Summit on Aging in America

Note: This is an unedited transcript. For direct quotes, please see video here:

Sarah Dash:  Morning everybody. Oh, wow. Good morning, you guys are awake. This is fantastic. Thank you so much for joining us here today for our summit on Aging in America. My name is Sarah Dash, and I am the President and CEO of the Alliance for Health policy. Welcome. For those not familiar with the Alliance, we’re a non-partisan organization dedicated to advancing knowledge and understanding of health policy issues.

Sarah Dash:  We’ll be live tweeting during this event. You can join the conversation if you like using the hashtag all health live. And for those in the audience, we’ll be taking some questions at various times during the program as well. This is the second to last event in our 2018 opportunities for progress signature series. We created this series to highlight progress on persistent health policy issues, and examine prospects for moving forward.

Sarah Dash:  Earlier this year, we examined healthcare costs, and you can find those materials on our website. Today, we start our conversation on aging in America with this summit, and then the final event in this series will take place on December 7th, on Capital Hill, and we hope you’ll save the date for that and join us. I want to thank our 2018 opportunities for progress signature series sponsors, and you’re gonna have an opportunity to hear from some of them throughout this morning as well.

Sarah Dash:  We’d like to thank our visionary level of sponsors, Health Is Primary, and Pharma. Our champion level sponsors, ETNA, Anthem, Ascension, Blue Cross, Blue Shield Association, Cambia Foundation, Glaxo Smith Kline, and InnovAge. Our signature sponsor for the aging series is The Catholic Health Association of the United States.

Sarah Dash:  Very important note in your packet of handouts, you’ll find an evaluation from, so please fill that out throughout the event, and we really value your feedback, and we use it to help plan our future programming. Finally, we’re planning already for next year’s signature series. I appreciate your thoughts on the topics that we should cover. We have an annual audience assessment, and that is gonna help ensure that our events continue to provide thoughtful, balanced, and useful content for each of you.

Sarah Dash:  It’s an online survey, should take no longer than 10 minutes. I’ll probably give a pitch for it again at the end, but we hope that you will all participate. Okay, so finally, with those housekeeping notes out of way, I would like to invite the Alliance’s board Vice Chair and Secretary Tom Scully. We are thrilled to have him here. Tom, thanks for coming to give some opening remarks.

Tom Scully:   Brief.

Sarah Dash:  Brief.

Tom Scully:   Brief opening remarks, hopefully. Anyway, thanks for coming. I’m Tom Scully, and I’m just proud to be the Vice Chair of the Alliance. I’ve been on the board for a couple of years, and it’s been a great organization for a long time. For some, I’m an old guy, but I think I first got involved in 1982. Senator Rockefeller is a great friend, and he did the world a great service in healthcare by creating this thing a long time ago.

Tom Scully:   Back then I was the bush one healthcare guy. So, you can imagine Senator Rockefeller and I didn’t always agree on everything, but we became great friends because he actually likes to talk about issues on both sides. Republican, Democrat, Conservative, Moderate. And in Washington, there’s way too little of that going on now. It was a little better 25 years ago, but [inaudible 00:03:03] Senator Rockefeller, but I always found the Alliance is really one of the very few places in Washington where you can actually talk about serious policy discussions, and have very little politics and lots of substance, and I think it’s been a great source of briefings for staff, and members, and staff at HHCS, and other people for many years.

Tom Scully:   So, I’ve been very proud to be involved in it. Senator Rockefeller’s an old … I see John down there who’s been involved for about 100 years as well. Rather, he’s younger than I am. But it’s just been a great organization for a long time. They’ve done a great job for a long time, and when people ask me why do you support the Alliance? Because if you wanna be in the middle of fair policy debate in Washington, you should support the Alliance.

Tom Scully:   So, my firm, I’m a partner in a private equity firm in New York. We’ve been a supporter for a number of years, because we’re just proud to be involved. And actually also the next speaker here, [inaudible 00:03:48] briefly at InnovAge, I happen to be a Chairman on the Board of InnovAge. I’m a zealot on improving longterm care, especially for poor, frail, elderly folks. PAIC, if you don’t know, there’s a program for all inclusive care for the elderly, but you’ve got a lot of folks up here that are senior care options program Massachusetts.

Tom Scully:   All of your panel are talking about innovative and creative ways to do a better job of taking care of seniors, particularly frail elderly seniors. And that’s the kinda thing people should be talking more about, instead of throwing bombs back and forth about very vague issues of what you should do with Medicaid work requirements. Not that that’s important, when nobody really gets in the details, the Alliance gets into the weeds on lots of issues and talks about things that matter. And that doesn’t happen enough anymore, on either side.

Tom Scully:   And finding a creative policy middle without politics is a critical thing, and they do a great job. So, I’m very proud to be the Vice Chairman. Also proud to be the Chairman of the Board of … and I’ll introduce Sylvia. Where’s Sylvia in here? So, I’m also the Chairman of the Board at InnovAge, which the other board members include Marilyn [Tavener 00:04:49], so there’s a bipartisan group for you. I was the CMS administrator to Bush. She was under Obama. She’s a good friend.

Tom Scully:   Ted Kennedy Junior. Peter Thomas. So, I mean, it was the [inaudible 00:04:57] lawyer in town. But we’re all fired up about trying to find the right way to take care of frail elderly seniors, and there’s a lot of ways to do it. I happen to think PAIC is one of the more massively unutilized programs in that area, but there are lots of them. And how often do you go to a conference where somebody’s talking about taking care of frail elderly seniors outside of the Alliance? Not a lot, and that’s a sad thing.

Tom Scully:   So, I’m very proud to be Chair of the Board of PAIC. Proud to have Sylvia. We just acquired four big systems in Philadelphia. Sylvia’s run, so she’s now are running the East coast operations of our company and she’s been with us for a few months. And we love her. Hopefully she loves us back. But anyway, we’re happy to have Sylvia here this morning to talk quickly about InnovAge. But I’m proud to be involved in the Alliance. Proud that they’re having these kind of forums, proud that at the end of every one of them that I go to, you can find that they’re fair, balanced, and factual. And that’s a rare thing these days in Washington. It’s something the Alliance should be very proud of.

Tom Scully:   Sylvia, you wanna come up? Thanks.

Sylvia:           Thank you, Tom. I am definitely in love with InnovAge, just to clarify. So, InnovAge is proud to be a partner with Alliance and the summit. The topic of aging in this country continues to be a really important topic, one that deserves our attention because our seniors deserve our best efforts. Alliance’s focus on having non-partisan policy discussions is right in line with InnovAge’s approach to helping serve more seniors.

Sylvia:           As the largest provider for PAIC, the Program of All-Inclusive Care, as Tom mentioned, InnovAge is committed to bringing personalized comprehensive models of care to seniors. That’s neither a blue or red issue, because as each and every one of us continue to age, the opportunity to serve more people in PAIC is staggering. Since the US government launched PAIC in the 1970s, the program has grown to serve 45 000 seniors in 31 states.

Sylvia:           Today, there are 12 million seniors who are duly eligible for Medicare and Medicaid, and 1.7 million of them are candidates of PAIC, meaning that they are at least 55 years of age or older, they can live independently in the community with some support, and they live in a area that is served by a PAIC program. For those of you who don’t know, PAIC is an alternative to institutionalizing seniors.

Sylvia:           PAIC provides a customized healthcare and social engagement to frail seniors to help them age in place in their own home, and their own community as long and as safely as possible. Participants have personalized care plans, and they receive most of their healthcare and social support within a local center.

Sylvia:           PAIC is really a different way to think about aging. And InnovAge is a different way to think about PAIC. So, my colleagues and I look forward to continuing the conversation about aging in America, and we encourage you to consider PAIC as one of the viable options in this ongoing discussion. Thank you so very much for this opportunity.

Jennifer Fuller:   Good morning, I’m Jennifer Fuller from Cambia Health Foundation in Portland, Oregon. Cambia Health Foundation is the corporate foundation for Cambia Health Solutions, which is a total health solutions company dedicated to transforming the way people experience healthcare. We were founded in 2007, and we’ve invested over 58 million dollars to advance patient and family centered care.

Jennifer Fuller:   We strategically invest in philanthropy to change the way people experience healthcare from birth to the natural completion of life. On behalf of the foundation board of directors and staff, we’re very pleased to help sponsor today’s summit and be an active participant in the conversation around reframing aging in America, and ways to improve health outcomes for older adults.

Jennifer Fuller:   Since it’s inception, the foundation has made purposeful philanthropic investments totaling more than 30 million dollars to advance the field of palliative care nationally. We invest in emerging leaders in the field in support of workforce, we invest in consumer awareness, and we invest in systems innovation and change in order to ensure that palliative care is everywhere.

Jennifer Fuller:   Palliative care is an extra layer of support for people with serious illness. It’s about designing solutions that enhance quality of life for both the caregiver, and the person they’re caring for. It means starting with the person receiving the services, or the person providing the care, listening to their needs and hopes, and asking what matters to them in deciding their course of treatment, rather than what’s the matter with them.

Jennifer Fuller:   It’s my pleasure and honor to introduce our keynote speaker this morning, Doctor Preeti Malani, Chief Health Officer and Professor at University of Michigan, who will address perspectives of older adults and caregivers. Thanks.

Speaker 1:     Thank you. So, thank you for being here this morning, and thank you to the Alliance for inviting me to share a little bit about our journey with the national poll on healthy aging. Before that, I wanna take a step back and really talk about aging in America, and why we’re all here today at the summit on aging in America, and for that matter, why healthy aging matters at all, or doesn’t matter.

Speaker 1:     Does it matter to people? Does it matter to their families? How about to healthcare systems? Health provides? And certainly to policy makers. And again, overwhelmingly, is yes. But why? Well, Americans are living longer than they ever have. They’re living longer and working longer, and today on average, people are living to 79 years, which is three decades longer than a century ago.

Speaker 1:     So, it’s a remarkable change in a relatively short period of time. And living well, really being productive in their older years is a priority for older adults, as well as their family members. This is a picture actually taken from in Portland, Oregon, where Jennifer is from. Where I did my geriatrics fellowship. And this is Mister Mark [Saul 00:11:33]. I took this picture with him a few days after his 103rd birthday.

Speaker 1:     And he went on to die peacefully a few years later. And although he required full care at 103, he was really robust and active, and independent, into his late 90s. He was pretty active volunteering in the community. I don’t think he was driving at that point, but he was quite active. And although the overall number of people that make it to 105 is small, the absolute number of Americans who are living into their late 90s and beyond is growing exponentially.

Speaker 1:     Over the next decade, we will see continued growth in the population that’s 50 and above. And as you see in this slide, the 50 and above group is gonna grow by about 15 million in the next decade. It’s about a 13% increase, and in comparison, the younger adults 18 to 49 will only grow by 8.6 million. So, we need to think about not just the extremes of age, but also about people who are aging in. So, even the 50 year olds who are sort of pre aging.

Speaker 1:     So, I wanna bring this back to a health policy lens. So, why does healthy aging matter? Well, this group of individuals who are 50 and above, they require a disproportionate number of resources. The amount of care they receive, the cost, the expenditures are all gonna be a lot higher in this group, so it’s very important from a money standpoint as well as a social standpoint. And just to give you a sense of what that means, about 110 million individuals fit this US 50 plus population. About 85% of them have filled a prescription in the past month.

Speaker 1:     And as you look at the older portion of this group, it’s much higher. It’s six medications on average. About a third have been to the emergency department in the past three years, and more than half have gone to the dentist. When we think about healthy aging, we really should ask those who are aging what’s important to them, and these are data that were taken from the ARP member survey from a couple years ago, and they asked members 50 and over, what’s important to you?

Speaker 1:     And the percentages shown here are people who responded that they were either extremely concerned or very concerned. And again, this list shouldn’t really be surprising to the folks in this room, but it’s worth looking at. So, staying mentally sharp, 84%. Having Medicare in the future, 83%. Living a healthy lifestyle, 79%. Having health insurance, 77%. And declining physical health, 69%.

Speaker 1:     I wanna put some of these numbers into a little more personalized context, and to do that I’m going to show you a picture and share a story. And this is my grandmother. We call her Dotty. Although, my brother and I kinda refer to her behind her back as The General, because she’s a pretty tough lady. And she is 95 years young. She lives in Michigan with my parents, and she’s actually an avid watcher of Days of Our Lives. She’s watched Days of Our Lives for almost 40 years, and it’s kind of interesting.

Speaker 1:     But she’s learned a lot of English from Days of Our Lives. Although, Hindi is her primary language, and she has a number of these interesting idiomatic expressions, and one of my favorite is, in Hindi it’s [Hindi 00:15:03], which roughly translated means as long as my hands and feet work, everything’s good. But if they don’t, it’s not so good. And I brang that up because in geriatrics we talk a lot about this concept of functional status. You know, activities of daily living. Can you get to the bathroom? Can you feed yourself? Can you bathe yourself?

Speaker 1:     My grandmother is not afraid of dying. She is terrified of losing her independence. And she is not alone. I think this is really a very real fear for many people. I wanna shift gears and talk a little bit about academics. So, I’m an academic, from the University of Michigan, and the academic timeline for getting things done is a little different. It’s a little bit slow. We might have an idea, we might write a grant, we might get the grant funded. A few years later you do a study, you write it up, and if you’re lucky, if you’re really, really on point, something you’ve done might actually impact health policy.

