Most people think senior care is boring.
I think it’s the most interesting industry nobody talks about.

I’ve spent fifteen years here. 
Worked the floor, did the sales, ran the consulting projects. Saw what works and what doesn’t. Mostly saw what we all pretend works but just burns everyone out.

Now I’m seeing, AI land in senior care whether we’re ready or not. Some operators are figuring it out. Most are drowning in vendor pitches and don’t know what’s real.

That’s where I come in.
Think of me as your AI wingman for eldercare. I help you separate signal from noise and figure out what’ll actually move your numbers. Not the conference presentation version. The Monday morning version that works in your building naturally.

I’m not just consulting on this. I’m building it.

I run Burst Medical Billing. We’re creating AI technology that helps SNFs recover Part B revenue they’re missing. 

Raised $1.5M and integrated with PointClickCare. 
We’re launching the first AI-powered revenue stack built specifically for skilled nursing facilities in 2026. So when I talk about what works and what doesn’t, I’m not guessing. I’m testing it in production.

What you’ll find here: 
Honest takes on the AI landscape in senior care. 
Strategies you can actually implement. Occasional rants about things nobody wants to say out loud. Sometimes a joke, because this work’s hard enough without being miserable.

I’m building toward something bigger. 
A future where senior care isn’t healthcare’s afterthought. 

Where operators have tools that don’t require heroics just to function. Where the people doing the hardest work get the support they deserve.

If you want to talk AI strategy for your operation, get paid for your Part B supplies, or book me to speak, let’s connect.

Senior Care’s #1 Super Fan | CEO & Managing Partner, Burst Medical Billing | The only person who finds both Medicare Part B and machine learning genuinely fascinating

ERIC HANSEN

The federal government wants to fix nursing homes by telling them how many people to hire. 

I need to say upfront that this is not a terrible 
idea. It is, in fact, the kind of idea that sounds 
so reasonable you feel like a bad person for questioning it. 

More staff. Better care. 

Who could argue? 
Try arguing it at a dinner party. 

Try saying “actually, the staffing mandate 
might hurt the people it’s designed to help” 
and watch the table look at you like you just 
advocated for kicking puppies. 

I’ve done it. (Not the puppy kicking part)
I was roasted.

But there’s just something outsiders don’t get. 

Try any GD policy you like.
Mandate ratios, minimums, 

Set floors so high the industry has to pole-vault to clear them. Fine. Do it. I’m not against it. 

What I’m against is writing the requirement on 
one piece of paper and the funding on another 
and then losing the second piece of paper, 
which is what the federal government has 
done with nursing home regs for 30 years. 

Sooner or later you stop calling it 
oversight and start calling it intentional.

A staffing mandate without money behind it 
doesn’t land as “hire more staff.” It lands 
as a sorting mechanism. 

The facilities that can afford the bodies 
(the ones with enough private-pay residents 
to subsidize the gap) they’ll clear the bar. 

The facilities that can’t, the ones running on 
Medicaid in towns where there aren’t enough 
aides within driving distance to fill the shifts 
even if the budget existed, 

those facilities don’t hire more staff. 
They close.

Think about who lives in 
the ones that close.

Not the private-pay residents in the suburbs. 
The Medicaid residents. The ones who already 
had the fewest options and the least leverage in every conversation about their own lives. 

The mandate will move them. Out of a building 
that was understaffed into a building that’s 
farther away, or more crowded, or both. 

Some of them won’t survive the transfer. 
That’s not rhetoric. There is research on what 
happens to elderly residents when their facility 
shuts down. 

They die at higher rates in the months after. 
Their bodies remember the room even when their 
minds don’t, and being moved to a new hallway 
with new sounds and new smells is not a neutral 
act. 

It is an injury that doesn’t have a deficiency code. 
Nobody gets cited for it. Nobody fills out a form. 

The resident just arrives in an unfamiliar bed and
something in them, something the care plan 
never captured and the regulation 
never weighed, breaks.

I want more staff in nursing homes. Desperately. 

The word “understaffed” has become a 
euphemism the way “food insecurity” is a 
euphemism for hunger. 

What I want even more is for someone, anyone, 
to stop mandating things without funding them 
and then acting surprised when the gap 
produces harm. 

The mandate is coming. The money isnt. 
The rule has mass. 

And the underpaid CNA on the night shift 
can already feel its gravity.​​​​​​​​​​​​​​​​

-eh

Medicare Part B’s Best Kept Secret | Senior Care + AI | Speaker | Founder & CEO

I worked as a CNA for five years. 
I don’t say that the way people usually say it.
With a wince, or a brave face, or the word 
“rewarding” deployed like a shield. 

