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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.
David C. Grabowski, PhD: When
you sort of add all this up and
what we spend as a country in
terms of our gross domestic
product, and we're almost
spending one out of every five
dollars on health care, so it
takes a big chunk of our economy
in this country. So health care
policy is incredibly important
that we get good value for that,
that investment we're all
Caroline Moore: Welcome to Now
or Never Long-Term Care Strategy
making.
themselves. 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.
Kosta Yepifantev: Hey y'all,
this is costly. And today I'm
here with my guest, Dr. David
Grabowski professor of
healthcare policy in the
Department of Healthcare Policy
at Harvard Medical School. Dr.
Grabowski is a member of the
Medicare payment Advisory
Commission, an independent
agency established to advise the
US Congress on issues affecting
the Medicare program. Throughout
his tenure, Dr. girbau skis
research has been supported by
the National Institute of Aging,
the Agency for Healthcare
Research and Quality and the
Centers for Medicare and
Medicaid Services. Today, we're
talking about health care
policy, and why you should care.
Welcome Dr. Grabowski to start
off, would you give us a brief
in overview of your background,
and what led you to focus on
health care policy, specifically
in the area of long term care
and aging? Sure. So
Unknown: first, thanks for
having me on today, as a guest,
I'm delighted to be here. So I
got interested in health care
policy, oddly enough for my
family. My dad is an economist,
my mom is a registered nurse. So
my interest in health policy is
almost the perfect overlap of
their careers. And I very early
was hearing about health policy
issues. Unlike a lot of my
friends and colleagues, I wasn't
interested in, per se, in
becoming a clinician of any
type, deliver of health health
care services, I was really
interested in kind of how it all
worked in terms of health care
policy. So that's what first got
me interested in this area. I
was an undergraduate major in
public policy, interested in the
health area was doing a
independent study as a senior.
And my advisor at the time
suggested I write on long term
care. Like most college seniors,
I had no idea what he was
talking about, I just kind of
nodded my head, went back to my
dorm room, kind of what is this
long term care thing? I started
reading on it, I ultimately did
write my independent study paper
on long term care, okay. And
I've never looked back, it was
everything that interested me
about health care policy. It was
was here only more so in long
term care, the role of
government the role of
incentives, the role of
substitution between family and
formal services, just, it was
all here. And it was all super
interesting to me. And I spent a
year working in Washington, DC
went and got my PhD at the
University of Chicago. And then
throughout my career, I've
dabbled in some other areas, but
my my heavy foot and research
has always been on issues around
long term care and aging.
Kosta Yepifantev: Can I ask
since you started to where we
are now, what do you think's
changed the most in long term
care?
Unknown: It's changed
tremendously. So I think when I
first got in this field, even
2530 years ago, it was very
nursing home or institution
focused. That's where the money
was. That's where the people
were. That's, that's where a lot
of the research and just all the
attention was there. And if you
ask anybody about long term
care, that's not really where
they want to receive services.
I'm not saying we should
eliminate nursing homes where I
think we're always going to have
them. Hopefully, we can have
better nursing homes. I'm sure
we'll talk more about that issue
as we share well, but but I
think we were so nursing home
dominant are focused on what's
really changed over the last
three decades has this been this
transition out of the nursing
home and towards the home in the
community with more services. So
30 years ago, it was a nursing
home or family and loved ones
providing care in the home
today. There are a lot more paid
services in the home and then
there's a lot more steps between
home and the nursing home,
whether it's a boarding care
home, whether it's assisted
living, there's just a lot more
options. I think the the menu
has really broadened out from
home from family and nursing
home to a lot more options. And
I think that's great. That
doesn't mean we don't have a
long way to go in terms of
improving quality access to
services. Who pays for this.
There are a lot of issues, but
we've come a long way and we
have a long way to go In terms
of long term care policy,
Kosta Yepifantev: could you
simplify health care policy more
broadly, and why it's important
for us to understand it?
Unknown: Yeah. So I would define
the sort of long term care
health health care policy
broadly is kind of the financing
the payment, the organization
and delivery of medical and
social services for individuals
in our in our system. And we
have a health care policy model
in this country, other countries
have different models, all of
them kind of have a reliance on
public and in privately
delivered and paid for services.
We have at you know, health care
policies at the federal level,
of course, and in terms of long
term care and aging, there's a
lot of important federal policy.
But you know, state policies are
also incredibly important in
this area in terms of Medicaid,
Medicaid is the dominant public
payer of long term care services
in this country. And then at the
area or local level, we have we
have policies as well that are
quite important. So I health
care policy, it's it's
incredibly important because it
ultimately matters for our the
quality of care that we receive,
I'd want to what I mean by that
is how we pay, how we deliver
how we organize services
ultimately impacts our quality
of care, it's going to impact
our access to services, it's
going to impact what we all
spend on services, both out of
pocket, but also as a country in
terms of our tax dollars. So
when you sort of add all this
up, and what we spend as a
country in terms of our gross
domestic product, and we're
almost spending one out of every
$5 On health care, so it takes a
big chunk of our economy in this
country. So healthcare policy is
incredibly important that we get
good value for that that
investment that we're all
making.
Kosta Yepifantev: Well, and
also, if you consider the
statistics, one in four
Americans is receiving Medicaid.
So that means that's roughly
about 80 million Americans who
are currently on some type of
government sponsored insurance.
I mean, I know we're talking
about long term care, and not
all of those people that are on
Medicaid qualify. But I think we
forget just how much health care
touches our lives. And we were
talking about this a little bit
earlier, before we started the
show. I mean, in smaller towns,
and ruler cities all across the
United States, health care
sometimes makes up 50%, if not
more of the entire available
jobs. And how can we corral a
system to work better for
Americans, with it being the
size that it is, I mean, it's
like a behemoth.
Unknown: It's a huge behemoth.
