Susheel: Robert, thank you for taking time out of your busy schedule to talk with us. DistilNFO appreciates it!
To start with, tell us about yourself, your career journey so far and your current role.
Robert: I first got involved in healthcare, and senior care, in the early 1980s as a state legislator in Maryland. I served on the House committee that oversaw healthcare policy at a time when we were going through the first wave of managed care, with utilization review boards and the like. At that time it became clear to me that the nation was totally unprepared for the increasing longevity and future explosive demographic growth of the older adult population.
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In 1991, I co-founded the National Investment Center for Seniors Housing & Care (NIC), an education and research not-for-profit focused on educating investors by supplying data on the opportunities in the seniors housing and care field. That organization grew to be the go-to resource for data, analytics, and thought-leadership for this rapidly growing business sector. In 2017, I stepped out of the CEO role into a role as strategic advisor, and in April of 2020, in response to the disruptive impact of COVID-19 I launched Nexus Insights to rethink aging and reimagine the future of aging services.
Robert: Without question for me, the most exciting thing is the changes in healthcare payment and delivery that I thought would take years to happen have become mainstream in a matter of a few months, as a result of the COVID-19 pandemic. These changes, along with changes in consumer attitudes, especially among older adults and their children, are making it possible for the first time to bring healthcare services to older adults where they live, rather than forcing them to be transported to the ER or even the doctor’s office.
Susheel: The whole economy is finding a new normal amid this [COVID19] pandemic. How is this impacting the payer and providers?
Robert: The seniors housing and care sector is home to more than three million seniors, the vast majority of whom have multiple chronic conditions. For payers and providers who work with seniors, the new normal presents exciting opportunities, for three reasons. Fear of traditional healthcare delivery settings by older adults and their families; the dramatic growth in the utilization of telehealth and telemedicine; and the increased desire by older adults to stay at home and have healthcare delivered to them there.
When you couple this with the increasingly high rate of penetration of Medicare Advantage plans, with 36% (more than 24 million) of Medicare beneficiaries now participating – and higher than that in a number of states – and the increased flexibility provided by CMS, both in 2019 and 2020, to expand the types of covered services, we can now truly begin to manage the underlying health conditions of seniors where they live.
In seniors housing that means seeking healthcare provider partners to be able to manage chronic conditions of residents, to prevent acute care flare ups, and to be able to provide onsite triage capability. This is all to enable residents to stay home, to the greatest extent possible. COVID-19 has made it clear that both healthcare services and wellness and prevention programs must be integrated into seniors housing and long-term care settings. The senior care sector needs both healthcare providers and healthcare payers to accomplish this.
Robert: If you’re a payer, particularly a managed care group, an important healthcare objective is to keep this frail population out of the hospital and the ED. That accomplishes the objectives of payers, the senior care provider, and also the residents and their families. For health systems and physician groups, particularly those that seek to take risk through capitated payments for populations such as this, it presents opportunities that simply did not exist before COVID-19.
Another issue brought into the spotlight in senior care is that in addition to addressing infection control and safety of residents, it is equally important to address the loneliness and social isolation that can be brought about by restrictions imposed by the pandemic, whether in a senior care setting or a traditional residential home or apartment, or the simple realities of older adults living alone.
Health is about more than physical condition and medical services. There are social determinants of health, and a need for a sense of engagement and belonging. For the first 3-4 months of the pandemic the focus in seniors housing and care was on infection control. Now it’s increasingly on combatting social isolation and loneliness. The role of tech in this area is huge, providing a virtual sense of connection and also spurring moves to more creative programs for social engagement that do not rely on large group or one-size-fits-all activities.
Robert: There’s a difference between source and driver. COVID-19 is a driver, forcing innovation. This event is a crisis, both in senior care and healthcare. It forced us, and CMS, to think differently about payment models, and to open the spigot in terms of telehealth. Similarly, and ironically, one of the greatest fears – of congregate settings- is also a reminder of how we miss being with one another. That will drive innovation in the area of connection and community engagement.
Many innovative ideas have been out there, but government, payers, and providers haven’t been forced to try them until now. Not every innovation will work perfectly, but we would never have done the new things we’re now doing were it not for COVID.
Responding to this crisis, we’ve seen government, healthcare systems, payers, and providers all trying new tools in the toolbox. At the same time it has also spurred even more interest from venture capital and private investment, who are investing in disruptive innovations and technology. They are enabling remote patient monitoring, no-touch wellness programs, and voice-activated video calls, connecting home-bound seniors with their families. These innovations have injected incredible energy and excitement in this area, particularly in models such as hospital-at-home and the delivery of primary care services where people live.
Robert: What will stick and what will fall away, and how quickly? Decision-makers are facing all of these new technologies, new healthcare partnerships, new regulatory flexibility, new trends in bringing healthcare to seniors where they live. But they cannot know which of these will be around in the long-term. That makes planning and developing strategic responses all the more challenging.
