2023 NIC Spring Conference Preview
Nirav R. Shah, MD, MPH, a Senior Scholar at Stanford University’s School of Medicine and Chief Medical Officer of American Health Associates, is a leader in care innovation for older adults. Dr. Shah will share his expertise in health and healthcare as a keynote speaker at the 2023 NIC Spring Conference (March 1-3). Shah’s research focus areas include improving care for family caregivers, expanding the reach of PACE programs, and improving outcomes in nursing homes. Board-certified in Internal Medicine, Dr. Shah is a graduate of Harvard College and Yale School of Medicine, and is an elected member of the National Academy of Medicine.
In advance of the upcoming NIC Spring Conference session, I recently spoke with Dr. Shah about how changing healthcare landscape and payment models can mean opportunities for senior living operators.
Marcet: Dr. Shah, tell us about your experience in healthcare and how that has shaped your beliefs about the future of healthcare payment and delivery.
Shah: I’ve been a practicing physician, regulator, operator, payer, and public health leader. Collectively, these experiences have convinced me that we need to move upstream and keep people as healthy and active as possible. By focusing on prevention rather than only taking heroic measures when it’s often too late, we can do good and do well. That is, I think the healthcare system is finally starting to align incentives so that we can consistently have that upstream focus. With more systems taking on risk and learning about value-based care, the only way to make margin is to keep people healthy and out of the hospital, to know an individual’s health needs, and help deliver health at home. In fact, this is what people want, and is perhaps a good “side effect” of what Amazon and COVID-19 taught us, that consumerism when it comes to healthcare demands high quality, safe, reliable, and timely care that’s personalized and on your schedule at home — not just when it’s convenient or how it’s been done by traditional healthcare delivery systems for decades.
Marcet: What is driving the changes in how we think about health and how and where healthcare is delivered and paid for? Does this shift change the value of senior housing and care to our healthcare system?
Shah: For years, seniors housing focused on the residential aspects of an individual or couple’s needs, and stayed away from healthcare because of regulatory concerns. Now, with the shift in how healthcare is paid, the many opportunities to keep people healthy are most apparent in the home. So there is a big move away from focusing on hospitality alone, to delivering healthcare as well. For some, this means renting space to a PT practice onsite, or affiliating with a physician group. For others, “frontier” operators are even running their own insurance plans. While that model may not make sense for most operators today, there is lot of value to be captured by thinking outside the box, and partnering with healthcare providers and insurers in ways that keep people healthy and thereby in your environment longer. This is especially urgent given the changing demographics — with older residents who have multiple health conditions the ‘new normal’ in seniors housing.
Marcet: Specifically, what are the implications of hospitals coming to be viewed as cost centers rather than revenue centers? Why does this shift matter to the senior housing and care industry?
Shah: Today a hospital in a value-based contract will be paid the same regardless of a one-day stay or a five-day stay for a given procedure. So hospitals want to shift care — and cost — outside their four walls to other sites. For a traditional nursing home operator, becoming a “super SNF” that combines medically complex care with high-end hospitality (and resulting higher reimbursement) might make sense. So, the hospital of tomorrow is an Emergency Room with an ICU on the second floor — most elective surgery and procedures such as colonoscopies have already moved out of hospitals to ambulatory sites. The nursing home of the future is today’s hospital ward. And home is where people want to stay and get care, and this becomes the main site for almost all care supported by telehealth, remote patient monitoring, visiting clinical staff, and even hospital-at-home care models.
Marcet: Value-based care (VBC) is an acronym we hear a lot these days — along with talk of risk-based models of care and payment, social determinants of health (SDOH), Medicare Advantage (MA) plans, and ACOs (Accountable Care Organizations). Is this just the latest fad or buzz in healthcare similar to the push to managed care in the 80s and 90s that then faded away with negative press and consumer reaction (there has been a lot of negative press about MA plans lately, for instance) or is this a movement that will fundamentally reshape healthcare delivery and payment in the U.S.? Put another way, as a senior housing and care operator, owner, or investor, should I be paying close attention to this movement and anticipating NOW what it means for me and what opportunities/challenges it offers, OR should I sit back and wait till the dust settles to see what meaningful long-term changes result?
Shah: There is a component of hype with today’s level of interest in Medicare Advantage plans and the many other new programs. But their fundamental premise of paying for value is built on decades of previous work. So while MA may see reimbursement cuts in the coming years, for example, the promise of paying for value remains, and learning how to function in a world where upside and downside risk is shared, where personalized health is prioritized, where the “consumer” is king, and where dollars flow to whomever can best keep people healthy — these are foundational elements that won’t change, even if another acronym is the primary vehicle of value-based care.
Marcet: Does the current push “moving health home” provide opportunities for senior living providers and, if so, what are necessary steps to take advantage of those opportunities?
Shah: First, providers have the opportunity to understand their residents better than almost anyone else. Who best than someone with 24/7 access to a patient to understand her unique wants, needs, and preferences for care? Invest in those skills.
Second, as a trusted partner to a resident, senior living providers can best guide an individual to the right mix of services to keep her healthy. That means providers need to be able to discern among healthcare options, and not just go with whomever has the best marketing or revenue opportunity — but serve as an advocate for the resident. It’s incumbent on providers to take on the stewardship role, as they know the geographic region with its unique mix of clinical providers better than any single family, and can take a long-term perspective for the resident’s benefit.
Third, in the near future, every provider will need a good answer for in-person or “last mile care” in the home, which includes diagnostics such as radiology and laboratory, triage with home-based assessments, and post-acute care monitoring and management. Already family members ask about such healthcare options before they ask about a facility’s dining options — and this emphasis on high quality healthcare in the home will only accelerate.