Pandemic Flexibilities in Long-Term Care
October 6, 2020
The COVID-19 pandemic has exposed both new and longstanding needs of long-term care patients. Congress and the administration modified over 200 Medicare regulations, which has afforded response flexibility to providers, Medicare Advantage plans, and Part D plans. But how do these flexibilities impact the long-term care sector? Experts overviewed the recent changes, remaining gaps, and benefits and risks to long-term care patients, caregivers, providers, and payers. Panelists discussed whether similar actions should be replicated in future public health emergencies and highlight policy options to bolster the long-term care system moving forward.
Speakers
- David C. Grabowski, Ph.D., Professor of Health Care Policy, Department of Health Care Policy, Harvard Medical School
- Eric De Jonge, M.D., Chief of Geriatrics, Capital Caring Health, Chair, Public Policy Committee for AAHCM
- Gretchen Jacobson, Ph.D., Vice President, Medicare, The Commonwealth Fund (moderator)
This event was made possible with support from The Commonwealth Fund.
Event Resources
Key Resources
Additional Resources
Event Resources
Key Resources
“Long-Term Care Policy After COVID-19 – Solving the Nursing Home Crisis.” Werner, R., Hoffman, A., Coe, N. The New England Journal of Medicine. September 3, 2020. Available at http://allh.us/qpVX.
“Commission Final Report.” Coronavirus Commission on Safety and Quality in Nursing Homes.September 2020. Available here http://allh.us/aJCU.
“Strengthening Nursing Home Policy for the Postpandemic World: How Can We Improve Residents’ Health Outcomes and Experiences?” Grabowski, D. The Commonwealth Fund. August 20, 2020. Available at http://allh.us/fNPB.
“Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19.” Centers for Medicare & Medicaid Services. August 20, 2020. Available at http://allh.us/UQDv.
“CMS Payment Policies & Regulatory Flexibilities During COVID-19 Emergency.” American Medical Association. August 17, 2020. Available at http://allh.us/cVQR.
“Regulatory Changes to Medicare in Response to COVID-19.” Podulka, J., Blum, J. The Commonwealth Fund. August 4, 2020. Available at http://allh.us/9EHr.
“Early Impact of CMS Expansions of Medicare Telehealth During COVID-19.” Verma, S. Health Affairs. July 15, 2020. Available at http://allh.us/T3yv.
“Long-Term Services & Supports State Scorecard.” AARP, The Commonwealth Fund, The SCAN Foundation. 2020. Available at http://allh.us/cEnX.
Additional Resources
“Experiences of Nursing Home Residents during the COVID-19 Pandemic.” Montgomery, A., Slocum, S., Stanik, C., Altarum. October 1, 2020. http://allh.us/wdyr.
“The Overlooked COVID Crisis in America’s Assisted Living Facilities.” Paulin, E. AARP. September 29, 2020. http://allh.us/fFNJ.
“Verma: CMS Will Mull Which COVID-19 Flexibilities May Stick Around Post-Pandemic.” Minemyer, P. Fierce Healthcare. September 21, 2020. Available at http://allh.us/AfvH.
“AARP Answers: Nursing Homes and the Coronavirus.” Markowitz, A. American Association for Retired Persons. September 17, 2020. Available at http://allh.us/bT4a.
“Telemedicine: What Should the Post-Pandemic Regulatory and Payment Landscape Look Like?” Mehrota, A., Wang, B., Snyder, G. The Commonwealth Fund. August 5, 2020. Available at http://allh.us/AFyW.
“Key Questions About Nursing Home Regulation and Oversight in the Wake of COVID-19.” Musumeci, M., Chidambaram, P. Kaiser Family Foundation. August 3, 2020. Available at http://allh.us/KJE3.
“Building the Long-Term Care System of the Future: Will the COVID-19 Nursing Home Tragedies Lead to Real Reform?” Chernof, B., Mann, C. Health Affairs. July 31, 2020. Available at http://allh.us/RPWY.
“Telehealth: Delivering Care Safely During COVID-19.” U.S. Department of Health & Human Services. July 15, 2020. Available at http://allh.us/E9jW.
“Solving the COVID-19 Crisis in Post-Acute and Long-Term Care.” Laxton, C., Nace, D., Nazir, A. The Journal of Post-Acute and Long-Term Care Medicine. June 16, 2020. Available at http://allh.us/dFbB.
“Reimagining the Nursing Home Industry After the Coronavirus.” Eaton, J. AARP. June 8, 2020. Available at http://allh.us/U3Qt.
“More Flexibility Still Needed in Health Care for COVID-19 Response.” Schaefer, N. The Heritage Foundation. June 8, 2020. Available at http://allh.us/KbTv.
“Grappling With COVID-19 in Long-Term Care Facilities.” Strohman, A. American Action Forum. May 15, 2020. Available at http://allh.us/XwhA.
“COVID-19 Issues and Medicaid Policy Options for People Who Need Long-Term Services and Supports.” Musumeci, M., Chidambaram, P. Kaiser Family Foundation. April 16, 2020. Available at http://allh.us/9xwg.
“COVID-19 Helpful Links.” National Association for the Support of Long-Term Care. 2020. Available at http://allh.us/BJkf.
“Medicare & Coronavirus.” U.S. Centers for Medicare & Medicaid Services. 2020. Available at http://allh.us/Agke.
Experts
Speakers
Eric DeJonge
Capital Caring Health
Chief of Geriatrics
edejonge@capitalcaring.org
David Grabowski
Harvard Medical School
Professor of Health Care Policy
Grabowski@hcp.med.harvard.edu
Gretchen Jacobson
The Commonwealth Fund
Vice President, Medicare
Gj@cmwf.org
Experts and Analysts
Jonathan Blum
Health Management Associates
Vice President, Federal Policy and Managing Director, Medicare
jblum@healthmanagement.com
Cindy Mann
Manatt, Phelps & Phillips, LLP
Partner
cmann@manatt.com
Vincent Mor
Brown University, Florence Pirce Grant University Professor
Professor of Health Services, Policy and Practice
Vincent_Mor@brown.edu
Jennie Chin Hansen
Altarum, Senior Strategic Advisor;
The SCAN Foundation, Board Chair
chinhansensf@comcast.net
Government
Larry Bonander
Centers for Medicare & Medicaid
Deputy Director, Medicare
lbonander@cms.hhs.gov
Lance Robertson
U.S. Department Health and Human Services
Assistant Secretary for Aging, Administrator of the Administration for Community Living
administrator@acl.hhs.gov
Stephanie Cameron
MedPAC
Assistant Director
scameron@medpac.gov
Edwin Walker
Administration for Community Living, Administration on Aging
Deputy Assistant Secretary for Aging
edwin.walker@acl.hhs.gov
Stakeholder
Jean Accius
AARP
Senior Vice President, AARP Global Thought Leadership
JAccius@aarp.org
Michael J. Barnett
National Association for the Support of Long-Term Care
Manager of Legislative & Regulatory Affairs
michael@nasl.org
Alison Barkoff
Center for Public Representation
Director of Advocacy
abarkoff@cpr-us.org
Gina Buccalo
UAW Retiree Medical Benefits Trust
Chief Medical Officer
gbuccalo@rhac.com
Richard Feifer
Genesis HealthCare
Executive Vice President and Chief Medical Officer
Richard.Feifer@GenesisHCC.com
Christine Aguiar Lynch
Association for Community Affiliated Plans
Vice President for Medicare and MLTSS Policy
clynch@communityplans.net
Anne Montgomery
Altarum
Co-Director, Program to Improve Eldercare
anne.montgomery@altarum.org
Shannon McCracken
ANCOR
Vice President, Government Relations
SMcCracken@ancor.org
Cheryl Phillips
Special Needs Plan Alliance
President and CEO
cphillips@snpalliance.org
Rylin Rodgers
Association of University Centers on Disabilities
Director of Public Policy
rrodgers@aucd.org
Maria Town
American Association of People with Disabilities
President and CEO
mtown@aapd.com
Scott Tittle
National Center for Assisted Living
Executive Director
stittle@ncal.org
Transcript
(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)
0:07
Hello, everyone. Thank you for joining today’s webinar, Pandemic Flexibilities and long-term Care. I’m Katherine Martucci, Director of Policy and Programs at the Alliance for Health Policy.
