirements on behalf of the family.

What advice would you give to other healthcare leaders to help their team to thrive?

Without a doubt, my number one piece of advice is “listen to those you hired.” There’s a reason you chose them, so listen to their ideas. I have a Top Ten List of Behaviors that I give to all our new employees. One of them is “if you find yourself talking more than listening, then just shut up.” Too often, we hire for skills and then sit back and tell them not only what to do, but how to do it. Dead wrong.

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.

You are a “healthcare insider”. If you had the power to make a change, 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.

1. First and foremost: Reprioritize long-term care into the home setting. It’s well-known that caring for a person in their own home costs much less than a nursing home — approximately $30,000 less per resident per year — but little is being done to reinvest healthcare dollars to encourage these savings. In fact, the exact opposite is true. Since the Medicaid program’s creation in 1965, there has been a “default” policy in place which directs vulnerable individuals to nursing homes for care, even if they would prefer to be cared for at home. This archaic policy separates people from their families and communities, it puts them in institutional settings where they may face infection, neglect, and other risks, and it imposes avoidable costs upon federal and state budgets. This is wrong, but there is an available solution: “Home First” is a reform initiative that would involve screening individuals up front to determine their suitability for home care. If it is a sensible and realistic option, and if they prefer it to institutional care, their right to be treated there would be preserved. This would be incredibly beneficial for our nation’s most vulnerable populations, their families, and for Medicaid budgets.

2. Protect spouses from impoverishment. Another example of the often-lopsided nature of Medicaid policy is that the program protects spouses from impoverishment — but only if their loved one has been institutionalized for treatment. If, on the other hand, that care is being delivered in the home, no such protection exists. As a result, many vulnerable spouses are forced to make the painful decision to place their loved ones in a nursing home in order to be protected from poverty. That makes absolutely no sense to me, and it needs to be fixed. BAYADA and our national partners are supporting and advancing legislation that would remove this institutional bias by permanently extending spousal impoverishment protections to all individuals who receive long-term care — whether in a nursing home or their own home. This would eliminate the incentive for seniors to choose nursing home care to avoid impoverishment and enable couples to stay together, age in place, and avoid costly institutionalization.

3. Attract more of the workforce to the home health care field. The US population is aging rapidly, with 83 million Americans expected to be 65 or older by 2050 — nearly double today’s 65+ population. At the same time, we are facing a major gap in the number of home health aides and nurses who will be available to care for them. The problem is that our workforce is often attracted to other settings (such as hospitals and nursing homes) and other industries (such as retail and fast food) where wages are often better. The number one way to strengthen our support for these vital caregivers is to increase state Medicaid rates. Home health care providers like BAYADA rely on those rates to pay staff and offer them benefits, training, and supplies. But in most states, those rates have fallen below the cost of living. The more we can give our employees, the more people will be attracted to the field. We found through an internal study of home health aides that 25% of those who were offered a job but declined it cited dissatisfaction with the wages we could offer them as the #1 reason. Aides do an incredibly important job in keeping people safe at home and out of nursing homes, and as a society, we are basically showing them that they’re valued more if they work at McDonald’s or Walmart.

4. In addition to Medicaid, changes must be made to modernize Medicare. Currently, there is no structure in place to ensure that a Medicare beneficiary discharged from a hospital will receive the post-acute care they need in the setting that’s right for them. Instead, we have a “patchwork quilt” of treatment settings — long-term care hospitals, inpatient rehab facilities, nursing homes, and home health agencies. Logic would dictate that beneficiaries are always placed in the setting that’s right for their needs — but, unfortunately, that is often not the case. The reality is our nation has an inadequate discharge planning process that is made even worse by a highly skewed payment system. With no uniformity on placement protocols, beneficiaries are often placed in settings that are not right for them. Worse still, we as a nation are placing priority on costlier institutional settings, even if the beneficiary wishes to be served much less expensively in their own home.