I say it because it’s what happened. 
I was twenty-two years old and I needed a job 
and someone told me you could get 
certified in six weeks, so I did. 

Six weeks of classroom, a skills test on a dummy, 
a written exam I passed by 12 points, and then 
they put me on a floor with 23 human beings who
needed things I had not been taught to give.

Nobody tells you what the job actually is. 
They tell you how to transfer a patient from 
a bed to a chair. How to check a blood pressure. 

How to change a brief without making 
someone feel like a child.

You learn to maintain dignity the way you learn 
everything else in a nursing home: 
by drinking out of a fire hose.

I did that for five years. Then I sold medical 
services to nursing homes and walked into 
nearly a thousand of them across 25 states, 

and I saw the floor from the outside for 
the first time. Saw it multiplied, replicated, 

the same hallway 
and the same arithmetic 
and the same exhausted aides doing 
the same impossible math in buildings 
that smelled the same 
and ran the same 
and broke the same.

After that I started a company in the long-term 
care space and learned the business side, which 
meant learning that the people running these 
places were not the problem I’d assumed they 
were when I was twenty-two and naive (dumb).

They were doing math too. 
Different math, with bigger numbers 
and thinner margins 

but math that came out wrong in the 
same places mine did

At the bedside, where the gap between what’s 
required and what’s funded takes the shape of 
a person standing in a doorway choosing. 

Choosing to help Mrs. Smith or Mr. Roy.
Choosing to record the slip as a fall or not at all. 
Choosing..

That’s not a comfortable thing to say. I know. 
I spent a long time trying to find a way to say it 
that didn’t sound like I was blaming the people 
who wrote the rules. I’m not. 

They were solving a real problem. Are.
They saw genuine horrors and they built a 
system to stop them and in many ways it worked. 

But it also calcified. 
It stopped learning. 

It kept adding rules and never subtracted any, 
and it never reckoned with the fact that the 
money wasn’t following the mandates, 

and now we have a system that demands a 
standard of care it refuses to fund and then 
punishes the people at the bottom when the 
standard isn’t met. 

I didn’t set out to write about that. 
I set out to write about what I saw. 
It turns out they’re the same.

-

🔔 Follow for senior care content 
without the AI slop

#lethalbenevolence

No alternative text description for this image

Ernie has a stunning beach bod.
But it isn’t meant for the office.

Medicaid pays for 6/10 people in nursing homes. 
And it pays eighty-two cents on the dollar. 

Medicaid is Ernie.

$0.82. 
I want you to hold that number for a moment
because everything that follows depends on it. 

Eighty
two 
cents.

Not a slim margin. 
Negative 18%.

Some facilities get less than seventy cents for
every dollar it costs to keep a person alive, 
clean, fed, and turned every two hours so 
their skin doesn’t open into a wound 
that lets you see what people look 
like on the inside.

You cannot run a building on seventy cents. 
You can run a version of it. A thinner version. 
Fewer aides. Longer wait times. Call lights blinking like tarmac lights.

Congress used to require states to pay based 
on actual costs. Then they gave states flexibility. 

Then they repealed the last federal 
floor on payment adequacy. 

That was 1997. 

The floor was removed. 
Nothing replaced it.

The facilities on the thinnest margins serve 
the most Medicaid residents, operate on half 
a percent profit, and are concentrated in the 
poorest communities serving disproportionately black and brown residents. 

Your zip code and your insurance card 
decide which building you die in.

Drive twenty minutes in any direction from a 
facility running on fumes and you’ll find one 
with twice the staff, half the turnover, and a 
lobby that doesn’t smell like the 70’s. 

One building has enough Medicare residents 
to subsidize the gap. 

The other lives on $0.82 per $1.00

And now Congress is cutting nine hundred 
and eleven billion from Medicaid over the 
next decade. 

The residents can’t organize. 
They can’t march. 
Many can’t speak. 

That line is closer than any of us think. 

Six out of ten of us will cross that line. 

When it’s your turn, look down and
hope your tummy isn’t showing.

-

🔔 follow for irreverent content on #SeniorCare 

DM me to learn how much your Part B supplies are worth each month.

There is a 68 year old woman in Alabama
A retired school administrator, 
Spent forty years saving carefully.
And cannot afford to get old.

Not the way people mean it at cocktail parties. She’s not worried about gray hair or crows eyes. 

She has $180,000 in the bank and a house worth 
roughly the same, and a body that has started 
requiring more than her body can manage alone. 

She needs assisted living. 
The kind with a nurse aid nearby and 
someone to help with the things she 
can’t do anymore without falling.

The place her daughter likes 
costs $6,400 a month.

