Now or Never: Long-Term Care Strategy is a podcast for all those seeking answers and solutions in the long-term care space. Too often we don’t fully understand the necessity of care until it’s too late. This podcast is designed to create solutions, start conversations and bring awareness to the industry that will inevitably impact all Americans.
When I've gone and given lectures to professionals, people who know and understand know the statistics and saw in at the beginning of a lecture I'll say, Okay, how many people think that they are personally going to need long term care before they die? Very few people raise their hands. Then I say, How many people think the person next to you is going to need long term care? You know, everyone raises their hand because they know that it's roughly half. It's very hard to imagine your future self
Welcome to Now or Never Long-Term Care Strategy with Kosta Yepifantsev a podcast for all those seeking answers and solutions in the long term care space. This podcast is designed to create resources, start conversations and bring awareness to the industry that will inevitably impact all Americans. Here's your host Kosta Yepifantsev.
Hey, y'all.
This is Kosta. And today, I'm here with my guest, Marc Cohen, Professor of Gerontology at the University of Massachusetts, Boston, and co director of the leading age LTSS. Throughout his career, Mark's work has been published and quoted extensively, including interviews by the New York Times Wall Street Journal and Time Magazine as a thought leader on issues affecting elder care financing. Today, we're talking about the business of aging, who's paying for it and why it matters. Mark, you've spent the majority of your career researching and analyzing public policy and how it impacts how we pay for and receive long term care. What is this work mean to the everyday American?
Well, first of all, thanks, Costa for having me on your show, I really appreciate it. Whenever I have the opportunity to talk about long term care and Long Term Care Financing, I grab it, because one of the challenges that we have is that many people don't really understand how it can affect them on a day to day basis. And so I think your first question is really a great lead in the fact of the matter is that roughly half of us who live to age 65 are going to experience some significant long term care needs as we age. And what that means and those needs, which are typically supportive care, help with everyday living activities, bathing, dressing, maybe shopping, medication management, those types of services can be provided both by paid caregivers, and by unpaid family members. But what we're seeing is, especially on the unpaid family side, that network of support really stretching, it used to be that there were seven caregivers for every one person who was disabled. Today, it's down to three, you know, there's long distance caregiving, children are living away from their adult parents, and so on.
So that means that there is growing reliance on the paid system of care, home health care aides, and so on. And what we find is that most people don't understand that they are going, they're going to face this risk and this need. And currently, there are not really great options for paying for this care. And it can be really expensive. I'm not just talking about nursing home care where today latest rate latest research shows, you can spend upwards of 85 to $90,000 a year in a nursing home. When you're in that situation. What typically happens is people take their either they don't have any money to begin with and the Medicaid system will pay for them. Medicaid being a federal state partnership, that pays primarily for nursing home care, or if they have savings, they spend that money fairly rapidly on that care until they reach Medicaid eligibility eligibility levels. And then Medicaid will kick in, which basically means they spend their life savings paying for that type of care. So it's so there are the only other alternative available right now is private long term care insurance. And there was a lot of hope placed in that industry.
And there was some fairly rapid growth all the way up until the year 2000, which sounds like a lifetime ago, where it's almost 25 years ago, tells you how long I've been at this. So unfortunately, the insurance for a variety of reasons, is out of the reach of most middle income Americans is too expensive. So people are faced with some really, really nasty alternatives. They can rely exclusively on family which is becoming more and more difficult. Not to mention as a caregiver the challenges that caregivers face, they can rely on savings, but typically most people will not have saved enough. Or some people may never need care and they will be saving for no particular reason.
Or they can rely on Medicaid, which I will say has improved quite a bit over the years in terms of paying more Home and Community Based Care and not just nursing home care, but still does not typically their long waiting list. There's some flexibilities that don't exist, and it's very uneven across the United States. So like it or not, many people whether whether they believe it or not, are going to end up facing some significant financial challenges as a result of this risk.