And unfortunately, it's a very
fragmented bohemian, you use the
word system, and I use that as
well to describe it. But is it a
system, when you have all these
Kosta Yepifantev: sort of silos
and a moving target, it really
Unknown: is and think about just
the care of older adults. So
that's just a small part even an
important part because they
spend a lot on health and long
term care services. But just to
give your listeners a kind of a
window into this, this group, so
as you suggested Medicaid is
paying for their their long term
care services, so their nursing
home care, their home and
community based care, depending
on the setting, then Medicare's
paying for all of their health
care if they need to go to the
hospital, their physician care,
their short state care in a
nursing home, that kind of post
acute rehabilitative care,
that's Medicare, hospice would
be Medicare, all their drugs
spending would be Medicare. And
so trying to put those two very
different benefits together. And
this is just two benefits for
one group of individuals, has
proven to be very challenging
for our country. This happens
every day for all of us. You're
trying to put together all these
different payers, all these
different providers of care
across the spectrum from long
term care to acute care. And
it's just it's incredibly
complicated. behemoth is a good
word. I wish it was more of a
system. I call it that as well.
But I wish it was more of a
coordinated system because yeah,
I think I think we could get
much better care if it if it if
it was but unfortunately, it's
quite fragmented.
Kosta Yepifantev: Are there any
countries to your that you're
aware of that have a health care
system similar to the United
States?
Unknown: No, we are we are.
We're an outlier and not an
absolute way. And we spend a lot
a lot more than these other
countries. There are certain
things that I'm not trying to
put down any of the providers or
clinicians or people in our
system, we have amazing places
and people in our in our system.
We do something very well, but
as a as a kind of as a whole,
like we are we spend so much
more and we don't look so, so
good relative to a lot of other
countries in terms of outcomes.
Kosta Yepifantev: And I know
that we're getting a little bit
off topic. So we're gonna go
right back to the questions here
in a second. But before I do, I
think it's almost in our nature,
though, like, I think the way
that we've been programmed from
a very young age, we've called
we've incorporated some
capitalistic ideology into all
of our decision making. And so
just just because it costs more
money doesn't necessarily appeal
as a negative to us and may even
do the opposite, because we
value things that are more
expensive, because we think it
provides higher value or better
quality, the interesting pivot,
go ahead, no,
Unknown: no, I was gonna respond
to that say, I totally agree
that it's really about our
values, and we value the
services and being able to get
that that cancer care, whatever
it may be those high price
drugs, it's really important, as
you asked earlier about health
care policy, they're people like
me that study health care
policy, in countries all over
the world. And when I meet with
with colleagues who study health
care policy in Europe, they
often use this term solidarity,
and then we're all in it
together. And if I get very
expensive cancer care, does that
mean, what does that do to the
budget and or in terms of long
term care? Should we all kind of
pay into this system such that
there's something for everybody
here versus the more
capitalistic? So it's finding
that balance, we are who we are.
And I there's a lot of great
things about our system, but
it's these kinds of trade offs,
never hear the term solidarity
in our in our system. And we
have, when you think about long
term care, we have a system
that's that's public, private,
and it's very much based on all
fun, my long term care and your
family will find yours and head
on and on and on.
Kosta Yepifantev: Let's talk
about your work with the US
Congress. As a member of the
Medicare payment Advisory
Commission, you advise the US
Congress on issues affecting the
Medicare program, what are some
of the most pressing issues that
Medpac is addressing right now?
And how might these issues
impact our everyday lives?
Unknown: Yeah, great question.
So Medpac. So first of all,
we're a 17. Body Commission, we
advise, as you said, the US
Congress on on different issues,
some of which we identified, but
many of which the members
identifying come to us with
questions. You know, we've done
reports recently on telemedicine
on the safety net, you name the
part of the Medicare program,
we've looked very, very closely
at it. And I think the issues,
I'll highlight three and try to
tie them to how they affect our
day to day lives. The first is
that Medpac has been very
concerned about what is the
right sort of payment rate for
these different sectors. So
Medpac is congressionally
mandated every year to make a
payment recommendation to the
Congress about you know, what,
what should hospitals be paid
on, which is physicians be paid
and skilled nursing facilities
and hospice and on and on and
on. And I trying to figure out
the right kind of rate has been
something that the commission
has long had an interest in
doing. But I think it's never
been more important given. We
all know, some of the some of
the looming budgetary issues
here with the Medicare program
and how we're going to fund this
in the years to come. And so the
conversation Oh, absolutely. It
How do you think about what's
the right rate to be paying to
these different providers,
understanding that each of these
dollars is somebody's job? And
you mentioned earlier labor in
these workforce issues and
trying to figure out what what's
the appropriate rate. So that's
been a huge area of focus. The
second is really been the growth
in Medicare Advantage. And
quickly for your listeners this
I know, this is a very
sophisticated group, but this is
there's two types of Medicare.
One is traditional fee for
service and that your each of
the each of the different
services are paid, kind of
separately, a payment rate. The
managed care version of Medicare
is called Medicare Advantage.
And when I first got on the
commission six years ago, on
Medpac, about a third of
Medicare beneficiaries were on
Medicare Advantage today, it's
just under 50%. So this
incredible are growing like
gangbusters. Yeah. And what
where's it gonna be in another
six years, it's soon going to be
more than 50% of the program.
And so Medpac has been very
interested in kind of what are
we paying these different plans,
this is privatized? Are we
getting good value for that
investment? How do we
incentivize good quality
competition, all of the issues
you want to think about in the
fee for service space, but I
think historically, when most of
our beneficiaries were in
traditional Medicare, I think
Medicare Advantage was was kind
of not on the back burner, but
wasn't it wasn't front and
center guests going forward that
can be front and center. And
then the final issue that I that
I want to touch on quickly, I
think is really important
everyday lives is how do we how
do we get good value given there
still are a lot of beneficiaries
in fee for service and Medicare
Advantage? How do we make sure
that even though we're paying
kind of a prospective a fixed a
predetermined rate? How do we
make certain that there's good
quality that's happening, and
there's been a lot of advances
over the last five to 10 years,
and these alternative payment
models like accountable care
organizations, and all these
buzzwords, I don't want to give
all the acronyms because I think
people's heads spin. I know, I
bet. But that said, these are
this is the future. And this is
where the healthcare system is
going, how can Medicare help
make certain that beneficiaries
are getting really, you know,
good, good quality care here,
and that we're actually lowering
spending for all
Kosta Yepifantev: of us? I have
follow up questions to each one.