Her savings will last about two years. Maybe three if she’s doesn’t buy the AARP subscription or pay for the Lyft rides to her stylist anymore.

After that, Medicaid. 
Except , wait, Alabama doesn’t pay for 
assisted living. So after that, what?

A nursing home.
Or a different kind of facility. 

Definitely a longer drive for the daughter. 
A room that fits a twin bed, a tv, and a recliner.

That’s basically it.

This is the forgotten middle

The several million Americans who saved too 
much to qualify for assistance and not nearly
enough to buy their way into the places built 
for people who saved more. 

They are too wealthy for the safety net and 
too poor for the market, which has spent the 
last decade building memory care units with 
wine bars and concierge services for the people
a smidge above them while the people below 
them got Medicaid beds and the people in the 
middle got a bureaucratic line in the sand with 
no name and no product and no plan.

Now some operators have a plan. 
Strip out the wine bar. Pull the concierge. 
Cut the fine dining program and the lobby 
that looks like a Marriott.

Build something functional. 
Price it at $3,200 and cater it to the middle.

The industry calls this a no-frills model. 
Critics call it warehousing. 

Both sides are describing the same building. They just disagree about what it 
means that the building exists.

Here’s what I think, for whatever it’s worth. 

The argument about amenities is the wrong 
argument. It is a debate about the furniture 
inside a structure nobody is questioning. 

The structure is this: we have a population that 
needs care, a market that cannot profitably 
serve them at a price they can afford, 
and a government that has 
declined to bridge the gap.

The no-frills operator didn’t create that structure. 
Neither did the luxury operator. 

They are both rational responses to a 
market that was handed to them busted.

The woman in Alabama doesn’t need a wine bar. 
She also doesn’t need a warehouse. 

She needs a place that can afford to staff, 
which requires a margin, which requires 
a price she cannot pay for more 
than thirty-six months.

The math doesn’t care about the amenities.
It never did.​​​​​​​​​​​​​​​​

-eh

🔔 Follow if you’re looking for a 
different kind of LinkedIn post. 

One that doesn’t 
sound like AI slop.

PS. Dm me if you’ve ever wondered whether 
your part b supplies are reimbursable?

Everybody knows the 3-day rule.
Researchers just proved it doesn’t work.

But it’s still on the books.

Medicare’s three-day rule. Written in 1965. 
Requires three consecutive inpatient days 
before Medicare covers nursing home rehab.

When the rule was written, hospital stays 
averaged ~two weeks. Three days as a 
checkpoint made sense.

Today, hospitals move in hours. 
The rule hasn’t moved in 60 years.

Brown University just published the numbers. 
600,000 Medicare hospitalizations.

After the rule was reinstated post-COVID, 
hospitals started keeping patients longer 
to hit the three-day threshold. 

Was it because patients needed more time?
I doubt it. I’d wager that it’s because 
Medicare required it.

And it led to 2,000 extra hospital days. 

In 
one 
month

SNF use didn’t drop. 
Outcomes didn’t improve. 
Mortality didn’t change.

The rule added cost and days. 
It added nothing else.

The lead researcher expected the rule to reduce 
nursing home use. That was the whole point.

“That’s not what we’re seeing in the data” she 
said.

But this is only half the damage.

Hospitals face Medicare auditors who can 
retroactively deny inpatient claims. So hospitals 
increasingly classify patients as “observation 
status.”

Your mother is in a hospital bed for 72 hours. 
IVs. Tests. Monitoring. She gets discharged 
to a nursing home for rehab.

Medicare says no. She wasn’t an inpatient. 
She was being ‘observed’.

Those days don’t count.

Now she owes $350 to $600 a day. Out of 
pocket. For care everyone agreed she needed.

One rule. Two opposite harms.
It forces some hospitals to extend stays nobody 
needs. It gives other hospitals a reason to classify 
patients in ways that erase their coverage.

Both responses are rational. 

AND THATS THE PROBLEM!
It’s a built-in structural trap.

Every time Congress tries to kill this rule, 
the effort dies. Not because anyone 
defends it on its merits. 

Because the CBO scores ‘repeal’ as increasing 
Medicare spending. (It does).

But the spending the rule creates is scattered. 
Diffuse. Thousands of hospitals padding 
stays by one extra day. 

You can’t photograph that.

A CBO number you can.

So the cost of keeping the rule stays invisible. 
The cost of removing it gets a price tag. 
And the price tag wins. Every time.

(Read that part one more time 👆)

That asymmetry is how broken systems survive.

A rule from 1965. Applied to a system its authors 
wouldn’t recognize. Kept alive not because it 
works, but because the structure that created 
the problem also protects the problem from 
being solved.