And so you brought up a lot of different models. So we talked about Medicaid paying for long term care, which I'd like to see your opinion about whether or not you think that's really the only payer of long term care at this point. Companies such as ourselves, were funded primarily by Medicaid, because we've come to realize that a lot of people can't pay for long term care out of pocket, because it is so expensive. But I would like to know, in 2023, what are some of the most promising models for delivering Long Term Care, specifically, what makes them successful, and ultimately, who is paying for them.
So I would say that there have been a number of states that have put in place sort of supplemental home care programs. And these are programs like in California, Massachusetts, other states that try to provide some financial support for people who are not poor enough to actually be on Medicaid, but not rich enough to afford the services on their own. So it's, it's really targeted toward this lower middle middle income folks, those programs are at the really the initiative of the state, without much without federal government backing. So you know, it depends on where you live, whether you're going to be eligible for a program like that. Now, there are a host of models that are out there that are really trying, let's separate out the financing and the delivery of services.
Although the delivery is significantly constrained by the financing that's available for sure. On the institutional side, there's a move toward smaller nursing homes, the greenhouse model of the nursing home, where you're looking at people who are living more in a home like environment, maybe seven to 10 rooms, keeping people in individual individual rooms in particular, especially given that we've just come out of the pandemic, where infection control was an enormous issue.
And frankly, this pandemic devastated the nursing home population in particular, there's a much greater move toward trying to change the infrastructure of the nursing home. The problem is, and one of the big challenges is that most nursing homes rely for the bulk of their funding from the Medicaid program. And the Medicaid program is a growing represents a growing proportion of state budgets. So as the population ages, and more people have to rely on Medicaid, it becomes a bigger part of the state budget, and it can crowd out other policy priorities. So what's the easiest thing for a state to do? When it's when it's feeling that pressure, we're going to pay a bit lower rate.
And that's why you see, many nursing homes around the country have been closing because they're the claim is that they're not being paid enough to actually provide the level of care that's required. So there's a feeling that we need to move to a different model smaller, and smaller homes and so on.
If the state is wanting to save money, and I live in Tennessee, so we have a very unique state and we have an expanded Medicaid. We have a block grant for our Medicaid program, which is the only one in the country. And it still makes up almost 30% of our entire state budget. And we have made a managed cares program, which is pretty common nowadays with regards to Medicaid. If a nursing home and the model that they've built requires them to have 100 to 120 bed facilities How can they make the financial model work? Having individual rooms, having smaller facilities and not getting any more reimbursement?
The key is what you said at the end, not getting any more reimbursement. If there's not, if there is not a stream of new dollars, lowing in that system, then, because and I'll tell you what nursing homes have done up until now, if there's not a new stream of dollars, it's almost, it's almost impossible. You've got constraints that simply cannot, cannot be addressed. What nursing homes historically have done, is they have reserved a portion of their beds for people who are coming out of a hospital post acute care for, let's say, rehabilitation, and so on. Why are they doing that? Because the Medicare program pays for those costs. And the reimbursement rates are much higher. So for many for many years, how did nursing homes make this work?
Well, they had a certain number of private payers, like people come in, and they're spending down there their assets, so they're getting private dollars.
They're getting Medicare dollars. And they're using whatever margin they have on those dollars to make up for potential shortfalls on the Medicaid side. So very different, difficult balancing act, very difficult balancing act.
Has it changed now because I mean, every every nursing home that I've ever encountered has a rehab wing. Since the pandemic is that model still tenable.
Very interesting what happened during the pandemic. So during the pandemic, you had hospitals, wanting to get their these patients out as quickly as possible and get them into the nursing homes. Well, guess what?
The nursing homes were not equipped with adequate infection control. So what did this mean?
Those patients were coming out of the hospital, many of them maybe have the beginning symptoms of COVID COVID, spread throughout the entire nursing home. So then you had nursing homes saying wait a second, you know, during the pandemic, don't send these patients in the hospital saying we don't have beds because so many people are coming in. It was a it was a mess. It was a mess. And people have not fully recovered from that to be to be honest.