And so anybody that's that's
watching this or listening to
this, just hold on, because this
is about to get really
technical. Oh, no. So with
regards to affordability, okay,
the the latest statistics says
that most retirees, they
typically retire with a little
over $200,000 in total and total
money. So that's not a year or a
month or anything like that.
That's literally their entire
savings. They get Social
Security. How can people afford
to access the services like long
term care if they don't qualify
for Medicaid? And they only have
$200,000 to spend? Why do we
have policy that essentially
says, You'll spend all your
money, and then we'll put you on
Medicaid? Like why?
Unknown: Yeah, it sort of comes
from this idea that a private
market will develop. But as
you're suggesting, the private
market has really targeted a
much wealthier group of
individuals. We wrote this paper
several years ago, before the
pandemic called The Forgotten
middle. And it's exactly the
group you're describing. They
have some savings. So they're
basically too wealthy for for
Medicaid, yet not wealthy enough
to buy into a very expensive
senior housing or senior living
community there, they're sort of
stuck in the middle. And we've
expected that, oh, they'll
they'll buy into maybe private
Long Term Care Insurance, that
market has never taken off. Most
people haven't. And so
ultimately, they do exactly what
you suggest. They end up
spending down their assets and
qualifying for Medicaid. And
that really wasn't how we
intended that program to work.
But it's really become the
safety net. And it's much more
individuals who were kind of
middle income, their entire
lives end up using Medicaid to
pay for their their their long
term care services Exactly. For
this reason, because there
hasn't been enough in the
system. Enough options in the
system. And so one of the things
that I've advocated for is we
we, you know, there are other
countries that approach the
financing of long term care very
differently and have much like
we have Medicare, this is
comprehensive medical coverage.
Why don't we have comprehensive
Long Term Care coverage that
would cover you know, all of
these services and kind of, you
know, we could pay into these
kinds of models over our life
course, and then have this much
like the Netherlands or
Switzerland, mainly northern
European countries that have
really figured this issue out?
Kosta Yepifantev: Well, and
Washington is, you know, their
absolute king with that. And we
talk to the to the director of
the Washington cares fund, and
it's fascinating what they've
been able to accomplish in a
short period of time, you know,
and also maybe even, and I've
said this on previous shows,
maybe even making long term care
insurance, like auto insurance,
you know, it's just a
requirement that you have to
have the other follow up
question. I'll just leave it at
two, because we'd be here all
day. Keep going. The other
follow up? Question is, I don't
want to this is more of like a
theoretical hypothesis, more or
less for you, you know, well, I
don't think that will that we
will ever have the political
feasibility to pass a single
payer system at the federal
level. So let's just go ahead
and anybody watching this, y'all
can just stop thinking about
that, because that's probably
never going to happen. However,
as Medicare Advantage grows in
popularity, these insurance
companies that are that are
offering these plans, they have
a higher and higher overall
gross revenue coming from
federal and state governments,
businesses, merge, businesses,
you know, consolidate industries
become smaller. Do you think
that there is a possible future
for a consolidation of the
industry to reach a single payer
system that is doing directly in
partnership with the federal
government. So it's kind of like
a work around policy to get to a
single payer system, where the
federal government is talking
directly to one entity, the
entity controls, not controls,
but the entity is responsible
for all the individuals on on
Medicare and Medicaid. And the
federal government dictates all
of the finances, essentially.
Unknown: Yeah, I don't see us
having just one company. And I
think that kind of consolidation
I think, I think we we really
resist for lots of reasons,
maybe giving too much bargaining
power to this other entity,
although is your substance, as
you're suggesting, if you had
the federal government and the
state government saying, here's
what we're willing to pay, you
know, it both sides have a lot
of power in that negotiation,
you would think. But I do like
where you're going with this,
that eventually if if lots of
our beneficiaries are in managed
care, on sort of both sides on
both the Medicare and the
Medicaid side, and it's the same
company, can we think about
coordinating? Can we think about
really being very uniform in
terms of benefits, and all of a
sudden, maybe it's not just a
single payer system, but it is a
much more coordinated, uniform
system. You can almost think
maybe Medigap isn't the best
example. But here's, here's the
kinds of policies you have to
offer. Here's what's covered,
here's what you can charge, you
know, that kind of model, I
think we can we can sort of be a
lot more forceful, in terms of,
of dictating what these policies
look like. And your point, maybe
it's one big company, but do we
care if it's 10 companies, as
long as they're offering this
kind of, you know, Chair above
this level, and I think we have
the right chasis to build those
models, as more and more of our
beneficiaries go over to manage
care.
Kosta Yepifantev: It's kind of
like a health care to change.
healthcare.gov, you know,
regionally, they're specific,
their specific insurance
companies in each individual
region. And then there's big
insurance companies that cover
the entire United States. Right.
And so, maybe it'll I just, I
guess what I'm trying to say is,
the foundation has been laid
very slowly. Yes, we're slowly
Unknown: headed. right
direction. You're right. It's
just progress is slow. But but
we're slowly getting there.
Kosta Yepifantev: Very true. So
on that note, though, can we
talk about how healthcare policy
has evolved to address the
growing demand for long term
care services? And also what
improvements can still be made?
Yeah. So
Unknown: So going back, I think,
to my to my earlier answer, it's
federal health care policy with
with respect to long term care,
I do think we've seen this huge
evolution away from the
institution. And I think today,
you know, many states now and
Medicaid are paying a lot more
for Home and Community Based
Care. Unfortunately, a lot of
states have huge waiting lists
for those services, it turns
out, they're very popular.
That's why they're popular.
That's what people want. And I
one of my lines is that I've
been doing this a long time.
I've never met the person that
wants to go to a nursing home.
That said, I've met a lot of
people that want care in their
home or in the community. And so
how do we continue to expand
those services? And I think
there have been really positive
steps in that direction on
assisted living, how do we make
that more affordable? Right now?
It's very much a private pay
market, how can how can we get
more more sort of Medicaid
coverage of those services that
that's what what our
beneficiaries want? I, once
again, I don't I think the
pandemic has really driven this
point home, I think this this
shift out of out of the nursing
home into the community has been
a really powerful one.
