Q4 2020 Leadership Letter - Bill Dombi

October 19, 2020

Bill Dombi

President of National Association for Home Care & Hospice

Bill is President of the National Association for Home Care & Hospice (NAHC), the largest and most respected professional association representing the interests of chronically ill, disabled, and dying Americans of all ages and the caregivers who provide them with in-home health and hospice services. NAHC is a trade association that represents the nation’s 33,000 home care and hospice organizations. Bill has served as NAHC's President for the past 3 years after serving as their Vice President for Law since 1987. A graduate of the University of Connecticut, Bill has been helping shape policy and advocacy for the home care and hospice industry for more than 30 years.

**This conversation was recorded in August 2020. Some of the information discussed is specific to the time of recording.**

Matt: Many people in the home health and hospice industry know who you are, but I'd love to learn a little more about your background and what drew you into home health and hospice, and specifically NAHC. You've been a part of the organization for a long time. Can you share the story of how you first got involved in the industry and NAHC?

Bill: Well, given that I'm an old person, it probably goes back quite a few years. It could be a long story. But I will tell you some things that I have told several other people about how I got to where I am. I'm trying not to embellish it or add unnecessary humor to it, but it was all because I was an okay softball player.

When I was in college, I did an internship at a legal aid program. I was at the University of Connecticut and I got to work on some litigation that they were focused on, which happened to be a school desegregation case. I worked on some individual matters benefiting people who were essentially, really poor people. That's why they qualified. So there were many things that we tried to do to assist those individuals and I enjoyed doing that work. So I spent a year after college working there as well. During that year after college, we put together a softball team, and we nearly won the league championship. Then I left for law school in D.C. I got a call sometime after, I think it was April, May, or something of that year, asking if I would be coming back to Connecticut and if I would be interested in playing on the softball team. So I said, I very much would like to do that but I need a job for the summer and I want a job that's worthwhile to me. And so they said, we'll worry about that when you come back. We’re most interested in softball. So I found my way back to Connecticut for that summer. When I showed up at the office, I asked what work do I have to do - what is it that you've got in mind? And they said, “Well, we always wondered why we haven't done any real work around Medicare as the largest health insurance program in the country. And we assume, like many other programs, that they probably have some issues that we could help people with.” So I spent the summer doing a review of what are the Medicare issues that might affect beneficiaries. In the process of doing so, I met a number of the home health agency directors across the state and found that there was a strong partnership interest on behalf of their patients and our beneficiaries in the legal services program as they were the same person, we just titled it something different. Thereafter, we found that there was an area of work that we could be helpful in. During that second year of law school, I wrote up a grant proposal to get a special advocacy program funded to represent Medicare beneficiaries in the state. When I finished law school, I went to work for that program because the grant was funded. There we developed what I’ll loosely describe as the preeminent advocacy organization for Medicare beneficiaries. The reason why I could say that way was there really wasn't anybody else doing the work. In the course of that work, which was a combination of litigation, congressional advocacy, and individual representation, I found that the greatest partnership was with home health care agencies. Hospice was not yet even a benefit of the Medicare program back then. I just found that our common interests just helped fuel my passion to try to help people as a lawyer. 