I mean, so what are the after effects? And what does the future look like for long term care providers specifically, when it comes to making sure that they're adequately trained? And whether or not they'll ever be adequately compensated for their work? Yeah,
so Well, we just got spent a lot of time on the nursing home side. Most people don't receive care in the nursing home, as you know, because the most most are receiving care in the community.
And you you you hit that beautifully. Let's talk what's going on on the community side.
So what's happened on the community side is we have a dramatic shortage in home health care workers home health aides companion services, for a host of reasons. The largest reason is that people can earn more money working in a restaurant and providing care that wages, people have not been paid a living wage. So it's here we have labor shortages all over the country, right? We've been reading about this for the last year, this lowest unemployment in 50 years and so on. We know, given the ageing of the population, where people live, and what services they're likely to need, that there are I think we need like 30 to 40,000 more homecare workers over the next I don't know, five to 10 years, some enormous number. Two things have gone on. One is that we need to pay folks more. Okay, in order to attract them to this industry. That's number one.
Number two, we've had a major, major limitations were placed on immigration. Now people don't often connect immigration to long term care. What does that have to do with long term care?
Here's what it has to do with it. nearly 1/3 of the long term care workforce in the in the United States is comprised of immigrant women. So if we don't have a supply coming into this country, it's unclear where we're going to get the labor.
Such an interesting thing we all talk about. How much we value our elders, as you know, incredibly important resources that have such wisdom and have helped to build this country.
And yet, we pay the people to care for them. Oftentimes less than what is paid to serve a McDonald's hamburger, something.
Yeah, poverty rate wages, we did a study, which I recommend, it's called making, making care work pay was put out by the leading age LTSS center that looks at what the impacts would be if you actually paid a living wage across the country. And, you know, it's funny, people often focus just on the cost side of the equation and not on the benefits side, if you actually paid a living wage, A, you would have reduced public assistance payments, a lot of these people who are working right now are getting welfare at the same time that they're working. So you would reduce public expenditures A, B, you would have greater productivity. So you'd actually be getting more for the dollar.
If you paid a living wage, C, you would have increased revenues being spent in the local community, which supports local economies. So there's all sorts of benefits associated with that. But we always say, Oh, my goodness, it's going to cost you know, $2 more an hour, you but you have to take the long view on this, not just what's happening to me on this particular day.
So when it comes and I don't want to get into like too technical of a conversation, but there, you're literally like saying all of the things that I say I think that there's only three solutions to our long term care problem. In terms of the capacity, either family members start caring for their own parents, and they have the resources and the means to do so. We pay more money to paid caregivers so that they can have a living wage and a high quality of life, which also increases tat employer and employee pay taxes, which is more revenue for the federal government. Or the third one is to follow the model that Canada did, which is to create a visa program and for specifically for healthcare workers, so that we can bring in people even if we have to target them for just health care work.
I mean, our immigration policy is completely out of whack. But that's a we'd be here for three hours talking about that. But I do believe that that is the third solution. When the companionship exemption for people that don't know what the companionship exemption was, in 26 2015, the Obama administration said you have to pay long term care workers over time. Prior to that there was a clause going back to the Fair Labor Standards Act of the 30s.
That exempted a lot of essentially caregivers, whether they were working privately or for a company to not receive overtime. When that exemption was removed, and caregivers started receiving overtime, why did states not start reacting, like putting to putting the pieces of the puzzle together two and two together to say the costs are going to increase exponentially as people continue to age which statistically, it's not rocket science to seek to connect the pieces connect the dots? Why do states not act in a proactive manner to try to head off some of the crises that we are now experiencing? Because we've essentially scarred this industry and eliminated a pipeline for future caregivers, and even the capacity to create that pipeline? And the people that should be managing this problem unless Medicare steps in and says, Okay, we'll pay for long term care. Aren't managing it? Why?
So this is, this is what I've come to what I've come to understand after many, many years in this area, the biggest impediment to change is something called inertia. So, unless people are convinced that the costs of doing nothing exceed the costs of doing something, nothing will happen.