Nobody designed this. 
But of course that’s what happens.

#lethalbenevolence

Okay... I'm fired up today. Excited and angry. 
Because something is finally being done.

*Pulse rising*
Think about what it actually takes to run one of these nursing homes. You are managing one hundred human beings at the most vulnerable point in their adult lives. 

Your staffing grid has three open shifts and the agency wants $67 an hour to fill them. 

A state surveyor is coming Thursday and the pressure ulcer documentation on Room 114 is giving you indigestion.

A family on the second floor has called four times this week and there's always 5 too many expletives. 

You have a dining complaint ("too much salt"), a serious med error to investigate, and you're covering for a tour in 20 minutes with the sweetest (and slowest) 104-year old woman and her daughter.

Somewhere in the middle of all of that, a Part B supplier just walked through your door. 

*Blood pressure rising now*
He has a delivery. Supplies for several of your residents. He has a CMN (a Certificate of Medical Necessity) for each one. 

Four sections. The supplier filled out his parts already. He just needs the attending physician to sign Section D. 

The physician signs. The supplier leaves.

You never saw the paperwork. 
You never saw the claim. 
You won't see it ever. 

NOT
EVER

*Starting to sweat*
Because while you were managing those hundred people, that supplier billed Medicare for items delivered inside YOUR building, to YOUR residents, under YOUR care. 

He collected the reimbursement. 
The one that belonged to YOUR building!

*Mad now*
Imagine hiring a contractor to renovate your kitchen. You pay for the materials, schedule the work, supervise every nail. 

Then you find out the contractor also billed YOUR homeowner's insurance separately (for the same job) and kept the check. 

You didn't know you could file that claim yourself. 
Nobody told you. The contractor counted on it.
And pocketed the money anyways.

*Pulse slowing*
That is what Part B suppliers have been doing to nursing homes for thirty years.

The nursing home provides the care. The nursing home carries the liability. The nursing home employs the staff. And the nursing home 
always had the legal right to bill for those supplies itself. 

*Breathing easier now*
The supplier exploited a billing architecture complex enough that a two-person billing team couldn't track it in real time, and walked out with your money.

*Feeling vindicated*
This month the federal government launched CRUSH and froze new enrollment for the entire Part B medical supply category for Part B suppliers. 

Nationwide. 

Six months. Because in FY 2024, these suppliers carried a 21.4% improper payment rate. More than triple the Medicare average. 

They built an industry on the assumption that you would never figure it out.

Some of them were right. 
Until now.

PS. You can bill for these. Ask me how or follow me to join an upcoming webinar where I teach you exactly how to do this yourself.

#burst

“Spend your life savings if you want our help.”
That’s the rule. Not a misprint.

The Rule.

You want Medicaid to pay for your mother’s 
nursing home, she needs to be broke first. 

Savings gone. 
Investments gone. 
The car if it’s worth too much. 

The money she set aside for forty years 
because she didn’t want to be a burden…

Gone. 

Asset limit in most states: $2,000.
Two thousand dollars.

I want you to sit with that number for a 
second before we move on.

Got it? Next…

Care costs run $7,000 to $10,000 a month. 
Medicare covers about 100 days if she 
qualifies, if the paperwork holds, if the stars align. 

The thing people don’t realize,
the thing I didn’t fully understand 
until I started pulling the thread

is that the spend-down doesn’t just wipe her out. 
It wipes out what she was trying to hand you. 

The house she raised you in. 
The account she never touched. 
The inheritance that was supposed to help 
your kids start somewhere instead of nowhere. 

It doesn’t evaporate. It goes to the facility. 
Then it goes to zero. Then Medicaid arrives.

After she dies, the state may come for 
whatever’s left. Sometimes aggressively. 
Sometimes quietly.

Either way, the option exists, sitting there in the 
statutes like a guard dog on the other side of 
the door… waiting.

The numbers are just the numbers. 
16.4% of nursing home residents spend down 
their assets and enroll in Medicaid during their 
stay. 

After four years, 61.8% of people who entered 
as private-pay have made the transition. 

Median savings of an older American: $36,000. 
Annual nursing home costs: up to $288,000. 
Do that math once. It’s easy. Do it.

Somewhere (we actually know where) 

A decision got made, that public money should 
only reach people who truly can’t pay. 

Which sounds like good stewardship until you 
understand what “truly can’t pay” requires a 
family to go through first.

There’s got to be a word for a safety net with a 
hole that size. I keep coming back to trapdoor. 

Most families don’t know it’s there. 

They find out the same way everyone finds out 
about the things that were always waiting for 
them.

