Sign Kentucky Banking Living Will Later

Industry sign banking kentucky living will later

good morning everyone my name is moshe schuper partner at roth company rotha company was founded in 1978 by abraham roth and has evolved into a leading accounting and financial services firm with over 170 people and locations in new york new jersey illinois and israel we have a large healthcare client community and i am one of the partners that maintains a strong focus on skilled nursing assisted living drug treatment centers and home health industries as part of our mission to be a valuable resource to our clients and the community we have hosted a variety of webinars on topics that are critical to today's environment this is a continuation of that with the focus today being this nursing home industry i'm proud to be hosting this conversation with two outstanding individuals in the industry mark parkinson and steven zifferman mark is the president and ceo of the american healthcare association which is now the largest association in long-term care and represents over 14 000 skilled nursing and assisted living facilities mark served as the 45th governor of the state of kansas and prior to that was the owner and operator of facilities in kansas and missouri mark is widely recognized as one of the top lobbyists in the country steve is a managing partner at ltc finance and advisory services ltc is a premier healthcare firm that has close to a thousand employees and revolutionized the industry by providing a full centralized bank office for operators ltc also provides a full suite of financial services including financial cycle management and reporting due diligence and underwriting advisory services steve has earned a reputation as being one of the most trusted advisors in the industry welcome and thank you both for joining us mark if we can start the conversation with you sure um obviously the country obviously the country has gone through a crazy time last few months um and the nursing home industry has been hit really really hard from your perspective how do you think we're doing today compared to three months ago or even a month ago well moshe it's great to be with you today and appreciate the opportunity to talk with all the folks that have signed up for this uh and get get the word out on kind of where things are at and how things are going and where we think they're headed from here um you're right no doubt this has been the toughest year in the history of long-term care and i i doubt we'll ever have a year that's this mad we'll go through recessions and depressions as a country in the future but nothing that just so dramatically impacts what we do because we're the center of this and so it's been it's been horrible on the clinical side um you know 40 or 50 000 plus deaths in long-term care the emotional toll that's played on our workers and our frontline heroes has been incredible and challenging and difficult and it's going to take a long time to recover from that on the business side it's also been really really tough um nationwide we've seen a drop in occupancy that's differed by provider type but has been significant for all i think nationwide we're looking at about a ten percent drop in occupancy on the snip side maybe five percent on the assistive living side a little less than that in senior living and then in those parts of the country that have gotten hit hard by cove but particularly the northeast the census drops are much more dramatic than that an average of 20 or 25 so you know we have a double whammy of incredible clinical challenges and incredible business challenges i think the good news is we're doing better on both fronts than we were three four five months ago on the clinical side the number of new cases in nursing homes has dropped dramatically the number of deaths has dropped dramatically we've been much more able to contain it on the business side a combination of really enormous resources from the federal government and some from some of the states i think has put most providers in a position where they can start to see some light at the end of the tunnel we came into this with certain objectives in dc we've been able to exceed all of them and so i think you know roughly the total amount of reimbursement from dc from the cares act is now up to 12.4 billion dollars by the time that this last 500 billion dollars gets paid out which is going to take about four months the average provider will have received over eight hundred thousand dollars on top of that there's been a lot of other things that have happened that have been helpful so all in all we think we've been able to achieve maybe about 20 billion dollars of recovery i think that what that has done for about 80 percent of the sector is it's allowed them to keep their head above water and hopefully make it through to the end of the year when we can get a vaccine i still think there's about 20 percent of the sector that got hit really hard by covid these are buildings that are principally in new york new jersey connecticut massachusetts they got hit really hard early on that need a lot more help than what we've been able to get so far but i'm optimistic that with our lobbying efforts in dc we're going to be able to get those buildings held if the pandemic is over at the end of the year and we really do have a vaccine in january february i think we can get through this i'm not sure i would have been that confident four or five months ago in saying that on that note um how long do you think the occupancy will go back to pre-covered levels any idea of what you think that's going to take that's really the most important question on the business side how long will it take us to get occupancy back we follow occupancy very closely and there was about a one percent decline in occupancy every week from roughly mid-march until the first of june occupancy seemed to flatten at that point it seemed to have bottomed out and we thought this is great we bottomed out we can start rebuilding unfortunately the numbers indicate that we're not rebuilding it has not gone up materially since it bottomed out on june 1. in order to have a true recovery occupancy has to start improving and that's a combination of several things first the hospitals have to get fully engaged in accepting patients doing elective surgeries creating the discharges that create our post-acute business and secondly the public is going to have to get confident in being able to send their parents and grandparents to live in our buildings unfortunately i think both of those things are going to take longer than i would have thought though i wouldn't be surprised if occupancy is relatively flat for the rest of 2020 but that we then start gradually rebuilding in 2021 particularly when there's a vaccine and we can get the public confidence back steve on your front um what have you been seeing with your your clients your financials um how's it going now compared to three months ago so first of all moshe i want to start with a with a huge shout out to to both you and mark and the organizations that you represent um you know i firstly with the host you know roth