It's as simple as that. And I want to I want to make two points about this. There are some states that under have understood this. And the best example of that is Washington State. Washington State did a series of analyses And they looked ahead and they said, Holy smokes, we're on a trajectory, that's not possible to sustain, we need to do something. Okay.
And the policymakers got together with stakeholders, this is the second big lesson that I've learned. Unless there is demand from the bottom up, you won't see policymakers do anything. In other words, there has to be active advocacy coalition's that are saying, Hey, this is a pain point. We need help here. And those two, precisely those two things came together, for example, in Washington State, where the policymakers looked, and they said, Medicaid is unsustainable.
We're, we can't, we can't continue this way. In 15 years, we're done. Okay. And you had middle class folks saying, We've got, we can't provide all this care to our own family members, it's too hard, we're gonna have to leave the labor force, it means that when we retire, we're gonna have less less social security available to us. We need help others are saying we're spending down our income and assets. Isn't there some other solution? So you had these confluence of these two factors?
And what did they do? They understood that, you know, one of the things private long term here insurance is exactly the right idea. Insurance, I should say, the issue is whether it should be private insurance or public insurance. That is for a whole nother segment. But let me just say the following long term here is a perfect risk for insurance. Why? Because you have a small probability of a very catastrophic event, you have roughly half of the people who retire will end up not needing it, maybe for some of them for for, you know, bad reasons, they will they will die before they need it, or what have you. And the other half will need it. And as an individual, you don't know where you were in that distribution, you lie. When, when describe that way. It's like every other kind of insurance, it's like, homeowners fire insurance, right? Life insurance, automobile insurance.
And it's not like one of these things where you say, Geez, I've been paying for my life. And I've been paying for my homeowners insurance for 20 years, I've never had a fire I got ripped off. Nobody says that. But people have a hard time thinking about long term care that way. So the question is, is really there? If there was an insurance mechanism, for a host of reasons, the private market has not worked the way we all thought it would. So Washington state has decided they're gonna do a public insurance, a mandatory public insurance program, where people will pay in a Social Security tax like point 6%. And if they become disabled, they will get the equivalent of $100 a day in long term care, insurance protection. So they're the first but there are a growing number of states, California, Michigan, New York, Illinois, Hawaii has a caregiver program. These are, these are states that understand a couple of things, one, that their Medicaid programs are not going to be sustainable. And let's suppose you're a legislator who cares a whole lot about education for kids, or, you know, health care for, you know, other other groups and stuff. Well, if the whole budget is going to be eaten up, by let's say, long term care, you want to do something about it, because you became a legislator for a reason you want to make a difference with something.
That's so that's, that's part of it. And again, the other part of it is the aging of the popular unfortunately, it's like, you see this tsunami coming in the distance, and you're watching it, and you're watching it, and it's getting closer and closer.
And then right before it hits the shore, you said yourself, holy smokes, I probably need to do something to protect myself.
Yeah. And it's, it's for many states, it's to well, it is because
and I say this often on the podcast, you know, the baby boomer generation was born between the years of 1946 and 1964. The first baby boomers turned 75 in 2021. And that means the tsunami is now washing on up to shore, you know? Yes, I am curious. And then I'm going to ask you one more question. And then we're going to talk about housing. So, legislatures, legislators, tours, they are over the age of 65. A lot of them are and so like they in their personal lives. I've in their friendships and their acquaintances are confronted with this long term care issues day in and day out.
And they obviously understand that there isn't a state solution because Medicaid is unsustainable. I mean, I think that everybody at this point understands that Medicaid is unsustainable in its current model. Two questions. First off, why is nobody getting out on the stump and talking about long term care and the issue of aging, and the fact of wean us needing to fund it adequately to provide quality care to families get, you know, take away all the profit centers and all that stuff and just talk about giving money directly to families so that they can support their parents and loved ones. But the second thing is, why don't current legislators actually put policy in place and maybe even see if it's feasible for Medicare to take this big, you know, big, hairy monster of long term care on within their own budgets?