Speaker 1:     Now, the timeline for health policy is actually very, very different. So, at the University of Michigan, we have the Institute for Healthcare Policy and Innovation, and this is a very multidisciplinary group. More than 500 faculty across our campus, 18 schools and colleges, people all working together on various aspects of health policy. Some of the current work that we are doing include opioid misuse in Michigan, and some of that work has actually changed laws around prescribing.

Speaker 1:     Also, the Medicaid expansion in Michigan evaluation. About four years ago, the leadership at IHPI said, “You know what? What topics are gonna be really important in the coming years? Where should we be putting our resources? What should we be thinking about to position IHPI to really be very impactful?? And aging rose to the top of that list. And one thing lead to another, and this really lead to the institute for healthcare policy and innovation’s national poll on healthy aging.

Speaker 1:     And when we think about aging, we’re not thinking about just the frail elderly, or extremes of age, we’re really thinking about 50 to 80 year olds. So, people who are aging, and people who are getting ready to age, and people who are actually caregivers for older adults. And we’re also thinking not just about health, like traditional medical issues. We’re talking about health, health policy, healthcare, and really expanding that vision to think about all the things that are really important to people.

Speaker 1:     So, there are a lot of questions that are just difficult to answer with traditional research methods. The randomized control trial is really good for certain things, it’s not so good for really understanding behavior change, and what people are thinking in their everyday lives. What are their experiences? And one of the big goals with the national poll on healthy aging was really trying to capture that voice, that experience, the perspective of older adults and their families.

Speaker 1:     What is it that they do on a every day basis? And with that in mind, our overall goal was to develop, implement, and sustain a reoccurring nationally representative household survey of US adults, and again, I mention 50 to 80 year olds. And all aspects of health, health policy, and healthcare. And we’ve been able to really sort of go beyond the usual medical issues with this.

Speaker 1:     Also, dissemination of the results was really a big part of our initial goals. And again, academic dissemination tends to be sort of stagnant, and slow. Writing papers, making posters, we really wanted to have an impact immediately. And so, with that in mind, thinking about things like media, communications, and also who our partners were.

Speaker 1:     We thank about three broad audiences for our poll, which is consumers, or patients, people who provide care, health systems, and clinicians, and then finally policy makers, and people like you. Really happy to report that we have succeeded, at least in terms of putting out reports, we have had 13 reports. The first one came out 15 months ago, so we’re really, really pleased, and these are just some examples of reports. And I have actually brought some with me, which I can leave in case anyone would like some copies, and they’re also available on our website, healthy aging poll dot org.

Speaker 1:     One of the things that’s really made us successful is a really unique and special partnership and collaboration with AARP, and I’m really pleased that some of my AARP family is here today. This is something, this is a very non-traditional partnership. It’s a discussion that began maybe in a space like today’s space where it was sort of an academic group, a foundation, a consumer organization, sort of coming together to think about how they could find some common ground.

Speaker 1:     AARP provides financial support for the poll, but the poll is independent. It’s at the University of Michigan, it is our product, but they also, AARP provides so much more. They have incredible depth of research experience. They have a team that’s very, very committed to the care of older adults. Also maintaining health, and sort of disrupting aging, all the things that we’re thinking about today. And not only have they helped us make the poll better, and really get the poll out to their 38 million members, and help us with everything like what topics, what questions, but they’ve also come to visit us in Ann Arbor, and our entire IHIP community has benefited.

Speaker 1:     And you can see on the right, they had a chance to meet with our investigators who are interested in aging, and to really think about making academic work much more meaningful and really powerful in terms of getting into that policy space. This was our first report, and this was one on drug costs. A really common topic. But instead of just talking about how much people were spending, and how many drugs they were taking, we really were interested in how people go about getting their medications. Do they go to multiple pharmacies? Do they ever ask the pharmacist about cheaper alternatives? Do they ever talk to their doctor about how much they’re spending on medications?

Speaker 1:     And one of the things we identified was an interesting relationship in that there was this assumption for a lot of patients that my doctor knows how much I spend on medications, but yet they had never had a conversation about it. Those individuals who had a conversation about drug costs, they said, “Yeah, you know, I had this conversation, and by the way, my doctor gave me some advice or prescribed a cheaper drug.”

Speaker 1:     So, it was kind of an interesting thing that we found. We also found that with pharmacists, that a little bit of conversation might actually go a long way, and please don’t assume that your doctor knows how much you spend on medications because as a doctor I’ll tell you, I don’t always know that.

Speaker 1:     And this is an example of a graphic that was in the AARP bulletin. So, the editors of the bulletin independently took the data we had, recrafted it, made it into something that was important for their membership, for their readers, and really helped us disseminate these results more broadly, and it’s a little hard to see but on the far right side it was sort of the portion of folks had actually got a cheaper alternative by talking.

Speaker 1:     And it’s a sizable number. So, again, pretty simple message that you can … it won’t solve every drug cost issue, but it’s just something simple that people can do. We had another report on dental care, and this time we focused on 50 to 64 year olds. And again, interesting findings. Different patterns of use, where some people were prevention focused, some people only went when they had a problem. There was not, surprisingly, a very close correlation in terms of people being embarrassed about their teeth, which is such an important thing socially if they weren’t getting good care.

Speaker 1:     One of the interesting policy points we found was that a large portion of people didn’t know where they were gonna get dental care when they were older, and many of them thought that Medicare would cover them, which clearly it doesn’t. Many people in that 50 to 80 year old group are also caregivers for loved ones with dementia. And in this report, we wanted to look at what are some of the health effects on the caregiver. And we found that many people who were caregivers had their own challenges, health wise.

Speaker 1:     27% were delaying their care, or they weren’t getting the care. Two thirds said that caregiving interferes with their ability to really take care of themselves and their everyday activities. And again, to folks in this room, this doesn’t really sound that surprising because many of you work in this space, but I don’t know that all clinicians really stop and think about it. Pediatricians, people who take care of children, probably stop and think, and they know that the parents of their patients are caregivers, but we don’t always think about it with some of the ones that we’re seeing, particularly in that 50 to 80 year old range.

Speaker 1:     So, one of the take-home messages to our healthcare providers was ask. Ask people are you a caregiver? Because it has an important impact on people’s health. One other partnership that we have forged in recent years is with health affairs, and not so much the print journal, and the academic journal, but with the blog. We wanted to take a deeper dive into some of the policy aspects of a few of the reports, and so far we’ve had two. In June, our report on patient portals, and how people are using or not using patient electronic portals was something that we were able to write about in health affairs.

Speaker 1:     And again, different audience, we were able to engage some people like all of you, and we also did this with our overuse of low value care services, how to engage over adults. So, this gave us a chance to really take a deep dive into the policy aspect, something that wouldn’t really be as appropriate for consumers, or even clinicians. And I wanna just stop with my last slide, and thank my team. I don’t know if there are any college football fans here, or any Michigan fans. But legendary football coach at Michigan, Bo Schembechler, talked about the team, the team, the team.

Speaker 1:     And my team back home in Michigan, we worked together to really put this out. Although I’m the one here representing them, it’s such a team effort. We also have important team members in DC with our government affairs office, and then of course, AARP who has been a partner from day one for us. So, I would like to thank you for your attention.

Sarah Dash:  Thank you so much, Doctor Malani. That was really, really informative. So, before our first panel, I’d like to invite Andrew Barnhill, who’s director of federal policy at Glaxo Smith Kline, to briefly make some remarks, and introduce our next moderator. Thank you.

Andrew Barnhill:           Thanks so much, Sarah. It’s a pleasure to open today’s panels for the summit on such an important topic. On behalf of Glaxo Smith Kline, and our nearly 100 000 employees all around the world, we wanna thank the Alliance for recognizing the importance of aging, and the larger discussions about healthcare in America.

Andrew Barnhill:           I have a pleasure of leading federal policy for GSK, a global manufacturer in pharmaceuticals, vaccines, and consumer health. And GSK’s mission is to help people do more, feel better, and live longer. Over the past several years at GSK, we have developed a concentrated effort to support the goal of healthy aging for all of our customers. And as one of the world’s largest adult vaccine manufacturers, we believe that as the US population ages at an unprecedented rate, it’s essential to improve awareness of vaccine preventable diseases, and increase access for older adults.

Andrew Barnhill:           Vaccines have the potential for significant economic and social returns for public health overall, as many of us know, and GSK is proud to be a leader in that space. In addition, we at GSK recognize that as our industry’s innovation continues to grow and develop through time, Americans are continuing to live longer and healthier lives. GSK, now through our partner Vive Healthcare, has helped people all around the world living with HIV live longer and healthier lives.

Andrew Barnhill:           Through new and innovative anti-retroviral therapies that continue to improve with the latest research and development and technology. So, GSK and the whole bio-pharmaceutical industry is committed to being leaders in this conversation about how best to prepare for an aging population here in the US, in the decades to come.

Andrew Barnhill:           And so with that, I would like to introduce our first panel, with the focus on the drivers of health for older adults, and the moderator for this panel, Stewart Butler, senior fellow of economic studies, at the Brookings Institution. Welcome, Stewart. Thank you.

Stewart Butler:   Have a panel coming up, right? Great, thank you. And I just wanna echo first of all, something Scully said at the beginning about the importance of the Alliance. And really how its been in the forefront of engaging in these kinds of conversations on these very important topics, and the topic of aging in America, of course, is one of the most important that faces us. The older I get, the more I feel that’s the case.

Stewart Butler:   And I was telling my daughter, who’s 30, the weekend that I was doing this, I was gonna be here on this panel, and she said, “Well, I really hope it’s very successful because I don’t wanna spend my life paying for you.” So, this is a good example of family love, as you can tell. But anyway, in my role at Brookings, one of the things I do is actually convene a monthly meeting of people, of researchers, policy makers, and practitioners from …

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Stuart:           For researchers, policy makers and practitioners from different sectors, housing, education, healthcare, social services, and we look at these issues where the road to better health, whether it be for children with mental health issues or for the elderly is not simply a medical path but looking at these other issues that a play a really important part in that. So it’s very important, I think, to begin with the panel looking at these drivers of health for older Americans because the nonmedical factors are so important in reaching a healthy and happy life. And so we’re going to look at some of these drivers, with a distinguished panel that comes from different perspectives, some of these drivers, how they play and what some of the policy issues and other issues are associated with them. I’m going to introduce the panel very, very briefly, that you’ve got their bios in your packages.

Stuart:           And then we’ve got strict instructions to keep opening comments very short so we can have some time for a discussion and including from you from the floor. So let me begin first by we’ll hear from Dr. Yael Harris, who’s vice president of health research at the American Institutes for Research and has been very focused the last 20 years on looking at data driven efforts in the healthcare system to redesign access. Melanie, Melanie Bella is the chief of new business and policy at Cityblock Health, in which is a care delivery system built for low income people in urban populations and so on. The ground sees these issues every day. Jason Barker is the regional market president of GENMED in South Florida and for many years has been, involved it says on these notes with the dysfunctional nature of how the system typically functions and trying to feel how to deal with that issue.

Stuart:           And then last, by no means least, we’ll have Lucy Thalhimer who is chief strategy and impact officer of Meals on Wheels. I talked about one of the services that is so crucial for aging in this country and she spent a lot of time at ARP looking at these sorts of issues. So let me start by handing over to Yael.

Dr. Yael H.:  Thank you so much and I want to thank the Alliance for this really wonderful opportunity and to all of you for putting up with hearing from me. This is a really exciting opportunity for me. This is a field I’ve been in since I first left Grad school and I actually was at Michigan studying with … There was an institute on aging at the time, so I don’t know if it still exists, but I was there under [inaudible 00:31:49].

Dr. Yael H.:  Kimberley. Don’t tell them how old I am. So, anyways, it’s been a real pleasure. Right after that I went and worked at CMS and specifically worked on aging and long-term care and quality of care. And since then my career has moved into really supports and services. So we talked about social determinants of health and I think that’s a critical piece, especially in the early stages of life. Think about the stressors in life that affect your health in the long-term. And then when you think about after that, determinants are still important, but it’s also community supports and services. And so that’s something really I want everyone to think about when they think about aging well and aging in America, it starts with your physical health, but that’s only roughly 20 percent of your overall health. So it’s really important that we’re addressing things like housing, nutrition, transportation.

Dr. Yael H.:  And then the thing I think a lot of people overlook is safety, the high rates of elder abuse. And it’s beyond that. It’s also the safety of the housing. One of my favorite stories is I visited a rural hospital and they said when they discharge anyone over 70, they require someone to go check the house out and make sure there’s no loose rugs that their accommodation is in place because they don’t want the person coming back from another fall. So it’s really thinking about the environment and does it meet the needs of that person so that they can live independently in place. I also want to point out that when we think about investments, we all know the cost of Medicare going higher, a lot of people are dually eligible now as they age, but we also don’t think about the investments and social services and the number of federal investments in social services has actually decreased over time.

Dr. Yael H.:  So it’s just something to think about as the population ages, as we faced this silver tsunami, we don’t have … The funding isn’t going to the places to really support them, it’s just going to that 20% medical care costs as opposed to the real holistic needs for an individual. So, excuse me, my current position, I am with the American Institutes for Research. We’ve been around for 80 years. We are a social science and Behavioral Health Research Organization focusing on a variety of topics to support vulnerable population. So that’s really a focus of our work. I am in the health research area, so we support clients from the federal government, CMS all the way down to foundations and even local and state governments. So we really are trying to work on the issues that matter most in the communities because it varies from the federal level thinking about policy change down to the community level, working with people in the community.