Fast forward about eight years at that point, and we've been doing lots of various litigation across the country, and I got a call from somebody I met some years prior, a guy named Val Halamandaris, who was the President of the National Association for Home Care. He said, “I'd like you to come to Washington, and have a discussion with our board of directors. We're looking at the possibility of filing a lawsuit against the Medicare program.” So I said, Sure. I flew down to Washington, spent the day with his board of directors going through all the ins and outs of issues that they were facing. We described it as the attempted dismantling of the Medicare program. One out of every three claims were being retroactively rejected by Medicare, denying payment to the provider of services. They were destabilizing the structure of delivery of care and putting beneficiaries at risk through what you could label as a chilling effect. Once a provider got burned by the Medicare program once or twice, they were avoiding the risk of getting denied and they became very conservative on admitting patients into care and extending Medicare coverage. After that meeting, Val took me back to the airport and said, “I think the board will agree that we need to file a lawsuit and we want you to do it.” I said, well, we represent beneficiaries, not providers to services, but I could see a case being made on behalf of the beneficiaries being stronger than providers here, so let me think about it. He said, “Well, you may have misunderstood. I want you to come to work for NAHC and file the lawsuit. I want you to create a public interest law firm at NAHC and to be our litigation arm and our strong advocacy arm in doing so.” I said no, half a dozen times. I liked my life in Connecticut. I liked the work that we were doing in Connecticut. But, I started thinking. If I don't do this, somebody else will… and my ego got the best of me, perhaps and I concluded that somebody else doing it will probably screw it all up. So I agreed to come to Washington to work for NAHC. My wife asked me -  “How long do you think we'll be there?” I said, three, maybe four years... And that was the beginning of an endeavor that continues today, to fuel the passion that I have to provide the resources that are needed to do the kind of advocacy that's necessary on behalf of both patients and providers. That's the way we look at what we've been doing at NAHC for all of those years. What we're doing on behalf of providers is intended really to bring a benefit to those people that they care for. It's not about the business of home care, it's about the service of home care that is preeminent within our membership and within the organization. That's what keeps me going.

By the way, we did win the softball championship. 

M: I'd like to talk about influences that have impacted your leadership style. Have you had anybody that's had a significant influence on your leadership? Whether it’s a friend, mentor, or advisor, who is that person?

Bill: Well, I think it goes back really to the one I considered at the top of that list, a guy named Doug Crockett. Doug was the director of the legal aid program which was called Tolland-Windham Legal Services at the time, and I was his intern. He was a unique individual in terms of his leadership style, but much of what he did stays with me today. Primary among that - here he was a very experienced and successful attorney, and he took me under his wings to a point that I actually lived in his house with this family for the summer after college before I went back to law school. Mostly what he showed me throughout that period was an incredible amount of respect and assignment of responsibility. I was a college student, and I was a first-year law student, yet he gave me opportunities with the work we did to really grow and to grow quickly. Showing somebody respect is something that I believe is a necessary component of leadership. If you don't show them respect, if you don't give them the opportunities, if you don't recognize this is a next-generation in some people or that other people besides yourself are highly capable, you're not going to have the achievements that you can have. So Doug was somebody who gave me that view of leadership early on, balanced with one other thing. This is a bit of an anecdote of sorts. He said, “If you need to talk with me, sit in my chair in my office, and when I come back, I’ll know you need to talk.” So leaders have to be accessible too and if they're going to mentor, if they're going to help advance people, you can't do that remotely, you can't do that without a hands-on approach. I found that to be invaluable to me. I think the return on the investment of his time was equally valuable to the organization. That's what leadership is all about, ultimately, is taking a team of people and making them high performing. So that's why I put Doug at the top of my list in terms of somebody who influenced me and somebody who mentored me and taught me a lot about leadership. He didn't have a commanding aura about him. I don't know of anybody who had a greater impact on me than Doug.

M: How have you taken that experience and perspective that Doug provided you and used it to influence the culture within NAHC as the President and into the industry of home care and hospice?

Bill: One of the things I took from that experience was - If you had a culture of ownership, it would trigger a high level of engagement and performance. So when I worked at something when I was in law school, I believed this was mine to work on as part of a team or individually, either way.  But that ownership aspect of it drove me to perform. I believe that's the culture that we've been working to bring into NAHC and into the NAHC membership, and I think we've had a lot of success on that. What that translates to is what I labeled in one of my early speeches as the President of the association, is the power of “we” in that we are incredibly strong when we work together as a community. As much as you have ownership individually, you have ownership as a community. The power within that community of home care and hospice is not yet fully tapped, but the skill sets are just almost endless. If you pull them together properly the outcome can only be positive so that with ownership, an emotional aspect of it translates into a community-based ownership mentality and culture to achieve what we hope to be greatness. So that's what I've been endeavoring to do for many years before being President, but now in a position as President, I have a little more license to be able to try to effectuate that kind of culture. Whether it's within the staff of the organization, the governance body, the board of directors or the committees, but most importantly, at large with the membership, ownership is key. The word ‘association’ translates to being a team. It's not a bunch of hired guns doing somebody's bidding. It's people coming together for the benefit of that community at large. But you have to be an owner of that community to be engaged. So when I think culture, this is where we went from our strategic plan and on forward, was that culture of ownership, engagement, involvement, and working together as a community.