Ultimately, we need to transform
nursing homes to but as we're
shifting individuals out, let's
let's give them the options and
let's let's help them pay for
them. And I think you said it
perfectly earlier. Most of our
retirees don't have a lot of
resources. If anything there
house rich and kind of cash poor
and you know, once they sell
their house, then that's that's
all they have to live on. And so
it's we have to find option for
them that that work.
Kosta Yepifantev: We talked
about how fragmented the system
is, sometimes when I'm trying to
go to sleep at night, and I'm
pondering, I think to myself,
are we making it even more
complicated? Because and the
reason that I bring that up is
because in an institution's in
the facility based care setting,
right, so in an institution,
you're a vessel and you're in
you are essentially moving
people into that environment. To
create efficiencies in any
market. You need to have some
streamlined You know, processes,
something that you consistently,
you know, rinse and repeat,
something that you can follow.
When you incorporate community
based care, which is what I do.
So I'm very familiar with it.
Every single environment is
different. Every single training
is different. Every single there
is no set handbook. And it's
very hard to scale and build
capacity with so many variables.
Do you guys ever talk about that
and your policy? We absolutely
Unknown: do. And I, for better
for worse, like, as you said,
nobody wants to be in a nursing
home yet, once you're there, the
services can all come to you.
And for whatever reason, you are
the hub, the nursing home as a
hub, there are economies, as
you're not reinventing the
wheel, a lot of the more
innovative care models happen at
the nursing on level just
because you have this
concentration of individuals.
And once you move to the
community, you lack all of that
we wrote a piece and convened
some some thought leaders around
this issue recently, we were
really perplexed just around and
exactly the point you're raising
around navigation, like
everybody has to figure this out
for themselves. Are their
resources for how do I find that
homecare aid? How do I
coordinate that person with my
medical services? And what
happens if my health declines?
And I need to transition? What
are my next options, and we
called the long term care
system, the title of this piece,
we published it in the hill, we
called it a road to nowhere. And
it's because it's like, it's
just there's not that, you know,
it's there's nowhere to go here.
And there's no one guiding road.
And it's really, it's really sad
that we you know, that we
haven't figured out kind of that
coordination function, we have,
as you know, some resources,
like what we call the triple
A's, the area agencies on aging,
some are quite good, some, some
are lower resourced, but they
don't always meet all the needs
in terms of sort of coordinating
and navigating the system.
There's a lot of private
services that are that are out
there. I some, some are better
than others, but I'm a little
wary of a places that accept
payment to direct you to certain
right certain communities. So I
I would ask your listeners just
to be weary of kind of what
what, what's out there. But I do
think the triple A's are a good
first place on this, but but we
have a long way to go in terms
of figuring out the navigation.
Kosta Yepifantev: And so in
Tennessee, just for anybody
that's watching, it's in
Tennessee, there's development
districts, and the triple ad is
the area for a ageing Area
Agency for aging disabilities is
housed under those development
districts. And there's one in
each region of Tennessee, I
wanted to ask you one more
question before we moved on to
quality of care specifically in
facilities. You know, when I
talked to 10 care, we talk about
training for for DSPs direct
support professionals and
caregivers. As they're
describing what a training model
should look like, I immediately
start to think like, wait a
minute, this is like a book of
human psychology. So if I needed
to understand the psyche of an
individual, the training manual
would be this thick. Because
it's not as simple as learning,
you know, the typical non
medical home health care tasks
of you know, grooming, and
bathing and errands and cooking
and cleaning. Like it's not just
those things. But here's the
point. And I told you we're
gonna get a little technical on
this episode. So bear with me.
One of the biggest issues in
where I live in Cookeville,
Tennessee, and I'm assuming that
this probably affects a majority
of the United States is a lot of
people don't have what's called
soft skills and employment. They
they don't know essentially how
to work. And I wonder, given
that community based care
requires people to have that
proficiency, they have to have
soft skills like that's the
number one requirement is soft
skills. How do we affect the
problem of not having enough
caregivers? Because we don't
have enough qualified people to
care for all the people that are
aging?
Unknown: Yeah, this is the
number one issue I hear. Like
when I when I talked to
providers, policymakers,
everybody today it's it's where
are we going to get the
caregivers and I think there's
probably several different ways
one, and I'm a health economist.
So you can probably guess my
first thing I'm going to say
here is it's about wages, and we
just have to pay this workforce
better. We lost a lot of workers
during the pandemic to Walmart
and Amazon and lots of other
employers and once again, who's
working in a nursing home or a
homecare agency, yes, there are
RNs and LPNs. And they are
likely going to other health
care jobs. But there's a lot of
certified nurse aides or home
care aides. They bounced between
health care and non health care
jobs. And so making this a job
worth having. So the first is
wages a second. And I think it
goes to your point about sort of
softer skills, we need to sort
of give them training and also
empower them and give them
autonomy once they're this is
more of an issue, I think, in
the institutional settings where
there's a real hierarchy and how
we set up our workforces and
CNAs. It's a really it's a
challenging job to begin with.
You're, as you said, bathing and
dressing and grooming and doing
all of those tasks tough. With
residents who often have high
levels of dementia, it's it's
super challenging, super
rewarding work. But but super
challenging. I think part of
this is that we we don't always
treat our staff very well, the
culture in a lot of nursing
homes that I've been in around
the country aren't great. There
are some counter examples of
places where we do really
empower this workforce and
giving them autonomy and give
them voice in this job. But all
too often we don't. And so yes,
let's give them a set of skills.
But let's also let them use
those skills once they're in
these jobs. And that sounds very
simple or trite, some and this
is where policy meets kind of
management and delivery of
services. On the policy side, we
can mandate or at least try to
encourage better wages for
workers. That's a policy
instruments changing the culture
in the buildings. That is that
health care policy, there's
there's management in that, no,
it's not. And so like that, but
that I don't I think wages are
higher wages are necessary, but
they're not sufficient, we're
not going to get workers alone,
one of the very quickly a
research study that came out
across all health care jobs,
nursing home workers actually
experienced the largest relative
increase in wages across all
more so than physician offices,
hospitals, home health, any of
the other jobs during the
pandemic, yet we lost the most
workers in the sector. And it's
it's really about the idea that
the culture, you know, we it was
this is really challenging work
and got much more challenging
during the pandemic. And so,
yes, we need higher wages, but
we probably even need higher
than we, then we've increased
them to date, plus a change in
the culture.