Great question, honestly. And I think that there are, there are two answers. One is that, for the most part, there's a tremendous amount of denial going on, agreed that, and I'll tell you something really interesting. I've said this a number of times when people have asked me when I've gone and given lectures to peep to professionals, people who know and understand know, the statistics and so on. And at the beginning of a lecture, I'll say, Okay, how many people think that they are personally going to need long term care? before they die? Very few people raise their hands, then I say, How many people think the person next to you is going to need long term care, you know, and everyone raises their hand because they know that it's roughly half perfect example. So people don't, it's very hard to imagine your future self, right?
I look at myself and I say, Well, I'm gonna everything's gonna be the same. I'll just have maybe No, no, or gray or hair. But I'm still going to be able to ride my bike and jog and so on. There's denial. There's also misinformation. Many people mistakenly believe, well, that's what I'm covered by Medicare.
Not true. People will say, Oh, well, there's Medicaid. Now there, right. What they may not realize is that to get down there, they're going to have to spend their income and assets.
So you've got, there's a lot of education that needs to be done, because this stuff is complicated. The fourth piece of it is, we don't have a good agreement or consensus on where public responsibility begins and ends and where family responsibility begins and ends.
And that's why we see lots of differences across different cultural groups, but how people feel in terms of what they're supposed to be doing for their parents. So many people would say, I don't expect paid caregivers to come into my parent, that's my child, I'm the adult daughter, son, or what have you. So you've got that constellation of figure of issues, then, that what nobody likes to admit is that it costs money, it's going to require more money, it's going to require either premium, call it what you want a premium payment, a surtax a new tax, you have to infuse more dollars into the system to make it work the way we want it to work. That's a very hard sell for legislator.
Now, the benefits would be so immediate, but you take those two things. First of all, the confusion, denial, and uncertainty about roles means that it's hard to get together a coalition at the local level to
push the you know, or I have a theory. So as this tsunami, I know a lot of people don't like us using that term. But as more people age.
It's not necessarily like the first 10 years of somebody turning 65 That is the most significant or labor intensive.
It's those last two, you know, before they pass those last two years before somebody passes, whether it's you know, the ages of 75 and 76, or 85 and 86.
Those are the years that break the morale of a family caregiver. And I believe that as more people age into those later years, and these problems start to happen. They're already happening often, but they're going to start to happen over and over and over again. I believe that it's going to have enough like you were saying earlier inertia for policymakers to say oh, like we don't have any resources. available to these families unless they want to literally sacrifice all of their generational wealth, which is the whole. I mean, that's the American dream. Unless they want to sacrifice the American dream, we're going to have to figure out a solution.
So yeah, you're absolutely right. Think about it this way. Our current system right now is basically a welfare based system. Okay, social safety net will pay for care may not be what you want. And we may not be able to stay in your homicides aren't. But we have a welfare based system. The idea is to move it to an insurance based system. And frankly, I've always been agnostic, it's irrelevant to me, whether it's private or public. But I've now been able to see that a voluntary private market will not move the needle enough.
That's why we need a public program. But once you move it to an insurance based system, there's another thing that happens. When you have, I'll give you a perfect example, you'll be able to break up onto in a minute. Social Security, why is it called the holy grail of politics, because every single American has a stake in that program. Either because they've been paying it and they're waiting to when they retire, they get their benefit.
Everyone has a stake in that program, which means that it has enduring public support. Once you move long term care from a welfare system, to an insurance based system, where everyone has a stake in the success of that system, you're going to get the same level of enduring public support. And that's really, that's really important, frankly, you need
and let's let's make the problem even more complicated. Let's talk about affordable housing for senior citizens. How does affordable housing helps support seniors that are aging in place.
So that is such a, you know, you talk about some of the really great models that are emerging around the country. So what's so nice about affordable senior housing, is it actually provides a very efficient platform for surfaces. So if you have a cluster of elders living in a building, okay, then, to the extent that you're able to put services in that building, and I'm giving you a concrete example, it's a really innovative program here in Boston, then it's, you can help people age in place, you have eyes and ears in the building.