0:19
For those of you who are not familiar with the Alliance, welcome. We are a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues.
0:31
I want to take a moment to thank the Commonwealth Fund for sponsoring this event and remind everyone that you can join today’s conversation on Twitter using the hashtag all Health Lies, and follow us at all Health policy.
0:44
We definitely want this to be an active conversation today, So please, get your questions ready, and you should see Dashboard on the right side of your web browser that has a speech bubble icon with a question mark. You can use that speech bubble icon to submit questions you have for the panelists at anytime.
1:03
We will collect these and address them throughout the broadcast.
1:06
You can also chat any technical issues that you may be experiencing, and someone will help attempt to help you with them.
1:15
And please make sure to check out our website, all health policy dot org, where you can find background materials that accompany this. And this event, including the slides, a resource list, and expert lists, and a recording of today’s webinar will be made there available soon.
1:33
Now, I am so pleased to introduce doctor Gretchen Jacobson to moderate today’s discussion. Doctor Jacobson is the vice President of the Medicare Program at the Commonwealth Fund. Prior to joining the fund, she was at the Kaiser Family Foundation, where she served as Associate Director of the Organization’s Program and Medicare Policy. So doctor Jacobs said, I’m very pleased to be leaving the, just this discussion in your expert hands. I’m thank you so much for joining us.
2:04
Thank you, Kathryn. It is a real pleasure to moderate this panel today.
2:10
The kogod 19 pandemic has expense longstanding needs long term care of patients.
2:16
A recent report card from AARP on Long Term Services and support concluded that many states may not be well prepared to offer affordable, accessible, long term services and support choices for individuals in the future.
2:30
The curve at 19 pandemic has illustrated the vulnerability of the Medicare population and has made it all the more pressing to look at our long-term care system.
2:39
Some estimates have shown that a staggering 40% of all US covet deaths are linked to nursing homes.
2:46
In contrast, for home health care provided in the home, we have less information and the forthcoming brief highlights a lack of information about current infections and deaths and home health care.
2:59
My over 200 Medicare coverage and payment policies have been modified by Congress and the administration since the 19 pandemic began, many of which have affected long-term care providers and their patients.
3:12
While the majority of these regulatory changes were declared to be temporary, when they were announced, in ministration has indicated plans to make some permanent. And in doing so, it’s important to understand the tradeoffs and Medicare spending patient outcomes, health equity, and provider accountability.
3:31
So today, I’m very pleased to have two experts that, together, can help us look at both health and community based long-term care on community based long-term care and nursing home care.
3:42
First, doctor David Grabowski, who is a professor of health care Policy at Harvard Medical School, is also a member of the Medicare Payment Advisory Commission, and recently served on the CMS coronavirus Commission on Nursing Home Quality and Safety.
3:59
Next, I am pleased to introduce doctor Eric Young, who serves as chief of geriatrics or Capital Carrying Health which exists to help create the skilled and affordable team that help frail elders, live with dignity at home. He also serves as the Chair for the Public Policy Committee for the American Academy of Home Care Medicine.
4:20
Previously, doctor Young was the Director of Geriatrics at Medstar Washington Hospital Center.
4:28
Thank you for joining us. We’re going to start today hearing from doctor David Crevasse. David, I’ll turn it over to you.
4:35
Great, thank you, Gretchen, and thanks to both the Commonwealth Fund and the Alliance for Health Policy for inviting me to speak today. I’m going to focus predominantly on nursing homes, talk about what’s the, what’s the crisis in nursing homes, what’s been the response, and going forward, what should policy look like in this space? Next slide, please.
5:02
So, I call it a crisis just now but it’s really when we think about covert in nursing homes, I like to say it’s a crisis on top of a crisis. So, let’s start with that, the top crisis and the short-term crisis. Covert 19. So, we know, as Gretchen mentioned, in her introductory remarks, this pandemic has hit nursing homes, their residents, and their staff, particularly hard. So, we’ve seen in long-term care facilities, predominantly nursing homes, roughly a half million kovac cases, resulting in 80,000 plus deaths. So, those are huge numbers. That’s that’s obviously about 40% of fatalities in the US have been in long-term care facilities. Unfortunately, many of the deaths and cases have been concentrated among.
5:58
Nursing homes, the care for larger shares of minority residents and have larger shares of minority staff members. So, we had disparities in nursing home care before the pandemic and this has certainly magnified those disparities. Beyond just the effect of covert itself, the virus, the pandemic has also had an impact on nursing home care. For years and years, we’ve tried to make nursing homes more engaged, more and more person centered, but a part of the community, if you will. This has actually pushed us in the opposite direction. Residents are incredibly isolated, lonely during the pandemic. We’ve had to close nursing homes to visitors.
6:49
We, we haven’t had communal activities and so, we’re hearing reports of nursing home residents suffering from loneliness, depression. This has had a massive effect. It turns out the virus kills, but the loneliness and isolation also harm and kill residents, and so that’s had a huge effect on this has not just been hard on the residents. It’s been hard on the staff.
7:16
We did a quick sort of back of the envelope calculation that we then published as a Washington Post Op ed, suggesting when, when you, when you do the analysis, nursing home caregiver is now the most dangerous job in America, more so than logging workers. Or a commercial fisherman. We have more caregivers over 800 since the start of the pandemic that have that have died and that’s probably unfortunately an undercount and then we’re seeing huge declines in admissions and occupancy and nursing homes nationwide. Some of that’s obviously due to fatalities, but we’re also seeing the shift away from from nursing homes. We see very few fewer patients coming from, from the hospital to, to, to nursing homes, and then fewer individuals entering from, from the community as well. That’s the short-term crisis, but we basically overlaid that on a on a long standing Christ.
8:15
This nursing homes were not did not enter this pandemic from a position of strength. Medicaid is the dominant payer in nursing homes that they pay for long stay care.
8:27
They, in most states, pay below costs and so, nursing homes depend on Medicare paying for short stay care to cross subsidize that long stay care for Medicaid recipients. It’s a very tenuous business model and during this pandemic, as we’ve seen fewer and fewer hospital discharges going to skilled nursing facilities. We’ve seen that more profitable group of patients kinda dry up, and nursing homes are largely left with Medicaid recipients.
8:57
We’ve had a long standing history of poor quality, low staffing, a workforce that’s paid close to minimum wage. Lots of racial and ethnic disparities. Physicians have been termed missing in action in nursing homes, We have very poor sort of clinical infrastructure in many nursing homes. We have a lot of nursing home regulation, but, it’s quite fragmented, and often inadequate, both in terms of the enforcement, but also just in terms of the rules themselves. And then, finally, quality is often pretty pretty opaque. It’s not very transparent for stakeholders about what’s actually being provided in the way of good quality of care and good quality of life. Next slide, please.
9:46
So it’s this crisis that we really have to have to view, like, which nursing homes have had outbreaks to date. And I just wanted to talk about one study that we did, we published in the journal, The American Geriatric Society a couple of months ago.
10:02
Because this result has largely held up that the largest predictor of whether a nursing home has a covert outbreak is basically where it’s located. And you can see, I just took that panel there on the left, from The Wall Street Journal, highlighted our results. And you can see that it’s really about kind of where the home is located with it, with a couple of exceptions.
10:28
Larger homes have been more likely to have kovac cases and when the share of black residents is greater than, a more likely to have more cases, which, Obviously, I, As I mentioned earlier, as part of that, disparities in care.
10:45
It’s really interesting, however, beyond sort of these, these kind of community issues, a lot of, kind of factors around prior quality are unrelated to whether a facility had a case. So, higher rated facilities, whether they had a prior infection violations or profit status, change status, their Medicaid share all unrelated. It’s really about where you are, not who you are. And I think that the key point to this is that this is a system level problem, not a bad apples problem. If we’re going to help nursing homes, we really need to think about resources for all facilities. Next slide, please.
11:26
I was part of the Nursing Home Commission. The CMS commission that was tasked by the by the White House to look at what could be the framework, the roadmap, for moving forward out of this. And I apologize, It’s small there in green, but we We highlighted 10 key themes that CMS should address in order to protect nursing home residents and staff from kogod. I won’t read those to you, but it shouldn’t be, surprising, you know whether it’s testing and screening, and PPE. And, co hoarding and I just mentioned visitation earlier and on down the list, but there’s a series of areas, and these 10 key themes then drove towards 27 recommendations and over 100 action steps.