Kosta Yepifantev: And I think a
lot of it also is the fact that
when we talk about nursing
homes, you know, we always start
with skilled rehab, because
that's what Medicare pays. And
then we start talking about
private pay patients that pay
out of pocket. And then we kind
of kick the can around and say,
oh, and then there's those
Medicaid patients, we got to
keep all those beds open for. I
mean, if you could change the
narrative, you might be able to
start changing the culture. But
there's a common thread between
all three categories. And that's
your reimbursement rates. And so
at some point, you got to, you
know, call spade a spade. And
I'm not here to talk about
provider rates and advocacy or
anything like that. I'm just,
I'm just saying, sometimes the
problem is just so simple, that
if we just, if we just were
willing to accept it for what it
is, and say, Why don't I guess?
Yeah, makes sense. Let's see, if
this works, then we might
actually have pretty systemic
change, positive systemic change
quickly. This was far
Unknown: and away my greatest
frustration from from the time
I've been on Medpac. Medicare.
So very quickly, for the
audience, Medicare pays for a
relatively small share of
nursing home days, that's post
acute rehab following a
hospitalization. So basically,
you know, four weeks, five
weeks, up to 100 days, but very
few of our benefits would get
out to 100. It's really, on
average, about about a month a
month of rehab. But huge margins
on that care for providers are
making double duty nursing homes
do really well on those short
stay patients. The vast majority
however, their bed days are, as
was just suggested, long stairs,
these individuals who some are
private, but the vast majority
are Medicaid. Medicaid is a
loser and most states and so you
have this really odd setup in
nursing homes where a very small
number of post acute rehab
patients are from one government
payer Medicare are cross
subsidizing this other
government payers. So, unmet
act. Going back to my earlier
comment, we would be
recommending cuts for skilled
nursing facilities in the
Medicare rate because it was so
generous, even though a lot of
nursing homes don't during the
pandemic were struggling. And so
how did the how do you sort of,
you know, kind of come to grips
with these these two ideas that
you're on Medpac we were very
focused on Medicare policy.
That's what's in the name.
That's what that's what our job
was for the Congress. And so
from a Medicare perspective,
we're overpaying nursing homes
from policy from an overall
health care policy perspective,
however, you said it well, you
know, we need to make sure that
that we're paying a rate that's
commensurate with good quality
care in many state Medicaid
programs just aren't. That's not
to say there are other issues in
nursing homes. But But that's an
important one, and we should
make sure we're paying them a
fair rate, and then that those
dollars are going into direct
resident care.
Kosta Yepifantev: Let's talk
about quality of care. And your
opinion, what are the key
indicators of quality and
facility based care? So
essentially, nursing homes, and
what potential residents and
their families do to ensure
they're choosing a facility that
provides high quality care?
Unknown: Yeah, so my number one,
and it will be 123. staff, staff
staff, like it's really nursing
home care is about staff. It's
not highly technical. In most
instances, it's about delivery
of, you know, assisting these
residents with activities of
daily living, like we've been
talking about bathing and
dressing and toileting, that's
about having enough staff there
to meet the resident needs and
ensure they get good quality
care, but also have a good
quality of life, if they want to
eat something if they want to,
you know, whatever, whatever
they want to do, they need help
with the with things you and I
do every day and our take take
for granted they need assistance
with and so you don't have the
staff there. And not just the
numbers, but the experience. And
so I would encourage anyone
that's looking at a nursing
home, the first stop, go to
care, compare care, compare on
the on the medicare.gov website,
go into the nursing home,
compare part of the web, and
check out the staffing both the
levels, but also the turnover in
these buildings to make sure
one, the turnover isn't too
high, but then the levels are
sufficient. And that would kind
of be my my first stop, that
wouldn't be my last stop, it
would be one of my first I made
sure. And then I think on top of
that going into the building,
and not just when the admission
director takes you around, but
also at some other time, maybe
unannounced, maybe on a weekend,
maybe in an evening and really
kind of get a sense of the
building talk to some of the
residents or their families,
talk to some of the staff like I
love to talk to staff when the
admissions director the
Leadership isn't around, you can
learn a lot and in the best
nursing homes, i No one should
be nervous about me talking to
anybody if you're running a good
quality facility. You don't care
if I'm talking to your staff,
and I wouldn't care if you were
talking to my AI it that should
go without saying
Kosta Yepifantev: you should
talk to like two or three CNAs
on each floor each weighing and
all you need to know yes about
you know whether this nursing
home is doing a good job or not.
Because I'll tell you, you know,
obviously we employ a lot of
caregivers DSPs aides. And they
are they are solid. When it
comes to telling the truth. They
really do understand what's
happening on the ground, and you
don't get any salesmanship from
from those positions. They are
very much going to tell you how
it is.
Unknown: Now one of my
colleagues likes to say when you
go in to a nursing home or
assisted living beware of the
glass chandelier effect like you
say ignore the ignore the
chandelier, talk to the staff.
Staff will give you the real
story. Just walk all the way to
the back. That's right, there's
no facade up front. Nice
paintings are the rug up front
all of that do not. Do not fall
for that talk. The staff will
give you the real story.
Kosta Yepifantev: Let's talk
about the pandemic. Yeah, so the
pandemic has had a significant
impact on long term care
facilities. As a member of the
CMS nursing home Coronavirus
commission, can you share some
lessons learned from that
experience and how those lessons
could help improve long term
care facilities moving forward?
Unknown: Sure. So I was part of
this CMS 25 As part of this CMS
Coronavirus commission with the
idea of giving back this was
back in 2000 giving kind of
nursing homes and policymakers a
roadmap out of out of the
pandemic and our recommendations
were very much about supporting
nursing homes, they needed a lot
more resources at that point.
And the research was really
clear. It really the pandemic
hit nursing homes based on the
spread in the local area. So if
COVID was in the community
around a nursing home, it was
highly likely it was coming into
that building. And so that
suggested we needed to support
nursing homes across the board.