Dr. Yael H.:  So we actually have a center on aging. You may have seen a recent article about our center if you didn’t, I suggest reading it. It was in the Washington Post just a couple of weeks ago and of course I told my 15 and 10 year old look, we’re the number one news story on the iPad. And they were like, “Yeah, who cares?” But my job is really pointless to them. But, it was about a study we have called Project Talent. It is a study of high school students in the 1940s and 50s that took a test, some of the questions of the tests are online, I probably failed them miserably. I don’t know what the right answers were, but they were pretty strange questions. But looking at that data now we’ve tracked down a number of those people who are in their 70s and even 80s and are talking to them. And we have found that the data can actually predict things like Alzheimer’s and health and wellbeing.

Dr. Yael H.:  I know a Sarah looked at me with funny. It’s very surprising, but the Alzheimer’s one was the one that made the newspaper, but I would suggest looking at our center website, it’s really interesting. We continue to do more funding with NIA to look at the predictors of aging and aging well and find out what we can do earlier on to ensure that people are aging well. And it’s great that we have this data set and also the technology. Before I talk about my passion, which is technology in your eyes, glaze over. I also want to mention on our website, there’s two reports, there are just over a year old now which makes them old. But in my mind 12 months goes like that. So it doesn’t seem that old. So we have a report called All Together Now, focused on integrating health and community supports for older adults. And another one specifically called Community Based Models for Aging in Place. So just, we were pretty prescient about this conference a year and a half ago and wrote these papers in advance.

Dr. Yael H.:  So a lot of our work focuses on populations that are vulnerable, including the aging. And right now we’re focusing on several models that are intended to help aging in place. One of them is a social impact model. I don’t know if you guys had heard of Pay for Success, it’s growing by leaps and bounds. One of my partners in this is working with Meals on Wheels right now on this, but we are looking to fund about 13 to 15 programs across America that will be basically kind of a challenge grant. It’s a grant and people compete for supporting aging, aging well, and I hope anticipate, we don’t have a say in the matter of who applies, but we’re hoping a number of those are about aging in place and really supporting community based needs for aging.

Dr. Yael H.:  So we’ll see which applicants come but AIR will be doing the evidence synthesis to inform that. And we’ll also be doing the evaluation of that and we’re really hoping that we will find some really concrete models that can be expanded out.

Stuart:           You need to wind up for the moment.

Dr. Yael H.:  All right winding up. That five minutes went fast.

Stuart:           I know, tell me about it.

Dr. Yael H.:  The thing I really want to talk about in lesson one second, is that technology is really going to transform the aging process and I think a lot of people are overlooking that. There’s models now where there are sensors in the house that are really helping people age in place, making sure that they’re up and active, turning stoves off if they leave them on, social engagement is the number one predictor of long term care admissions. So helping people engage whether if they can’t get out of the house, engaging through social media, engaging through even online video games such as Solitaire. So really helping people to age in place by providing the supports and services they need so that their home can provide those accommodations for them. Everything from telehealth to smart pills. And then even helping with making sure that there’s follow up care to that patient so they know when someone needs to come out, what types of services are needed. So happy to answer questions about that later on. But my time is up.

Stuart:           Thank you. And I still think this technology development is really very interesting in this area. Melanie.

Melanie Bella:    Good morning, hear me all right? Yes, thanks to Sarah. And to the Alliance for having me, my past life has been on the government side on the policy side, so it’s exciting to be here today. Talking to you from the on the ground side at Cityblock Health. So just quickly, Cityblock is a provider organization that addresses medical, behavioral and social needs for low income populations in urban communities with a focus on dual eligible and medicaid populations. We have kind of three pillars to our model. One is a technology platform that is sort of a care facilitation platform that importantly has a real emphasis on social data, not just the more traditional sort of medical data that’s been used in the past and that drives all the interaction with members and it drives workflows and it drives a whole host of things.

Melanie Bella:    The second piece is an interdisciplinary team, much as you would expect, I would say, except for really important team member for us and relevant to today’s conversation is what we call our community health partner. These are non-clinical folks hired from the community who have lived and breathed and worked and have lived experience for the types of populations we’re serving and the needs we’re trying to meet, so particularly relevant when you start talking about the social needs and understanding how to connect people with social resources and communities. And the third piece is a hub that we call a community hub. It is as much a community gathering space, a safe space as it is a place to get medical care. By definition and by design it is intended to feel much more community. We’re a relatively new organization we’re live in Brooklyn, New York, and when we surveyed the folks in the community, many of whom are now receiving these services, what they wanted out of a physical space, it was uniformly four things. One, a place to charge their phone, two a place to get Wi-Fi, three air conditioning and four a sandwich.

Melanie Bella:    So nowhere in any of those things is, coming in to get my flu shot or a mammogram or doing any of these things rank, what ranks is getting access to things that they need for their daily lives. In this model we work with payers and at risk providers. A really important piece of our model is that we could take financial risk. We believe that in order to address the social needs of populations, you really need to have a capitated flexible funding arrangement that allows you to align incentives and make investments in ways that you just can’t make investments in fee for service models. And so that is, in our view, really critical to being able to provide individuals with individual needs that they have that typically are not medical. And then we partner closely with community based organizations.

Melanie Bella:    So everything about our model is deeply embedded in local communities, the people we hire from the communities, the people we serve live in those communities and the organizations we partner with have been there a long time, but they need help, they have gaps that they’re not able to fill. And so we come in as a partner trying to fill those gaps and build networks of community based organizations just like you would build a specialty network or just like you would build a primary care network and try to drive financial incentives and performance based contracting on the social services side as well. Again, so that we’re putting resources in the system that can tilt it from the medical slant to more of the social and the behavioral slants. I would say that, so we’ve been up and running now for a few months.

Melanie Bella:    So we’re working on a hypothesis that addressing the social needs is really going to improve the outcomes and also improve the cost. It doesn’t happen overnight. This is a long-term bet and an ability to have good partners both at the policy level, at the state and federal level and at the payer and provider level. But we’re pretty excited and happy to be part of the panel today to try to talk about what this type of model, where we think the potential is and why we think it is so important to be addressing the social needs. And I guess I would say one last thing, although the focus is on older adults today, we find this by being in the community, we talk a lot about high risk people, we’re talking about high risk families and high risk communities. And when you’re in the home, you may be in the home to see a senior, but that the risk profile of that family and the ability to impact that family there’s a real sort of spillover effect.

Melanie Bella:    So when we’re talking about addressing the needs of older adults, I think it is important to think about the positive benefit that has to their caregivers, to their grandkids, to everyone else, because that individual risk is part of family risk and until we kind of look at it at the community, to the family, to the individual level, we’re really not going to get sort of ahead of the game like we need to be, so thrilled that this is a topic of conversation and also excited to think about the benefit of making investments here for seniors and how that helps communities and others at large.

Stuart:           Great. Thanks very much and I think very much the family risk issue is a really important one for us to keep thinking about. Jason.

Jason Barker:     Great. Good morning everybody. Thank you to the Alliance as well for the invitation. I am the Florida president for ChenMed. ChenMed actually operates in many states. We’re actually in seven states. You may have seen us operating under the names of JenCare as well as Dedicated Senior Medical Centers. So we do have a fairly far reaching a organization. I was really thrilled to be part of this panel because one of the things that we have realized and is critical to our organization and our model is that, and I’m sure many of you’ve seen this, this notion that if you look at somebody’s health status, 20% is attributed to genetics, 20% is actually attributed to what we do in healthcare and the other 80% is actually attributed to things such as behaviors and social determinants of health, your zip code where you live.

Jason Barker:     And we’ve actually tried to sort of engineer our model of care so that we expand beyond that 20% impact that we can really have on the health of individuals and into that 60%. I realized they just did my math wrong. Everybody’s saying, this guy is a joker he can’t even add [inaudible 00:44:47]. So our model really is a model where we sort of characterize it as we bring concierge style medicine to people in very difficult communities. Really to the old, the poor and the sick in communities and neighborhoods that really nobody else wants to go into. And we do that using the Medicare advantage as a vehicle for that. So when you think about the social determinants of health, I’m going to describe for you a little bit about our neighborhoods and our models and I think hopefully you’ll see how we’ve been able to develop a model that speaks to a lot of this. Not all of those by any stretch of the imagination but, but a lot of those.

Jason Barker:     So first we lead with primary care, and in primary care, we believe every one of our patients’ needs, like a quarterback of care. So we need somebody who’s really minding everything that’s going on with that patient. We give them very small panel sizes. Our physicians and our nurse practitioners on average have less than 400 patients. So we position our PCPs to be successful with the patients and to be able to see them as more than just sort of a collection of chronic conditions. So we really want them to see the whole person. So by having a small panel size, we also have very frequent visits, we expect our patients and our PCPs to interact that we stand on a monthly basis.

Jason Barker:     But frankly if our patients want to come in every single day where we’re happy, we’re actually happy to do that. So again, we go into this sort of very difficult communities position, our PCPs with very small panel sizes create a very tight bond between the PCP and the patient. Our PCPs give their cell phone to every single one of their patients. And if they don’t have a cell phone sometime we’ll actually take the patient’s cell phone and actually put the number in. Our patients have 24/7 access to us, whether it’s through a call center or they can directly call their PCP. If there’s an issue we can send a paramedic to their house. We can do an assessment and take orders from their PCP, if they are having access issues with respect to transportation, we already have full transportation available to every single one of our patients, but we can also send a car immediately to them as well.

Jason Barker:     So we’re really trying to address that, that access issue. We have onsite medication dispensing. It’s a big issue for many of our seniors, not only sort of access to the pharmacies to be able to go get their prescriptions filled, that actually even just the cost. So most of our medications that are dispensed on site are tier one, tier two generics that are of no cost to the patient. So we knocked down the cost barrier, we knocked down the transportation barrier. We’re also sort of very mindful of how we work with other professionals and community based social network organizations as well. We know that we cannot do this alone and so we do a lot of outbound outreach and we do a lot of partnership. We’ve also actually partnered with Meals on Wheels and for patients who have been discharged or moving to different level of care moving into the home, we actually worked to bring meals to those patients. So again, we have a lot more work to do, but we have a model that we believe is very successful and really makes a difference in the lives of the seniors that we care for.

Stuart:           You’re right. Thanks so much Jason. Lucy.

Lucy T.:        Good morning everybody. Thank you for having me here this morning. I’m very excited to be here. So I’m with Meals on Wheels America. We are the National Association and we are the Voice of some 5,000 local community based Meals on Wheels providers across the country in every community in this nation. So the risk of being a little bit redundant because we’re all saying something about social determinants of health, we know that those are the conditions in which people are born and they grow when they live and they work and they age. And we also know that those factors have greater impact on health and wellbeing than what happens in the doctor’s office or in the hospital, but when it comes to issues like employment and housing and access to transportation and access to high quality, affordable healthcare, we also know that these are hugely challenging problems that many of us had been working on for decades and they are the types of problems that are so deeply rooted that they’re going to require huge investments in the nation’s infrastructure if we’re really going to overcome them.

Lucy T.:        And that assumes we can even get everybody to agree on what the best solutions are and who’s responsible for solving those problems. But despite that, I believe that there are opportunities to bring solutions to bear that can bear fruit sooner rather than later. And a piece that I really want to highlight and I think some of my colleagues here have touched on it, is the need to really look in a very focused way of building bridges between clinical and non-clinical providers. That is a huge opportunity, I think, to really try to address the issue of social determinants of health. So for years we’ve had community based organizations working out there to bolster those who are most vulnerable, most at risk. There’s armies of staff and volunteers that are touching these high risk individuals every day and they’ve known for many years what many of us are just coming to understand and that is how to address the social determinants of health.

Lucy T.:        They’re deeply rooted in the community. They have trusted relationship with the individuals being served and other community based providers and they know how to connect people to other kinds of resources to keep them as safe and independent as possible in their own homes and communities, which is of course where they all want to be. There also some misconceptions I think about community based organizations. Meals on Wheels programs of today are savvy businesses. They’re not sleepy charitable organizations that many of us may remember volunteering, well maybe some of you are too young, many of us may remember volunteering for when we were in high school or college. These are savvy businesses that understand what it takes, they can speak healthcare, they have built the infrastructure and the systems required to collect and share important information about clients across providers. They know how to connect with services, they understand the financing world, what they struggle with most often is two things. I see Edwin over here nodding, so that’s good I’ll take that as a good sign.

Lucy T.:        They struggle with the recognition of the role that they can play and the skills and the expertise that they have. And quite frankly, they struggle with the resources because many are under the impression that somehow these services don’t cost. We don’t have to spend money on them like we have to spend for primary care physicians. And those are huge, huge barriers. We know today that making an investment in these kinds of services improve outcomes, improve lives, keep people independent and prevent very high cost incidents like trips to the emergency room and hospitalizations. We have data to support this. The programs are collecting data to support this. So we have a huge opportunity to bring this forward. We were encouraged earlier this year when CMS initially put out a letter about the potential for expanded supplemental benefits that there was going to be some opportunity to really expand the resources available for programs like Meals on Wheels services and we were very disappointed to see that CMS in a follow on letter essentially ruled out using those kinds of services for the purposes of addressing social determinants of health.