and company i i have to say that you you know you you besides for being a great accounting firm once coveted hit um you guys took an extremely aggressive proactive approach you set up a designated advisory team and a series of webinars that really helped the masses thousands of people through ppp and the cares act and the unemployment family leaves sick leave hhs funds all the confusion that came along with that so you guys did a really unbelievable job helping individual clients as well um you know really really unbelievable uh i also want to give a shout out to to mr parkinson um governor you you and your you know there were i remember conversations prior to prior to covet and talking about the the importance of you know getting in front of elected officials and the importance of the advocacy that you do and i i think we've all learned that you know lived that lesson over the last few months um you know really your you know your organization bringing our you know bringing our needs and our challenges in front of the elected officials making sure that the skilled nursing industry does not get forgotten and um really saving us from the brink of disaster so you know huge thank you from us and our clients for everything that you do uh regarding the the financials um i'm really you know seeing on on the ground we're seeing the same thing that um that mr parkinson just just spoke about which was that yes our clients in the in the northeast new york new jersey pennsylvania massachusetts connecticut um many of those places have seen occupancies going down from approximately 85 percent to to close to 60 percent on average um we've seen a tremendous impact a lot of loss of life and and you know a lot of big dramatic you know issues the a lot of the midwest as you go towards middle america um you know they've got gotten hit a little bit later and maybe not to you know as large and large of an extent they're seeing occupancy drops of five to ten percent um you know clearly the the electives are hurting us the the the media uh perception of us is not helping at all either and the fear that people have of putting their loved ones into skilled nursing facilities is not helping us um the positive obviously is the is the fact that as we move through april and may the the government the federal government um certainly stan stood behind us and a lot of the state government stood behind us so really just echoing a lot of that i think that we were all hoping for a v-shaped recovery and we all thought that okay come the other side we're going to come right back up and obviously that's not pain playing out but the the widespread um distress that we were panicked about in april and may has not played out either uh at this time what do you think so are some of the last long lasting effects of this whole thing um going forward a year from now what do you see as some of the effects that won't change and and things that potentially will be the same because of the whole pandemic i think certainly the the way we we assess um risk in this industry has has changed completely you know we used to talk about we used to talk about the fact that um you know it's a high risk industry um but there was always the risk of pen stroke that the government maybe can you know can really hurt us with with with the stroke of a pen and by changing some reimbursement and making it more difficult for us we also the risks we had we were having tremendous staffing issues uh prior to covid um i think that a lot of that the risks have changed not necessarily gotten better or worse but the the um the lay of the land has changed where we see that our industry has turned upside down our world has turned upside down and we've seen that pen stroke risk actually work the other way where the federal government came in and helped us stabilize our our industries and our businesses and our facilities we've also seen that the staffing at least in the short term we've seen that we've seen ironically we've seen a you know being we've seen a dedication from our staff we've seen that the staff that are there um are there because they want to be there because they want to service their the the sick and the elderly and we've always also seen a little bit less at least in the short term we've seen less competition from other industries in terms of of get you know hiring being able to get our staff on board mark i'd like to ask you the same question where do you see us a year from now you know on the on the business side of it um i think a year from now we'll be past this uh i've been honored to to be asked by secretary azar to serve on a national vaccine panel and we get briefings every couple of weeks on where we're at with the vaccine what the plans are and we try to give good input and i'm really i'm really optimistic about the vaccine development and also the development of some therapeutics to to reduce the the overall deaths rates i think we're going to have huge progress in the fall and i think we're going to have a vaccine by january i think it's going to take longer to get it out to people and folks realize it's a logistic challenge but i think that by i think it's going to be a one-year phenomenon the country basically shut down in march of 2020 i think by march of 2021 this is hopefully behind us that's what i think and i think that once that occurs we we will slowly grow our occupancy back and we'll slowly grow the competence level back with the public and so on the business side you know i think we'll be in in much better position than we are right now um on the government side we're going to have a massive amount of oversight regardless of who wins the election in november they'll be hearing after hearing in dc and probably in the state capitals on you know what went wrong and what needs to be done to fix nursing homes and there'll be a lot of ideas and some of them will be helpful and some of them will be terrible and it'll be our job to make sure that the ones that make sense get get adopted and the ones that are terrible don't but a lot of the wish list things of our critics will be on the table under consideration there'll be minimum staffing requirements that are pretty dramatic and not paid for that will be under consideration there'll be folks that think that we need to have even more surveys and more deficiencies and those things will be on the table but hopefully there'll be some thoughtful things as well and one of the things that we've learned from this is that having private rooms has really been helpful in keeping the pandemic from spreading the fibers from spreading if we could get some government assistance to recapitalize our infrastructure and convert or build new buildings that have more private rooms that could be a really positive development there'll be a greater emphasis on infection control you know we've had a big emphasis in the past that's going to be multiplied and if we can get the government to get off of our backs on the stuff that doesn't matter very much so that we can spend our resources and our time on infection control we can reduce deaths not just from covet but from a lot of other viruses