12:18
And it’s certainly the case that I wish our federal response had been earlier. And I wish that had started in March, but given that didn’t start in March, second best time for it to start is today, and I really believe that these 10 areas and these 10 key themes are a great roadmap moving forward. So, so, these are what we suggested. What has the federal response bend like today? Next slide, please?
12:47
Um, we have seen some attention on nursing homes, as I just asserted, I think it’s been a slow response and an adequate response, but there has been a lot of relief funds directed towards nursing homes. There’s also been some relaxation or waiver waivers of some rules, for example.
13:10
Prior to the pandemic, we’ve had a longstanding rule in place known as the three day or three midnight rule where in order to qualify for HUD nursing for skilled nursing care for Medicare covered care in a nursing home. If you’re in traditional Medicare, you had to have spent three days in the hospital.
13:33
We’ve relaxed that rule and I think the reason we’ve had that is to prevent long stay nursing home residents from just being converted over from from Medicaid to Medicare that’s been called skilling in place. And so it’s really it’ll be interesting to see how much skilling in place is happening since the pandemic started. And what’s, what’s the impact of that? But we are hearing, anecdotally, that that’s been an important source of resources for facilities. Federal government is currently supplying testing. They’ve had a couple of kind of attempts at providing personal protective equipment to facilities. As I mentioned earlier, nursing homes have been close to visitors that’s actually had a lot of negative impacts on residents and we’ve slowly seeing nursing homes re-opening. The Federal government has invested in data and enhanced monitoring.
14:24
There’s been increased infection, control surveying, and and some fines and then, we’re going to talk more about this uncertain.
14:32
Eric will touch on this, but there’s been a lot of flexibility in terms of telemedicine reimbursement, which of these kind of policies could become permanent? I want to focus on two. Next slide, please.
14:46
I think that the biggest candidates towards towards what we could see going forward in nursing homes are the waiver of that three day rule. And changing the payment rules around around telemedicine, which could have a huge impact on clinical care in the nursing home setting.
15:05
If I had to make a prediction which is always dangerous, I would say the three day rule will go back in place and telemedicine will be made more flexible. So I think one area we won’t see much change on is the three day rule. one area that we will see a lot of changes is in telemedicine. With a three day rule, why I say that is that it’s been in place to guard against exactly what we’re allowing nursing homes to do right now still in place.
15:31
The concern is that if we waive this rule permanently, it’s just going to open the floodgates, and some of that care will be will be high value, but the concern is that a lot of it will be low value care. I do think we could see some reform around the three day rule, in terms of how we treat emergency department or observation stays in the hospital. I think that could actually be valuable to rethink why it’s three days and what helps contribute to that, that three day period. And then it’s important to note that there are some parts of Medicare where the three day rule doesn’t apply. Medicare Advantage, of course, and Accountable Care organizations are two examples. ACOs often have this rule waived, and the reason that MA and ACOs don’t have this rules because they’re an at risk entity. And when you have an at risk entity, you don’t need this this safeguard in place.
16:30
What about telemedicine? I don’t have time to talk about my research in this area, but we’ve found telemedicine to be very productive in the nursing home setting towards preventing hospitalizations. But the concern has always been, once again, will introduce a lot of low value services. Will it actually improve care? There have been benefits. I think this is going to be really important. Historically, Medicare only paid for telemedicine in rural nursing, in rural settings generally, but rural nursing homes. In particular, I think going forward, we’re going to see some some guardrails here. But we will see broader coverage of nursing home services. Next slide, please.
17:14
So, so my, my, my oh, thanks. Final slide, and this comes directly from a piece I wrote for the Commonwealth Fund under under Gretchen’s Direction. I know, I think there’s a lot of ways that we can strengthen that longstanding crisis in nursing homes that I discussed earlier.
17:36
We obviously have to improve Medicaid payments and really better align Medicare and Medicaid such that we’re not overpaying and Medicare and Underpaying, Medicaid. We need to get more clinicians on site and really think about ways, whether it’s telemedicine or institutional special needs plans, or other payment models, and encourage clinicians on site. We need to pay our direct caregivers better, The idea that we’re going to pay them near minimum wage and under … ask them to put their lives on the line is is, is is, is really led to, I think, a critical staffing shortage. Morale is down. I think the staff are incredibly fragile right now. Going forward, I would love to see minimum staffing standards coupled with with better pay. We need more quality transparency, We need regulatory reform, better enforcement, and we need to link that enforcement to, to, to, to quality improvement, and really make the regulations about, what, what would matter to patients and residents and stakeholders.
18:41
I’m a big proponent of small …
18:42
home models that they’ve done really well under …, and I would love to see the smaller home, more resident centered models, be applied more often. one of the aspects of … that’s that’s really been been drawn into sharp focus is the idea that much care, especially for, for the non elderly, disabled population, and many older adults, is that long-term care can also be done at home.
19:11
And it would, I think, be great if we could transition more and more individuals going forward into home and community based settings. I think we’re always going to need a nursing home for, or some group of residents, Let’s make that the best nursing home possible. Resident centered, smaller home models are, would be great in that regard. But they are not opposed to each other. We can both invest in home and community based care, and I know Eric is going to talk more about that in a moment and also make nursing homes as strong as possible. And, finally, at some point, our country’s going to have to invest in some sort of national long-term care benefit. I hope that’s, I hope, if there’s a silver lining to … around around long term care. It’s that we put this off for far too long. And the time is now to really focus on this area. I’ll stop there and turn it back to Gretchen. Thank you.
20:09
David, now I’m going to turn it over to doctor Eric, Diane. I wanna first also remind our … questions panel of that answer interface to submit your questions at any time and get into the queue for the chat.
20:23
I’ll turn it over to you, Eric.
20:28
Thank you, Gretchen, and thanks to the Alliance for Health Policy and Commonwealth Fund, for having me on as well.
20:35
So I’m Eric De Jonge, geriatrician, here, working in the Washington DC Area for Capital Carrying Health, which is a non-profit that does a lot of work with advanced illness, primary care, and hospice and palliative care.
20:47
I serve in the role as Chair of our Public Policy Committee for the American Academy of Homecare Medicine, but I’m thinking really about this population as a whole and not specific to the home or the nursing home, but how can we have payment policy that really supports care of the most sick, most frail elders in our communities and keep them safe and well cared for. Next slide, please.
21:10
So the major topic is going to be long-term medical care at home. So long term care can be done at the home. It can be done in the nursing home, or assisted living.
21:19
So, I’m gonna layout, are for my first goal, is, I think any payment policy change needs to really have the goal of a nationwide infrastructure of mobile teams that can do home based primary care. They have to have the skills and compassion to do that kind of work.
21:36
They need to be equipped with adequate technology, and they need to be available on every community.
21:45
So I’m going to talk about what is possible.
21:47
I’m going to use a case of a kind of an amalgam patient of ours, and just highlight how you can do this kind of care with both high touch in person, physical touch and a lot of kind of compassion, but you also need some of the high-tech tools that the pandemic flexibilities have given us.
22:05
It has to be done with equity for all elders.
22:07
As David kind of painfully points out, the minority and, kind of low-income folks really have died at a much higher rate, and that their access to good primary care is also much less.
22:19
two ways to do that, however, is to eradicate the payment silos that kind of currently discourage kinda good primary care at home.
22:28
And the barriers by income and education, actually up some of the telehealth rules as well as just workforce availability.
22:36
I will kind of make the case, the good news is, that home based primary care and kind of home care medicine as a whole, as shown in multiple ways, whether it’s primary care, actually hospice, hospital at home, to be able to lower total cost of Medicare by 15 to 20%, when done well and when held accountable for good results.
22:58
So, what has been the effect of the pandemic flexibilities on kind of medical care at home.
23:03
There has been a lot of relief, I think CMS deserves a lot of credit for their rapid relief on documentation requirements, allowing us to use telehealth for house calls when needed. Relaxing some Privacy rule us about which, you know, audio visual, tool you use. There is the Hospital Without Walls that allows acute care at home. And I put an asterisk here because there are some still some rules in the current guidelines that require, say, 24 hour nurses to be present at home doing hospital at home, which may not be necessarily be necessary or feasible.