Lucy T.:        This at a time when it seems like everybody else has figured out the connection and connected those dots, including Congress when they passed the Chronic Care Act to take effect in 2020 a missed opportunity to fill a gap before that bill takes effect. So that’s something I think we need to talk about. To close up, I do think that value based payment models will provide incentive to focus on the right things, but they will take a long time to bring those solutions to scale. But in the meantime, I think we have the opportunity to leverage these community based organizations in a much more systematic way. I appreciate what my colleagues are saying, but if we’re doing it one program, one service at a time, it’s going to take long time. We can leverage organizations like mine and other national associations to try to be more systematic about how we leverage the power of those community based organizations. I will stop there.

Stuart:           Great. Thank you very much and I want to thank you all for being [inaudible 00:54:04] which gives us a decent amount of time for questions and conversations. On a total we have three methods you can use to raise a question or a point. You should each have in your folders a green card or some green card, so if you want to write down a question on those then somebody from Alliance will pick those up and give them to me. Secondly, there should be two microphones somewhere or two people with microphones am I right? Two microphones and you can use those. I can see people walking around there and then if you really want it to be new age, you can go on twitter whether that will ever reach me. I have no idea. But such is the magic of the modern world. So there are three ways, so why don’t you like to invite everybody to get started, but let me just begin actually with one question myself if I may.

Stuart:           As you’re thinking about your questions, Melanie, you raised the point about the difference between, the impact of, if you like, or the implications of a capitated system and a fee for service system. And I wonder whether you are just think that … As we think about the Medicare Advantage program as a cool part which is expanding, getting more popular, a capitated system and now more recently changes in the law and regulations to allow Medicare Advantage to actually cover not some non-medical services that we know enhance healthcare. Is something like the Medicare Advantage program a crucial platform so to speak or vehicle to do exactly what we’re talking about. So maybe just some quick responses to that and we’ll go to questions. Anybody who wants to?

Jason Barker:     I’d be happy to. I think it’s absolutely crucial. I’ve been in healthcare for 30 years and I really believe that the best vehicle to make sure that we’re able to actually see and care for the whole person, all of the needs is through a risk based capitated arrangement that lets you make those decisions that you can’t make and a fee for service environment to do what’s best for your patients, best for your members and not have to worry about at the end of the day, how do I build somebody and get paid for it?

Stuart:           Anybody take you [inaudible 00:56:23].

Lucy T.:        I would just add that I think it’s a good step that CMS is allowing this, but they it is not broad enough. So for example, it doesn’t include nutrition as a fundamental need tied to overall health and wellbeing. So I think there’s a lot of work to do to expand those opportunities. I think more Medicare Advantage plans are open to it and interested in it. But I think that there’s still a long way to go before we really get them-

Jason Barker:     I would-

Melanie Bella:    I just … Sorry.

Jason Barker:     Go ahead.

Melanie Bella:    I was just going to add one thing. I mean, and I think it’s great, where were Medicare’s going to give more flexibilities so you can tailored individually is really important. We could take a lesson from Medicaid in this respect and Medicaid for a long time has recognized and tried to find more creative ways to fund and so kind of bringing the best of those things together, I think it could propel us a little bit even further.

Dr. Yael H.:  And if I could just take it to the policy level, Medicare’s allowed that flexibility, but a lot of plans don’t understand what services and supports are available and how to maximize them. So one example, there is a waiver for Medicare Advantage to use more telehealth. They don’t have limitations that Medicare typically puts on telehealth and analysis of several Medicare advantage plans. They’re not using the telehealth waiver, they don’t even understand that they can provide telehealth in the home, that they have expanded, that it doesn’t have to be rural, it can be urban. So I think some of these services and the ideas that we’re discussing, we really need to educate Medicare Advantage plans about the flexibility that they have under these new rules.

Jason Barker:     Can I just make one thing-

Stuart:           Let’s just get to questions because I did promise everyone.

Jason Barker:     Okay. All right.

PART 2 OF 5 ENDS [00:58:04]

Stuart:           [inaudible 00:58:00] let’s get a question because I promised everybody. So, yes.

Dr. Caroline: I’m Dr. Caroline Poplin, I’m a primary care physician. I’m a medicare beneficiary, plain medicare and it disturbs me that Medicare Advantage plans are being given extra resources to do things that plain Medicare can’t do. What concerns me about all this is that we have different plans doing different things in the same community. Aetna does one thing, United Health does something else and I think what you really want is public health.

Dr. Caroline: I know the reason that you’re putting the social determinates in the medical system is because the medical system has a lot of money. What you really want is to have the services in the community, like social, people who can help everybody. Not just the ones in Aetna and the one in United because what I’ve seen that they do is looking for home health aides there are agencies that have the home health aides and they charge $30 or $35 an hour and they pay their people $10 an hour. There’s huge turnover, those people get no benefits of their own. If they get sick they’re stuck. What you want is a public system with something like VNA where it’s nonprofit and the money goes directly from the client to the person and you don’t have to deal with different people every day. We need to keep this simple and look–

Stuart:           I think we got your point.

Dr. Caroline: Okay.

Stuart:           Is the question right? Can we only do this effectively through a completely public system or can we actually work within the current arrangements?

Jason Barker:     The only challenge with that is it’s just, again I’ve been doing this for a long time, we don’t fund those things. As a country, we don’t fund those things. The only reason why we as providers are even having to dabble into things like transportation and housing and all these other issues is because nobody else is going to do it. Consistently, sustainably, all of us who’ve worked with community based social support networks, organizations know they don’t get funded, they live from grant to grant and we’re doing this because this is probably the most financially long term sustainable way of being able to provide these services to people who desperately need it and who don’t get it.

Jason Barker:     We go into these communities that have a lot of these systems and they have terrible access, they’re poorly run because they’re underfunded and they’re chronically underfunded. When somebody convinces me that we’re actually going to fund a lot of these sustainably, I’m right with you. Fundamentally I agree with what you’re saying, the reality of the situation is somebody’s got to step in and fill the void.

Stuart:           It’s certainly true if you look at other country’s like the UK, where I’m originally from, that the proportion of money that’s spent on social services that have a health component as opposed to medical care is much different from here. We are an outlier in terms of medicalizing. As opposed to addressing these things in other areas, but I think you hade a question. Yes?

Fran Soistman:  I don’t think you’re gonna like this but I’m Fran Soistman. I’m Executive Vice President, President of Government Services for Aetna.

Jason Barker:     Since you illustrated your point with that one.

Fran Soistman:  This wasn’t planned but timely. Jason made my point and that is that two thirds of American Medicare eligibles are in original Medicare. We’re only talking about one third of Americans who are eligible for Medicare and Medicare Advantage. Frankly, if it wasn’t for a Medicare Advantage and it’s evolution over the last 40 years we wouldn’t be this far. The innovations of breakthroughs have occurred in Medicare Plus Choices, Medicare Advantage, that’s where we are today. Value based care is being pioneered in Medicare Advantage, not in original Medicare unless you call the ACO’s pioneering it but they’re aren’t too many success stories yet.

Fran Soistman:  We’re cheering them on but there aren’t too many success stories quite yet. We don’t have time on our side. Right? I think, who was it? It was Yale who said the silver tsunami. I love that. It’s here. We’re gonna have 83 million Americans over the age of 65 in the next 15 years. It’s a huge number. We don’t have the tax base to support that. We gotta do these things. We got to do them now. We got to do them at an accelerated pace. We don’t have time to debate it anymore, we just got to get moving on them and moving on them quickly and I think Medicare Advantage is exactly the place to do them.

Fran Soistman:  With all due respect, I see things a little differently.

Stuart:           Next question. Do we have somebody? Yes.

Terry Davidson:            Terry Davidson. Just a citizen.

Stuart:           We all are.

Terry Davidson:            [inaudible 01:03:31] what were some of the things you thought Meals on Wheels could do if there were expanded resources?

Lucy T.:        Well Meals on Wheels can do way more than people think they do, so yes they deliver nutrition services and that includes meals, often times two meals a day. They do nutrition education and counseling. They also do safety checks in the home. They make sure those rugs are not gonna cause any fall hazards. They are monitoring, since they are the one service that is touching most of these high risk individuals on a daily basis, they can monitor changes in condition. They can see if something doesn’t seem right, they can report that back in, they connect people to other services, they can provide care coordination support. They can alert a PCP if something seems to be seriously wrong. These are eyes and ears in the home. They can be true extensions if you will, of the healthcare system and they can also be a hub to engage other community resources if and when that becomes necessary.

Lucy T.:        So, I think it’s a huge opportunity. I totally understand where the physician is coming from, I wish there was one single answer to this but I think what most of us, these programs spend so much time trying to find that where the next dollar’s gonna come from because there is so much need out there that they cannot meet through available funds. The older Americans Act is great but, Edwin will tell you it only goes so far. Serves about we think a third of the need of people who are facing isolation and food insecurity. I think those are some of the things that Meals on Wheels programs can be doing.

Jason Barker:     They’re also incredibly cost effective.

Lucy T.:        Thank you.

Jason Barker:     We partnered with Meals on Wheels to bring hurricane disaster food to a number of the folks in south Florida and I was astonished at, as well as our post discharge program, I was astonished at how cost effective. It has to be one of the most cost effective interventions around to make sure that people are getting nutrition they need. It is.

Lucy T.:        I have to say one more thing that I think and that is today most Medicare Advantage benefits, which are great, are post discharge. Where we have not come to terms with yet, is recognizing the preventative aspect and providing services on a longer term basis so that you can evert some of those serious episodes before they happen. I think that’s an area where we could do a lot more.

Stuart:           I do think this issue of the eyes and ears in the community, critically important. You mentioned this with Meals on Wheels, we see it in other areas too. This idea of training people to some degree, not become physicians, but to be able to spot, to identify potential issues. I’ve seen it in my work with a whole range of people. Ministers, just can pick up issues from congregants. Visitors of various kinds of the senior village system in this area, one of the things many of them do is train volunteers who are visiting just to keep their eyes open. To look in the fridge, and sort and spot things and that can be so critical. There’s some pretty low cost ways of, as you’ve said of identifying problems at the beginning.

Stuart:           At the back there. Yes you sir. [inaudible 01:07:07]

Speaker 3:     I’ve got a big mouth so [crosstalk 01:07:09] [inaudible 01:07:11] policy translation and great panel. The question I have for you is it’s a zero sum game, okay, health care spending, we spend about 20% of GE on healthcare today. City block by your very name is a one off on a city block. [inaudible 01:07:31] how do you scale this? What are the policy levers it pull, to move away from the medicalization because that’s the way we have to finance what people really need, which is food, shelter, transportation, social engagement. How do we get there other than…and I worry about healthcare, everything is about risks and I get the need to move to [inaudible 01:07:59] because it creates the flexibility [inaudible 01:08:01] spending things on nonmedical things. But boy, it’s beginning to sound a lot like the casino. Is that really what we want to do is put all our eggs in the private sector basket? What are the safe guards to protect against risks? Easy question.

Jason Barker:     Yeah, easy question. Two things, one is I don’t view capitation as risk I view it as freedom to be able to make choices for what’s best for our patients. Number two I probably answer your question the same way I answer the earlier question which is we have to fund it so I think you’re maybe alluding to the commonwealth study when they compared [crosstalk 01:08:45]

Stuart:           It’s included.

Jason Barker:     Yeah, so we have a disproportionate spending on medicalization because we underspend on the social goods. We’ve known this for a long time that in our country, healthcare seen as an economic good it’s not seen as a social good. Health in and of itself has to be beyond healthcare. We are trying to use a vehicle to make that happen, that is difficult to scale. We’ve scaled in the seven states, we believe we can scale across the country. But, are we gonna be able to solve the problems? No. Now, what we’re doing I would tell you is very replicable but most healthcare organizations don’t have the will to do it.

Stuart:           Melody, your…is it a question of one block at a time? Or is there a policy that would help this really expand rapidly?

Melody.:       Yeah. I mean a couple things. One is technology is going to be really helpful. The technology cannot replace the human factor and so what we’re doing is very resource intensive, it’s very individually customized. You cannot have these one size approaches for certain segments of the population. You can have technology to facilitate the linkage of supports and services and doing a better job of leveraging resources in the community.

Melody.:       We have way too many clinical supports that were throwing up problems. We are not doing a good job at all within communities of using non clinical resources, whether it’s in the home or whether it’s connecting to social services and supports. I take a little bit of issue with the zero sum. Yes, it is a fix pie but Let’s take dual eligible for example, my favorite, we got a pie of somewhere between three and four hundred billion dollars a year for eleven million people, that’s ridiculous. We have more than enough resources in that amount of pie to provide care for these folks so we need to redirect. To me scale and the policy side is redirecting, facilitating the redirection of resources out of institutional and medical buckets into less medical buckets and you can do that one the policy side and then it’s a matter of mobilizing the workforce on the community and being smarter about how we’re deploying clinical and nonclinical resources and using technology to facilitate.

Melody.:       At the end of the day, this is a people game. This is solving peoples needs which requires people. It’s not gonna be overnight you can just go drop these. If we’re dropping them in multiple markets on a dime then we’re probably not doing it right. Unfortunately, I think it is going to take time but I do think there’s both policy and sort of delivery levers that we can be pulling and doing a more effective job of [crosstalk 01:11:27]

Stuart:           Do we have to overtime retrain the whole workforce and what is now the medical sector so instead of having medical schools we might have health and social determinant schools? Where people actually learn different things? Is that what’s required?