that we face throughout time we also hope that we can use this as an opportunity to develop a more collaborative survey system the survey system is horrible it doesn't work it creates bad outcomes and part of our job at aca will be to hopefully create a new survey system that will be more collaborative so what i'm hoping for the future is a more collaborative approach with the survey teams a real dedication to working on outcomes for residents and uh just some changes that i think can really create those things what we'll be fighting off will be irrational oversight that just attempts to blame us because what's what has occurred over the last five months i i think you definitely see that in the the new york politics um that's for sure um going into the government side of things obviously ppp and the cures provider relief had a huge impact it really provided i think a lifeline to many homes and many many providers talking about that hhs recently released a a 5 billion or news about an additional 5 billion that's coming out the initial reports were that it was related to high coveted uh homes or or people struggling or or providers that are struggling now it seems like it's more related to to performance measures could you give us a little insight about what's going on in the hill in terms of what type of performance measures what change sure well we were very pleased that we were able to get another five billion dollars out of the cares act we had previously received uh 7.4 billion which frankly on a proportional basis is more than any other provider group so when we got the additional five we were quite happy with it we had specific suggestions to hhs on how to allocate the five billion and some of them they adopted and some of them they didn't uh it's really not an issue for the hill it's it's just totally within the decision of secretary azar on how to spend this five billion dollars and so the release that they issued on friday did not give much information but prior to the issuance of the release i was ab e to talk with secretary azar's top people on this program for about a half an hour and they explained to me uh exactly how how this all works i'm i'm here in bethesda right now moshe and we're by the national institute of health which is where we live and there are all these helicopters that come in and out all the time so i apologize for that background noise i think they're now they're now past us uh so let me let me give the the folks on the call some really fresh information about this five billion dollars you have to think about it as four different programs the first two and a half billion dollars will be sent out to every single building in the country it is not an application process it's just like the first three payments you're going to show up one morning and you're going to see some funds that hit your account the money is for ppe testing and staffing you get to decide what you want to spend the money on it's your decision how much you get depends upon two things it depends upon whether or not you have already received one of the point of sight antigen machines that they have agreed to send out to everybody about 1600 buildings have already received those machines and it also depends upon the number of beds that you have for an average size facility which they define as 104 beds i know i'm getting very specific here but for an average size facility if you have the antigen machine you will get a check for 90 000 for your building if you don't have the antigen machine you'll get a check for 170 000 a building it will show up sometime 10 to 14 days from now that's that's the time point that they're trying to get it the reason that folks with antigen machines will receive less is because they believe that the cost of testing will be much lower for them and it is you know the cost of those tests is somewhere between 20 and 40 bucks the cost of the pcr is somewhere around 100 bucks there's no free lunch so coinciding with when this money goes out cms is very likely to issue a rule that says that if you're in a state that has a positivity rating of of above 5 you need to test staff once a week now ironically those are not the states that are in the northeast so your buildings in new york new jersey connecticut massachusetts pencil all those buildings states that got hit hard early on their positivity rate is less than five percent you won't have the weekly testing requirement so you can spend the money on staffing or ppe um so you're either going to get an average of 90 000 or 170 000 a building so that's two and a half billion of it two billion of the 5 billion will be spent on a value-based purchasing program they're trying to incentivize us to do everything that we can to keep cobit out of the buildings i mean i know we already are but they believe that this program will further amp up our efforts and so you know they they listened to and adopted almost all the suggestions that we had on the program it is prospective so what's happened in the past doesn't matter there are four separate programs one for september one for october one for november and one for december each of them has 500 million dollars that's available they will exclusively use the nhsn data you don't have to submit anything they'll just look at your nhsn application and for buildings that have an average or better than average coveted case count of new cases average or better than average of your community the community that your buildings are in you will receive a payment the amount of payment we don't know yet it's a it's a complicated formula they haven't they haven't i'm not sure they've actually come up with it yet but they're going to brief me on it in a few days they don't have it yet we think that the average building that qualifies for a payment will get about seventy thousand dollars a month but it could be lesser it could be more but net net it's going to be around seventy thousand dollars of building so there's a tremendous opportunity for you to work with your folks in your buildings incentivize the people in your buildings to really keep those numbers low not just obviously the right thing to do clinically there there is money available there each month is a separate month so if you don't get it in september you can get it in october and vice versa if you did get it that doesn't necessarily mean in one month that you'll get it in the next month it's completely prospective past cases don't matter cases that you admit that have coveted so if you've set up a cove but only wing and you're taking people from hospitals or other buildings as a service that doesn't count against you either it's new cases of coba that develop within your building and then there are two other amounts with the 5 billion there's a 250 million dollar fund to reimburse people who set up covered wings or cobit-only buildings as they originally had it written it was just for future expense we're encouraging them to include past expense because i've explained to them that i think you know all the cobot only buildings that have been set up are probably all it is going to be set up so they need to reimburse people