23:36
Then there’s just been direct funding for providers who are doing a lot of this care.
23:40
I think it has given us a window to what could be a wider and more sustainable model of home based medical care down the road.
23:48
So, what are the policy changes that I’ll touch on both now and at the end? You know, one, I think there needs to be serious change in fee for service incentives. The old saying is, you get what you pay for, and I think that’s been true with Medicare and healthcare delivery in our country, and we’ll give a couple of examples of that.
24:05
Telehealth flexibility does need to persist. It has to find a way to balance the in person value of a house call, of seeing that person, where you can do a thorough physical exam, Touch them, talk to their families, see their home environment.
24:20
So all virtual, I think, does not the right way to go, but you can find a balance between in person and virtual to be more effective and sustainable.
24:30
And finally, I’ll talk about value based payments.
24:33
Probably the kinda highlight is getting really an adequate PM PM, a per member per month payment.
24:39
That really covers the costs of team based care, but the most ill and whether it’s in the nursing home and assisted living or at home.
24:47
But couple that with shared savings. Meaning, you’re on the hook for whether you save total costs or you increase total costs and you get to share in savings and be accountable for some key patient and family kind of clinical outcomes.
25:03
Next slide.
25:04
So, the overarching goal is to serve a population that are the most ill, and I’m gonna really focus as to nursing homes in general, and those who have severe illness of cognitive impairment. Let’s think about that. If they’re physically or are kind of psychiatrically severely ill and they have cognitive impairment, they’re not going to be able to do an easy Zoom link right there under Served to begin with.
25:27
And they’re also very high cost, So this is the 5% of Medicare, maybe about two million of them, who generate almost 50% of the Medicare budget. So investing in these patients and this population across settings, home, And then they may need to use a skilled nursing facility and kinda integrate the clinical models, is the population we’re serving.
25:50
What is the need?
25:51
The basic need is what these mobile teams with a workforce that’s interdisciplinary, medical, social work, nursing, administrative kinda co-ordinators, who have technology to do both diagnosis and treatment at home. You can get a good pulse ox which is now famous. You know, the Pulse actually put on your thumb.
26:10
That’s been a tool that home based medical teams have been using for many years to decide if someone needs to go to the ER or not be able to do IV therapy at home.
26:20
There’s a bunch of changes that could be made for IV infusion to support more acute and urgent care at home.
26:26
You have to commit to managing all of their care, 24 7, the available, a live person, to do primary, palliative, co-ordinate their specialty care, make urgent visits, and manage their acute care. This is a full service commitment. It’s not just in a silo of a place or a certain type of care, and that’s the kind of team that we need to pay for, in order to get good care of these folks.
26:51
Ultimately, I find that kind of rubber meets the road. If that team can prevent 911 phone calls, and if they trust you that they’ll call you and they choose to call you, instead of 911, you can often keeps people at home.
27:05
So, homecare medicine as a broad category includes home based primary care and palliative care which is kind of the area I practice a lot in where you take primary responsibility for these populations of patients.
27:17
But urgent care and hospital at home care has to be combined with this, so you can give a full service, and the payment model needs to support all of this.
27:27
You need to be really closely connected with hospice services, ability to care for people at the end of life, maybe not just in the last six months, but how can we integrate primary care and hospice care? And we’ll talk about that. And then make sure your team has access, and can support daily, social and support services. Next slide.
27:45
So, what is possible? And give a brief story of a patient of ours, again, with some changes made for privacy. This is a 95 year old person who was resident of a nursing home in early April.
27:56
It came down with fever …, which is shortness of breath, and confusion was diagnosed with Cove at 19 and April.
28:02
Jazz, moderate, dementia, and spinal arthritis, basically wheelchair bound, and she was admitted to hospital was there for 12 days. Never went on a respirator.
28:11
Had renal failure, was on oxygen, very sick, develop stage four pressure ulcers on her backside, but ultimately survived and was discharged to the family home for some home based primary care.
28:25
You can advance, yeah. Thank you. So, she’s a retired teacher. She now lives with her son, and unfortunately they have july 24th seven aides. She’s bed bound and when we first saw her was non-verbal and totally dependent in advance.
28:39
This is what happens. So Friday afternoon, I actually made a house call and saw this person. She was hypoxic her oxygen was in the high eighties. She was delirious these deep wounds. She was non-verbal and it was a pretty startling event, right? So first step is to talk to the family about the goals that you want to go back to the hospital that you want to be on a ventilator and the ultimate decision was to try to care for her at home.
29:02
So we what did we do?
29:04
We adjusted her meds, we add an oxygen, and this was a pandemic flexibility, we were able to get oxygen immediately because of some flexible rules on oxygen ordering, 24th availability That’s on call this 12 times on Friday night, instead of 911, and every one of those calls he could have call 911.
29:22
We got hospice actually set up urgently on a Saturday.
29:26
We did all of these other things at home, including DME, hospital bed, suctioning, wound care. They check Vital signs twice a day at home and reported those to us. And, our nurse practitioner visited a couple of days later to do caregiver training and continue to adjust the meds. And the oxygen we did have to change our Oxygen and D&B from primary care to the Hospice Funded Services. Next slide.
29:50
So what are the barriers to doing this kind of care right now? So basically the number one is underfunding for team based primary care, at home, and at the SNF.
29:59
For example, it may be just benign neglect, but in the 2021 Medicare fee scale, that for some reasons that are unclear to us, there’s a 10% arva you cut and payments for house call. And nursing home visit codes, for due to budget neutrality rules where some things have been increased and the house call and nursing home co has got cut.
30:21
That’s a direct incentive to decimate the workforce for doing this kind of work.
30:26
That needs to change 2021 Telehealth Role as they currently are saying, they’re gonna split up code. So, some codes for house calls are going to be allowed, and some are not. The home is not allowed as an originating site which limits what you can do with telehealth.
30:42
And if you’re gonna go out and make a house call, you can’t decide before a house call whether the code is going to be a level 1, 2, 3, or four codes. So, you’re not gonna be able to use telehealth fuel air on the side of going to visit that patient, but that will potentially lesson access for patients going.
30:58
The other rules that are barriers are this three day stay that David mentioned, where you have to be admitted to the hospital. For three days before you can use subacute care.
31:06
And then there may be a reduction in the audio only telehealth codes and many of our patients who are poor or low-income.
31:14
Don’t have audio visual capability. So audio only is important.
31:19
So this is an example of incentive. You get what you pay for.
31:22
So there’s the biggest glut of doctors. And I love love them dearly our cardiologists in GI doctors and they get paid a certain amount of money for a similar amount of time. Is that a house comments? There’s lots of other good reasons to go into cardiology MGI but part of the reason, I think students go into these fields is to help pay their loans. And because of the financial incentives, on hospice is a great success story of this.
31:46
It’s relatively is quite well funded, It’s about $170 a day, close to $5000 a month and they have to pay for a lot of things, but not necessarily inpatient care. And that is, I think, partly why there’s hospice services in every corner of the country.
32:02
Outclassed, by contrast for primary and palliative care might get $450 a month whether it’s fee for service or even in the PCF payments that are coming out soon.
32:14
Next slide.
32:15
So, what is possible for this woman? Let’s just finish her story, she got twice weekly visits by both the hospice, nurse, and or the nurse practitioner. We adjusted her meds and or oxygen managed, her bowels, severe constipation.
32:29
Complex wound care got july 24th support, we re tested her for covert at home several times until she was negative and dead blood tests.
32:40
In July and August, she is actually improving, now, four months into this. She gets more weekly visits, lots of in person contact, including telehealth visits, social work, to help the caregiver manage, Continue. Now, we’re starting to do rehabilitation with PT, OT, and speech, that was private pay, because there’s not as much access to that in hospice.
33:01
So, she had improved function and now, in September and October, in advance, it’s the 170 days since that first house call, her stage for wound, has healed. She’s interactive. She’s enjoying music and TV at home. She’s eating well. She’s off oxygen. She may actually graduate from home hospice.
33:24
And so, how did this work?
33:26
So she has had at least about 13 to 15 medical visits between the doc in the NP, 40 plus hospice nurse visits, D T and O T, all the other services that were put in place at home. So this is how it’s possible. You can do this at home.