Jason Barker:     I will tell you my wife is in University of Southern California’s family nurse practitioner program, it is housed in the School of Social Work. It is exactly what the leading edge academics are realizing is that we have to be more holistic about how we’re approaching health.

Speaker 4:     I would take it back to my comment about [inaudible 01:12:02] guidance. I don’t think people are avoiding bringing community based services, I don’t think they understand the integration. One of the things that I’ve been a strong proponent of is having the electronic health record identify, and this is what the accountable health communities that CMS is funding, using the electronic health record to identify key determinants of health. Just adding a small set of questions, there’s a number of standardizes tools to help identify what those social determinants of health are. Then linking them to the resources in the community. Having that repository of here are the resources of the community that you can refer to, but then we need to close the loop.

Speaker 4:     Then we need to take it back to we’re not just giving a patient a handful of paper and saying, here’s a homeless shelter. What if that homeless shelter doesn’t have food? Doesn’t have beds? It’s really fulfilling that link and that’s where the technology comes in. It’s the whole system of then following up, making sure the patient is coordinated with the Meals on Wheels service, and that the right one that serves the community live in etc. Really bringing holistically from the time the doctors working with the patient, identifying them as the point of care, to getting the blink into what’s in the community and making sure that facilitation continues to happen on behalf of the individual. But, still personalizing it to what those individuals risks are and needs.

Stuart:           We got a lot of demands here. Who has the microphone? There we go.

Megan Wolf: Good morning. Thank you for this wonderful and very timely conversation. I’m Megan Wolf with Trust for America’s Health, we are a prevention and public health advocacy and policy nonprofit. We had just launched an initiative in Florida working with the State Department of Health and local departments of health to explore how public health can address healthy aging. We really feel like this is a pivotal time that public health can begin to play some of these roles that we’re talking about her in terms of convening, and connecting the dots and looking at gaps and gathering data.

Megan Wolf: Stuart I’d love for the public health sector to have a place at your table.

Stuart:           Mm-hmm (affirmative). Absolutely.

Megan Wolf: If you could think about that. [crosstalk 01:14:07] Dr. Harris I wonder if you’ve, in your research and your reports if you’ve thought about and if any of you have thought about the roles that public health can play in connecting the dots and really trying to come in. Public health doesn’t have anymore funding either than any other sector does. We really feel like because of where the public health sector is and because of who they connect with that there are definitely some significant roles that can be played.

Stuart:           I do think that who takes the lead in this is really a very critical issue. A friend of mine once said, in these different sectors, whether it be education, or housing you have all these case managers and so forth and in healthcare we need a case manager to manage the case managers. In a sense of somebody has to take the lead. I think that’s an open question. Still if you want to comment on that or we go to the next question.

Melody.:       I would like to add that public health at least public health agencies, they know the community they’re working with.

Stuart:           Right.

Melody.:       I think their ideal to be this coordinator of the services to, my comment about the HER connected community health services that would be the perfect entity that could help facilitate the follow up, it’s the funding. That comes from the county, and the state, there’s just not enough resources. I love that model, I think it’s a great model, I really think public health could help with that population [inaudible 01:15:35] piece in terms of facilitating but we come down to we’re a capitalistic society, the federal funding goes to the medical care and unfortunately public health agencies don’t have the resources so we’d need a grass roots effort to make sure the investments go where they can best be served.

Jason Barker:     I do think public health can teach providers how to think differently about health. My graduate school was in a school of public health, that shaped my viewpoint on addressing health. A lot of the theories and approaches in public health are very appropriate to be thinking about as a provider.

Stuart:           Okay. We’ve got time for maybe one more question. This gentleman here.

Bob Griss:    I’m Bob Griss with the Institute of Social Medicine in Community Health. I’m wondering if the problem with public health is not the concepts but the lack of resources. The accountable health, the Obamacare plan was for hospitals to play a role in community health needs assessments by organizing with the representatives of different social service and health agencies. To what extent is that happening? Is that a good model? Or do we need something more like the certificate of need process, which used to be built into the healthcare system to make sure that hospitals were not over-medicalizing and conducting a needs assessment at the community level to identify needs, and make sure that they were going to be served by the resources in the community. It seems like there’s an institutional gap here that public health philosophically is designed to address but it doesn’t have the resources. I’m wondering if this kind of gathering can be recommending some institutional actors like the certificate of need process.

Stuart:           I think you know, bare in mind the idea who should take the lead, what about this proposition that community benefit requirements of hospitals should be used much more creatively, bigger requirements on hospitals, we’re certainly going in that direction I think. If we can see what your thoughts are as the last question.

Jason Barker:     I probably am gonna offend a few people in this room. Probably 20 years of my career in Catholic healthcare. Running Catholic healthcare organizations. Much of what we did 30 years ago where we’d make a bad, bad financial decision because it was the right mission decision, you just don’t see that anymore. The problem with ACO’s is that you’re trying to anchor it to an institution that it is counter to their incentives to have people be healthy and in the community. They want their beds full, they have debt to pay. I think ACO’s can serve a purpose but they need to be in the hands of physicians not necessarily integrated delivery systems and hospitals. It needs to evolve to look more like Medicare Advantage so you’re not still trapped in a dysfunctional fee for service payment mechanism when you’re trying to do the right thing by your patients.

Stuart:           Still, I think the CHNA requirements on nonprofit hospitals is certainly stimulating hospitals to look more creatively at how [crosstalk 01:19:25] it’s a requirement, a tax requirement.

Jason Barker:     It is absolutely a requirement [crosstalk 01:19:29] it’s treated in a way that you would comply with any other[crosstalk 01:19:33]

Stuart:           I understand that but there may be some opportunity there we should be thinking about in the future.

Jason Barker:     Yeah and believe me that its not monolithic there. There are organizations that are good thinking and are gonna do that right.

Stuart:           Well, 50 minutes goes very fast as you can tell and the purpose of this panel is not to solve every problem and answer every question but to kind of get some of the issues on the table that we need to think about and I want to thank all the panelist for doing that very effectively. I know you’ve got lots of more questions but you’ve got other panels that you can ask those questions to. I want to thank you all and appreciate you being with us. Thank you.

Sarah:           And then we’ll be back, we’ll be talking about care models and policy implications so don’t go away, we’ll be right back.

Sarah:           Alright, well thanks everyone. Some really great discussions in the last panel and I think we’ll be continuing those conversations and getting to some new information in the next one. Welcome back. Really excited to be here again. For our next panel which is going to be on care models. I’m really pleased to introduce Dr. Aelaf Worku who is Regional Medical Officer at CareMore an Anthem company and Dr. Worku is going to make some opening remarks and introduce the next panel which I will be moderating. Thank you.

Sarah:           Without breaking my leg.

Dr. Worku:   So you were pretty strict on the time so I’m just gonna make sure I time myself. Again my name is Aelaf Worku. Regional Medical Officer for our D.C. market for CareMore. Just opened up, August 1st. CareMore serves 11 markets and our D.C. clinic which I’m quite proud of does not just primary care but also behavioral health support for our D.C. Medicaid population. I am previous to Washington D.C. I was actually in Las Vegas in the same capacity but instead serving our Medicare Advantage population. I have to admit I think I became a better doctor, let alone administrator serving this population with respect to being a better listener, working with caregivers, being comfortable with having goals to care conversations, and just being present. I’d like to share a few experiences that I hope bring some additional clarity to what it’s like delivering care to vulnerable populations.

Dr. Worku:   When CareMore started out 26 years ago in Southern California, it consisted of a few rogue physicians who wanted to do more with the healthcare that they offered their patients, they wanted more control over the healthcare delivery than HMO’s were willing to see at that time. In the process of asserting their beliefs about what healthcare should look like, they did something unusual. They actually began to offer clinical services that enticed engagement. One of the PCP’s was a former Mr. California body builder and with some of his patients he started offering fitness tips.

Dr. Worku:   Eventually, the demand was so high that his practice started offering classes for a group of patients at a time. Eventually those sessions were spun off into true entrepreneurial spirit, into a dedicated fitness center, dedicated to elder populations. This center called Nifty After Fifty became a tremendous draw for patients and was actually a selling point. Whether for physical therapy or fitness classes. Some of you might be thinking So Cal, Venice Beach, pumping iron while gazing at the waves on the Pacific Ocean but it should be noted that our Richmond Virginia market actually has our highest Nifty After Fifty engagement rate.

Dr. Worku:   What makes Nifty After Fifty even more compelling, is not the services it offers but rather the social engagement that occurs in these centers. Seniors talking to other seniors. Seniors talking to staff. It turns out a lot of patients enjoy each others’ company and success. They like to compete and be apart of something greater than themselves. Often, people like to be around other people, even if their day to day activities don’t reflect this need. Which brings me to my second point which is social isolation is simply put an epidemic.

Dr. Worku:   According to Kaiser Family Foundation survey from earlier this year, more than a fifth of all adults state that they often or always feel loneliness or lack companionship or feel left out or isolated from others. Social isolation does not discriminate by age, or race, or religion. Social isolation is not necessarily a manifestation of depression. Instead, it’s a consequence of multiple factors. What we do know about isolation is that it is associated with increase morbidity and mortality and current literature also suggest that isolation leads to increased utilization.

Dr. Worku:   I’m actually very proud that CareMore has taken on social isolation as a challenge and championed it into prominence among policy makers. From an outcomes perspective with our loneliness imitative we’ve witnessed a 15% reduction in acute care costs and 22% in depressive symptoms among enrollees. I’m actually proud that in D.C. later this year we will be CareMore’s first Medicaid market to conduct programs to address social isolation. CareMore is able to leverage relationships with it’s patients to accomplish remarkable outcomes in both the outpatient and inpatient setting. Whether it’s the 18% reduction in A1c percentages for in-program diabetics, or inpatient metrics such as 16% fewer admissions, 20% fewer readmissions, 20% lower lengths of stay, 58% ESRD inpatient stays, 26% fewer CHF readmissions or 19% fewer COPD admissions. We have some success to build upon with these relationships with the patients.

Dr. Worku:   We leverage those relationships to the entities outcome so they trust us and in return we have to reward their faith. The future of healthcare supported by CareMore and other providers to offer such programs that allow us to meet patients where they are so that we can identify their needs keep them engaged and support their health. Thank you.

Dr. Worku:   I will reintroduce Sarah.

Sarah:           Alright, I’d like to invite my next panel up and to take their seats. Thank you.

Sarah:           Alright, thank you so much Dr. Worku and thanks again everyone for being here. I’m delighted to be moderating the next panel which focuses on future care models for aging Americans. So let me first introduce our panelist. To my right is Dr. Rushika Fernandopulle, he is the practicing physician and co-founder….

PART 3 OF 5 ENDS [01:27:04]

Sarah:           It is Dr. Rushika Fernandopulle. He’s a practicing Physician and Co-founder and CEO of Iora Health, a venture-backed National Primary Care Group based in Boston, Massachusetts. He serves on the staff at the Massachusetts General Hospital, on the Faculty of Harvard Medical School and on the Boards of Families USA, and the Schwartz Center for Compassionate Care.

Sarah:           Next, we’ll hear from Cheryl Wilson. Cheryl has worked in the healthcare field for over 40 years and has been the Chief Executive Officer of St. Paul’s Senior Services since 1990. She’s also a board member of CalPACE, and the San Diego Senior Alliance.

Sarah:           Then we will hear from Dr. Cheryl Phillips. So you had to be named Cheryl?

Phillips:        That’s right. She’s Cheryl one, I’m Cheryl two. We’ve done this for years.

Wilson:         And she’s right.

Sarah:           We’ll hear from Dr. Cheryl Phillips, who’s president and CEO of the Special Needs Plan Alliance, a national leadership association for special needs and Medicare-Medicaid plans serving vulnerable adults. Cheryl served as a primary care health policy fellow, under HHS Secretary Tommy Thompson and was appointed by the governor of California as a, California Commissioner on Aging.

Sarah:           Finally, we’ll hear from Gina Buccalo, who’s the Medical Director of the UAW Retiree Medical Benefits Trust or The Trust. Dr. Buccalo provides medical leadership strategic direction, oversight and support to the Trusts Clinical and Population Health Programs. As a Board Certified internal medicine physician, Dr. Buccalo has also practiced in Metro Detroit for more than 25 years.

Sarah:           So welcome to all of you. And with that I will turn it to Rushika to get us started with some remarks and then we’ll go into our questions.

Sarah:           Thanks.

Rushika:       Great. So thank you all very much for having me here. It’s great to be here. I was telling them that my parents live in DC, so it’s a good excuse to go have dinner with mom and hang out.

Rushika:       So I think it is not news to anyone that the current care models aren’t serving any of us well, but I think it particularly aren’t serving seniors very well. And so I started Iora about eight years ago. And what you hear echo, some things that you heard from our friends from CareMore, you heard from our friends at ChenMed, I think there’s a shockingly small but growing number of us who’ve simply decided that we don’t have patience to sort of, incrementally tweak the current model but what we need is actually start from scratch.