On the way down.

-eh

——

🔔 Follow if you’re looking for something different on LinkedIn. 

DM me to learn how we help nursing homes recover their Part B supply reimbursements 
the compliant way.

A nursing home gets cited for a fall.
Not a bad nursing home. 

A facility running short because the state 
reimburses $198 a day for a human being 
who needs round-the-clock care. 

(That’s less than a mid-tier hotel room).

So the surveyor writes it up. 
The facility writes a Plan of Correction. 

New fall prevention protocol. 
New documentation requirements. 
New staff training module. 
New audit schedule.

Nobody asks where the time come from.
(They come from the floor and admin team).

The CNA who was already covering 22 residents 
now spends thirty minutes charting what she used to spend on care. 

The nurse who caught the early signs of a behavior last month doesn’t catch it this month. 

She’s in a care plan meeting about fall risk 
documentation with the leadership who worked 
70 hours last week.

Three weeks later, someone gets a UTI that 
goes septic. 

New citation. 
New protocol. 
New documentation.

The cycle doesn’t announce itself. 
But it’s there. 

Pressuring everyone with more compliance.
More checklists.

Every rule makes sense on its own. 
Every corrective action looks responsible 
on paper. 

But each one pulls staff time away from the work 
the rules were written to protect. 

And when care suffers because the staff was 
busy proving they provide care, the system 
doesn’t pause to ask why. 

It adds another requirement.

I call this Compliance Gravity.

It’s the slow, cumulative, one-directional force 
that bends a facility’s entire operation toward 
compliance as its primary function. 

Not care. Compliance. 

The weight only accumulates. 
Regulations stack. They almost never subtract. 

And the pull gets stronger the fewer resources you have to resist it.

Well-funded facilities absorb it. 
Medicaid-heavy buildings get crushed by it.

Worst of all, the system’s own response to 
failure is the catalyst for the next failure.

Low on resources / staff / cash -> 
Mistake -> 
New POC / reg / fine -> 
More documentation -> 
Less time for care -> 
Even less resources / staff / cash -> 
Mistake -> 
Repeat ♻️

What Is Compliance Gravity?

Grab a nursing home penalty notice off the shelf, would you? The weight of it tells you things before you read a word. The formality of the letterhead. 

The dollar amount in bold, always presented as though it were the final word on the subject.

It never is.

CMS imposed $202.9 million in nursing home fines last year. Hold that number, because what happens next is more interesting than the number itself. 

Seventy percent of penalties get reduced before a dollar is collected. Waive your appeal rights and the system hands you an automatic 35% discount, like a coupon for getting caught. 

A hundred-thousand-dollar fine quietly becomes 
thirty-five thousand before the check is written. 
Not that size alone indicates accountability. 
Many large fines are performative theater.

But there is that matter of where the money goes.
Money has weight. In this case, I'd say each piece
of paper is 120 to 212 pounds.

Ask anyone who works in the business office of a nursing home running on 1.8% margins.

Follow it past the headline. The Medicare portion flows to the U.S. Treasury. 

Not to CMS. Not to residents. To the general revenue account, the "Fines, Penalties, and Treasuries" account, where it vanishes as miscellaneous receipts. 

The Medicaid portion goes back to the state for reinvestment. Grants capped at five thousand dollars. No capital improvements allowed. 
No technology. No core services.

Is there any rationale for believing this reaches the residents it was taken from? 
(I'm not convinced).

Eleven states are sitting on more than $190 million in accumulated penalty funds they haven't 
spent. North Carolina holds $42 million. 

Enough for a $5,000 grant every day for twenty-two years. 

The money just sits there while the facilities it was extracted from cut second-shift staffing to make the quarter work.

I built a slide deck that takes this machine apart gear by gear. 
The intake valve. 
The erosion funnel. 
The splitter. 
The reservoir. 

The self-reinforcing loop where penalties shrink budgets, budgets shrink staff, and fewer staff produce the next citation. 

(I'll be sharing more of it over the coming weeks).

Because at its most basic we are only discussing a penalty system. 

But you'd do well to remember we are also talking about a broken machine. 

And broken machines don't fix themselves.

#LethalBenevolence

The Anatomy of a Broken Machine and the Quiet End State

Congress just reformed PBMs. 
(It only took 60 years)

Pharmacy benefit managers were created 
in the 1960s to do one thing. 

Negotiate lower drug prices for 
the people buying them.

Then somebody tied PBM compensation 
to the size of the rebate.

A middleman paid on the percentage of the 
discount has a structural incentive to 
keep the starting price high. 

Higher list price. 
Bigger rebate. 
Bigger PBM revenue.