M: With keeping the idea of cultivating a culture, when you're pulling together a leadership team or even a personal advisory board, what kind of people do you look for? What skills, behaviors, or mindset do you look for when building out your advisory team or one for NAHC?

Bill: The first thing that I look for is whether they're capable of being a team player. You've seen this in sports, you bring in nine all-stars onto a baseball field and they get beat by a bunch of people who are playing in the minor leagues the year before because those guys are playing as a team. In basketball, one of the greatest teams ever had been the Boston Celtics in the Red Auerbach era, and they played as a team. It was remarkable what they could do with a basketball. I went to the University of Connecticut and was a long-standing admirer of the women's basketball team because they play like a single unit and they just performed year after year after year. Now, you can have an incredibly skilled government relations person, an incredibly skilled Chief Operating Officer, and an incredibly skilled Director of Education, but unless they realize that the culture that we have requires them to operate like the University of Connecticut women's basketball team or the Boston Celtics, they're not going to fit in, and they're not going to perform. A team of all-stars does not necessarily translate to a high performing organization. That's the first thing I look for in people, can they work with other people. From there, you look at their ability to also work within associations. The reality is this, NAHC is a membership-driven organization. The membership wants the support of our staff and wants leadership coming from the staff. It's still membership driven. That's the other part I'm looking for in leadership staff, can they understand that it is membership driven? And the third thing, which some people look at is the first thing, is do they have the skill sets? The reality is there are lots and lots of people who are highly skilled in certain functions. They might be highly connected to the House of Representatives or the Senate for government relations purposes and can score a meeting anytime you need it. Or that they understand what it takes to make a successful education program from a content perspective. There's a lot of people who have those skill sets, but do they fit within the culture that you want of teamsmenship and also membership-driven recognition? That's what I look for in people.

M:  I want to dive into some of the things that might be a little more personal to you to understand your thinking a bit better. Do you have any unique habits or unusual things that you love that other people find different?

Bill: A few people know this, but not that many. The ones who really know it are my neighbors.

Whether you call it a habit or an interest, I enjoy cutting my lawn. When I was a kid, I cut lawns for money, but it's a completely different set of reasons this time around. I have neighbors who don't even know my name, and they call me “The guy with the lawn.” When we built this house we laid the sod ourselves, 50 pallets of sod. Me, my brother, and my wife. So we have a lot of good reasons to take care of it. Mostly, the reason that I wanted to take care of my lawn was that there's so much I do that never seems to be finished. While, yes, the grass is growing immediately after you've cut it. It looks done for a while. You can take a look and say, I finished that last row and I know I'm finished. In contrast to that, one of the projects that I've worked on for the last 13 years finally came to completion this year. But even still, it’s not really completed. That project was to get legislation passed to allow non-physician practitioners like nurse practitioners and physician's assistants to take on the physician’s role on the Medicare home health benefit. We now had to shift to the states to get all the barriers removed. But 13 years working on one piece of legislation, that is not easy to do, and you’re wondering if it's ever going to come to an end. But back to the grass. It is going to come to an end. It’s going to be completed. It's also how I get to be social with my neighbors. I drive around on my John Deere with my headphones on playing 70s classic rock most of the time and enjoy myself in doing so. It's for enjoyment, it's for the pleasure of getting the job done. I had one neighbor one time that said to me and I won't use the actual language that he used, but he essentially said, “What kind of lawyer can you be if you have to cut your own grass?”

M:  Having gone through law school as well as the need to be up-to-date on policy and legislation in your current work, I’m sure you’re fairly well-read on a variety of topics. I was curious to know if you have any books on leadership that are a favorite of yours or that you typically recommend to others?