for the past we'll see when the final rules come out if they do that and then they've also set aside 250 million dollars for providers who want to collaborate with outside groups on plans to reduce covet in their buildings that's very undefined and we don't know very much about it so we'll have to see the details so you know the first 2.5 billion is simple just a check will show up the other 2.5 billion dollars is money that's available to you if you do the right things and go after it uh and you know part of what we'll do at aka is we'll make sure our members know exactly how to get that done and we'll work with you every step of the way to hopefully get as many of you possible um some of those additional funds can i mark can i jump in with a question sure not you know part of what we were hoping at least for our new york new jersey clients was that um they'd be you know they'd be getting some targeted funds because they were hit so hard with kovid um they the these you know a lot of people in these states did not get state um assistance and now apparently they're not getting you know at least special treatment in this this targeted distribution is that going is that completely off the table or is that something that people are looking for yeah i mean we've been advocating for that steve and we we haven't succeeded in it yet but we we haven't given up on it um we still have a shot at it i mean i don't know if you saw the president's comments friday evening at his new jersey news conference but those comments that were very supportive of the sector and very supportive of folks that have gotten hit hard early on came just two days after we had an opportunity to make our case to him and so we're we're lobbying you know obviously at the highest possible levels and so we don't think that this allocation means that that payment which we call the covet hot spot payment is is done we still think that we're in play on that uh and we're actively advocating for it i have a hard time handicapping the probability of it it's i wouldn't say that it's likely but i also wouldn't say that it's a hail mary it's somewhere in between uh and it is our major focus at this point now that we have this distribution of five billion dollars figured out our 100 percent lobbying effort on the hhs fund is exactly what you're saying which is a cobot hotspot payment and another issue will be whether there's any money added to that fund or not it's down to 50 billion right now if a stimulus bill passes they'll probably put more money in it which will make it easier for us but you know a lot of people are starting to point the finger at us and say hey this the snips have gotten quite a bit you know we need to get some more help so you know there's there's there's challenges but i i think that we're in the running to get that payment we still have a real shot at it there is there a reason that uh certain states have not had not come forward is there a reason that certain states are have come forward with their own you know uh stimulus and let's say the new york new jersey have not well it comes back to the conversations that you and i had before the pandemic if you are active politically if you've worked your tail off for the last 10 or 15 years like we have at occa to develop the political relationships that you need you can get stuff done in dc and the same is true with the states so in some states the our ability to influence the governors and the legislatures is greater than it is in other states and i mean i think it's just it's horrendous that's what's happened in new york to the providers in new york and they've received absolutely no support from the state uh in fact i think there's been a one percent medicaid kind of i'm not mistaken so we need we need to do better politically um in new york and the the members and the operators have just got to you know and one of the problems with new york is that the members are not are not united there's multiple associations and there's not this there's not a single voice etcetera we need we need to do better we have a really good affiliate in new york but they can't do it on their own we need folks to join up with them and help us fight the effort in new york how does an operator um join the the government and plead their case you have any recommendations obviously joining the association is important um you have any other recommendations things that they can do to have their voices heard well i mean i i hate to i didn't mean to come on and do this as an advertisement so but i'm going to do this anyway you know people can look at my face and they can see i'm almo you know i'm almost done with this career so this is not for me this is for the future of the sector the only way that we can win is everybody has to join their association that's the number one step and i i you know we told people that before the pandemic and i really appreciate steve's comments once the pandemic occurred people realized and understood what we were talking about if we didn't have the ability to go in and talk to leadership go ahead and talk to the president when it was it's really important and we need to do it we would not have gotten these funds these funds did not come because they thought oh man we really need to do everything we can to help the skilled nursing these funds occurred because people have worked their tails off for 10 or 15 years to create these these relationships it is very frustrating to me when i talk to people and they say i don't see the value of joining my association what's the value and the value is that when you you know are about to go extinct which is what's happened here there's somebody there to rescue you so the number one thing for people to do if you're not a member of your association even if you think the association's incompetent join it become a part of it and fix it that's the number one thing the number two thing then is any additional political activity that you're willing to do and thank goodness we have people across the country that are willing to write very big checks that really improves our level of of access around the country so it's it's a combination of getting involved with your association and getting involved politically um searching gears a little bit i know that you're still advocating um for additional funds i know you've been quoted as trying to get an additional 100 billion with the election coming up how does that play out and and obviously um i think it's needed and the question is how likely would it be well you know i'm sure everybody on the call knows that they're trying to pass what we're calling the fourth stimulus bill stimulus 4.0 is what that's being called in dc they're flopping around right now they're not negotiating the consensus in town is that they'll get their act together here maybe not in august but possibly even as late as the end of september and that they will pass another stimulus bill the democratic version calls for a hundred billion dollars to be added to the cares act fund the republican version calls for 25 i think most people think they'll end up maybe adding another 50 billion to it so if