The entity hired to lower your drug costs 
got paid more when they didn’t.

(Read that again 👆)

Every actor in the chain did exactly 
what the incentives told them to do.
(This was predictable).

Manufacturers set high list prices 
because PBMs demanded large 
rebates for formulary placement. 

PBMs preferred high-rebate drugs because 
their compensation was tied to rebate volume. 

Employers saw big rebate checks and 
assumed the system was working.

You, in the deductible phase, paid full list price. 
You had no idea a rebate existed.

Here’s what the new law does. 
It delinks PBM compensation from rebates. 

Flat fees only. 
Mandates transparency reporting. 
Requires 100% rebate pass-through 
to employer plans. 

Here’s what it doesn’t do.

It doesn’t touch the architecture.
The law fixes the compensation. 
Not the structure.

One company can set the formulary, 
own the pharmacy, fill the prescription, 
and adjudicate the claim.

And it doesn’t cover Medicaid. 
77 million Americans on the program that serves 
the poorest, sickest, oldest people in the country 
got a study instead of a fix. 

They’ll wait for the next round.

Maybe.

The structure created the incentive. 
The incentive shaped the behavior. 
The behavior produced six decades 
of predictable BS. 

Nobody designed it on purpose. 
But of course that’s what happens 
when you pay the gatekeeper a 
percentage at the gate.

#lethalbenevolence

Medicare Advantage costs the federal 
government roughly $2,500 more p/yr/per 
enrollee than traditional Medicare. 

The care isn’t better. 

They’ve just mastered the art of getting paid 
for sickness.

They upcode. 

They enroll healthier patients and bill as though they’re sicker. 

MedPAC, the nonpartisan agency Congress 
created to advise it on Medicare, estimates 
MA overpayments will hit $76 billion this 
year alone. 

Did that stick? 
$76 Biilion in OVERPAYMENTS.

14% more than it would cost to cover the same people in traditional Medicare.

Three insurers now control nearly sixty percent 
of the market. Up from a third in sixteen 
years. 

That’s an 84% relative share expansion through
organic enrollment growth, aggressive M&A, 
and sustained regulatory arbitrage.

They use lobbying and litigation to block every
reform that would slow the money down.

The star rating system that’s supposed to keep this honest? 

MedPAC says it doesn’t reliably indicate quality
and has led to unwarranted bonus payments. 

Fifteen billion in quality bonuses flowing to plans
that figured out how to score well on paper.

Meanwhile, every Medicare beneficiary

including the ones who chose traditional Medicare

pays higher Part B premiums because of MA overpayments. 

The people who opted out are subsidizing the system they rejected.

Over the next decade, MA overpayments are projected at $1.2 trillion. 

That’s not a typo. 

That’s the cost of a payment formula that 
rewards documentation over care, in a system 
where the entities with the most lobbying power
capture the most resources and the populations 
with the least power absorb whatever’s left.

The money isn’t missing from American healthcare. 

It’s in the wrong waiting room.

The agency nurse costs more than the 
administrator’s car payment. Per shift.

That number sits in the back of every 
operator’s brain like a bad tooth. 

You don’t forget it. 
You just learn to stop thinking about it.

Here’s what it means. 
It means the facility already lost. 

Not tonight, months ago, maybe years ago, 
when the staffing math stopped mathing and 
the only options left were leave the hall 
uncovered or call the agency. 

The agency nurse costs $69 an hour.

The permanent nurse she replaced cost $44.

That $45 difference doesn’t come from nowhere. 

It comes from the cash flow sheet, which means
it comes from the family down the hall who 
doesn’t know they’re subsidizing it, which means
it comes from whatever’s left of the margin after that, which means eventually it comes from somewhere it was supposed to go instead.

A repair. A well-deserved raise. 
The third aide on the overnight 
that never got hired.

Operators don’t choose agency because they 
like it. They choose it because the alternative

the empty shift, the uncovered hall

has consequences the agency bill doesn’t. 

You can absorb a bad month of agency costs. 
You cannot absorb the lawsuit, the citation, the 
immediate jeopardy tag that follows the night 
you left the building short.

So the math becomes: pay the premium now or 
risk a cost that makes the premium look cheap.

It’s really more of a hostage negotiation with your
own balance sheet than it is a staffing decision.

Oh, and it compounds!

The agency nurse costs more and knows less, 
which means more incidents, which means more
documentation, which means more nursing time
on paperwork and less on the floor, which means
the permanent nurses burn out faster, which 
means more vacancies, which means more 
agency.

(Oof… that was hard to write)

The industry has a name for this. 
They call it the agency trap.

And I think it stinks!
It’s just stinks!