Also, innovation and change has moved so quickly that’s it’s gotten ahead of research. It’s becoming clear that we can’t wait until people are 93, and have 7 chronic conditions and lost mobility before we move them out of their homes. We know we need to act more quickly, providing appropriate settings and care earlier on. We are beginning to understand the importance of social determinants of health. But we don’t have the data to support long-term decision-making and understand financial impacts.
There is very little research on the impacts of much of the flexibility provided by CMS to pay for indirect healthcare benefits through MA plans. Payer executives need to understand utilization rates, what will it cost, and how these new approaches will impact overall spending for these individuals. While this flexibility is exciting, payers today lack the data to determine costs and returns. They have to navigate their way through that.
The uncertainty for payer and provider executives is exacerbated by the fact that you cannot normalize data from the COVID period. Patterns of utilization and spending are clearly an anomaly, and understanding what 2021 will look like is very tough.
Going back to business as usual is not an option, but at the same time, we cannot assume that the degree of flexibility in payment and delivery structures that existed in the spring of 2020 will continue.
Robert: What an exciting time to be a future executive, because you are living through a time on which case studies will be written in healthcare management and administration programs for years to come. You are both an observer and participant. But make sure you’re reading perspectives from outside your sector. In times of great change, leaders of the disrupted sector are often the last to know they’re being disrupted. Read widely, and make sure you understand how the Amazons, Googles, and Apples of the world are viewing what’s going on in your sector. How are CVS, Walmart, Best Buy, and Walgreens viewing it? These are all potential disruptors. If you don’t understand how they view your space, there’s a risk you may be blindsided.
Follow in particular what’s happening in the senior care sector. All the companies I just mentioned have their eyes on this huge customer group who live in these settings. They are already experimenting with new approaches to serving them, using their brand names, and the trust they already have, to carve out potentially significant new revenue streams. You must understand how their efforts will impact your business.
Robert: There are more than three million people, on any given day, whose home is a senior living setting, a number that will grow significantly in coming years. Skilled nursing and assisted living residents average 85+ years, have multiple co-morbidities, and require assistance with multiple ADLs, requiring close contact with caregivers, day and night. Large numbers of these residents also have cognitive impairment.
When it comes to producing better outcomes at lower cost with better access – the “Triple Aim” – this moment presents an opportunity not to be missed. You have an exploding population of older adults and, at the same time, a path forward to rethinking how we deliver health and healthcare services to them.
The key shift is from routinely transporting frail seniors with underlying health conditions to the healthcare provider, to bringing healthcare services to seniors where they live. This is not just a matter of convenience. It’s better for their health. COVID has underscored what has always been true; we need to keep frail seniors out of acute care settings, such as the emergency department, to the greatest extent possible.
This is a disruptive moment. It’s essential to move from a health delivery system built around reactive sick care, to proactive management of underlying health conditions. The future, therefore, of promoting health and providing healthcare services to this population will be delivering services where they live, managing chronic conditions onsite through monitoring, and triaging at home whenever possible, to prevent unnecessary trips to the ED.
This has been a wakeup call for the seniors housing and care sector, that they need to be providing this proactive chronic disease management and deliver healthcare services where seniors live. But for the most part we don’t have the necessary expertise. We need physicians, health systems, and payers to help us think through how to best design packages, with options such as Medicare Advantage plans and managed Medicaid, as we integrate health and healthcare services into our seniors housing settings. We need partners in health and healthcare. We offer access to millions of seniors, where they live. We can also help to test what works best to serve this population of older adults, so it can be expanded to the broader population of seniors living outside senior care settings. Those lessons will be critical when serving the many more seniors who live in traditional residential homes and apartments, to help them better manage their conditions and avoid unnecessary trips to the ED.
This is also your future, as hospitals increasingly become intensive, critical, and trauma care settings. The focus is shifting. Now is the time to partner with seniors housing & care settings, as we strive to bring care to our residents, better manage their health and keep them out of the hospital.
Robert: Place matters, where you live matters, but we must be careful that in jumping on the aging-in-place bandwagon, we don’t actually consign millions of older adults to settings where they are lonely, socially disconnected, and depressed.
With growing numbers of older adults living longer, often with complex care needs, and with fewer family members to provide care, we will need a full range of housing and care options that can be scaled to meet the demand. These options must integrate housing, wellness, healthcare services and personal care so that we deliver the right services at the right time in the right setting. Most older adults want to age in place, but the key for their health and wellbeing is living in the right place – a place where, instead of being isolated and feeling abandoned, they can thrive with a sense of belonging and community. Providing that, in combination with partnering with healthcare providers to deliver services onsite, will be a major driver towards achieving the Triple Aim for millions of America’s elders.