With more personal protective
equipment and more testing, just
just more resources to really
help training to help help
staff, your benefits and pay
your hazard pay for staff, these
were the kinds of measures that
were really important. Yes,
there were some bad apples in
places that didn't didn't handle
the pandemic. And we read about
those and saw those those places
on television. But in the vast
majority of instances, it was
about where you were not who you
were. And, you know, it wasn't
about being a high Medicaid
facility. It wasn't about a
facility with a history of, you
know, deficiency violations or
anything like that. I also
think, you know, in terms of
other lessons, we really
learned, you know, what didn't
work trying to ask nursing homes
to get their own personal
protective equipment PPE, or get
their own testing, that that
didn't work? Well, what worked
well was when we centralize
these approaches, and I'll point
to a success story, where the
vaccine clinics that the federal
government ran, where they
actually went in and set those
up for you know, came into each
nursing home and assisted living
facility in the country three
times, we got a lot of our
residents vaccinated. And we've
really seen the benefits of that
vaccination effort. And that was
very centralized. We had
pharmacies that did that and
went, you know, there were a
couple of states that did their
own thing. But most were in the
federal model. And that that was
highly successful. I wish we had
been more centralized with with
all of our, with all of our sort
of COVID policies in regards to
nursing homes. The final lesson,
and and this one kind of caught
me off guard, but it makes total
sense was that, you know, we saw
COVID spread, yes, it was about
the local area, but the way it
spread in the local area was
about the staff coming in and
out. And you know, they were
asymptomatic. I'm not blaming
any staff, they didn't know they
had to work and but they were
going home to a community, if it
was all around their community
back in 2020 20. And 2021, it
was going to be it was going to
be in the nursing home. And it
turned out nursing homes that
were smaller, with fewer kind of
staff going in and out did
better. And we have these huge
nursing homes in this country.
And many times the staff were
working across buildings and
worrying across different
nursing homes. And we found
other researchers found that
that actually helped spread the
COVID from from one nursing home
to another, having more staff in
and out. So smaller nursing
homes with kind of staff that
are that are directly
responsible for that nursing
home. last use of contract
nurses, these things could have
helped during during the
pandemic, two things.
Kosta Yepifantev: And then we're
gonna we have a few more
questions. And then we're going
to wrap up. Sometimes I feel
like in long term care have been
doing this for about a decade
now. So aside from I had a job
for five years, at a Land Rover
dealership when I was 19. So I
did that first. And then we
started working in this
industry. And then we ended up
buying this company in 2015. So
my wife and I have owned it
since then. I've seen a lot.
It's changed dynamically over
the last, you know, seven, eight
years. Sometimes I feel like
it's somewhat of blind leading
the blind. And let me tell you
why. So and when I say blind,
leading the blind, I mean, state
agents, state Medicaid, and
wherever the policies that
they're getting, wherever
they're coming from, you know,
to decipher back to the provider
down to the provider level, it
just seems like where did they
come up with this? And who's
talking to who about, you know,
implementation when the pandemic
happened? March, no, April of
2020. At the end of the month,
I'll never forget it. We're
sitting there with myself and my
COO, and we're sort of trying to
game out exactly what's going to
happen, no idea what's going to
happen. But we know that one way
to prevent the spread of
COVID-19 was to reduce staff
entering and exiting our
residential homes. And we have
about 40 residential homes with
three individuals in each home.
And we usually have staff
turnover every shift change
every eight to 12 hours. So I
said, I've got a great idea.
What about we create a live in
caregiver environment for two
weeks on two weeks off, and
we'll shoot and we'll change
them out every two weeks now. It
wasn't ironclad, you know,
because early on testing was a
little bit scarce. But we
started that process in on at
the beginning of May. And when I
told the managed care
organizations that I was going
to do this They thought because
it didn't fall in line with what
they call home and community
based settings rules. They
thought that I was, I don't
know, like, they thought I was
crazy. Let's just put it like
that. And I just said, well,
listen, we're in a pandemic,
y'all don't know what's going to
happen. I don't know what's
gonna happen. And I think this
is the best path forward. Within
four weeks TennCare, which is a
Medicaid in Tennessee, put out a
memo that said, best practices,
and they listed that as one of
the best practices for for our
program. And I and I look back
at that period. And I think to
myself, maybe it's not a top
down to solve this problem,
maybe it really is a bottom up,
like the people who know what it
will take to improve the
dynamics. I know that there is
this, everyone wants to kind of
shy away from giving too many
people at the ground level, too
much power to make decisions.
But at some point, I think we
really should do more listening,
instead of policy
implementation, and at the
higher level, and then have it
trickle down to the lower level.
Unknown: Yeah, first of all, I
love that I heard or read about
a few other examples similar to
yours of this kind of living on
site. And I think there was even
one written up in the New York
Times very much during that same
carrier of like setting up
trailers. And I thought that was
incredibly innovative. And
exactly what was what was
needed. So that outside the box
thinking, and I think you're
exactly right about sort of this
bottom up versus top down I what
I meant earlier about
centralized, these were about
resources, like asking your
company or others to go out and
find PPE and compete with
others. And that was such a
crazy time that that that made
absolutely no sense to me, let's
like we want everyone using you
know, high quality PPE, let's
produce it or let's let's do
that yet. Like, let's also not
try to police this, let's let
the best ideas come up. And if
that means having folks staying
on site, if that, you know,
there are all sorts of ideas, we
heard of like, you know, places
having kind of wings are built,
one building was a COVID Ville,
I like places tried some very
innovative things. I was
involved here in Massachusetts,
in an effort to try to find some
COVID Only specialized
facilities and you know, how to,
you know, helping sort of as a
relief valve for some of the
hospitals and there was some
really outside the box thinking
that was kind of coming from
from the providers and others in
that community. And I, I know
that was a really important part
and some of the best ideas, I
think that came out because as I
said earlier, I've been highly
critical of the of the federal
COVID response in a lot of ways
I there, there's some, there's
some nice examples like the the
vaccine rollout, but there there
are a lot of counter examples to
there where I think mistakes
were made.