5. Last but never least, we need to stop the constant attacks on Medicaid and Medicare. They are more than government programs — they are social institutions that were created to meet a real and pressing need … and they have met that challenge in extraordinary ways. All of us know people who are elderly, disabled, or suffering poverty. Those attacking Medicare and Medicaid are essentially saying that the needs of these millions of Americans are not important and that meeting them should not be a national priority — and I could not disagree more. I’m proud that BAYADA is leading the industry, particularly as our national partners are now more united and driven than ever. It’s more impactful to drive towards meaningful healthcare changes as an industry that agrees Medicare and Medicaid can and should be reformed in a positive way — not by slashing or destabilizing these programs, but by improving them.

Ok, its very nice to suggest changes, but 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?

To make positive reform a reality, our state and federal decision makers need to be convinced — by individuals, corporations, and communities — that they need to make real, meaningful changes to health care laws and policies. We are the ones who elect our legislators, and it’s our duty to share our opinions about what affects us — as constituents and voters, we’re they’re bosses!

Individuals can get involved in advocacy by sharing their voices with decision makers to communicate their priorities. Whether it’s by writing an email, making a phone call, sending a tweet, signing a petition, or showing up at a town hall meeting, it’s our duty to tell lawmakers how healthcare affects us and what we think would make the situation better. If not, those directly impacted by government decisions will not be heard by those making them.

Corporations also bear a big responsibility here. Get your people involved and empower them with the tools they need. Encourage your employees to vote by allowing them to leave the office on Election Day to do so. Share your views on current laws and regulations with your clients, and show them what you’re doing about it and how they can get involved too.

Communities go beyond geographical settings. At BAYADA, we’ve seen how social media has enabled disease groups, parents of medically complex children, and family caregivers, among other populations, to band together. It’s important that communities not only communicate with one another in a silo, but that they also focus on actionable advocacy at the individual level.

Leaders at state and federal levels are in the best position to make changes on behalf of their constituents. Making real changes to health care will involve commitment. Listen to the people that come in to speak with you, and follow your conscience. As a decision maker, it is your responsibility to do the right thing.

As a mental health professional myself, I’m particularly interested in the interplay between the general healthcare system and the mental health system. Right now we have two parallel tracks mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?

You hit the nail on the head. As I already mentioned, the lack of integration is one of the biggest overarching problems with our healthcare system. I think Mark [Baiada] put it best when he said, “When you enter someone’s home, you enter their lives” — and that’s a responsibility I — and all of us at BAYADA — take seriously as part of the healthcare ecosystem. We take a holistic view of our clients’ needs, whether it be medical or personal care, or support of mental health and intellectual or developmental disabilities through our behavioral health/habilitation services.

BAYADA recognizes the opportunity, and responsibility, we have as health care providers to improve the continuum of care for our clients. In 2017, we launched the BAYADA Center for Integrative Care, which is designed to provide each of our pilot group clients an employee who is dedicated to looking at the client’s needs as a whole and making the essential connections with not only their BAYADA services, but by connecting them to other services — including mental health, food shelters, and other nonprofits — to ensure clients have everything they need to find comfort, heal, and thrive at home.

While we have taken steps to improve this internally in our own practices, to really change the “status quo,” as you put it, we’d have to put a true and actionable emphasis on integrating all facets of individuals’ health as a priority nationally. I don’t want to beat a dead horse when I say that it’s up to lawmakers to make meaningful reform, and up to all individuals to share that message with them.

How would you define an “excellent healthcare provider”?

Actually, BAYADA has put a lot of thought into defining exactly that in 2002 when we decided to develop a company philosophy — the guiding force in our daily work, which we call The BAYADA Way. Our philosophy is based on three core values that will help us realize our vision, which is becoming the world’s most compassionate and trusted team of home health care professionals: compassion, excellence and reliability.