-eh

I think some of you are fibbing to me.
I asked everyone how much their premiums
were going up in 2026.

Nearly half of you said not at all.

I have to scratch my head at this because the odds are next to zero that 44% of you would not see premium increases.

Even under normal circumstances where we weren’t in the middle of a political quagmire, premiums go up year over year to accommodate for inflation.

What am I missing here?

Mine went from $1,247/month to $1,453.
That’s a 16.5% increase.

Some friends saw their premiums jump from $500-$800. That’s a 60% increase.

Now, I know political tensions were ripe with fear because of the shutdown and people were digging their heels in but which of you out 
there really saw no premium increases?

Because if like your reps number. 

Thanks 🙏 

-eh

graphical user interface, text, application

I’m not a policy researcher, but I get through six or seven regulatory reports a month. I don’t read them to study the system. 

I read them because after fifteen years in elder care I can’t stop. 
Yet there is a learning process going on. 

Every report has its own lesson, and quite often the bad ones 
teach more than the good ones.

When I was selling medical supplies I visited a facility in rural 
Missouri that had just been hit with a $40,000 penalty. 

A building running on margins so thin the administrator kept a 
whiteboard next to her coffee mug to count days of operating 
cash. 

The staff cared so much it made your chest hurt. But the fine 
that was supposed to fix things was about to make both 
problems worse. 

It was terrible, actually. A system populated by paper-thin logic 
and outlandish assumptions about what punishment accomplishes. 

The penalty money wouldn’t go anywhere near the residents it 
claimed to protect. For me it was the regulatory equivalent of a 
smallpox vaccination: I have never, so far as I know, looked at a 
CMS fine and assumed it was doing what the press release said. 
Maybe one day I will.

Almost everyone in elder care can remember the first time they 
watched the system punish a struggling building and thought: 
this isn’t fixing anything. This is making it worse. And I think I 
understand why.

One learns most clearly what not to do by studying bad policy. 
One building like that is worth a semester at a good policy 
school.

Because here’s what they don’t teach in policy school. The 
Medicare portion of every nursing home penalty flows directly 
to the U.S. Treasury. Not to CMS. Not to a quality improvement 
fund. Not to the residents who were harmed. 

It vanishes into general revenue as miscellaneous receipts. 

The Medicaid portion goes back to the state, where eleven 
states are currently sitting on more than $190 million in 
accumulated penalty funds they haven’t spent.

The money leaves the building. It does not come back. 

That administrator in Missouri with the whiteboard next to her 
coffee mug? She lost $40,000 from an operating budget that 
was already underwater. The government collected it, split it, 
and sent it somewhere that has nothing to do with the people 
living in her building. 

And then we wonder why the same facilities show up on the 
same lists year after year.

#LethalBenevolence

Pay attention sales people.
Blair is giving you pro tips for free
(straight from the pianists mouth) 

Say that five times fast
Guaranteed laugh.

What stinks Blair, is you’re asking the bare minimum here. When Shawn Barron and I teach this sales stuff, your suggestions are the freshman level curriculum.

This is what every sales person should do
And yet… 90% do not.

They feel the pressure to sell.
To hit quota and they believe (incorrectly)
That they should press hard.
Get straight to the pitch.
Push to get the sale.

What they don’t realize is this is one of those
“Slow down to speed up” scenarios.
Meaning, you close more deals faster by avoiding the high pressure sale.

Funny thing. It’s never been harder to be in sales
(Because prospects are awash with AI-BS and the pitch fatigue is real).

But it’s also never been easier
(Because you just need to be authentic and human).

Who would have think that with all of this advancement the best way to sell is not New school.

It’s Old.

Vice President of Operations | Senior Living/Senior Care

View Blair Quasnitschka, LNHA, FACHCA’s profile

Sales…the approach works as a vendor and operator. 

So when a sales representative comes to me assuming they can solve my “problem” - you’ve already lost. 
1. Assumption - how do you know I am struggling in the service line you are selling?
2. Bandwidth - in the vast litany of focuses and initiatives an operator is dealing with, I likely have prioritized already and you possibly do not fit at this time. 
3. Connection - if you have done nothing to research me or my organization, you have no chance. Honestly, treat it like your resume needs to stand out in the stack of thousands. 

The solution:  do some homework and CONNECT first. Ask where our pain points are. Ask if we are considering what you solve for in the next 6-12 months. 

I think about it when our Lifestyle Advisors who consult with seniors every day - they don’t dive straight in assuming we have the solution to their life’s next chapter in an attempt to beat them into submission to our doorstep. We connect first and determine does our individual Community’s experience align with their individual journey, at that time, down the road, or never. 