33:41
She spent 100% of her days at home, 170. I’m counting. She feels much better. She said zero ER visits and hospital admissions. And she has a lot of peace of mind for both her and her son. Next slide.
33:54
So, what policy changes are needed to kind of replicate this kind of care across the country, whether it’s in the nursing home, in combination with the home, or just in the community?
34:04
Basically, I think policymakers need to recognize the value of long term, team based primary care for the most ill subgroup of people and pay for it.
34:14
The fee for service chassis is still the core of this to change behavior and build a workforce definitely to stop the 10% cut in the 2021 primary care codes for both house calls and sniff visits. I would recommend for a substantial increase in workforce increasing the value of those by at least 20%. But at the very least, a 10% increase would give us a chance that more sustainable practices.
34:39
In telehealth, we need to keep all established and Thomas Ciliary codes in Categories 1 and 3 allow the home to be an originating site and keep the audio only option.
34:49
I would make the case however that initial visits maybe after the PHA should be in person because there’s nothing like seeing someone in person to have the trust and knowledge of their home environment that you need.
35:01
And finally, and the value based side, you can’t just give fee for service funds indefinitely, right? Because there’s there are risks for fraud and overuse.
35:10
I think it needs a whole providers accountable for results, not for process, not for checking different boxes, but do they keep people at home? What is the percent days at home of their population? Less that patient and family experience? And what’s their total cost of care?
35:25
Then pay an adequate T N PM for the cost of this kind of care. In our case, It’s in the ballpark of 400, 400, 500 a month.
35:32
Shared savings and use concurrent risk adjustment. So you really reflect the correct serious of illness.
35:38
Finally, I’ll just close with removing that three day rule for better SNF use, so you don’t have to use the hospital as much. And that’s true in many value based programs. So last bullet. I think there’s one more.
35:54
If you could go back just really quickly.
35:56
Yeah, my last bullet there is, too.
35:59
The aspirational goal is to integrate payment models for team based primary care and hospice care. So, rather than have these silos, where you’re paying a very different way for primary and hospice care, figure out a way to integrate those payment models, so you’re not having to force a diagnosis and prognosis of six months, in order to get that kind of great interdisciplinary care. Thanks for your attention, And I know we’re glad to answer questions.
36:29
OK, well, thank you both for giving us lots of fodder for discussion today and I want to remind our attendees that you can use the questions panel to submit your questions at anytime.
36:40
I’ll start with a few opening questions for Beth ROM panelists. So, doctor Grabowski talked about a crisis on top of a crisis to effect interactive effects of that curve in 19 pandemic and racial disparities.
36:54
What do we know about racial disparities in nursing homes and home and community based settings? What are some key barriers to access and wet policy solutions?
37:05
Yeah, I’d be happy to start, and then maybe Eric could go second. So, it’s actually interesting. Nursing homes. We have 15,000, almost 16,000 nursing homes in the US. We like to say this, just to give you a frame of reference, be more nursing homes and Starbucks in the US. Nursing homes are highly local. There, they’ve been found to be our most segregated healthcare institution because they’re so local. We have about 6000 hospitals to give you another benchmark. So, these are going to be much more neighborhood focus, much more local. They draw their staff from that local area, and their and their residents from that local area. A lot of research suggests distance is the most important factor towards predicting where individuals choose to receive nursing home services. So, nursing homes are already highly segregated.
37:57
A lot of evidence Gretchen suggests that those nursing homes caring for more african American residents have lower quality, more deficiencies, more more Medicaid recipients, more hospitalizations. you know, your staff, you name the quality measure. It’s unfortunately not very good. So we and this was all true prior to the pandemic, but then once again we know, the areas of the country, even in local markets that were particularly hard hit. They were, they were often communities with, with lots of minority residents, that then led to some of these individuals working in nursing homes, staff members, bringing it into the nursing home, and so, we’ve seen these same disparities, and they’ve been height.
38:46
Final point, how do we address this going forward? This is such a key area and something that’s been longstanding. Unfortunately, I think it goes back to what Eric was suggesting we get what we pay for.
39:02
We all too often in these communities, we asked the nursing homes to largely care for 100% or close to 100% Medicaid recipients, that’s just not gonna work. And these facilities end up providing lower quality or actually closing this, This, this model of having short Stay, Medicare cross, subsidize these longer thing. Medicaid recipients just doesn’t work, and I think … really highlighted what happens when the Medicare patients stop nationally. But, this has been true, and in these facilities, caring for greater shares of African American residents for a long time. And so, we need to figure out ways to enhance reimbursement.
39:47
And resources in these, in these facilities. And I really hope this is a policy priority. Some of this is obviously providing more resources across the board, facilities, but really highlighting those facilities that, that are, that are more concentrated in terms of Medicaid and oftentimes, with higher shares of african american residents.
40:11
Thanks, mmm hmm.
40:14
And tap into wrong, Do you have any anything else to add?
40:19
Not so much about the nursing home side. I think Dave is exactly right, that it’s concentrated and reflect the communities often that these folks live in and the kind of racism or low-income that they’ve already suffered from.
40:29
But I think what’s kind of the good news is that if Medicare where to think about integrating payment models for primary care in the community, nursing, home payment, hospice payment, you could develop interdisciplinary teams that help keep these folks in the community at home with a lot of intensive nursing, medical, and social supports. But it would really require rethinking how CMS and Congress pay for care of this really high risk population, DC is a great example. There’s very little primary care and kind of the Wards 7 and 8 south-east area. And there’s tons of doctors and primary care people in the north-west DC. So, it’s really kind of incentivizing the workforce to go to those neighborhoods and work there that, I think can make a big difference.
41:17
So, moving to telehealth, so, had colleagues have written for the Commonwealth Fund, the Team mehrotra. one of doctor baskets colleagues talked about how much the rise and telehealth during the pandemic was supported by regulations and rules that have been changed: eye health and human services.
41:39
What do we know about the impact of these changes on long term care, and are all patients benefiting equally, or where does telehealth really not make sense for this population?
41:52
So I think inevitably that huge rise that doctor Moreau Trout documented. Some of it is being directed to to nursing homes. We’ve had, as I noted in my, my earlier presentation, historically, huge barriers to delivering services in this population. one of my favorite studies, we did a randomized study here in Massachusetts that found huge benefits to off our telemedicine coverage. We were super excited about it. We’d published in health affairs, and you know, we were really just super, super, super amped up about the results and then right after we published the paper that the nursing home chain actually stop the telemedicine service. They decided that, you know, they can no longer supported just because they were paying the.
42:46
know, the costs of the telemedicine, and the benefits were going to the Medicare program and fewer hospitalizations. And so we had found the successful study. But as Eric said earlier in his remarks, it was fragmentation and payment that really doomed it. And so once again, go back to this idea, if we can align payments and whether that’s within MA, Medicare Advantage. If that’s an Accountable Care organization, There’s real opportunities for telemedicine. I still hear a lot of concerns about applying telemedicine in a fee for service world. And I think Eric did a nice job during his remarks are talking about some of the, some of the challenges there, because it does encourage high value use, but there’s also this concern about low value use of those services, And so, I think telemedicine will have some guardrails built into it Going forward in the nursing home setting.
43:36
Or more generally, But we know it can do a lot of good in terms of encouraging better primary care, encouraging discouraging transfers to the to the emergency department in the hospital. So I’m, I’m very bullish, Gretchen, but very worried that policymakers will be very focused on that inappropriate use, and I do think this is an area where value based payment models can really encourage high value use as an at risk entity. But I do think we’re gonna see expansion expansion, even in traditional fee for service.
44:13
I would just add, Gretchen, that I think a blank check and fee for service for telehealth is probably not a great idea, but you also have to sort of in value based world. It’s much easier to hold people accountable for the results of that kind of telehealth work.
44:28
I will say the process in which the current codes are set up for 2021, is that a fragmented? Like a level two code you can do telehealth, but a level 3 and 4 Maybe you can’t do I think fragmenting the codes into what is allowed for Telehealth, what’s not, is not practical on the front lines. And so I think it has to be partly holding people accountable for the results, but then giving a fairly flexible use of that tool within a practice.