they add that and we end up with 100 billion dollars in the fund that really increases our chance of giving getting that cobit hot spot payment that steve and i were just talking about the election has a gazillion ramifications on us um and you know if a scenario right now is that democrats end up controlling everything if you look at the polling today you know biden would win democrats would take the senate and they would take the house on funding issues that's probably good for us they tend to be more supportive of medicaid and republicans but there is a there's a counter point too which is that on regulatory issues uh it's going to be really really hard if these take everything these these topics that i discussed like minimum staffing requirements banning arbitration more regulations more oversight more hearings we'll be facing those on a weekly basis i've said before that i think what works best for the sector is when we have divided government and one party doesn't control everything that's what we usually have but every once in a while we'll have a two year period of time where one party controls everything and things get really hard the two-year period of time when republicans had everything in 2017 and 2016 after the 2016 election we almost got medicaid taken away in a significant way i think if democrats control everything which is the way it looks to me right now it's going to end up we're going to have a really challenging two-year period of time on the regulatory and oversight side i know we've been talking a lot about sniffs anything on the assisted living side of things um i'm happy to jump in again steve i don't want to dominate the conversation i think the assisted living side has beard has fared better than the sniff side um if you look at the occupancy numbers the numbers have been about half the decline and there's a lot of reasons for that um but i think that because it's fared better during the pandemic it'll probably come out a little better after the pandemic but steve let me turn it over to you for your i thoughts i i know i did hear a concern from a lot of our assisted living um clients where they're saying that the their the return to normal in an assisted living or independent living may be more difficult because a lot of that care is more volunt voluntary meaning they're able to technically be at home whereas in a sniff the acute acute residents are not able to so you know i guess i guess there's there's two sides of that so their decline has not been as as strong but there is concern i am hearing concern about the time it's going to take to get back to normalcy what about um one of the questions that came up is liability protection um has there been any talks mark you can answer steve if you know anything about it um has there any talks about liability protection for the nursing home operators yeah our our top issue in the stimulus bill so you know where we're at right now is that in dc most people think they'll pass one more stimulus bill and that's it and a while back people thought that would happen last friday and it all got broken down and so we'll see probably not this week but our lobbyists still believe that sometime in august or september they will pass a stimulus bill in the stimulus bill leader mcconnell the republican leader of the senate from kentucky has put in his version of the bill some really really helpful language it covers assisted living it covers skilled nursing and it basically excuses us from any conduct unless it is intentional or gross neglect it also limits the amount of recovery so the putative damages can't be more than actual damages and it removes all the cases to federal court which is really helpful because the runaway verdicts have occurred in state courts normally we would have no chance of getting a liability protection like this because it's a very partisan issue with republicans typically supporting this but democrats not and both sides feel very very strongl about it but we have a chance this time and the reason we have a chance is that leader mcconnell has said that this is his number one issue and he will not let a bill pass the senate that doesn't include this language if he sticks with us on that we've got a real chance now again it requires a stimulus bill to pass which right now looks a little bit iffy but hopefully a stimulus bill will pass and we've got a fighting chance for this language to be in the bill if it's not you know we've got a real problem the plaintiffs lawyers are gearing up the statistics for us are bad it'll be hard for the plaintiff's lawyers to win these cases in front of a jury because there's a lot of good facts for us we're doing everything we could we just didn't have equipment we didn't have testing this virus was spreading by folks who had no symptoms all of those are facts that will help when we get to a jury but it costs a lot of money in defense to get to a jury so we really need this liability switching a little bit i know that there's been steve there's been some issues related to change of ownership and how to apply and related to the funds from the stimulus package i know i definitely feel that a bunch of calls are related to it what have your what's your experience related to that so i will say as a lot of our client base are active active buyers so we do have a you know a number of clients that uh change ownership in 2020. so you know the way this played out was that um when you know when the cures act and the provider relief fund was set up hhs was tasked with getting out a lot of money in a very short amount of time and they um they did you know actually a great job getting out that money to the masses to the facilities um they did not you know there's a lot of the details were left to be taken care of later so those um buyers those sellers that sold their facilities in 2020 were instructed to return the hhs stimulus funds and that the buyers may have an opportunity to get additional funds at some later date wasn't a lot of information that came out over you know the last couple of months between may june and july until the end of july when they did come out with uh with a new portal indicating that those owners that purchased facilities or had a change of ownership in 2020 would be able to uh report their revenue and sign up and be able to be uh eligible for targeted funds at this point um i don't know if mark if i know if you know if they've finalized what exactly those funds would be would it be exactly like the other facilities or something different yeah i'm we're in the same position as the two of you are we've taken a lot of questions from members on the chow issues and you know i think i think the news on that is pretty good now um i think you're exactly right steve they did a really good job at getting a ton of money out to people that were kind of in a normal situation but if you'd had a change of ownership your payments probably went to the prior owner and the prior owner probably ended up sending them back to hhs and that's extremely frustrating we've been talking with hhs about this for the last four months and they've been saying the right things