Treating sales like a sprint instead of a marathon likely leaves you losing whatever damn race you’re running.

In 1966, an economist named William Baumol 
noticed something about string quartets. It took
four musicians forty minutes to play a Beethoven
piece in 1826. 

Still took four in 1966. 

The labor hadn’t gotten more efficient. 
It couldn’t. Labor was the product.

He called it cost disease. 

In most industries, technology makes workers
more productive. 

One farmer feeds thousands now. 
Wages rise because output rises. 

But some work resists mechanization. 

You cannot automate a classroom. 
You cannot batch-process a violin concerto.

And you cannot build a machine that turns a 
ninety-year-old woman every two hours with 
the kind of attention a real person delivers.

Nursing home care is Baumol’s disease in its purest form. 

It takes the same number of human hours to 
bathe, feed, and reposition a resident today 
as it did in 1980. 

But the wages that aide needs to survive have 
risen, because rent and groceries and the 
entire economy around her have gotten 
more productive and more expensive while 
her job stayed exactly the same.

The thing that gets me… scares me a little.

Most states set Medicaid rates using general 
inflation measures. But general inflation tracks 
an economy where productivity gains push 
prices down. 

Nursing homes exist in the part of the economy 
where that never happens. 

Even if you closed the gap today (set rates at 
full cost this afternoon) by next year they’d 
already be falling behind. 

The index they’re tied to measures an economy nursing homes don’t belong to.

That’s why this argument never ends. 

Advocates push for higher rates. 
Legislators occasionally deliver. 

The rates cover costs for a year, maybe two. Then the disease does what it always does. 

The cost of labor rises. 
The index doesn’t keep pace. 
The wound reopens.

We’ve been having this same fight for thirty 
years. We’ll have it again next year. 

And the year after. 

Because the fix is indexed to the wrong economy, and nobody wants to say that **** out loud.

The quartet still takes four musicians and forty minutes. 

The bath still takes one aide and fifteen minutes. 

The economy moves on. 
The work stays the same.

-eh 🐼

The Director of Nursing at New Jersey's worst-rated nursing home had a license that expired in 2007. (This is a true story)

It had been suspended after an arrest for forged prescriptions. 

When investigators asked for documentation, someone submitted what appeared to be a fabricated RN license

(the number on the document belonged to someone else entirely).

Nobody caught it for years.

The man listed as the facility's owner hadn't visited in years either. 

When investigators asked how much he paid 
for it, he said "I don't know, I don't remember. 
I think it was nothing, almost." 

When they asked who owned the building, he said "I don't know, it's all Steve's things." 

He had, by his own admission, "absolutely no" involvement in running the place.

He was the licensed operator of record.

Two other men ran everything. They ran it through companies they owned, which contracted with the nursing home they also controlled, at prices they set themselves, for services investigators would later find they failed to provide.

On 75 randomly selected days across a two-year review period, the facility was understaffed every single day. Not most days. Every day. 

By nearly 50 percent on average. Some shifts had zero qualified staff on the floor. Yes, zero.

Of 34 resident files pulled at random, 12 had no care plan at all. Zero documentation of what each person needed, what they couldn't eat, what medications they were on.

A state surveyor found a resident weeping in bed, in a hospital gown, unable to reach anyone in social services. The resident had moved there four months earlier and still hadn't received their belongings.

This facility carried a one-star rating — the lowest possible — for over a decade. It kept receiving Medicaid funds the entire time.

From 2018 to 2021, the two men who controlled it allocated $45.5 million in profits to themselves. 

The facility reported $4.8 million in losses over the same period and was functionally insolvent by 2022.

The New Jersey Office of the State Comptroller released its findings in December 2024. The owner and both operators have been suspended 
from the Medicaid program. The investigation is ongoing.

A man who knew nothing owned the license. Two men who controlled everything owned the profits.

The people who lived in the building paid for it!

Thanks Michael Wasserman for sharing this story. You can read the full article by visiting his original post here: https://lnkd.in/dfA_zK7V

#burst #LethalBenevolence

Cost | Operations | Strategy

Many organizations are struggling with high costs and low profit margins.

This is where I come in.

For more than 25 years, I’ve been helping build healthy organizations.

Advantages of my services :

1.	Structural cost reduction & margin improvement (Design to Value)
2.	First Time Right product development (Design for Six Sigma)
3.	Operational excellence across global sites (Root Cause Analysis)
4.	AI-enabled analytics + change leadership (Decision making and adoption)

Aroop Bhattacharjee
BSc PgDip MSc EMBA MBB CEng CPEng IntPE
https://www.theprofitengineer.nl/

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