And it's much cheaper than let's, for example, say, sending a homecare nurse out to 14 different homes across a wide geographic area, think how much time is spent, when that person is going back and forth. You have someone right in the building, they get to know you, they know when you're complaining is, you know, demands of solution versus just an ear and so on. So there's a program in Boston that we were, we were fortunate enough to be asked to be the evaluators. It's called the our three program the right time. Right services, right place program. It was it's sponsored by Hebrew senior life, what they did in their senior housing, some of it affordable, it was basically mixed, some of it affordable, some of it not.
They placed a service coordinator with a half time nurse practitioner in the building. And we did an evaluation, both a qualitative evaluation to find out what did residents feel the impacts work?
As well as a quantitative evaluation. Did this have an effect on use of hospital services, ambulance services, the ER. On the qualitative side, the residents loved having someone in the building that they could talk to about routine issues, concerns, supportive care. Really, really love that having that available within the building on the quantitative side, which is like how do you pay for this stuff? We saw major reductions in the number of times, ambulance services had to be called reduction in use of the emergency room and reductions in inpatient hospitalizations. They targeted people who were at high risk, they did an assessment of everyone in the building set Oh, they're looking at five different risk four or five different risks, and they kind of put them on a list. Well guess what the service coordinator would check in with these people regularly and So people became used to, rather than if they're not feeling well, immediately calling an ambulance, talking to the Service Coordinator, the nurse practitioner, and the change in service utilization was dramatic. So you look at a health plan and you say, hey, yeah, that you can save a lot of money in this way. The big challenge with that model is that we have such a fragmented insurance system. You know, you might have three people from this health plan five people from that health plan. So there are some financing challenges, but the model itself has been proven. And it is, it is a really, really important model.
The last point I'll make about it is, we now know that there are many social determinants of health care use. And so you have Medicare Advantage plans, starting to address those issues, nutrition, housing, things of that sort. And when you have someone right in the building there exercise that can address very easily. So determinants of health, it has a really big,
my producer Morgan said, we need to keep it simple. But I just I can't help myself. So I'm just going to go off off into the weeds here for this brief moment. And talk to you a little bit about about CMS and the HCBS settings rule. So do you ever feel because with the way that you're describing this housing program, it's fantastic. And we also provide a residential program that's similar to that where we have clusters of homes in a concentrated area, and we see much more success and less utilization of ancillary services like ambulance and EMS in those in those areas as opposed to like a home that's somewhere, you know, far off by itself. Why do you think CMS doesn't in terms of their HCBS settings, compliance when they say that you can't have you know, these clusters, that it's a it goes against their rules?
Why do you think CMS is out of step with what actually works for people receiving long term care services? And I mean, the industry as a whole?
I don't know. I mean, I don't know if I would say that they're out of step. I think that, to its credit, CMS has been experimenting with lots of different models, with payment, payment reform models.
You know, they, for example, during the pandemic, when they basically said, Hey, we're given a 10% bump in in payments, do with them what you need to do many states put them toward a higher sorry, higher compensation and rates. The telehealth is maybe a mixed bag.
We don't know yet. But But that, so I would say that these things take time. And typically when, when there are potential cost implications, the approach that CMS has taken, which it seems to me to be fairly, you know, reasonable approach is, let's test it, see if it makes a difference. And we get what we want. Because a lot of times when you when you implement new programs, really smart people find it very difficult to project or forecast unintended consequences, right? When you think you're solving this problem, it's sometimes it's like whack a mole, you hit down this problem, boom, actually created something else on the other side. So I think sometimes, providers in particular, who are living it day to day feel like, this is so obvious, you know, let's, we got to make this change. And CMS takes a more methodical, methodical approach. I'm fairly sympathetic to people who are really trying to do good things and good work, even though we don't feel
Yeah, and we're from our perspective, you know, we're just trying to bring awareness to this issue because there's just not enough mediums that are talking about long term care whether it's, you know, the consumer facing or the or the company facing side of things.
