The Shifting Sands of Healthcare and Finance

David Macke, shareholder and FHFMA for VonLehman CPA & Advisory Firm.

Photo by Daniel Smyth


David Macke, shareholder and FHFMA for VonLehman CPA & Advisory Firm, has been working in the healthcare industry since he graduated college. He joined VonLehman in 1991, started the firm’s healthcare reimbursement department from scratch and has worked to develop it. He primarily serves home healthcare agencies, hospice and hospitals.

Through the years, he’s worked to stay abreast of the changes in the industry and utilize that knowledge to help his clients with the painful reality of adjusting to the ever-shifting climate, including attending more than 80 hours of continuing education programs annually. “It’s a challenge to try to stay out in front of things for clients,” says Macke. “Things change all the time in Washington – rules, payment rates and regulations change every year. You have to stay up on relevant information, because healthcare is such a big part of the economy across the country.”

One well known factor in adjusting to the healthcare climate, particularly as a small business, is staying in stride with the regulations of the Affordable Care Act. The Medicaid expansion and the ACA have created obstacles for many businesses as they attempt to both understand and adjust to the new guidelines they’re expected to follow. “The Affordable Care Act tried to do a lot at one time, and for a business owner it can be very frustrating to comply,” says Macke.

Additionally, there is a shift in healthcare from private practices to hospital communities; individual physicians are now more apt to work under the protection and umbrella of a hospital system than maintain their own private offices. Within this is the additional struggle that each state is not always capable of footing the bill for Medicaid-related services that involve the need for skilled care.

“Medicare pays for skilled care – specialized medical professionals treating a diagnosed condition,” says Macke. Many healthcare providers are taking pay rate cuts as a result of restricted government funding, which brings about financial hardships for many places. “Smaller, rural hospitals can’t take these cuts as easily,” says Macke. “What is worrisome about this is that when rural hospitals close, doctors won’t stay in those communities and access to healthcare in rural areas will disappear.”

“The Affordable Care Act tried to do a lot at one time, and for a business owner it can be very frustrating to comply.”

This, alongside the changes in Medicare for elderly patients, has brought a shift to the healthcare landscape in the last decade that is only going to become more pronounced.

The past few years have also seen a significant increase in the number of home healthcare and hospice companies. This is believed to be the future in home and community based care as the elderly population increases in size. Medicare doesn’t pay for all home healthcare services, only “skilled” services. Non-skilled services that simply pro- vide aid for the elderly in their activities of daily living can be paid by Medicaid or privately. With the rise in the number of agencies, not all agencies are reputable. A few bad apples have created problems for the industry. However, there are many good agencies that just want to take good care of patients. “The way Medicare pays for home healthcare is not fee for service but payment is for 60 days of care in one flat fee,” says Mack.

It is through all of these changes that Macke must guide his clients to be sure that, no matter what industry they may be in, everything is taken care of and in line with regulations. He must help them through annual Medicaid and Medicare cost reports in addition to traditional bookkeeping responsibilities, such as annual tax returns and odds and ends that are part of owning a business. In the end, however, Macke says despite the difficulties the healthcare industry might throw his way, he has no intention of ever walking away from it.

“I enjoy working in the healthcare industry,” he says. “It’s never going away either – there will always be a demand for healthcare and, in fact, that demand seems to be growing.”


VonLehman has offices in Kentucky, Ohio and Indiana. You can reach them at 800.887.0437, by email at or visit their website at