to us but they weren't really doing anything about it and i'm not really being critical of them it's because they were doing so many other things that they viewed as higher priority and just getting more monies out kind of out there to various providers we decided that two weeks ago we were going to take this into our own hands and we were going to create our own solution to this i talked with the folks at hhs they said they would appreciate that so if you're a member we've created a dedicated solution at aca you access it by sending an email to chow chow at ahca.org ciao ahca.org let us know your situation the name of your buildings what funds you have and have not received when your transfer occurred etc we're putting those together in a really user-friendly form for hhs and we're going to take them over to hhs and they say that they'll help us get them paid in addition to that hhs has agreed that they will set up their own portal the announcement would be set up the week of august 10th which is this week and so the way the government works we're assuming it'll get set up on friday and at that point they'll have their own portal where you can submit your own information to them but here's the deal there's a lot of other provider groups that have these same issues every other provider group home health hospice you name it so when they open up that portal they're going to get thousands of pieces of information many of which are complicated so what we're doing is that when you send us your information at ciao aca.org we're helping we're going to help you file with them on their portal but then separately we're going to take our stuff over to them and we're going to have separate meeting with them and we're going to get these sniff things paid so look for their portal but also contact us i think if you do both you're going to improve your chances of getting paid you good information um i'd like to switch uh to another topic public confidence um obviously new stories are out there uh it's it's um constantly out there whenever you open up fox news or any other news outlet it's a question of are people feel safe within the within the communities how do we restore that public confidence how do we bring it back to the point to pre-covet well i'll jump in steve uh and i'll i'll take this one first um the the view from the public is understandable you just have to ask yourself you know how comfortable would you feel right now about putting a parent or a grandparent in a nursing home i think the answer is it depends a lot depends on the nursing home it depends upon what's going on in the community etc and we know about the sector you can just imagine how people that don't understand our sector feel about it we we do a lot of polling um you know my background in in politics has taught me the importance of really understanding where the public is coming from so you're not guessing and you're not making decisions based on anecdotes so we've been polling what the public feels about nursing homes and about assisted living buildings each year for the 10 years that i've been at the american healthcare association so we have a really good database and understanding of what the public thinks of us coincidentally we had polled the public and this is not this is a scientific you know we spend 35 000 we do the real polling firms that you've heard of and they do you know nationwide polling and coincidentally we polled in november before the pandemic so we knew exactly what the public thought of us pretty pretty fresh with the pandemic so then we pulled again in and and basically what the public thinks of us hasn't changed so if you ask them favorable unfavorable on nursing homes it's about 50 50. if you ask them favorable unfavorable on assisted living it's about 70 30 favorable interestingly enough if you ask them favorable unfavorable on skilled nursing centers it's like 75 25 favorable or unfavorable but you don't want to use the term nursing home in your home you definitely want to call yourself a skilled nursing and rehab center that gets you an approval rating above even even above assisted living so then we pulled again in may and we thought oh my god surely our numbers will be devastated from what's happened believe it or not the numbers went up and the reason the numbers went up is that for all of health care hospitals home health hospice the numbers went up people had an appreciation for what was going on in care we then pulled again in july and you might say why the heck would you pull again in july we pulled it again in july because our members agreed to a special 10 of bed assessment and some of our vendor partners stepped up and so we have allocated 25 million dollars to a nationwide media campaign to try to improve our reputation and so we were polling in july to see what kind of messages would move the public and kind of where we were at again and that july polling indicated that we had fallen back to the pre-pandemic numbers about 50 50. the public by and large believes that this was not our fault you know when you do the polling and ask them that doesn't mean that they're comfortable in sending their parents into our buildings but they don't blame us they blame the pandemic and some of the bad policies that that occurred so we are starting a nationwide campaign not network we can't afford network but nationwide cable campaign that's targeted at women age 40 to 60 because that's the age group that typically makes the decisions for their parents um that will start at the end of august and it is designed to tell our story to tell the story of the heroes and the front lines who worked double shifts just to save folks and and when they had the resources were able to do it so i just think it's a matter of that it's a matter of time it's a matter of the pandemic going away and eventually we'll get back to where we were but it's going to take some time i would i would just add on to that you know that i think it's unfortunate that the the hospitals where the heroes and the sniffs were the you know the skilled nursing facilities were or the bad ones i you know i know any operator that i know has has probably not slept in four months since the beginning of this pandemic the the the heroes they are the frontline heroes so you know i think that it's it is unfortunate the what the media has has portrayed over here and i would say that a number of operators have made the case you know now that uh people see how difficult it is in many instances to take care of their elderly parents at home and they see the need for skilled nursing facilities um they're making the case that in fact at this point the infection control measures are better at a skilled nursing facility than they are at home with where you have your children and grandchildren going to school and coming back and not implementing those same measures at home so i think there's an argument to be made and uh i do think you know we do think that with time we're going to get back to where we need to on the heroes front obviously um there's a there's a factor here that we should be discussing is employee morale how do you keep that morale