What is Health Care Policy? Why Should You Care? with David C. Grabowski, PhD

Join Kosta and his guest: Dr. David Grabowski, Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School.

Dr. Grabowski is a member of the Medicare Payment Advisory Commission, an independent agency established to advise the U.S. Congress on issues affecting the Medicare program. Throughout his tenure, Dr. Grabowski’s research has been supported by the National Institute on 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.

In this episode: As a member of the Medicare Payment Advisory Commission, What are some of the most pressing issues that impact our everyday lives? how has health care policy evolved to address the growing demand for long-term care services, and what improvements can still be made? Quality of care is a major concern for anyone seeking long-term care options. what can potential residents and their families do to ensure they are choosing a facility that provides high-quality care?

Find out more about Dr. David Grabowski:
https://hcp.hms.harvard.edu/people/david-c-grabowski
https://twitter.com/DavidCGrabowski

Find out more about Kosta Yepifantsev:
http://kostayepifantsev.com/

Transcript

David C. Grabowski, PhD: 0:03

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: 0:22

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: 0:45

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: 1:35

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: 3:20

Can I ask since you started to where we are now, what do you think's changed the most in long term care?

Unknown: 3:28

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: 5:02

could you simplify health care policy more broadly, and why it's important for us to understand it?

Unknown: 5:11

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: 6:55

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: 7:51

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: 8:04

sort of silos and a moving target, it really

Unknown: 8:08

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: 9:29

Are there any countries to your that you're aware of that have a health care system similar to the United States?

Unknown: 9:38

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: 10:11

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: 10:44

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: 11:53

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: 12:12

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: 16:03

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: 16:58

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: 18:44

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: 20:25

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: 21:53

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: 22:15

headed. right direction. You're right. It's just progress is slow. But but we're slowly getting there.

Kosta Yepifantev: 22:21

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: 22:35

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: 24:24

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: 25:33

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: 27:37

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: 29:25

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: 32:35

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: 33:47

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: 35:44

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: 36:01

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: 37:53

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: 38:28

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: 38:54

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: 39:15

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: 42:49

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: 46:18

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: 48:06

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: 48:56

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: 50:26

This was like, this was like Pompeii. Yeah, no kidding.

Unknown: 50:30

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: 52:24

I

Unknown: 52:24

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: 52:46

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: 53:26

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: 55:55

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: 57:36

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: 57:43

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: 59:15

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: 1:00:31

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: 1:00:49

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: 1:04:05

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 subscribe on Apple podcast Spotify or wherever you find your Podcasts, leave us a review or better yet share this episode with a friend. Now or Never Long-Term Care Strategy is a Kosta Yepifantsev production. Today’s episode was written and produced by Morgan Franklin. Want to find out more about Kosta? Visit us at kostayepifantsev.com