These three values are the very definition of an “excellent healthcare provider.” Compassion ensures that our clients and their families feel cared for and supported — through the services we provide and through the advocacy we employ to support America’s caregivers and those who don’t have a voice. Excellence means we do our work with the highest professional, ethical, and safety standards. And reliability assures our clients they can rely on us, without question, every time — to be at their house for a shift, to fight for them as they try to navigate the complex healthcare system, and to be that voice.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

I have always lived by a quote that one of the CEOs that I reported to for many years, and who became and still is my mentor, Dick Parsons (CEO, Dime Bancorp; CEO, AOL Time Warner; CEO, CitiGroup; CEO, Los Angeles Clippers; Chairman, CBS) said often and signed all his emails and memos — “Keep the faith.” While there are always so many reasons to become dejected, disappointed, and want to give up, just keep believing in yourself, in your team, and in your mission. Good always trumps bad.

Are you working on any exciting new projects now? How do you think that will help people?

From a company-wide lens, one of the biggest projects that we’re continuing to work on is transitioning BAYADA to a nonprofit organization. It’s the biggest stake in the ground I’ve seen a company make toward helping to solve the health care quagmire that is affecting consumers, and is also a brilliantly-devised exit strategy that will help to support the company’s legacy for generations to come — which, for those values-driven as Mark Baiada and the Baiada family, is about ensuring the company’s vision is realized.

This transition offers long-term continuity that allows us to play a major role in the transformation of the healthcare system and — important to both you and us here at BAYADA — ensure that the future of healthcare involves integrated systems. As our industry continues to experience ongoing consolidation, ownership changes of private competitors, layoffs and mergers — BAYADA is here to stay. It also helps in developing partnerships with other mission-aligned organizations — health care providers, mental health support and social services, nonprofits — to create a collaborative and integrated health community.

From a government affairs lens specifically, one of the biggest projects my team is involved in currently is making sure state lawmakers understand the need for increased state funding for Medicaid-based home health aide programs. There’s been a predominant trend over the past year where states are mandating a minimum wage increase. We support minimum wage increases, especially as home health aides are doing incredible work, but making low wages due to low Medicaid funding for such programs.

Lawmakers tend to overlook that home health care providers who provide Medicaid-based aide services rely on states as the sole funder for these programs, and that the funding must cover more than wages. We’re working to make sure that they understand that adequate funding is essential so that providers like BAYADA are able to comply with new wage mandates while still maintaining our standards for training, benefits, and supervision. The worst thing that could happen is, if these programs aren’t funded adequately, we may decide that we can no longer provide those services and remain sustainable. In such a case, the many seniors and individuals with disabilities that rely on us for home health aide services may be forced to go without that care.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

I tend to read a great deal on planes since I travel about 2–3 days a week. And, I like current political commentary. But, my favorite book in the past few years, where I think I learned a great deal about leadership, is Doris Kearns Goodwin’s Team of Rivals, which is about how President Lincoln deliberately chose those who opposed his views to be in important and influential positions in his administration. Wouldn’t that be something today? I also enjoyed David McCullough’s book, Truman, about the eponymous president who didn’t want the job, but leadership beckoned, as well as Tip and The Gipper by Chris Matthews — about a time when differences were worked out and progress was made. These books didn’t necessarily make me a better healthcare leader but, hopefully, have made me a better leader.

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.

What a great question! The change I would most like to see sweep this nation is related to the “Home First” reform policy we’ve already discussed. In our families and our culture, we revere the home. “Home is where the heart is,” is something we learn early on from our parents. And “There’s no place like home,” is a wonderful sentiment expressed in The Wizard of Oz and echoed in so many other ways since.

But our public policies are severely out of sync with this sentiment.

From the nursing home bias that exists in Medicaid to the deep cuts that threaten Medicare to the inadequate support and respect being given home care professionals, 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.

So, back to your question. If I could lead a movement, it would be to truly and consistently place home first — not just in the context of Medicaid screening but in every manner possible. This would mean pro-home reforms to our nation’s healthcare programs, it would include long-overdue steps to raise up home care professionals, and it would be underscored by incentives and initiatives that would make the home setting as highly prioritized in the future as institutional facilities were in the past.

How can our readers follow you on social media?

Readers are welcome to connect with me personally on LinkedIn. At BAYADA, we started 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 websiteFacebook, and blog. If readers are interested in learning about BAYADA and our services, they can check out, which will also link you to all our social media accounts.

Thank you so much for these insights! This was so inspiring!

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