up how do you create a facility create a system where the employees feel good about their job and feel safe now steve you go ahead yeah no i'll just say that some of what you know i again i'm not on the lines with the with the staff but i will say that our operators have done a tremendous job in um you know whether it's a social media or just that campaign indicating that hey we recognize that you our frontline staff members are heroes and i think they've gotten out that message to their staff i don't have more to say on that yeah you know i have a very specific philosophy about about running organizations and my philosophy is that successful organizations are mission driven and they're also driven by metrics you've got to be driven by mission and you've got to be driven by metrics and my view is that the most important metric in any organization is employee satisfaction and engagement employees that are satisfied and engaged allow you to achieve your other goals but if they're not satisfied and engaged it's really really hard to hit your other goals so what i would ask providers to consider doing is really doubling and tripling down on your employee engage engagement and satisfaction work measuring it figuring out where you're not doing well and then working hard to get better at it i hope that all of you saw the earnings from enzyme last what was that last wednesday night uh and if you don't know what i'm talking about pull up pull up enzyme they're a publicly treated company the ticker symbols en sg and enzyme announced a 90 increase in earnings in the second quarter of this year think about that the second quarter of this year not including any revenue that they receive from the federal government in fact they sent back the 110 million dollars that they'd received from the federal government i know the folks at enzyme really well and at inside they will tell you that their number one metric is employee satisfaction and engagement they'll even openly say that our customers come second our employees come first and so if you're not measuring employee engagement satisfaction if you don't have an accu program you are missing out on an incredible opportunity and i think that you know when you think about this value-based purchasing funds these four sort of contests in september october november and december where if you succeed your building might get an average of around 70 000 that's a perfect way to align your employees interest with yours get them involved in that program incentivize them you know if you receive a payment get everybody working and headed in in the same direction um and i think it'll it'll work out i'm i'm not just you know talking about this theoretically stacy and i that's what we what we did for our careers we were much younger is that we built and owned and operated buildings and once we developed an employee engagement and satisfaction program and we're actively measuring it every month and incentivizing our administrators to hit certain levels on the scores and really focusing on areas where we weren't doing well we completely turned our operation around and it became fun to run our buildings so i would just encourage people to really double down on employee engagement i mean i think internal marketing is probably just as important as external marketing um talking about the why i think at least in court in the culture here we talk about the why quite often why do we do what we do and i think that's very important in terms of every industry going into the deal making area um i uh based on my conversation with clients people are still making deals people are still buying steve what have you seen in terms of deals um are banks more apprehensive about financing uh tell us a little bit about it so it was interesting to see how everybody worked lock and step over here where where you had um when the pandemic started in april and may there was pretty much a complete stop where everybody put everything you know most buyers just put everything on hold anybody that uh anybody that would talk to me about a deal i was like really are you really looking at something right now uh nobody had any idea what's what's happening as the the government stimulus started to take take hold and as we moved into especially when we got um you know the five billion dollars you know specifically allocated to skilled nursing at that point it became clear that the federal government is going to support our industry and i i'd say across the board the activity that happened at that point that started at that point in terms of people looking at deals from an activity standpoint pretty much matches what it was prior to to kovid now the question will be you know will they over the next month or two or three um getting to the finish line is is slightly more difficult you know slightly more challenging at this point uh simply you know until you you get the right the right balance in terms of valuation but clearly there's an interest um clearly there's an interest in in buying there's equity equity partners are interested in coming and coming in um the lending partners the the banks um frankly i don't know if they have a better place to put their money at this point you know i don't know that office buildings or retail or restaurants or hospitality are better at this point or more secure than than healthcare so the the the equity partners are are very interested in getting in the the banking partners are there they are closing deals uh maybe a little bit uh you know maybe a little bit more diligence a little bit more conservative in terms of you know a little you know looking for for some additional recourse maybe slightly lower a loan to value that they're that they're willing to give but overall they are they are ready to to engage they're ready to close and there are deals happening i think i think a lot of the um the buyers that were the sellers th t were on the brink you know prior to covid see this as a tremendous opportunity to to sell they are um you know especially the the mom and pop type type operators the non-profits that you know don't want to or don't have the the strength or the the stamina to to go through this for you know for another year they're looking to to get out um but i would say that the the that the distressed purchases or the the heavy discounts that people thought would be coming would be coming our way have not presented themselves at the time slight there are slight adjustments in valuation um but you know overall there's interest in the in in buying and um the valuations are not yet at uh at a sharp discount in terms of mark in terms of hud uh 232 loans has there any talks related to that um any apprehension about those insured loans you know there has been we're working on something that right now doesn't look like we're going to be able to get i mean we're still lobbying it um which is that we're trying to get included in the stimulus 4 bill 4.0 bill a program that would defer people's payments for a year and then just allow them to refinance it as a second mortgage it'd be a tremendous cash flow benefit for anybody that has an existing hud loan and