Bill: I've had the good fortune of being at NAHC at our annual conferences, and hearing speaker after speaker after speaker who authored those notable business books. But the reality is that as much as they may offer some useful clue on how to be a successful leader, I gained more from two other publications that I know you probably have never even heard of. One of them is a book that was out back in the mid-90s and was called The Death of Common Sense. It was written by somebody named Philip K. Howard. It had a law connection and a leadership connection. It was all about how people are tending to create so much structure among themselves with laws and bureaucracy, that they lose sight of common sense. As somebody who has filed dozens and dozens of lawsuits against health care programs like Medicare and Medicaid, I was always pushing to have that structure apply. But what was necessary to be successful in that and I believe necessary in a leadership circumstance as well, is that you have to breathe life back into common sense. Common sense often will prevail over what we might call ‘clearly written law’. If a clearly written law doesn't make sense then it's not a good law. 

I have a second book that I recommend you might be interested in reading yourself. If you know the author, Caleb Carr, he wrote The Alienist taking place in the early 1900s in New York City, but he wrote another novel. You normally don’t hear references to books on leadership that are novels. Carr also wrote a book called Killing Time. It was a book that was set in the future, a future that has pretty much been realized. It was a future where information control was stronger than any presidential power that could exist out there. And that reliance on the internet led people to wonder, when were they actually seeing the truth. What could they believe? What was fact, what was fiction? That forms a basis in my leadership focus as well, that you have to be transparent and you have to be in such a way that you are factual and believable. Because there is so much doubt out there today as to what to believe. Are you getting hyperbole? Are you getting puffing? Are you getting outright lies? And so, in my efforts at leadership, I try to bring that combination of common sense and a sufficient level of credibility that is supported factually, so that people will listen, follow, or join me with whatever we're trying to accomplish. So no, it wasn't like The Seven Habits of Successful People kind of books that influenced me as much as these two that came to mind. I've been referencing people to both of these books now for years. The Death of Common Sense was a book given to me by a former official at the Health Care Financing Administration, which later became CMS, the Centers for Medicare and Medicaid Services. I've treasured what I've learned from that book since then.

M: Do you have any habits or behaviors that you've developed or changed over the past few years or so that's had a big change or improvement in your life?

Bill: Maybe aging has done this to me or maybe some things in my life that haunted me for a while led me to try to bring about a change, and that was to be a little more attentive to my family.

For many years, I thought about a conversation with my son, I think it was his eighth or ninth birthday and I was going to once again get on a plane and travel to some other part of the country for work. And I said, Alex, I'm really sorry, but I'm going to miss your birthday. And his response was, “What's the big deal you've missed a bunch of others.” He’s 35 now and has two kids of his own. Recently, I think after he saw some of the same things earlier in life that I did, he moved his family from Florida to be living 15 minutes away from where we are. My daughter and her family live that far away as well. So I’m trying to make a better effort to be a member of the family. It's showing me a reward that I wish I had embraced earlier on. Not that I think I'm a bad person, but I gave priority to work, and I still give priority to work, but I found out a way that you can still make work your number one priority and still have your family very high as well. It is possible to do both. What changed for me is - I think of them, I act in their favor, and I spend time with them. But then again maybe I'm being selfish here, that as I age and we do all this work with the senior population for health care -  I'm thinking you can't make it without informal caregivers so I better be nice to my family so they will be nice to me.

M:  I think failure is always such a great teacher, for us in terms of what we can learn. Do you have an example of a failure that you experienced that later helped you to make better decisions in the future because of that experience?

Bill: I mentioned before that I spent a lot of my professional life as a litigator. If you're not prepared for failure, you better not litigate. Any lawyer who says they won every lawsuit is probably the most conservative lawyer ever taking cases. I always felt that if you don't try, you know the outcome. That’s not exactly an original concept. I'm sure it's been said by many people well before me. But that approach is going to lead to some failure. You first have to look at failure as the opportunity to learn and not to be crushed by it. There's so much in life, where if you don't try, don’t take a risk, you're minimizing what your potential gain might be. If you wallow in sorrow because you failed then you're going to be deterred from trying again. I think failure as a concept is character building and success initiating because you've learned from that. 