Kosta Yepifantev: It's
interesting, because Brad Smith,
who was technology and
innovation coordinator for CMS
at the time, he's from
Tennessee, right. And I've met
him a few times. And I remember
reaching out to him and offering
that as a suggestion for
reducing the spread of of
nursing homes. And the reason
that I bring this question up is
because it ties into it on that
task. Next, here's community
providers. Here's nursing homes,
here's hospitals, why do Why are
hospitals, the ones that receive
the most funding and attention
versus nursing homes? And how
are we all going to, you know,
sort of rising tide lifts all
boats? How are we all going to
come up together to improve
quality of care? If we can't
value the nursing home industry
and the community based
Schneider industry,
Unknown: long term care broadly,
we I would said earlier, you
know, the US being this outlier,
we spend more than any other
country in the world on health
care. I like to say we spend too
much and we also spend it on the
wrong things. And so that's
exactly to your point. If you
look at a country once again,
like the Netherlands, they spend
a lot less than we do on health
care on hospitals on physician
services, but they spend a lot
more than we do as a as a share
of their GDP gross domestic
product. Every dollar spent in
that country. They spend about
twice what we do on long term
care. And guess what it shows
prior to the pandemic, I visited
Rotterdam toward a nursing home
saw everything that was going on
there, their their nursing homes
are much better staff, their
staff are much better trained.
They have a lot more community
options. They have smaller home
models. It's just it's really
powerful what investment and
spending can do. And I think
that that really came through
during the pandemic where people
kept asking me why Nursing Homes
just respond like hospitals. And
I said, Have you ever been in a
nursing home? I know you've been
in a hospital, we've all been in
a hospital. But like, it's just
it's not this high margin
provider, they largely do
Medicaid. There. I am not trying
to criticize anybody, but you've
been in nursing homes around the
space for a long time, is a lot
about putting out fires versus
trying and this was the ultimate
fire yet. They didn't have the
resources to really address it.
Kosta Yepifantev: This was like,
this was like Pompeii. Yeah, no
kidding.
Unknown: And so this was, I
called it in one of my papers, a
perfect storm, because it was it
was COVID. And everything that
brought but hitting this, this
sector that just didn't have the
resources to really respond to
it. It couldn't have worked out
any any any worse. And a lot of
buildings. And there was a
building I was I was, we
ultimately wrote this up for a
journal. But we had a place here
in Massachusetts, where we were
looking at it for maybe being a
COVID specialized facility. So
we first wanted to test all the
residents to see if anyone had
COVID. So this is the beginning
of April of 2020. Going test
every resident, it turns out,
about two thirds of the
residents had COVID, all
asymptomatic. Well, you can
imagine what happens over the
next three weeks, we track this,
about 30 residents died, about a
half of the staff ended up
getting it was just this like,
but if that's the kind of speed
we were talking about where we
went from, you know, testing at
the beginning of the month to,
you know, over two dozen
fatalities by by, you know, two
weeks later, it was terrible.
And it was just that kind of it
was it was it was very fast
moving. And I there was there
was nursing homes did not have
the same resources as hospitals
to really address this. And I
think it comes back to like,
what do we value and people ask
me a lot was this ageism? And
yes, there was there was some
ageism involved, but also
probably, you know, some some
sexism and racism about our
caregivers who are largely
women, many, many minorities,
immigrants. And so it just it's
really unfortunate that we
haven't made this investment and
one of my hopes coming out of
the pandemic is that we're, we
we've learned something, but
we'll we'll see if that if that
happens. Have we learned
something?
Kosta Yepifantev: I
Unknown: I, I one point I was
very positive that there was so
much attention on nursing homes,
and there was so much discussion
and national panels. And as I'm
looking at it today, I'm I do
think there'll be some small
changes around the edges. But
I'm not optimistic, we'll see
the kind of big transformational
changes that you and I would
both like to see.
Kosta Yepifantev: So I'm a
millennial. And I say this, on
almost every single show. I
believe technology can solve all
of our problems. Call me naive,
but I really do. So on that
note, do you think that there is
a component or something that
technology can attribute to the
long term care industry to help
lower the necessity for the
human element in the care
process? And incorporating some
type of technological solution
like remote supports, sensors,
cameras, etc, without infringing
on people's rights and
independent?
Unknown: Yeah, I think there's a
real role for increased
technology. I don't believe that
like in Japan, right now,
they're exploring the use of
robots as caregivers, I don't
know that we're gonna get there
the certain way you might have
to get there someday, but I'm
not holding my breath on that
one. Right. But I do think
there's other ways in which we
can leverage technology and one
of the ways I really like we've
been talking a lot about just
the long term care, but guess
what, everybody who's living in
a nursing home or living in
their in their home, they don't
just need lots of long term care
services. They also have a lot
of medical complexity and
chronic illness and they need a
lot of physician and clinician
time and having telemedicine
having that connection is super
important. I think, you know,
there was a colleague that wrote
a piece about physicians in
nursing homes and he called it
missing an action and they're
just not there in the numbers
that they need to be
telemedicine can help address
that I did a project here in
Massachusetts where we actually
did a randomized trial of off
our telemedicine coverage. So,
if Mrs. Jones has a medical
event on a Wednesday night at
8pm, rather than calling her
physician who's likely telling
the nurse you know, I don't know
what to do, Senator, Senator to
the, you know, down to the
hospital, you know, the the
ambulance takes her to the
hospital, she's large, she's
probably getting admitted and
having an inpatient stay and
1000s of dollars of spending for
Medicare. What it's like she's
looking just like I'm looking at
you right now. She's looking at
a physician and that physician
has a lot of peripheral older
that physician can can take her
blood pressure or listen to her
heart. And we found this
actually prevented hospital
transfers and saved the Medicare
program a fair amount of money.
The problem right now and it
goes back to our earlier point
about sort of fragmentation, the
program was quite successful in
that it save money, it just had
the wrong pocket problem, it
saved Medicare money, the
nursing home had to pay for the
intervention. So we'll see in
the future if we can we can get
the right pocket where the
savings go to the person
investing in this and haven't
you know, if you wanted to do
this and went to your buildings,
would you be saving money for
your communities and generating
some some some savings? Or would
you be saving the Medicare
program. And there may be other
reasons to do this as part of
like, if the residents are
willing to pay for it if if it
can help with attracting people,
but at the end of the day, there
has to be a return on
investment.