44:56
So, talking more about what you brought up David. With regard to nursing home outbreaks being correlated with a cobra outbreaks in the community moreso than any particular characteristic of the nursing home, per se.
45:11
So, how should the public assess how long term care settings taking appropriate steps to ensure the safety of its residents? Should they look at the quality writing, or any correlation with that, or is there any other information that they can really use to figure out, what’s the risk of their long term care setting?
45:31
Sure. So, I’m glad you circle back to this, because this has been a huge policy issues, policy issue. Who’s to blame when there’s an outbreak?
45:40
And as I mentioned earlier, a lot of data suggests shouldn’t point the finger at a particular facilities. If they have an outbreak, but that’s not to say that we’re absorbing them from from any role in this, and I think I think the key factors are one. Did they have access to personal protective equipment? We did a health affairs study that we recently published, suggesting about one in five facilities have severe shortages in personal protective equipment. Do they have access to testing? We know that most most facilities don’t have that rapid on-site testing, And then, finally, how are they supporting their, their staff in that same and what is the supply of central staff? And that same health affairs piece, we found, once again, that same number one in five facilities are experiencing a severe staffing shortage. That’s unacceptable.
46:34
There’s some really good data, a couple of different papers that have found that, although all facilities are at risk of having cases, kobuk cases in there, and they’re in their nursing homes, the number of staff can really be one way of preventing a huge outbreak, and that makes a lot of sense. You need staff to help cohort, You need staff to spend all that additional time, it takes to dolphin don PPE to get testing. If you’re if you’re understaffed, there’s going to be shortages. And there’s going to be quality of care issues that that was true pre covert. But I think that’s only been magnified under ….
47:16
So I think I would wanna look at PPE Access to testing and then what what is the sort of workforce look like and you know, if I could just add on slightly Gretchen going into the fall, people ask me like what, what, what kind of keeps you up at night, these days? Lots of things keep us all up nights. But I think that the big one with nursing homes is just the fatigue around, the direct caregivers, and they’ve been at this now, for six months, as I mentioned earlier. Many of them make close to minimum wage. We, we, we, we haven’t valued this workforce for a long time. But encoded it’s really exposed.
47:58
What, what we’re, what we’re asking of them and what we’re, what we’re giving back to them And there’s, there’s a huge gap there.
48:04
And I think, moving forward, raising their wages, making certain they have the requisite benefits, making certainly the PPE and the testing. Otherwise, my, my, my fear for the fall was, if we see spikes here in Massachusetts, in the north-east, other parts of the country, we’re gonna see some, some real exodus from the workforce just given this fatigue among the among the staff. I don’t know, Eric, if you have similar thoughts on on the home care front.
48:33
Yeah, and I would actually just highlight what you said about and the nursing home. So, as first, David, is that the heroes of this whole story are the staff are continuing to work 8, 12 hour shifts in a hotspot or in a high risk area, like a nursing home. And they are doing incredible work, but they’re kind of under the radar and they’re not really being recognized for that.
48:53
Piece of good news is that when I had three nursing homes I worked in over the last six months stop here, two with high income, mostly white clientele and one with low-income dual eligibles, the good news is that when they all three of them use universal precautions had adequate PPE got some decent staff and they all have good leadership. All three of them went from kind of about 30% positivity, positive cases in the facility, with 10 or 15 deaths to zero.
49:21
So it can be done in both low-income facilities, as well as high income facilities. But they need the financial support, I think you should honestly double the hourly rate for the certified nursing assistants and the aids, the most dangerous job in America. And they’re getting, you know, well, 15 bucks an hour, at most. But it can’t be done, but you really have to address the frontline staff, as David mentioned.
49:45
At Greg, if I could just add, sorry, we’re going on here, but I was just thinking, as I was really well said, Eric, and I just wanted to add on one final point. I had the opportunity is during the endemic to testify at a house hearing. And alongside of new was, was a frontline worker from Connecticut and she had the best line that, I just wanted to quote her today. She said, We don’t need another pizza party. We need PPE. And it’s really true that when we, when we provide these resources to our direct caregivers they can protect themselves and Eric … Exactly. Right, it’s, it’s, it’s about you can do this in any facility, but they, they need those resources, and that’s why I’ve been framing this as a system level problem.
50:33
Gretchen, just about home based care. We’ve had five in our practice, not a lot, five patients with … in 19 82 to 98. Interestingly, all five had survive. It’s a pretty minimal exposure to families. And the small room, the small greenhouse kind of approach that David might kind of alluded to earlier, having people living in individual homes or private spaces has a big impact on whether people survive in the dose of the virus that they get, but also kind of how much individual support they get going forward.
51:08
And along those lines, I mean we really don’t know to what extent covered has affected home health care and on health care workers, lack of PPE, there’s just less information about that. Are there any other information that you would highlight that we should have going forward during this pandemic?
51:32
Let me just add one again. I don’t, it’s not published. But at our institution, our Chief Medical Officer, doctor Matt …, environmental whole team here, I’ve put together universal PPE since mid March.
51:42
And with several thousands of patients, and about one thousand staff, we haven’t had a documented case of transmission between patients and staff with the use of universal precautions in a home environment.
51:55
And so I think it’s a, it’s just a real-world example. But I think in the home environment, it’s a little bit easier to keep people safe than when you’re in a highly dense kind of closed environment.
52:06
Gretchen, you’re 100% right. I think this is one of those areas where we, we’ve focused a lot on nursing homes, because in some ways, we have the data. We know a lot, we know something about assisted living. But, but, but less and then I think moving out to the home and community based settings, I think we know almost nothing. And so this will be a big research focus. one point I did want to make, however, and we’re already beginning to see some, some Medicare data about where individuals are going after the hospital. And this won’t surprise anyone, you know. Inpatient hospitalizations have been down since the start of a pandemic.
52:46
Admissions, as I noted earlier to skilled nursing facilities are also down and home health, at least early on in the pandemic, was down is just across the board.
52:55
What’s interesting that over the last couple of months, where the data’s available at home health is starting to come back and I wonder Gretchen, it’s going to be really interesting to follow how long this sort of change will persist, right?
53:10
That individuals have always wanted care in the home that that’s nothing new, but this idea that with, with the pandemic being able to be in your own home, you need the services. And that’s exactly what Eric has been speaking about. But is there this opportunity to shift from skilled nursing facilities, home, health agencies, for that post hospital care? I think more so than ever before. We’re going to see that. And I’m, it’ll be interesting to follow what that means for quality and patient outcomes.
53:45
So, along following that train of thought, and it seems like everyone on this panel agrees that the residents should ideally stay in their home or in the community for as long as they possibly can.
53:59
But, as we’ve talked about, the reimbursement system doesn’t support that, and in many systems, might, as he says, my actually discourage it. So, what changes should we be thinking about in terms of how we pay for home visits? What else is needed in terms of support for people receiving care in our home?
54:19
Our to add on to that.
54:22
Yeah, thanks, I can take a crack at that, Gretchen. I think that there’s kind of, I mentioned it briefly.
54:28
There’s three major changes I think we need to think about is really bumping up the fee for service chassis, of paying for home based medical visits. The travel time that’s required, the time spending in the home, it’s just as a more expensive way of doing primary care for a subgroup of people. So that’s one.
54:45
Probably more importantly, it’s actually obtain a prospective payment for a team of people, not too different from our hospices pay, right? That’s a, that’s a significant, higher per diem, but pay a prospective payment based on cost of doing good team based care in the home, so that you can be in the black, most non-profit hospital programs around the country are not able to breakeven.
55:08
So it’s hard to convince young people to go into the field when you can’t really say you have a breakeven proposition to do this kind of work.
55:16
But hold them accountable with, let’s say you pay $500 per patient per month for the team based care.
55:22
Hold them accountable for total cost of care.
55:24
And for some key metrics, like for days at home, patient and family experience, and really shift to a population approach, and then they can use the SNF when they need to is the smithy without a three day stay.
55:36
They can use the hospital or the ICU and they need to use the hospital. But you you reward the right behavior to help the medical behavior in order to keep people at home. There’s a whole separate question about have inadequate aid support: The daily home health care aides. And, that’s more of a feast or famine where if you have a lot of money, you can pay july 24 hour private days.