Rushika:       So a couple of propositions. One is, we should build for purpose. So our current primary care practice which tried to do all things to all people is ridiculous. No restaurant in the world tries to serve any sort of food you want. You want Italian, you want Chinese, you want Greek, they’ll cook anything. The cheesecake factory sort of tries, and their Chicken Tikka Masala is not that good. What we really need is to say, “We’re going to cook Indian food, and you want Italian food go over there.” So we said, “We’re going to focus on seniors. They have a different set of needs, and we need to build for that.”

Rushika:       Number two is, let’s actually rebuild the health system. The last question about, we’ve tried this sort of anchoring accountable care in hospitals and I think it hasn’t worked, not because they’re bad people but because their incentives are wrong. And we said, we should accurately anchor, go bottom up, and we should build accountable care but not top down, but bottom up. Start with the consumer align around them, and that appeared at the end of that sentence.

Rushika:       And who’s supposed to pay through this primary care? And why primary care? We can do primary care well, which is really important, which is chronic disease management obviously being there for acute problems. But we also need to then focus on what I call, the downstream and the upstream.

Rushika:       So the downstream, is all the other things that are maybe more important to actually improve health, particularly for seniors, but that includes how you eat, it includes exercise, includes stress, include sleep, and then a level down, it’s what we now has become trendy called, Social Determinants of Health. So we have to make sure you have enough food, you’ve got housing and there’s money on the table, you’ve got your family relationships right.

Rushika:       And then a level deeper is what a number of friends call, Personal Determinants of Health. If you look at what actually impacts aging, well, it has nothing to do with healthcare. It has to do with optimism, sense of purpose and social isolation again, as our last speaker just talked about. So we need to do all that. This is our job. Our job is not by the way, to do more visits to people, our job is improved people’s health. That’s it. We should focus on these things.

Rushika:       And then on the downstream, no matter how good we are at primary care or even all these other upstream things, eventually people are going to need to an encounter the medical system. And then they need someone to help them navigate this crazy system, who to be quite honest, the people in the system don’t always have their interests at heart. They’re trying to do more stuff to people. And too often, particularly with seniors, we’re doing things to people which are not consistent with their preferences or really what they need.

Rushika:       So we’re building a whole new system from the ground up. We have 35 practices, we’re in nine different states right now. I think like you heard, you have to change the payment model. Fee for service is the wrong way to pay. For primary care what we need particularly for seniors, is relationship based care, not transactions. Last I checked, transactions have never healed anyone. So don’t do it.

Rushika:       All these sort of, for the most of CMS current theoretical advanced payment models, are all some variant of fee for service. Fee for services wrong. Get rid of it. What we do is, we work through Medicare advantage, maybe find a way we can actually do this, and essentially take global risk.

Rushika:       Give us the healthcare dollar and let us get on with it. That allows us now to think of our job very differently. Our job really is we have a population of people, there’re problems. Improve their health, keep them out of trouble, do whatever it takes. We build these very robust team based systems, with health coaches from the community, we integrate mental health, we provide people rides through a partnership with Uber and Lyft if we need to, we do groups to get people together. We all know the right thing to do. Why the hell are we not doing it? And so we just do it all.

Rushika:       We’ve built our own IT platform, which really is the epics and other things of the world are built for transactions, to optimize nine, nine and two, and four buildings. Not what we need. So we had to build our own platform. Virtually all of us who were doing this, seriously ended up making the same decision.

Rushika:       And then finally, we build a different culture. And it works by the way. So what we’ve seen is, we’re doubling in size each year. The number of patients coming is doubling each year. We’re running four and a half, to five stars in all of our markets if you look at the Medicare advantage quality metrics, which I think by the way we’re not really the right quality metrics. The right quality metrics, you actually asked patients what they want.

Rushika:       And it’s really simple. We ask two questions for our patients, how do you think your health is? And how confident are you in managing yourselves? And we look and try to move those needles up, and we do really well. And then what you see is, if we do this well, you’ll make huge impact on hospitalizations, huge impacts on total cost of care, 15 to 20 percent. And that’s what pays for all of this stuff.

Rushika:       So again I think the bottom line is, there’s a lot better way to do it and I think we just need to start doing it.

Rushika:       Thank you.

Sarah:           Thank you. Alright, well next Cheryl Phillips, Cheryl Wilson sorry.

Wilson:         Thank you. And thank you for having me here today. Out on the table, I placed some of these so I won’t go through the history of St. Paul’s. But we have been an organization serving seniors for over 60 years, and in San Diego, California. And we started off with housing. And housing with services is really a way to age well, it provides for many of the things that have been discussed today, socialization, care management, social workers on staff, transportation to the grocery store, to the doctor’s office, to the bank, et Cetera.

Wilson:         All the things that seniors need, are provided in community housing plans that are plans supporting seniors to grow old. The average length of stay if people who move into those programs, shows 12 years, people live 12 years longer than if they’re living at home alone without any services and without a care manager.

Wilson:         So we have residential facilities. Of those facilities, We have HUD facilities, we have market rate facilities, we have skilled nursing, we have an Intergenerational Program where we have infants two months through five years, and also seniors with Dementia and it can be Alzheimer’s, Parkinson’s dementia, Lewy body, et cetera. But they all have Dementia.

Wilson:         And it took us five years to get the state of California to allow us to license that program, because they couldn’t see how those two populations could come together. But I can tell you having a grandson who went through that program who’s now 19 and who has decided to go into the Long-term Care Arena in his course of studies, it really does have a major impact on both ends of the age spectrum for the good.

Wilson:         We also have PACE Program. We actually have three sites and we serve the largest number of PACE people in San Diego County. And I’m not going to go into what PACE is, because you’ve already heard it. And all of the programs that you’ve heard about which provide not only the healthcare but also the social determinants of health care, that is what PACE is.

Wilson:         PACE started over 45 years ago in On Lok in San Francisco, and is a really a proven model. And the models that you’ve heard about today are really offshoots of that basic premise, that 40% of healthcare is medical, but 60% of healthcare is social. And when we compare our costs of care to the European, Canadian, Australian … Where I’m from, cost of care, what we do is we compare the healthcare costs. But what they do is they provide for that 60% of social determinants and that keeps people from needing so much of the health care. That’s part of the reason their healthcare costs is so much lower than ours. So I think we’re not comparing apples with apples when we do that.

Wilson:         We provide family support. One of the things that was mentioned earlier this morning was, the offshoot of caregiver burnout, a caregiver, work deprivation which means when, if you’ve been a caregiver for 15 years, you don’t have the work history, you don’t have the social security so you then are impoverished when you yourself retire.

Wilson:         But also the very sad fact of harassment and battering of seniors is very prevalent. And most often it comes from distressed, stressed out family members. So we give a lot of respite care. Through PACE we provide and we hear from the families that now they’re able to go back to work, they were able to live a life, yes we keep mom at home but you know what, I can have my life too. Now Intergenerational Program provides respite care for spouses and for family members, and we find that that is a huge community support and community benefit.

Wilson:         We also have another piece to our puzzle which is housing. We realized very early on with our PACE program, that people were under housed and poorly housed. They were living in absolute poverty, filth, and if you’ve been wheelchair-bound for five years in an older apartment, you can’t get into the bathroom because the doors are only two foot wide and you need a three foot wide opening to get a wheelchair in there. You can’t mop your floor, you can’t change your sheets and then get out of a mobile home, and go to the laundromat to wash them if you’re wheelchair-bound and you don’t have transportation.

Wilson:         The life impact of being disabled, and being elderly, and being poor is horrendous. So we have tried to do a lot of homeless housing, we’re currently serving 205 people who were previously living under bridges and in the bushes. So we’re very proud of that. And that is part of providing health care. There is no health without housing.

Sarah:           Thank you. Cheryl Phillips.

Phillips:        Well thank you. And there’s some recurrent themes I think we’re all going to be building from the last panel and this.

Phillips:        As a Geriatric physician, I grew up knowing that it was all of this integration. In fact, Cheryl and I do go way back because I began my geriatric career, and starting a PACE program in Sacramento, and I was Chief Medical Officer at On Lok. And so to me integration is in fact that core.

Phillips:        So when I think about integration, I think about it as tertiary prevention. We’re talking about models for successful aging, for high risk, high cost older persons. It is in fact the combination of Comorbid chronic conditions and long-term services and support needs. And I know that Larry Adkins is here from the Long-Term Quality Alliance, and their brief from October, 2017 pointed out that in fact that 13% of Medicare beneficiaries who need LTSS, are predictable costs three times greater.

Phillips:        So to me integration is the medical services and their long-term services and supports, and behavioral health needs. To me integration is, the integration of Medicare and Medicaid, because when you have two separate benefits that compete, two separate enrollments, two separate, the whole mass of networks of services.

Phillips:        But ultimately to me integration is the person’s-centered approach to care that integrates payment policy, regulation and practice. And so in the SNIP Alliance, we focus on how do we promote integration? Special needs plans for those of you who may not be familiar, there’s three types; Chronic care, those with serious chronic conditions, I-SNPs or Institutional Level of Care Special Needs Plans, or D-SNPs or Dual Eligible Special Needs Plans.

Phillips:        Special needs plans are a subset of Medicare advantage because again going back to her current theme, the flexibility of a capitated payment to where you can start to direct services in unique and different ways, is available under a prepaid or capitated model. So the special needs plans are a subset.

Phillips:        There’s currently 2.6 roughly, million individuals enrolled in special needs plans, 2.3 of which are enrolled in Dual Eligible Special Needs Plans. But merely just having a D-SNP doesn’t mean that you have an Integrated Dual SNP. Because States also have challenges, So in order to truly integrate, you need to have contracts with the State Medicaid Offices, you need to have coordination with LTSS, and a behavioral health and that means contractual coordination, information sharing.

Phillips:        Ideally you move to what’s called a Fully Integrated Dual Eligible SNP or FIDE SNP. There are I think 47 plans in 12 States, but they still, about 177,000 enrollees are fully integrated, but under a fully integrated, the beneficiary gets single enrollment processes, coordinated benefits and services, coordinated appeals processes. But it takes a partnership with the State, but many States are not in a position to do yet.

Phillips:        I want to touch just briefly on the supplemental benefits that were mentioned this morning. So another opportunity with special needs plans including all MA, but FIDE SNPs, have long had the ability to do more supplemental benefits. Just recently, CMS allowed the expansion of supplemental benefits to no longer be primarily medical.

Phillips:        I’ve heard people say, “Well good, this means we can do away with Long-term care insurance.” And so I’m going, “[inaudible 01:42:33]. That’s not going to happen.” Because these are small, there’s no new money. Medicare advantage plans have to within their own medical loss ratio in their bids, have to figure out ways to address these supplemental benefits.

Phillips:        But for the first time we’re able to look at benefits such as, Non-Emergency Medical Transportation, such as meals … It was mentioned by Meals on Wheels, home modification that we have long said. These are opportunities to really look at integration, what the person needs. What I am hoping going forward as the States move to integration and we truly see an alignment of Medicare and Medicaid, for medical and LTSS, that we can start to expand the application of these benefits.

Phillips:        Right now we’re still on early stages. We have a long way to go, but to me the real opportunity models for high risk, high cost older persons, with complex medical needs and LTSS, is in fact in that marriage and integration that looks seamless to them. That’s the ultimate goal of persons-centered integration.

Sarah:           Thank you.

Sarah:           Gina Buccalo.

Buccalo:        Good morning. Thanks to Sarah, and The Alliance, and everyone here today for allowing me to be here.

Buccalo:        I think I’m a little bit unique in that I’m, I think the only purchaser represented here today. I’m also a provider. I’m still practicing in the Metropolitan Detroit area and I represent the UAW Retiree Medical Benefits Trust or The Trust for short.

Buccalo:        And I wanted to spend a few minutes letting you know a little bit about The Trust, who The Trust is and what’s important to us in our strategies. There’s a handout, I think that was on the table as you came in that hopefully gives you a visual summary.

Buccalo:        The trust is the largest non-governmental purchaser of healthcare benefits in the country. So next to Medicare, we’re purchasing healthcare for our 668 … Right now is our current number, retirees. What’s interesting about The Trust is, we have our retirees once they join The Trust for life.

Buccalo:        So for me being especially interested in population health, this is a true opportunity to really test, and to measure, and to really understand what population health is all about. Our members average around the age of 71. Just as you’ve heard today, their most common chronic conditions are the ones that you would normally think of, Hypertension, Cardiovascular disease, Cancer, COPD.

Buccalo:        But also what’s interesting is, remember these are retirees who spent their life making our cars, musculoskeletal conditions. So we have a huge disproportion number of our members who need hips and knees, and they want both hips, and they want both knees and they also have spine issues as well. So we were always looking for new ways to be able to address those conditions in better ways.

Buccalo:        The trust spends $4,000,000,000 a year on healthcare. Half that is pharmacy. I know we’ve had some conversations this morning about pharmacy. One of the programs that we put in place, one of our strategies very early on, was to be able to address the pharmacy costs was really something quite simple is just promoting generic use rate.

Buccalo:        And so if you think about what new drugs are coming out, there aren’t very many generics anymore. They’re all specialty drugs, new emerging therapies that are being administered, and again that’s one of our medical costs, being administered under medical benefits. We’re spending half of that $4,000,000,000 on pharmacy alone. So it’s a big cost for us.