I, I can't find any of any facing at all. So just to have a conversation with people so that they can get educated as is really important. And I want to I want to talk about next I'm gonna talk about improving quality. So how can we improve the quality of life for seniors receiving care, particularly those with dementia, and other serious chronic conditions?
Yeah,
that is that is a really difficult challenge. And, you know, in focusing on the nursing home for example, I'm there's a coalition that's been put together called the moving forward coalition. It's, it's funded by John Hartford, and you a couple of was it a year or so ago, the national academy of science, engineering and medicine put out a big report on the state of nursing homes in this country, and had a series of recommendations as it relates to how to really take a broken industry and fix it. And there was a whole section on quality, quality issues in nursing homes.
And so I bring up this coalition because there's they're now working groups that are working on the quality issues at a high level. First of all, this is another thing I've discovered over many, many years, that the only things that are important are those things that are measured. Okay, if you're not measuring something, it's apparently not important enough to be measured. And so in, we need to improve our quality metrics measurement in the nursing home, in the home care setting. And there are many people not working to do that.
Like, what are the right metrics, people often talk about the need for person centered care, both in the community setting in the nursing home setting? Well, what does that really mean? How do we operationalize that? How do we measure that? Once Once we can agree on the proper measures for quality of life? Like when you said to me just now, how do we improve quality of life? Well, if I asked you to find quality of life, I'm guessing with BT may be very different from how I would define it. So we need to make those operationally measurable. Once we do that, then we can devise whole systems, I tend to prefer carrots rather than sticks. So I'm much more incent people to do this by rewarding them rather than hitting them over the head if they don't hit a metric. So you can imagine once once we have agreement on a set of quality measures, we say, Hey, listen, if you hit these measures, consistently, for two years in a row, we're going to increase your compensation levels by X percent. We have a system like that right now, for Medicare Advantage plans. It's called the star rating system, where plants who score on a whole host of metrics, if they get five stars, which is the highest rating, they actually get additional payments from Medicare. So I believe that, and there are all sorts of ways that this can be done. It could come even from you know, HUD, you know, HUD is the major finding as for of nursing homes in this country, well, maybe they could incent sort of interest repayment schemes by whether facilities are hitting certain metrics and so on. So that's, I think that's the only way to really get get change. What is really difficult for providers, whether it's on the homecare side of the nursing home care side, is to have a a mandate for certain quality standard, and then not be given the adequate resources to even have a chance of hitting that standard.
You know, Mark, you might be my my spirit animal. Because of the things that you're saying, as you're saying them, I'm sure I'm sure Morgan's like, this guy
is he does not coordinate,
watching the same person. Well, there's a mantra that I live, run my business by, and I and I centrally live by it's called if you can't measure it, you can't manage it. And so what you're talking about is is exactly 100% falls in line with, with everything that I value in terms of quantifiable success, everything that is subjective, you can't really take into consideration the decision making process has to be objective. And when you talk about value based purchasing with regards to long term care, I 100% agree that if people want better outcomes, if they want higher quality of care, they need to be incentivized. And they need to be just like in in in sports, for example, if you get if you practice and you put the time in and you reach the next level, you're going to receive it Better travel conditions instead of taking the you know, the the Greyhound, you might take a plane ride to the to the games, you know what I'm saying, you're gonna get free hockey sticks, I used to play hockey, so I had to use that reference, as opposed to paying$150. But you have to put all of that work in on the front end to be able to reach those outcomes.
And I am astounded that it's 2023. And we've been talking about this value based care process care model for I've been five years now in long term care space. And I know the pandemic has pretty much put everything at a halt. But I'm hoping that we are past. More future waves.
Now is the time yeah, like no more waiting.
There's no, there's no better time than the future, the present than the present.
And, you know, honestly, I'm a baby boomer. So, you know, I know that I know that these changes are not likely to really change the trajectory for me, but there's all host of generations of Americans behind us that feel we owe it, we owe it to them to make sure that they can look toward retirement with with a little bit of excitement rather than fear and apprehension.
