Outside box solutions needed for seniors care
WASHINGTON: When it comes to meeting the healthcare needs of seniors — especially those with low incomes and multiple illnesses — thinking differently is what’s needed, several experts said here Wednesday at a briefing sponsored by the Alliance for Health Policy.
For example, Medicare’s accountable care organizations (ACOs), under which groups of physicians, hospitals, and health systems work together to provide care for a specified group of patients, should be restructured, said Rushika Fernandopulle, MD, co-founder and CEO of Iora Health, a Boston-based company that helps providers form ACOs. “We’ve tried anchoring accountable care in hospitals, and I think it didn’t work — not because they’re bad people but because their incentives were wrong. We should build accountable care, not top down, but bottom up. Start with the consumer and align around them” using primary care as the anchor.
In addition, ACOs should be run by physicians, not by corporations, said Jason Barker, regional market president for the south Florida region of ChenMed, a company that runs medical practices that cater to low-income patients who have complex medical needs. “Probably 20 years of my career was spent 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 any more.”
“The problem with ACOs [is that] you’re trying to anchor them to an institution where it is counter to their incentives to have people be healthy and in the community; they want their beds full,” he continued. “I think ACOs can serve a purpose but they need to be in hands of physicians, not necessarily integrated healthcare systems and hospitals.”
Speakers expressed support for paying more attention to the social determinants of health, such as housing, transportation, and food. Lucy Theilheimer, chief strategy and impact officer for Meals on Wheels America, pressed for more interaction between the medical community and social service organizations like hers. “There is a need for building a bridge between clinical and non-clinical providers,” she said. “We have armies of staff and volunteers touching these high-risk individuals every day. They know how to address social determinants of health, and they are deeply rooted in the community.”
These Meals on Wheels workers “struggle with the recognition of the role they can play and skills and expertise they have,” she said. “We know that making investments in these kinds of services improves outcomes, improves lives, and keeps people independent. We have a huge opportunity to bring this forward.”
Theilheimer said her organization was encouraged earlier this year when the Centers for Medicare & Medicaid Services (CMS) put out a letter about the potential of expanded supplemental benefits because it seemed “that there was going to be some opportunity to expand resources available for programs like Meals on Wheels,” but then was “very disappointed to see that CMS, in a follow-on letter, essentially ruled out using those kind of services for the purpose of addressing social determinants of health.”
Another problem Medicare’s ACOs have is the pressure to produce results at the 1-year mark, said Fernandopulle. “Most of what we do with seniors — changing their behavior — involves deep-seated things in their life that take more than a year,” he said. “That makes it almost impossible to make the real investments necessary to do the right thing. What if you could sell a 5-year Medicare Advantage plan and measure results over 5 years? I think you could make a huge impact.”
Edwin Walker, deputy assistant secretary for aging at the Department of Health and Human Services Administration for Community Living, said his agency, which provides community-based services to seniors who need them, needs more respect. “Our experience far too often has been that the healthcare sector … refers people to [our] home and community-based services network and they refer to us as ‘those free services,’ and we’re not free. We need to be a player, an equal partner, in not only achieving the goal of good healthcare outcomes, but sharing in the reimbursement that goes along with providing healthcare.”
When it comes to leveraging federal funds to provide healthcare, thinking outside the box can help, said Nick Uehlecke, majority staff member on the House Ways and Means Health Subcommittee. “I’m encouraged when I see something like Hawaii, where homelessness and [the associated] pneumonia is such a problem that they’re thinking of turning homelessness into a medical diagnosis,” said Uehlecke, who was speaking for himself. “We’ll take all the ideas that you have … We have to find all the pieces and put it together correctly.”
Audience member Joanne Lynn, MD, director of an elder care improvement program at Altarum, a consulting firm here, was pessimistic about what might be coming. “I’m speaking from a position of despair and anger,” she said. “We need these innovations on a much bigger scale … We’re still using [fee-for-service] Blue Cross plans for old people, and that’s the wrong model. We’ve known this forever, but where’s the will to actually undo it?”