Kosta Yepifantev: There is this
ideology, I could say, in the
long term care space, where a
lot of the ways that people
improve their overall well being
is if they can have more
community integration, if they
can leave, whether it's their
facility, or even their home for
that matter. And they spend more
time in their community. I mean,
I don't know how long you spend
in your home every single day.
But I venture to say that you
probably leave it at some point
every single day to try during
the day. Right, exactly. So
imagine if you lived in your if
you stayed in your house for a
week or even longer for that
matter. And had all these
services coming to you. Whether
it's in a facility or in your
home, a lot of times, because we
are so compliance driven, a lot
of our sort of we supplant this
community integration with
doctor's appointments, and
doctor's visits. And so we have
these robust transportation
divisions that are just strictly
around, like, let's go, we'll
pick up your groceries, and
we'll take you to the doctor.
And you know, we'll call that
community integration. And
occasionally, we'll plan this
big group trip, and we'll all go
to the park. Right. And I would
think that if you could find
other technological solutions
like telemedicine to remove the
necessity for having to go to
those PCP appointments all the
time and having to make those ER
visits on occasion, you could
actually use the transportation
divisions for community
integration, get them out of the
home, to really engage with the
community that they live in,
that they love that they grew up
in. Yeah,
Unknown: I love it, what's
actually improved their quality
of life versus let them do the
things that they they love
doing. Yeah,
Kosta Yepifantev: you know, I do
believe that there is a there is
room, it's not going to solve
all the problems. But I do
believe that there is room for
remote supports to just replace
the necessity for specifically
with people with cognitive
disabilities that don't need to
be in a nursing home, probably
live in their own home. And
there's only certain hours of
the day that are cause for
concern, or certain or certain
conditions that occur that could
create a concern. And imagine
having like a ADT, for people
that are elderly and physically
disabled. And so instead of
having this one to one care
ratio between a caregiver and an
individual receiving services,
you could have a four to one.
And that would technically draw
down the cost of care because
you're splitting that fee
instead of being instead of it
being you know, paying one
person to take care of another
you're actually paying one
person to take care of four and
so the fee for that individual
to to compensate that one person
would be split four ways. Now,
we're nowhere close to this
being scalable, but we are
starting a pilot with United
Healthcare and I'm optimistic
about the outcomes but again,
going back to what we talked
about earlier only out of the
box thinking I believe is going
to solve our issues with long
term care I totally
Unknown: agree we got to try be
put a lot of shots on goal and
see see what what actually gets
by we tried to we tried a sort
of a pilot program with it with
a big homecare company, you're
trying to checklist and I think
you know these are really
challenging but each time a
caregiver would end his or her
shift they would answer a set of
questions you know how is how
was Mrs. Smith doing and you
know that she seems different
and short of breath and sort of
these very quick you know,
adding maybe 30 seconds to a
minute as she's kind of clocking
here she is clocking out the
caregiver. They're answering a
series of questions and did
really well on the pilot. We
didn't wait you know when we
actually extended it out on
Unfortunately, it's really hard
for a lot of home care companies
that do anything with that
information so as being
collected, but what do I do? If
you tell me Mrs. Smith has a
changing condition? Do I have
the wherewithal, but as we get
greater integration in that home
care company it potentially is
integrated with with with
medical services, then then
we're, now we're cooking, you
know, it's sort of Alright, then
we can actually do something
with that information. So I love
trying to these different ideas
and sand, sand what works.
Kosta Yepifantev: So we always
like to end the show with a call
to action, what resources would
you recommend for our listeners
to learn more about health care
policy? Long term care and elder
care planning? Are there any
upcoming changes or policies
they should be keeping an eye
on?
Unknown: Yeah, for sort of
tracking all of this? I think
there's so much great kind of
national reporting on this
issue. The The New York Times
Washington Post, The Wall Street
Journal, yeah, there's just a
great set of reporters and
writers that really track this
closely. And I not just those
publications that many others
here in Boston, the Boston
Globe, and I'm sure Tennessee
has say, the reporting on health
care as has never been better.
And I think following Matt, is
super important in terms of big
changes for long term care, I
want to highlight two, that I'd
love everyone to track and weigh
in on and one of the things I
like to say is this isn't going
to change unless we change it
because all too often long term
care isn't a part of our agenda.
You asked me very bluntly, are
things going to change? And I
would like to tell you yes. But
if I'm being honest, I think I
don't I don't think we're going
to see major change, we're only
going to see major change. If if
if our politicians view this
issue as important and Long Term
Care never comes up in debates,
you know, at the Senate level,
the presidential debates or you
just don't hear it a lot in, you
know, from governors, and it
just it's not front and center.
And recently, Biden has had to
bring it up in some State of the
Union addresses. I think it's
getting more attention. And so I
think that's a really positive
sign. And all of us continuing
to hold our politicians to
providing more resources and
attention here, I think is
really important. And two
changes. I'd like to highlight
one. The Biden administration is
looking at minimum staffing
standards for nursing homes. I
said earlier, it's all about
staffing. We're going to hear
over the next month or so what
those standards are going to
look like. I know for providers,
this is going to be very
challenging. And how we pay for
this is going to be kind of an
interesting part of all of this.
But I really think I said
earlier, staffing is the most
important component towards good
quality. This is this is really
a huge step forward. The second
step just came out last week,
the Biden administration
announced kind of increased
support for family caregivers.
And we've talked a lot about
sort of the formal long term
care sector, there's always
going to be a role for family
even in Washington State with
all of their huge advances and
great policy work. Families
matter. They matter in the
Netherlands, they matter in
Washington state, they matter
all over our country. And they
always will and how can we best
support individuals because the
burden here largely falls on
women, lots of them have to
leave the workforce high rates
of depression, physical issues
with with with caregiving, how
can we how can we give them the
support that that's needed. And
so I love that, that we're
trying to both support you know,
our older adults in nursing
homes, but also support a lot of
those caregivers in the
community, which then supports
the individuals who need this
care in the community.
Caroline Moore: Thank you for
joining us on this episode of
Now or Never Long-Term Care
Strategy with Kosta Yepifantsev.
If you enjoyed listening and you
wanna hear more make sure you
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Long-Term Care Strategy is a
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Today’s episode was written and
produced by Morgan Franklin.
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Kosta? Visit us at
kostayepifantsev.com