Absolutely. I mean, are there other countries that have incorporated a process or program or model that we can look at and say this might work in the United States?
Well, this is, you know, we always talk about American particularism or exceptionalism? Yes, we are in this case, we are exceptionally poorly equipped to handle this problem compared to most other Western democracies. Almost all of them with the exception of Britain, okay, have in place, some type of social insurance benefit to pay for long term care, Germany, France, Israel, all of these countries have in place some level of social insurance, and it's the United States, that's sort of the odd person or odd country out in this respect. So we hate we have a lot, we have a lot to learn.
And, you know, we don't have to become Europe to take good ideas. We don't have a monopoly.
None of us have a monopoly on truth. And we could learn a lot by looking across our borders and adopting some of the things that will work in our context.
In your lifetime, do you think that we'll have a single payer health system? It's a loaded question.
No. I do not. I, you know, I didn't say wouldn't be great. But I just think that here's what I think. I think if we could start all over again, no one, no, Republican or Democrat, would look at our current system and say, this is exactly where we want to be.
This is exactly what we want.
Okay. Unfortunately, we have a system in place. And the way policy is done in this country, in particular, is incrementally.
And so we build and we, you know, we build and tinker, it took us 50 years after Medicare to get the Affordable Care Act really, really going. So I think it's very unlikely.
And I'll I'll be honest, America is exceptional in the sense that it can use market forces, to incentivize companies to move into the direction that they want them to without those companies even knowing that they're doing it. Because if you consider companies like insurance, big insurance companies like United Healthcare, 90% of the revenue comes from the federal government between a combination of Medicare and Medicaid, you know, Blue Cross and Blue Shield, Aetna, I'm sorry, Anthem, Aetna, Cigna, I mean they've got like practically all their revenue coming from Medicare Advantage in other in other programs. We're not I think people are don't know that we aren't that far off from insurance company primarily running an entire businesses from government funded dollars, which 100% means that when you have, you know, if you control the means of how a company is receiving the revenue, then you can, you know, push the push everybody together and say, okay, because there's only like six or seven big insurance companies at this point. Now.
Push them all together and say great, guess what you Receiving 90% of your income from us, meaning CMS. So you all work together, get on the same page, and let's make this thing go in the right direction.
Yeah, I totally agree. I think that there is market power that the government has is the primary purchaser where we're seeing it right now on drug pricing. Absolutely.
Really interesting what happened? They just said, you know, they were able to pass this just for Medicare. But the the pharmaceuticals saw the writing on the wall, and now they're offering Diabetes drugs for the same price $35 on the under 65. Perfect example of how the government can use its purchasing power for good.
Absolutely.
So other than obviously, the value based purchasing and all the other trends that we've talked about, are there any type of technological innovations that we can use in the long term care industry that could create more equity, better quality of care outcomes and accessibility?
You know,
I think right now we're looking and I don't know the answer. We're at the beginning of the research, we're looking to see what impact potentially telehealth robotics have. But I would say the jury is out on the jury's out on that. Remember, these are not complicated tasks we're talking about for long term care. It's not will technology enable us to do better brain surgery? It's, it's assistance with support activities. So but the jury's out on that.
Hopefully, in my lifetime, we will see technology Yes. forward facing approach to the care process, that's my hope. I'm a millennial. So you know, for me, technology solves all the problems in the world. Of course, anyway, so I always like to end the show with a call to action. How can we inspire advocacy and encourage civic engagement to ultimately create a system where all Americans can access quality long term care?
I, you know, to my mind, I started early out by saying it has to be coming up from the ground level and I sincerely mean that we need to educate people about the risks that they face, and that it's not hopeless, that the fact that you face the risk doesn't mean you can't do anything about it means you come together, and it's got to start at the ground level. It's got to be for caregivers. It's got to be care recipients providers need to form broad based coalition's and push at the state level.
Eventually it will go to the federal to move forward on financial
Thank you for joining us on this episode of Now or Never Long-Term Care Strategy with Kosta Yepifantsev.
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Today’s episode was written and produced by Morgan Franklin.
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