Buccalo:        One of the strategies that, The Trust is undertaking is really to figure out how we can work collaboratively with our payers, with our carriers. We work directly with providers and provider organizations, and we also work directly with our members, so we’ve done this. And in part it’s because upto this point, the model it hasn’t worked. The carriers do what they can, and we have vendors who do special programs for us and they’ve been successful, but we found that sometimes just going directly to the members, asking them what they want and what they need, is sometimes the best approach.

Buccalo:        So one program that we have found, was particularly successful, something very simple, it’s a Gaps in Care Program. We believe that engaging our members to come into the healthcare system is one way to get them before disease gets started and before it really takes hold. As an example, we had a Colorectal Cancer Screening Campaign and we were able to screen an additional almost 20% of our members above and beyond what our carriers were able to reach. A third of them had active Cancer upon screening. We have to remember the retirees are typically not good healthcare consumers. So, we’re constantly are trying to find ways to be able to reach out to these people and to get them engaged in the health care conversation.

Buccalo:        And another program again partnering with our carriers that we have found to be successful, is something called an In-Home Assessment. We’ve heard a lot about models that are community based and we’re very much supportive of those community based models, but what we’ve done with one carrier who actually is here today, has been successful with our retirees, is we’ve been able to get into the homes of one in four of our retirees.

Buccalo:        This is a rate that far exceeds what you would expect with what our retirees are able to do in going to see their doctor. So if getting into the home, usually people, the carriers want to get into the home because they see that as a data gathering opportunity. But what we did in this case is, we designed a program so that if they see a member who needs an urgent need, that they were able to refer them immediately to care. What we’ve also found is opportunities to refer them into other programs.

Buccalo:        One of the most popular, believe it or not, is something called SilverSneakers. It’s the most commonly requested program of our seniors and our retirees, at when we present the opportunities at meetings. The in-home assessments then have really been that good vehicle to get us in there.

Buccalo:        We heard a lot of talk today about social isolation from doctor from CareMore. As an example, 33% of our retirees have been recognized as being single and we’re really concerned about this. We know that a 103,000 of those, are male and really puts them at increased risk for social isolation and being able to address their care gaps. So The Trust is interested, especially today in conversations that begin to provide services for these people that we know are at risk today.

Buccalo:        Lastly, again I think our unique position as being the purchaser here today, we’re excited to participate in a conversation that provides new opportunities to really be strategic with you, on what it is that we need to do. We’re interested in community based models, we’re very primary care centric in the care models that we promote, but we also agree that value based care is the wave of the future. And we’re interested in finding out how we can really work with you to deliver the care that our retirees really are well deserved.

Buccalo:        Thank you.

Sarah:           Great. Thank you.

Sarah:           Thank you all for those opening remarks. And we will turn it to the audience for your questions. If you have a question, raise your hand. But let me just kind of, I just want to ask an initial question and then … I see you and we’ll get you a mic so you can go first.

Sarah:           But I want to go back to this theme about, kind of combining a couple of things. [inaudible 01:50:46] you talked about quality metrics and outcomes. I think just about everyone on the panel talked about, asking people what it is that they really want?

Sarah:           And going back to our keynote this morning, what is it that people really want? Dental care, to Melanie. Now they just want like a place to charge their phone and a sandwich, I forget the WiFi, and I forget the third one.

Sarah:           How do you do that? We have such a vast kind of system for quality metrics, whether it would be in Medicare advantage, or fee for service Medicare and it’s seems like we’re, are we getting to the right things? How do we get to the right outcomes and how do we make them, the outcomes more person-centered?

Sarah:           So if you could kind of comment on that and then we’ll go to our audience question.

Wilson:         We do an annual survey of all of our PACE participants and their families. And getting back to two key questions as Rushika said that, one of the questions is, would you refer somebody to the program? And are you happy with the services? And we continually for 10 years have rated 98 to 99 percent on both of those questions.

Wilson:         That gets to, are they able to charge their phone? Or whatever their needs are, whatever they perceive their needs to be, we are reaching out and meeting those needs. Baseline is good health and we provide that but the other things that improve the quality of life and their access to healthcare. So I think collecting and keeping it brief and getting to the heart of, what is it we’re trying to do with these seniors?

Phillips:        Special needs plans have the opportunity. Now not all of them do it perfectly well yet, but the opportunity is through the required care coordination. So under a special needs plan, you must have a model of care. And it has to include a person-centered plan of care. Now to me, person-centered means, not about or not two, but actually with the individual who sets that plan of care.

Phillips:        And so the ability to set goals, set priorities and build that into a care plan that goes across in a truly integrated model across the people who are working to support that individual, that ultimately is persons-centeredness. Do we have good quality measures that reflect this yet? Absolutely no.

Phillips:        I know that MCQA, and NQF are working on person-centered quality measures. There’s lots of debate, should they be processed? Or should they be outcome? And some high risk populations have greater challenges. But if you start with what matters to the person, so if they’re living under the bridge and they don’t have access to food, whether, or not they get a Colonoscopy may be important, but may not be their first measure of quality.

Phillips:        And so if we are looking at starting from the person what matters to them is the point of contact for care coordination and planning care, then I think that will go a long way. Then all of the other quality measures start to come into play.

Buccalo:        So in building on that point Cheryl, what I would say is, what we find at least in The Trust population is, they don’t typically access care. And the reason that I talked about the Colorectal Cancer Screening is, it was a way to get them engaged in the health care conversation.

Buccalo:        And so, we do go. The in-home assessment, as I’ve said, has been a great way to kind of open up the conversation and ask people what they need. We have rich benefits far beyond what our retirees had when they were actively on the line. And what’s interesting is, they’re not used to accessing healthcare so giving them, or finding those quality measures that kind of open up the door, I think are going to be a challenge for us. And we do need [crosstalk 01:54:34].

Phillips:        I’m certainly not disparaging colorectal cancer screen [crosstalk 01:54:38] but to many individuals that’s not their first measure of quality.

Buccalo:        No, but it was a way to open the door. So there was a study that came out recently that found that, if you open the door for women who had a Mammogram, that they were also more likely to get cervical cancer screening.

Buccalo:        And so campaigns again, it has to touch them. It has to touch them and it has to be important for them, is a way to open the door for them.

Sarah:           Terrific. Thank you. Okay. We had a question on fourth row.

Sarah:           Yes go ahead.

Speaker 5:     Hi, I’m [inaudible 01:55:10]. I’m an independent consulted. And I haven’t heard across the two panels a lot about, how do you address the special challenges of serving rural populations? Rural areas don’t have as much penetration of Medicare advantage.

Speaker 5:     You might not even have healthcare resources in the community to integrate with. And also, it’s probably pretty difficult to achieve the scale that you need to really offer some of these programs.

Wilson:         Well …

Phillips:        Oh, go ahead Cheryl.

Wilson:         Telehealth, outfitting the home, the farm, wherever, in rural Montana, or wherever with, a Pulse Oximeter, or the APP on the iPhone that can do a cardiac monitoring once a day, or, and then you can go and wire the house-

PART 4 OF 5 ENDS [01:56:04]

Speaker 6:     Monitoring once a day or then you can go and wire the houses, although we had a study done by UCSD, Jacob School of Engineering, the Qualcomm, inventor of Qualcomm. He came out and said, doing homes, smart homes, as we call them, is a big liability. It’s not cost-effective, and the people don’t put the batteries in the systems on the refrigerator or the toilet or the older systems, the motion sensors, and so actually doing something where they’re actually engaged via their phone, via their TV, or via their family is the way to go, but telehealth is really the answer, especially in inclement weather.

Speaker 7:     And I think for workforce, letting people practice to the scope of the license is an important thing, so sometimes that’s unusual to come from a physician, but nurse practitioners, PAs, these are direct care workers who may not have clinical skills training, this is the untapped army that we can leverage in very positive ways and there’s some really remarkable, innovative models that combine telehealth and technology for direct care workers, so, Susan, I see you back there, from LeadingAge, a big focus on how do we get to workforce into rural communities? And using direct care workers, and I would never use the term “unskilled,” because they’re very skilled. They may not have clinical license, but they’re very skilled, with platforms and tablets that they can interact with, decision trees to centers that can triage care or services. I think we need to leverage our workforce in very different ways.

Speaker 6:     If we were able to fund Meals on Wheels or home care agencies to have an iPad with the folks who go to the home so they can immediately say, all of a sudden I take the meal into the home. I put it into the refrigerator, and I see blood on the kitchen floor, you know, I see this, I see that, the dog hasn’t been fed, those kind of things, and immediately transmit that into their primary caregiver or their health plan in some way, shape, or form, that really is an answer.

Moderator:   Okay, lots of questions. So, yep, go ahead and then you. Okay. Thank you.

Sue Peschin:  Hi. I’m Sue Peschin with the Alliance for Aging Research. Thanks so much. I thought this was really interesting. I wanted to ask [Dr. Bukhalo 01:58:20], if I’m pronouncing that right, I saw on your fact sheet that you have 132% increase in utilization for vaccination. And I wanted to drill down on that little bit, and then I wanted, as a more open question, to anybody on the panel, for you guys to talk about the Welcome to Medicare visit, and whether or not that was something you focused on within your programs.

Dr. Bukhalo: Sure, absolutely. That’s part of our Gaps in Care campaign.

Sue Peschin:  Oh, I’m sorry. The annual Wellness visit. That’s what I meant.

Dr. Bukhalo: Yes. And again, what we found is again, members don’t want to get immunizations. They don’t wanna go see the doctor, so we were able to reach out to them either at retiree meetings, which is, to me, a unique aspect of the trust and the culture of our retirees, and it was a simple postcard campaign. We used somebody famous on the postcard, and I think it was able to touch them, such that they were … Pardon?

Male:            Who?

Dr. Bukhalo: I can’t remember who it was.

Speaker 6:     Really famous.

Dr. Bukhalo: It was before my time. I’ve only been here 18 months. But the campaign was successful in that they were able to, what we call, open gaps, so they were able to close the gap 132% beyond what the carriers had been able to achieve with immunizations, so for flu and pneumonia. So and we still had this campaign. Our goal, quite honestly, is we hope that our carriers will put this program out of business, right? That if we’re paying for carrier services today, and if those programs are successful, then we really should need to reach out directly to our members.

Rushika:       I think that part of the problem is that carriers are the wrong place to put these sorts of interventions, right? People’s relationship with their health plans are really continuous, right? I think their relationship with their doctors actually could be, could and should be really strong. I think a lot of these things that we’re now asking health plans to do are actually much better with disease management, closing gaps in care, are much better coming from us as primary care than coming from some faceless health plan.

Rushika:       And so we install a lot of things, right? So it’s that principle one. Let’s put all of these interventions as close to the consumer as possible, and one of the things it lets you do, in fact, with the annual Wellness visit, is not do one size fits all. Then when you ask carriers who think you’ve gotta do this, everyone’s gotta do the same sort of visit, that’s dumb, right?

Rushika:       Now is it important? We think it is. Is it important that we engage every one of our patients? Absolutely, and we get well over 95% of our patients in to see us every year. And it’s really important, but the most important is to build a relationship, right? So we know what their goals are, we know what to work on, and when something bad happens, they will come to us and not go to the ER, go somewhere else where bad things will happen.

Rushika:       Right, but now the content of that actually cannot be one size fits all, because different people have different needs. A healthy 68-year-old looks very different than a comorbid, an 88-year-old who’s at home near the end of life. So we’re able to sort of tailor the contents of that encounter to what the people need, but I think the principle is it’s really important.

Rushika:       And by the way, by going through Medicare Advantage and not having to worry about billing per thing, we promised this world that we were gonna pay for X, Y, and Z, but only X, Y, and Z is the same thing for everyone? That’s the wrong thing to do, ’cause no policymaker is smart enough to get that right for every patient. So our principle is let us take care of it, and then what we ought to be accountable for is not do we do annual Wellness visits the way you did, but our outcome’s better, and we’re keeping people healthy. We’re keeping them out of trouble, right? That’s what we oughta be accountable for.

Moderator:   So we live in a world where there are plans that have members. How can plans help facilitate, or if they can, those kinds of relationships, those one-on-one doctor-patient relationships, which we’ve heard a lot about, and we’ve heard a lot about also from the Hill, kind of cutting the red tape, that kind of thing, giving, allowing care to be more patient and physician or care provider-focused?

Rushika:       Yeah, so part of the problem is this sort of fragmentation. Again, the way most carriers do things is disease by disease, for instance, right? So you can have a patient getting six calls from six different nurses. The CHF nurse, the diabetes nurse, the close the colon screening nurse, the whatever, and we think that’s silly, right? That’s not the right way to do it, build bottom up. So we formed really close, you know, it’s relationship-based care, really close partnerships with our health plans.

Rushika:       So, for instance, work with Humana in four different states out west, and they delegate to us a lot of the stuff that they used to be doing at the plan level and decided this is better done by you. And so we’re not gonna have a nurse call them for the diabetes. That’s your job. We’re not gonna have … we’re gonna have the, whatever, disease management companies stand down, right? So I think it’s about conversations and coordination that needs to be done sort of explicitly in partnership.

Speaker 7:     Now I’ll add there is an opportunity, though, for high touch, particularly specialized managed care plan, so I think of some of our special needs plans that I made the reference to enrolling under the bridge. There actually are dual eligible high-touch plans that go under the bridge. They’re not seeing a doctor. They don’t have a relationship. So that community worker that’s engaging that individual from the health plan, in fact, is the nidus of the relationship, and that’s where, to me, the idea of integration begins. Then you can start doing the engagement with the medical, social services, housing, but you gotta start with that relationship. So there is a role for these high-touch, highly engaged health plans, and they’re almost always specialized managed care plans.