My first real failure in life, honestly, was a lawsuit that I had where my head was so full of success as I started it, I labeled the case in my first manila folder as “The Case”. It was going to be just a remarkable achievement to sue the Medicare program on this matter, so much so, that I asked my grandfather if he would be the first named plaintiff because it could apply to any Medicare beneficiary. Ultimately, I lost the case. And this ties back to some things I mentioned earlier, of common sense. When I was at the federal court of appeals after having lost at the district court level, I was before a three-judge panel. One of the judges asked me just two questions. He said: “How long has this policy you’re challenging been in effect? And how much will it cost if we agree with you?” So I’m thinking, where's that in the laws? I mean, the law says X, and I'm telling you, they didn't do X. But the practicalities of it was a lesson that I learned from that failure. You had to bring common sense into your litigation to succeed. Then the next time around, you'll try again, but you'll be better with your tries in the next case. The same is true in anything else that I would do from there afterward. I knew I had to take this case on, we did take it on, we failed. But then the next case we had learned from it and we could win. Then the next case after that, maybe we lose, but we still try. From failure, what I learned is, you know the outcome if you don't try.

M: I wanted to talk a little bit about current events. What are some of the actions your team is doing right now to help agencies and the industry navigate COVID-19 and what are you and your team spending time thinking about as it relates to COVID-19 for the industry?

Bill: At the top of my list, one thing that we've been trying and I think succeeding at was to raise the profile of home care. So this is a bit more of a 60,000-foot view kind of thing. When you saw the horrible aspect of this pandemic, you first obviously have to do what you can to protect your constituency, which we believe both the providers as well as patients, but also what can you do to find opportunities within it. The opportunities were pretty obvious as this was a chance for home care to shine and to raise the awareness of what it can do, to raise its profile in the public and to raise its profile in the rest of the healthcare community. There has been a multi decade long struggle to fight what we might call institutional healthcare and I don't mean nursing homes. I mean those sacred cows of physicians and bricks and mortar, and so on. Home care was for a long time, just not understood and perhaps not respected either. I think that there has been a lot of success around that. More than anything else the home care providers have helped bring about that increase in profile. We were able to tie into the media early on and focus on the fact that there are probably more people in every state that are COVID-19 infected getting care at home than those getting care in hospitals. When you look at the media attention, it started off about home care sending all these people out there without protective equipment and it's moved from there to a more positive light. One reporter for NBC asked me: “Do you think this kind of attention is going to improve your chances of getting workers to flock to work in home care because it's such a remarkable service delivery?” So there are so many ways to look at that kind of value. One of the issues for the industry to address is how do we find our way through the pandemic, but also how do we find our way through the pandemic with an improved status within the overall healthcare world. Then we’re getting into the nuts and bolts stuff. Money, money, money, absolutely important. Home care providers of services of all types, home health agencies, personal care service providers, Medicare and Medicaid, hospices, all of them, are stressed financially at this point with reductions in revenue and increased costs. We continue to fight for some relief to provide us the services in several ways. The PPE issue comes and goes and keeps coming back again. With surges in other parts of the country, we still find shortages out there. Regulatory flexibility, one of the big areas which we worked on from day one. Then a lot of information and support we think we did a solid job with getting that to our membership. Our communications from day one were strong, in-depth, focused, and available on the web. We've done these townhall webinars that have thousands upon thousands of people. We would bring in, for example, a team of people from the Visiting Nurse Service in New York while it was in the epicenter of COVID-19. They were sharing preparation information with everybody else, what they need to be doing to get ready for any surge that comes in their area. So I think we pulled together just a great series of supports and advocacy for the home care and hospice community. I wish we were done with the pandemic. We know we're not, so we clearly have to continue this.

Also, because of the groundwork that was done beforehand, where we are now is working to promote a several step advancement of care in the home, which would be changing several things to make home healthcare a truly viable alternative to Medicare beneficiaries using the skilled nursing facility benefit. So raising the resources that would be available to use in home health, which means paying for those resources too, but providing a true alternative for somebody who feels: “I don't want to go to a nursing home, I know I need an extensive amount of both skilled care and personal care supports with activities of daily living.” The current Medicare Home Health Benefit does not accommodate that. So we think this is a great opportunity to create some reforms that bring that about. One other stage that’s been highlighted is that we proved through COVID-19 care that there are patients who otherwise need a hospital-level of care that could be, with proper supports, cared for at home. One of the key factors in dealing with COVID-19 is preventing transmission of the disease. What better place to do that than to do it at home. Not only do you not have to deal with the issue where hospitals don't have enough beds because somebody already has a bed, but you've got an isolated environment that is appropriate and comfortable for that individual where you can bring services into that individual and can care for them without creating that risk of transmission that is so incredible in obviously the nursing homes but even in the hospital setting.