we we still have a shot at it unfortunately it did not make the cut in mcconnell's language but we have a bunch of folks that are lobbying on it and if we could get it those of you that have hud loans you know understand what how great it would be to not have payments for for a year and then be able to just to turn that into whatever the amortization period is left on the life of your loan so that's the only thing that's really in play right now on the hill as it relates to hud loans we have been able to get hud and and a lot of other people deserve credit for this other than myself and in the aca there's a there's a hud community of folks that have worked hard on these issues so i don't want to take the credit away from them but they've been able to work with hud and we've helped a little bit to get some improvements made around the edges of the program but there's just so far that hud can go before they need statutory authority to offer something as big as like a one year deferral on payments but we're still work we're still working on that um steve is there any key performance indicators that you think operators should be looking at differently compared to pre-cove at times well i think there's there's one key performance indicator is which was the same as before census census census uh you know a couple of operators were heckling me on the way in over here and saying so are you going to tell us how to fill out buildings or not so you know i kind of told them hey if you you know if you wait till the end if you listen to the whole thing then maybe you'll get the magic but um i don't care the reality is that none of us have the magic potion and that's gonna take time um but you know we have seen a lot of we've had a lot of conversations and we've seen a lot of focus on um burn rate and and in our environment what the burn rate means how many months do we have um you know how much cash and how many months of losses can we absorb before uh before we fall apart or we need additional stimulus funds from from the federal government so you know we we are looking and in places that have been hard hit it's a couple of months places that um you know places that are you know are less had less of an impact so they have a little bit more than a couple of months to you know to survive you know without without the profitability um cash you know cash cash and cash on hand and current ratios people are looking at you know a lot of burn rate conversations how long can we survive this um so steve i'm curious on your thoughts if you if you think about this next five billion that's coming the way i described it for the folks that aren't in the northeast that are kind of out there in the rest of the country how how far does that get them before they're in trouble again how many months runway do they have the the folks in the in the northeast again the original funds got them a couple months let's say two three months so this will probably give them another um another two three months if if they're lucky enough to um to have been able to participate in ppp they may have you know some additional time so i guess we're kind of looking at with this money hopefully most most operators can get close to the end of the year um but you know at that point we were really hoping for either a turnaround or uptick in census or at least people getting to the break-even point and then um you know and and if not you know having some additional funds coming our way okay uh we're running out of time here there's a lot of questions that come through if we don't get to them or if we didn't talk about them uh we'll try to follow up with another additional email or additional guidance on those um one thing i i do want to mention is that on the accounting side of things there's a lot of terms and conditions for all of these stimulus packages ppp the provider relief fund it's very important to read through those or have somebody read through them especially since they're updated on a continuous basis a lot of this was obviously pushed out to get the funds out as fast as possible and it's important to continuously look at the frequently asked questions and the terms and conditions to make sure that you're on top of that situation in terms of the compares provider relief fund right now it is considered a federal grant um and federal federal grants do require certain audit requirements um please be aware of that there's probably going to be additional guidance coming out of the next few months about that but providers should be aware of that at this time mark if you want to close us out anything you want to bring up that we haven't done so i was just looking at the chat to see if there's any other questions that i could answer but if you if you do you didn't follow up feel free to feel free to contact me i i would just say what i know that all of you have heard you know in the past which is that this has been the roughest five months in the history of the sector and i'm just really proud of you and the rest of the sector for not giving up one of the things that's going to be really interesting is when a deep dive is occurs on what's happened in the rest of the world we've already done the research on that and in the rest of the world in many long-term care settings the staff ran away from the buildings in fear of getting covered themselves and left all the residents to die you know here in this country we did really just the opposite our you and our teams and your teams rush towards the facilities and towards the residents and we received a tremendous amount of negative publicity but i really think that when the analysis is done that our story is going to be better understood and our story isn't over yet there's still a really rough five to seven months ahead of us and you know godspeed as you continue to work to save the lives of these folks and we'll do everything we can to try to make it a little bit easier for you but thanks for what you're doing steve so just to echo listen we've we've lived through unprecedented times the challenges are something that we've nobody none of us expected none of us have ever experienced um but you know one thing i would say to operators is that you're not alone you know we see the same challenges across every operator across every organization and more so i would say you're not alone largely because of the advocacy of akka the federal government is there they've indicated that they're going to be there to help us and you know i think that we're not alone and that gives me a lot of a lot of encouragement to know that we're going to be able to weather this and we are going to come through on the better on the other side stronger than before i agree um so i just want to thank you both i i think it was very insightful and i think um i hope our um participants enjoyed and and got something from it um thank you very much for coming um we are going to release additional guidance as they come through additional stimulus packages as the release we will be giving out additional webinars or uh email guidance about that so please be on the lookout thank you very much for joining have a great day