55:55
So if you’re on Medicaid, you may be able to get some aids, but everyone in the middle often is kind of is struggling to get those daily home health aides. And that’s a bigger question beyond the Medicare coding.
56:07
Yeah. No, I just to add onto that, I was going to speak to the long term care side of it with the caregiving aids. The data we’ve seen, we have about a million individuals nationally on on the waitlist for Medicaid home and community based services. So, there’s a huge demand for, for those, those slots, and in many states, those individuals who are receiving those services. It’s not around the clock care that, that Eric just described, It’s not that private duty where they can afford it. It’s a very kind of narrow benefits, very service or oriented, helping with activities of daily living versus that, that longer sort of companion care. That many individuals need. And in that setting. So I hope that we re-orient we historically finance nursing homes much more than a home and community based services. There’s been this huge, kind of push over the last 15, 20 years to quote unquote rebalanced Medicaid towards.
57:06
Amin, community based Services, but I think we have a long way to go on on that front And I had the opportunity to visit prior to the pandemic. Of course, the Netherlands and really get a get a window into their long-term care system. They spend about double what we do as a percentage of their gross domestic product on on long term care, and to Eric Appointments, can you get what you pay for, they get lots of home and community based services, and it’s, it’s a really rich set of benefits. And, indeed, they ration nursing home services. It’s and and provide lots and lots of home care. We do. The opposite were pretty generous. In terms of, not in terms of what we pay for nursing home, but but allow you onto that under that benefit. in Medicaid. Yet, we ration in home care. I think they have it, correct. We have it upside down. We need to borrow graduating from that model and complement it with the kind of clinical services Eric was describing earlier.
58:09
Continuing that thread, mean, there are models, additional models are home and community based services, like pace, Medicare Advantage plans, or have more flexibility with regard to provide caregiver support.
58:27
Although, we haven’t seen them take up that option, to a large extent, are these models that can really be built upon that can really help to feed into the long term care system?
58:42
Or should we really continue to think of them as separate types of models?
58:49
I’m happy to go first on this one. I, I would love to see some growth in those models. Pace is, a is a great model. Unfortunately, it’s very narrow right now. I’m always struck at Med Pac when we look at the number of beneficiaries in these different integrated models and see the skill of SNPs, The special needs plans, we see the integrated the Financial Alignment initiative and the integrated Medicare Medicaid plans there.
59:18
Pace is is a is a small fraction of those models of course. It’s a truly integrated model, Whereas some of the some of these other other models Say they’re integrated, But as we know some of the special needs plans are better than others in that regard So I Do think the Pace And the supplemental benefits through Medicare Advantage could could be a sort of an important plank. And a broader set of services. I think the key question ration Gretchen is how do we grow those those different options, because we have so few individuals in them right now. And how do we encourage enrollment? Because I, I’ve been frustrated, we did a study of the Financial alignment initiative, and it was hard to get a lot of dual dual eligible, beneficiaries into those models. Some states did better than others, but it.
1:00:12
It’s surprising. For many they, they want to stay. Many duals want to stay in fee for service because of the coverage and the lack of cost sharing.
1:00:20
And I don’t know how we make that case that, models like, like, pace, or better, and but they’ve gotta be better for beneficiary, you know. We’ve got to be able to get that enrollment. We can researchers like, us, just can’t keep telling them, telling everyone, it’s better that we have to see that, that in terms of enrollment. So I do hope. And the final point I was going to make is that there’s such a demand among the Medicare population for long term care. I’ve seen this, you know, with the Eric mentioned hospice earlier, But, you know, medpac’s been doing some work on Hospice. And as both of you know, that that benefits been sort of the type of individual enrolling in. Hospice has really changed from a cancer benefit to much more of a population with Alzheimer’s and other dementias. And.
1:01:10
It almost feels like some of that expansion has been this need for home care and other other services that just aren’t, aren’t there. Some of that is palliative. But some of that is really kind of just that, that long-term care, and so, we have a lot of Medicare beneficiaries whose needs aren’t being met. And I really like the way Eric frame that some of our beneficiaries can afford out of pocket to do this.
1:01:33
But, some have some Medicaid, maybe not enough Medicaid, but there’s too many, you know, that kind of forgotten middle there that they need services. And then I do think we could make the the Medicaid benefit much richer.
1:01:49
I would just add, Gretchen, I think just to give us a fighting chance. You have to kinda just K T a team for primary care in the community enough so that they can breakeven or have a little bit of margin at the end of the year. And faces a great program, may require several million dollars to invest in a pay center, its Senior center based, which may be more difficult now and covert 19 era. I think, kind of case without walls, as kind of a philosophy of building teams that, again, that aren’t micro manage, that you have to have these 11 staff, but hold them accountable for the results. Has to be enough to cover team based primary care, and that team can do a lot of great work in the community with the family, finding AAA resources, seeing if they’re eligible for Medicaid. You just need that core Primary Care team to be kind of thriving in the community, and they can find the resources to help the families, you know, do what it takes to keep that person at home.
1:02:43
Switching gears a little bit with another question from our attendees, can you talk a little bit more about the impact of social isolation and the mental health and well-being of older adults during this pandemic? So, there’s been plenty of concern with data showing the intersection of social isolation and medical complications. So, given where we are and the faculty may be in this for a little while longer, what do we know about the tradeoffs and how can we balance socialized, making people not socially isolated and infection control and long-term care settings?
1:03:24
Sure. I could start on this one, but I’d love to hear your perspective as well, think early on in the pandemic, like a lot of other folks, I minute, we learn about poveda, just this, how, how diarrhea would be for nursing home residents.
1:03:39
I think we all swung the pendulum towards safety and infection control, and let’s lock down these facilities and communal activities and, and, visitors, I think all of us wanted to kinda build a wall around these, these nursing homes and aye.
1:03:56
I think that made sense. And in the early period is, we’re still learning about the virus.
1:04:01
But this issue, I’ve been speaking a lot about, about permanent nursing homes over the last six months, This is six plus months, and this is the issue I hear about more than any other, just family members. Others reaching out, saying, you know, just just the negative impact that the, the lack of visitation engagement has had on on the residents.
1:04:25
And I think that pendulum Gretchen has swung too far towards safety and not towards resident dignity and quality of life.
1:04:33
And I think we, we we’ve now learned a lot more where we could actually do visitations safely in a lot of markets, nobodies, suggesting in the middle of an outbreak, bringing bringing visitors. And I think this is being safe. It’s being more nuance but in parts of the country where community spread is lower or the facility has resources around that, You know, PPE and testing, there’s no reason family can’t come in. And most staff, they realize it’s, it’s time consuming to kind of get, get, get family into the building, but they know the benefits that it has for the, for, the, for the residents themselves. We’ve just seen so many reports of depression, you know, failure to thrive. It’s, it’s, it’s really sad. And there’s a great report that all … released just last week where they did interviews sort of a qualitative study of just talking to residents and what impact this lockdown has had.
1:05:37
And it’s, it’s, put it bluntly. It’s a really tough read Just to just to hear how how hard that is locked down has been the pandemic has been. And as I said during my remarks as we know Kovac kills but it turns out this pandemic more generally has also killed by by really cutting off the lot of residents from from their families. And you know Eric mentioned greenhouse.
1:06:05
I’ll just say quickly as my last part of this remark that, know, that we become a long way, we have a long ways to go with nursing homes, sort of beginning to become kind of more person direct resident directed. Really, culture change has been one of the great steps forward in nursing homes, once again, lots of work to do there. But every step, every every All The progress that we’ve made, has really been pulled back, and I am all for good infection control. But I think there’s ways that we can balance.
1:06:40
No good infection control with with resident quality of life.
1:06:47
Yeah, I agree, actually, completely, what that, David said, and I would even take it a step further.
1:06:51
I think that with, in my interest, in our practice, we have seen tremendous amounts of depression. I’ve seen dementias get worse at a faster rate than I would expect them to get functional decline. People saying to me, you know, It’s really not worth living. This one woman at a senior community said: I feel like I’m just in a prison waiting to knock off, you know.
1:07:10
So what kind of life is that for these folks, the good news is that with basic precautions we can allow visitation we can allow physical contact even I read an interesting study about hugs, you know, brief hugs when you wear a mask are safe. So since I’ve read that, I’ve been hugging my mom. I’ve been bugging my family, you know, when I go visit people, we can hug if it’s brief. Anywhere. Mass, that’s fine so I think it was understandable that we reacted the way we did.