M: So is that something you guys are working on from a legislation standpoint?

Bill: We’re still fine-tuning the design of it, but what's ironic was that this started from a policy position that was at least 25 years old at NAHC where we were going to try to learn some lessons from how Medicaid was rebalancing Long Term Care supports towards home community-based care. We had been trying to learn what can we do with it on the more medicalized side of things within the Medicare program. For years as we tried to advance that concept, and it continued to fall on deaf ears. Whereas, today we see a much greater opportunity. So we're fine-tuning the design. There have been some conversations with some of the policy people around Washington about it. I think there's no better opportunity than we have now to make it happen. 

M: Especially since change has been essentially forced on everybody, it seems that now's the time to make those moves. With traditional timelines seemingly thrown out the window due to the pandemic, what kind of timeline do you think a policy change like this could happen?

Bill: Maybe I'm overly optimistic. I've never been accused of being overly optimistic, but I think we have to strike while the opportunity’s there, which puts us in a timeframe of six months to a year on the outside. If we don't succeed within a year, it's going to be harder to do so. So, our opportunity is at this moment. That's why when I look at six months to a year, someone might say that's pretty quick, but in a year, what is the world that we have? And did we not take all the opportunities that are out there for us to have this happen? Of course, I’m balanced as the point of reference I gave you earlier of how I had a 13-year project on the legislative changes for nonphysician practitioners. So, regardless, we’ll never give up. But look at the environment we're talking about. Do you think there's anybody that wants to support skilled nursing facility admissions at this point? Probably not.

Also, one other big factor and that is making sure we do not ignore the fact that there are competitors out there. If we go out there and say we can replace nursing homes, do you think the nursing homes are going to sit on their hands? We have to be prepared for that. If we're going to have a closer seamless transition between hospitals and the home health agencies, we've got to accommodate where the hospital’s interests are in all of this too. We can't ignore one other factor and that is the physician. How do we integrate the physician into this so the physician doesn't think we're taking his or her patients away from them and that translating to his or her business being taken away from them too?

M: NAHC’s annual conference is such a big part of the industry, so I’m curious to know what's the status of that this year? Many conferences are on hold, but what are you guys working on?

Bill: We'll be announcing this week that the conference is going virtual. Multiple reasons for that. The Tampa Convention Center told us we can't have more than 600 people total at the event and we can't do an annual meeting with just 600 people counting attendees, faculty, and our expo people. That would cut us down by two thirds or more than what we would expect to have there. What we've been able to pull together we believe will be a kind of best in class virtual conference. We've contracted with an outside company that is state of the art in terms of doing virtual conferences. We won't have holographic attendance by you, Matt, or me but it's going to be a solid visual experience for people. They'll walk into a convention center, rather than click on a website. There will be networking opportunities that are there. It will be focused around our conference period, but we will be extending it well past the conference to give everybody access to the full range of educational programming we would have done in person. This means somebody instead of going to four or six different educational time slots for single programs, we'll have all of the programs available to them. So we believe we can pull it off. We just did our financial management conference virtually, it was a solid success. Thanks to good evaluations, and helpful constructive evaluations we think we can up the game even more so in October. We really miss the in-person part of it. The hardest part of that conference to replace is on the networking side of it. That's going to be hard. We know that that's a key reason why people go to these events, the ability to network. We can't do the same kinds of vendor events. Tonight, actually we will be having a cocktail party with our board of directors virtually. We sent them a drink in the mail, be able to come together, at some level of networking opportunity. We're not going to be able to send liquor to everybody going to the annual conference but we certainly know the value of networking. 

M: I'm excited to see how that goes and I’m happy to be a part of it as well. Like you said the networking is going to be the trickiest part but back to your point about failure and learning. We must try because we know the alternative if we don’t.


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