Moderator:   Okay, we have a hand raised high. The young lady in the pink, and then okay, Tom Scully in the back, you’ll get to go next. So go ahead.

Margaret:      Hi. I’m Margaret McGinty from the National Quality Forum.

Moderator:   Yay.

Margaret:      I think, one, it’s a great discussion, and I see you have a lot of consistent themes, both in the previous one and here, going into the policy forefront. I can tell you, I [inaudible 02:04:34], I do get a lot of questions about beta, regarding long-term social services, so I think the radar is out there. There’s just the question of how to do it thoughtfully. We struggle. We actually host the metric incubator where we bring together various parties to hopefully spur development by measure developers in areas that we need, which is one, patient report outcomes, and touching on these non-clinical medical conditions and issues. So I would encourage you to send any data you have and come to the incubator so we can get these measures ready and out there for, I think, mass consumption.

Margaret:      Given that still, 80% of Medicare beneficiaries are under traditional Medicare, and that it’s going to take a lot of time to get them to transition to Medicare Advantage, which seems to be a concurrent theme that I’m hearing. What are some of your suggestions or ideas, best practices that we could incorporate in those larger Medicare programs, whether it be hospital-based, post MAPRA and the MIP space. I mean, you’re choosing six measures out of 236 measures, so there’s a lot of variety in there. What are some of your suggestions on how to incorporate that patient voice in those larger programs? Because we know it’s not going to happen tomorrow that we are allowed to have this kind of flexibility that Medicare Advantage can provide, so I’d be interested to know all of your thoughts on that.

Speaker 7:     Well, I think there’s a cacophony of measurement, but then NQF knows that as well, and many of the measurements are kind of right to work at, so one specialty has a list of quality measures that they need to do for their specialty. But I think that the core question is if you asked beneficiaries and fee for service, what are their needs? Not from a medical, just where are their needs, and had a platform for engaging that? We don’t have a good mechanism for doing that, but if you ask people their needs, they probably don’t come up with their medical needs first. They may, but their life needs is what frames their conversations, and we don’t look at measures. We don’t look at care planning starting from life needs, and that’s really, whether it’s social determinants, LTSS, but just starting with, if we ask people what they need, they will tell us a very different story.

Speaker 7:     So I think that’s the starting point, is reframing it not as medical measures, not as LTSS measures, but as person-centered life measures. That’s easier said than done. There are some vehicles where people have attempted that. Some of you may be familiar with Medicare chat. Marge Ginsburg is now on the MedPAC, and I worked with Marge. In fact, we’ve been part of the pilot in Sacramento that had started Medicare chat. And it starts. It’s a board game, but it starts with, if you were to build your benefits, what would they be? It’s like a game of LIFE. And while it sounds like trivial, it’s a way to say to the individuals, what would you do if you were building what you needed for care? That’s a starting point.

Speaker 7:     And then form follows finance. How we pay is what we deliver, and what we deliver is what we measure, and we measure what we have administrative data on, so therefore we drive quality by what’s easy to measure, by what we pay for, for what we have claims, so we create a circular thinking, and I think the opportunity going forward is how do we break that thinking? And I know it’s easier said than done.

Rushika:       You didn’t ask this question, but I think one of the other problems we have in kind of designed care models for seniors is this one-year timeframe, right? So we have this one year. You have to change your M.A. plan. One year to quality measure zero out. And the problem is most of what we do is seniors is about changing behavior, changing very deep-seated things, and their life takes more than a year. And so what happens when you put everything in a one-year time frame, it makes it almost impossible to make the real investments necessary to do the right thing.

Rushika:       So I think, from a positive point of view, if we could figure out a way to think about, particularly seniors that I’d argue maybe for everyone, in a longer timeframe, even two or three or five years. What if we could sell a five-year M.A. plan, and that what you were measured on is results over five years. I think we could make a huge impact by just thinking longer term about these things.

Speaker 7:     One of the things that I think impacts quality is the availability of the health care workforce. We all know we’re not gonna have enough physicians to take care of these seniors, and so as Cheryl said, if we’re able to allow mid-level practitioners to practice at their highest level, and in my state of California, that’s not allowed, and in PACE, you have to apply for a waiver to allow a nurse practitioner to do an assessment. Well, this is what they’re trained to do. They’re trained to do it so much better than the doctor is, and then hand off the information to the physician. Let the physicians practice at their very high level. Physicians shouldn’t be sitting in a room with a patient doing their social assessment. They need to know what that social assessment is before the patient gets into the room because they only have a snapshot of time, unfortunately, and it’s going to get more and more constrained.

Speaker 7:     So we need to be looking at the workforce issues and pushing down the care support to the level for where the training is provided and not all held at the doctor’s office.

Moderator:   Thank you. Tom, did you wanna ask your question?

Tom:            Yeah, just one last … Tom Scully, washed-up, former CMS administrator, a hundred years ago. No, I’m [inaudible 02:10:03] on PACE, and I won’t get into that, since you already talked about PACE a lot and I do think there should be a lot more than 40,000 people. Probably 200,000 people in PACE? The real issue that you haven’t brought up, which surprised me, is you get two great models in Minnesota and Massachusetts, senior care options in Massachusetts. Basically, it’s PACE without walls. Could be available to a lot more people. There are great waivers that have worked really, really well in both states. Melanie probably had something to do with creating them.

Tom:            But they really are fully integrated, totally comprehensive, capitated programs that work great, and they work great. I mention this ’cause Dr. Rashika’s in Massachusetts. Those have been spectacular success, certainly in Massachusetts. I have nothing to do with either one of them, but I admire both of them, and I wonder why people don’t talk about that more and why it’s not a bigger model. I think both states think it would save them a ton of money. It’s much better health care for seniors, and it’s fully capitated. It’s basically PACE without the buildings. Much more accessible to more people and just makes a hell of a lot of sense and I’m shocked it hasn’t come up today. So wonder if you’d comment on that.

Speaker 8:     Well, I’ll talk briefly, ’cause we do represent these Medicare, Medicaid demonstration models. So Minnesota and Massachusetts, and now that Massachusetts with their proposal to their 2.0, these are phenomenal examples, and using Massachusetts as an example, they integrate both affordable housing, housing with services, with the health plans, with assessment, with their LTSS needs, but it requires states’ participation, so you know better than I, and I won’t try to educate you, but for the audience, it requires a three-way contract. Right now, there are 10 states that have these demonstrations. California just had a report that came out in Health Affairs, so this last issue of Health Affairs, you can read about the California demonstration. Interestingly, they had good outcomes, reduced costs, also of report, self-report of hospitalization, but when you ask the individuals about care coordination, they had no idea who their care coordinator was, which I think speaks to this poly management syndrome.

Speaker 8:     But part of the challenge is how do we get states to align with the managed care organizations to align with LTSS providers, and that’s easier said that done. But I think that the opportunity, and both you and Melanie are our leaders in thinking about how do we move demonstrations forward as the platform for new thinking? And those two examples, I think, are very profound. Part of the hesitancy is the states’ resistance, and let’s be honest. We’re all in health care systems fighting for, we wanna do all this better, but we also want our own little sector to do well. And some of these things means blurring the lines between the sectors, whether it’s hospitals, doctors, health insurance, state Medicaid, these all become opportunities for making a messy finger-paint that sometimes is threatening for the individuals.

Moderator:   Thank you. So time is flying. Quick question and then I’m gonna ask one final question. Yes, Go ahead in the back.

Joanne Lynn:    I’m Joanne Lynn from Altarum’s Program for Improved Elder Care. And today I find myself speaking from a position of despair and anger. These are wonderful ideas, and things that have been put out today are terrific, and they’re also a molehill to a mountain. We are going to be in a position of abandoning the elderly in 15 years. We know who they’re going to be. They’re gonna be us. We vote, so we’re going to be able to cripple the economy by continuing to pull all resources toward elders. Caregivers and elders vote.

Joanne Lynn:    So we need these sorts of innovations at a much bigger scale, not even just the 200,000. We need two million. We need continuity to be a real anchor point. We need to really renovate the medical care is delivered and make it much less expensive. We need to be able to deliver services on a geographic basis so that we don’t have 60 home care agencies in Washington, D.C., serving every house in D.C. That’s crazy. No other country wastes money that way, with three and a half-hour minimums and enormous overheads.

Joanne Lynn:    We need an era of dramatic innovation and really loosening the reins and trying things out, especially on a geographic basis because so much of what matters in elder care is really anchored in your community, and you really need ways to get the transportation, the home care, the housing, the workforce working at a community level. What if we had 10 or 12 counties that really showed how to put all these great ideas together in one place and drive down the per-capita costs and drive up the reliability of services? We’re still using Blue Cross plan for old people, and that’s the wrong model. We’ve known it forever.

Joanne Lynn:    But where’s the will to actually undo it? If we just keep going at the current pace, we will have whole lots of evidenced-based innovations. And they will not supply most people. Most people will still face a chaotic, overly expensive, thoroughly under-serving situation in communities that do not know how to take care of them. That’s our futures. What are we gonna do about it?

Moderator:   Joanne, thank you, and I will take sort of that passionate call to action and will take kind of one or two more minutes to wrap up this panel and ask each of you, we have our panel of policymakers next. What do policymakers need to know as policymakers are contemplating the future of programs for aging Americans, and if we could kind of get a brief couple of thoughts from each of you, knowing that it’s impossible to contain all the ideas in just a couple minutes.

Speaker 6:     I’ll start. The words that pop into my head as you were talking, Sarah, were it’s all about access, so we have to be open to allowing our whole healthcare provider team to be able to provide direct care, whether it’s through telehealth, whether it’s community health workers, whether it’s advance practice practitioners, but we have to move beyond our traditional medical model that we have in place today. That, I think, is one.

Speaker 6:     We’ve already talked about the looming physician shortage projected to be, what, over 100,000 by 2030? Yeah, the lead article was one of the ones about the oncology crisis that is coming, so we need to be innovative and creative in really opening access to care, and I think that the trust would like to see more community-based models.

Speaker 6:     And then the second thing is we have to move out of our traditional payment system. We have to move to new models that pay for the right care at the right place and no more, and I mean, we had the conversation. If you pay the hospitals and the providers to see patients and put patients in beds, then that’s what they’ll do, so if you pay providers to do the right care and get the patients engaged, then I think we’re gonna move in the right direction.

Moderator:   Thank you.

Speaker 7:     And so I know I’ll agree with what everybody is saying, so I’m gonna add also integration. Right now it is our regulatory environment that is a barrier to integration. So CMS has its sets of regs. They often are in direct conflict to the Medicaid state regs, so what is our regulatory burden that’s in the way of integration, and what can CMS and the states do to incent moving towards integrating long-term services and supports and medical care? That’s another policy opportunity.

Speaker 8:     For me, it’s all the money. We need more money for housing, low-incoming housing, not affordable. Low-income housing. We need more money to offset the educational expenses of healthcare professionals, and that would include not only doctors but dentists and nurse practitioners and dieticians and the whole team, and then also having programs that are capitated, risk-based and one part of money so that the state isn’t fighting the feds, isn’t fighting the plan, isn’t fighting the doctors. One part of money, risk-based. Everybody then is incentivized to take care of a problem when it’s this big before it gets to be this big. A little bit of exercise upfront prevents a full and a fractured hip on the end. Saves money. My tax dollars.

Rushika:       Obviously, I agree with all that. I think if you think most of the innovator stuff out there is happening not surprisingly, with new entrants, like ourselves, Chen, CareMore. That’s why we exist, right? We’re not trying to maintain the status quo. In almost every other industry, what drives the industry to change? Think about computers, think about transportation are new entrants. It’s not the big guys.

Rushika:       There are so many rules in healthcare regulatory issues that lock in the status quo, right? And I think allowing new entrants, a simple thing. You can’t join an ACO unless you already have 5,000 or 10,000 lives. It blocks out new entrants, right? So we have rules of actually allowed new entrants to come in, and that, I think will spur a lot of innovation.

Moderator:   Great, well, on that note, thank you. Please join me in thanking this panel. We really appreciate it.

Rushika:       Thank you.

Moderator:   Thank you.

Speaker 9:     Thank you so much again to everyone. I wasn’t gonna do this, but given the story about the Louisiana doctor, I have to end on a point, ’cause I think it kind of closes it up. I’m sometimes asked if I’m related to Sam Dash, and I always say, well, not that Sam Dash, but I was related to someone named Sam Dash, and literally, all I know about this relative is that sometime in my grandparents’ era, he was a doctor, a family doctor in Philadelphia, and the only story I know about him is that he would make house calls and that he was known to leave money on the kitchen table for food.

Speaker 9:     And so I think it’s past this prologue, we’ve been working on these issues for a really long time. We’re gonna keep working on them. I really appreciate all of our panelists, everybody for giving such thoughtful, thoughtful and really thought-provoking presentations. You can be sure you’re gonna hear from the Alliance about some of these themes and how to move the conversation forward. I wanna thank all of you for being here and spending your morning with us. And once again, please join me in thanking all of our panelists.

PART 5 OF 5 ENDS [02:20:51]