1:07:40
But now I see in the senior community this morning I was at the Residents Association where lit into me today because they said everyone around here is depressed, They’re walking with their heads down. They have no joy in life and I think we can follow basic precautions and bring some joy back to life.
1:08:02
Really important client I think especially now for during the pandemic.
1:08:08
This is another question from our attendees and a bit of a different thread. There has been increased attention to how health care is contributing to climate change.
1:08:19
And long term care industry part of these conversations. How are these conversations around climate change being addressed, or is that not really part of the conversation?
1:08:32
Now, it’s very different than tend to this conversation, but an important component as well.
1:08:40
Yeah, I’ve been asked a lot of questions like, obviously, say, This is what I’ve not been asked, But I’m happy to think through.
1:08:46
You know, I, I probably think like a lot of other parts of our health care system, the long-term care system has a lot of work to do around climate change, and how we, How we think about delivery and balancing that with many other objectives.
1:09:04
And I’m trying to think through, you know, you can think about some of the benefits of having individuals in congregate living situations that might be good in some ways in terms of resource use and climate change, but but bad and others. And so, thinking about these tradeoffs, Scratch, and having home care or physicians that are driving out to people’s homes, I don’t think that in. And of itself, as a reason, not to move towards the home and community. But it’s certainly something to really think about. And, you know, I don’t know. This would be a really good question for, for, for nursing home operators. I think a lot of our capital and nursing homes is really old facilities built in the 19 sixties, 19 seventies. Certainly, we could do a lot, and, you know, and I look at some of the small home models.
1:09:59
And just, so, some of some of the innovations that are happening just in the physical plant alone. I have no doubt that, were, that, were that were. So it’s a more sustainable model that we have today, and these big institutional buildings that we had in the 19 sixties. So, I love that question. And it’s something that I’ll continue to think about, because it’s not an area, it seems. Like Gretchen, this could be a whole other issue. Brief in your series, that’s the climate change, and health.
1:10:29
I don’t know, Eric, if you have thoughts, because, you know, just, I think house calls are probably pretty low on the list of causes of climate change.
1:10:36
But in the benefits of House calls, I think that, if you have a team out there, that’s kinda the early radar, you know. So in heat waves, for example, in the summers and major urban areas or in rural areas, having that early radar of age, community health workers, NPs and docs to be out there, you know, getting air conditioners and getting hydration properly done. So for the heat effects of climate change. I think the home based medical care is a crucial tool.
1:11:08
OK, so, as we’re sort of approaching the end of our time, and I want to remind our attendees so they can still put questions into the chat box for us, um, addressed as well. But, I also want to ask our panelists asked me, sort of come to my clothes, are there any thoughts that you want to leave us with, or anything that you’d like to emphasize? We’ve touched on a lot of different topics.
1:11:38
Yeah, I’ll go first.
1:11:40
I think there’s this idea that either one, that the long-term care broadly, but nursing homes, that’s it’s, it’s inevitable, and I don’t at all feel that way. I think the data supports and I loved, you know, Eric’s anecdote about the three facilities. And when they got resources, personal protective equipment and testing, when we’re able to cohort facilities across the spectrum, are are really able to respond and protect their, their workforce, and the and, the residents. And this can be done.
1:12:15
I wish we had started back in March with these kind of activities, but we can start today. And so, I am just stress that it’s definitely not too late to put put into place a lot of these protections. But it’s going to take resources and very directed resources is going to take leadership and I hope kind of going forward that we’re able to get the resources and then hold these facilities accountable like nobody’s letting any of the providers off the hook. We’re gonna give them resources and but but ask a lot of them in terms of you know, paying their workforce and and Protecting the residents providing good quality.
1:12:55
Thanks, Gretchen. I guess I would just first say I think we should give credit to CMS and Congress for making some changes very quickly and early on in the pandemic so that we can kind of do things and on the fly and take better care of people.
1:13:11
But, you know, that being said, I think for the future, for home based primary care and medical care to try to keep people out of the nursing home and keep people in their homes as long as possible. You do get what you pay for. I think we need to invest in this team based approach to primary care over years, Not just the last few months.
1:13:29
where hospice, I think, has done a great job, but, you know, figure out a way to do that similar type of prospective support for team based primary care, for social, nursing, and medical staff in the home. And if you put those teams out there, they can really work magic with families to keep people safe at home, until the last day, until the last day of life.
1:13:48
And I guess a couple of specific examples, I think this 2021 Medicare fee schedule for both nursing home and M codes, and house call codes really needs to be fixed hopley, so that we don’t lose a lot more workforce of doing that kind of care.
1:14:08
Well, this has been great.
1:14:10
And I think both of you highlight the need for more resources, which, of course, is always at odds with making sure that we’re preventing fraud and abuse of those resources and making sure that we’re allocating them in the best way possible, which is always an ongoing challenge. And that was brought up. Sort of as our last question here by an audience member, wonder how do we ensure that there’s flexibility? But also prevent fraud and abuse utilization, particularly with an eye towards?
1:14:49
Sure, Solvency issues with the Medicare trust fund and sort of a lack of funding. And that way.
1:14:58
Yeah, sure. It’s pointing to the two issues I really focused on that are good candidates, Going forward to become permanent. The three day rule in telemedicine.
1:15:09
I think in both of those instances, simply relaxing, although all the constraints and opening this up, as Gretchen said, I know, I don’t think we’re being good stewards of taxpayer dollars. The Trust fund, the Medicare Program. Generally, I think we, we we really have to think about how do we encourage kind of The right care in the right place and the right amount at the right time, but also how do we make certain that we’re not, We’re not seeing that fraud and abuse. And so with a three day rule, I think you really need checks and I think that the big kind of risks there is that scaling in place that I mentioned earlier long, stay nursing home, Residents, just getting turned over to post acute. That works really well if you’re an institutional special needs plan or a ACO and you can manage that that that patient in the SNF and not down the street at the hospital or the or the ebi.
1:16:13
works less well in terms of traditional Medicare fee for service where it’s less clear, who’s really managing the services and whether this is done for financial reasons. And so I really think you would need a lot of accountability there, not not individuals coming from the community for that three day rule. But individuals who are long stay nursing home residents. I think we’re really going to have to keep our eyes on on that. So that’s that’s one way to sort of build those, those guardrails terms of telemedicine. I won’t spend a lot of time on this other than just to reference once again, that great Commonwealth Fund piece by doctor Moreau Trend of colleagues. They outlined a series of steps. Like, what are some guardrails here? What do we want to pay for? And where do we want to pay for it? I think, once again, telemedicine is here to stay.
1:17:06
I don’t think we’re putting, I don’t know, if you want to say the genie back in the bottle or it’s there, people are really, really appreciating, and I think it has real potential in long-term care settings to improve outcomes. But I don’t think once again, it’s opening up the floodgates and just saying telemedicine can be paid for anywhere anytime. I think they’re really have to be particular rules about what we pay and what instances in order to encourage those high value care. And really really protect I think the trust fund going forward.
1:17:45
No question. I guess I would say about fraud and abuse. It feels like they’ve been playing whack a mole with kinda fraud or abuse forever. And it probably will continue to some degree, but the good news is that if you pay a prospective payment on some sort of value based approach for taking care of populations, have 500 people or a thousand people.
1:18:02
And you’ll hold the providers accountable for number of days spent at home: percent days at home, family, and patient experience, and total costs. There’s not a lot of room there for fraud and abuse, because they’re actually accountable for good results. And then they can share. The other good news, is that there’s about probably at least 20% of Medicare costs into high risk group.
1:18:22
That you could reduce the total cost, so you can reduce total cost by substantial amount, And then if the fraud and abuse even stayed the same, you’d still be ahead.
1:18:35
I wanna thank our panelists today, for joining us this afternoon, and suspend a terrific conversation. And for our attendees, please take the time to complete the evaluation survey that you’re like same after the podcast, as well. And by e-mail and a recording of this webinar and additional materials will be available on the Alliance’s website. And David and Eric, thank you so much for joining us today.
1:19:03
Thanks. Thank you.