Seniors are going to receive primary care. In 2019, the question is where.
Primary care is critical for any person’s health. Yet across the nation, visits to those physicians are declining for Americans of all ages. Seniors specifically are faced with two unique barriers: travel, and the need for care overnight.
Seniors also face a greater need for primary care than younger generations due to their higher number of chronic health conditions, which are best managed via consistent visits with a primary care physician.
Add it all up and we see a landscape where bringing primary care directly to seniors in senior housing is more important than ever. In fact, four factors now in play are helping transform forward-thinking senior living operators into power players in the health care continuum.
“If the senior housing industry can bring primary care onsite on a large scale in the next few years, it can become the predominant pre-acute provider of care in the health care continuum,” says Andrew Carle, president of Carle Consulting LLC. “And being the predominant pre-acute provider of care can make you more powerful than the hospitals or the nursing homes or anyone else in the system.”
Primary care visits are crucial to managing chronic health conditions
“For young, healthy people, nine out of 10 times, (primary care visits) are wellness visits,” says Cindy Longfellow, vice president of business development, sales and marketing at Juniper Communities in Bloomfield, New Jersey. “But for seniors, the focus of primary care is chronic care management.
The diseases defined as “chronic conditions” vary depending on the source — the Centers for Disease Control and Prevention lists 22, while the Centers for Medicare & Medicaid Services (CMS) lists 18 — but in general the term applies to severe, persisting conditions, everything from hypertension to arthritis to dementia to ALS.
As people age, these conditions multiply: it is common for senior living residents to have between four and eight conditions. At Bluestone Physician Services in Stillwater, Minnesota, the average patient has nearly nine chronic conditions. These conditions cost: Americans with five or more spend 14 times on health services than people with none.
Increasing the frequency that a given senior meets with a primary care physician can improve that senior’s health, because the primary care physician comes to understand exactly how each chronic health condition is impacting the others.
Primary care visits are crucial to the success of ever-more-popular Medicare Advantage plans
Yet simply increasing the frequency of doctor visits in a fee-for-service marketplace puts further economic strain on a fattened Medicare system. From 2007 to 2017 alone, Medicare expenses rose from $425 billion to $702 billion. Overall, fee-for-service health care has sent costs skyrocketing ($3.3 trillion, or about 18% of the GDP) without making people healthier.
Enter Medicare Advantage.
In this program, private insurance companies bid to receive federal dollars to offer plans with all the usual Medicare benefits, but with flexibilities built in so that the insurer can potentially turn a profit while the senior receives additional services.
Perhaps as a direct result of these rising costs, the number of Medicare Advantage enrollees tripled between 2004 and 2017, from 5.3 million to 19 million. The Congressional Budget Office projects 22 million Medicare Advantage enrollees by 2020 and a whopping 41 million by 2026.
The main cause for the boom are the advantages that MA plans offer the consumer, the plan provider and the health system at large. Research shows that a person’s health improves with increased visits to primary care providers.
“If the senior housing industry can bring primary care onsite on a large scale in the next few years, it can become the predominant pre-acute provider of care in the health care continuum.”
Andrew Carle, Carle Consulting LLC
Meanwhile, the success of MA hinges on the ability to manage a patient population, as well as the ability for streamlined communication among players in a person’s care journey, particularly at points of transition, such as between a hospital and the home. Senior housing operators are realizing more and more the power they can have by showing MA plan providers the value of their services.
This year, for the first time, Medicare Advantage plans are also allowed to cover certain non-medical, in-home services. This raises the possibility of senior living providers being reimbursed directly for some core services, such as helping residents with activities of daily living.
However, to work with MA plans — or launch their own — senior living providers must show that they successfully keep health care costs down by helping residents thrive. Onsite primary care can help achieve that goal.
Senior housing is becoming an ideal location for primary care delivery, improving health outcomes
The basis for senior housing’s potential power in health care is its ability to manage a patient population, improve communication and deliver primary care more efficiently. In its 2017 Connect4Life report, for instance, Juniper Communities showed the power of integrating primary care within a care model.
“Anne Tumlinson and her team did research on Connect4Life, and what they found is that we had incredible results on reducing hospitalizations and re-admissions,” says Lynne Katzmann, founder and CEO of Juniper. “When you integrate service-enriched housing and chronic-care management, you really do impact hospitalization rates.”
Katzmann and Tumlinson found that with Connect4Life — Juniper’s integrated resident services program that includes an onsite primary care component — Juniper’s hospitalization rates dropped more than 50% from the rates of a similarly profiled population in the community, numbering about 6.5 million Americans.
They then studied the potential cost savings for Medicare of that reduction, and found it to be a staggering $10 billion to $15 billion.
“At that point it became clear that senior housing is part of the solution to the country’s health care crisis,” Katzmann says.
Other organizations innovating with primary care delivery to seniors boast similar success stories. ChenMed’s data shows reduced rates of hospital admission by 50% among its seniors. Ohio Living’s work in Toledo has a hospital re-admission rate under 3.5%, compared to the market average of about 18%.
Bringing primary care into senior housing also improves the other challenge for Medicare Advantage, which is population management. Health care providers are paying increased attention in 2019 to each patient’s social determinants of health, which the CDC defines as the social environment, the physical environment, health services and structural and societal factors.
Senior living operators naturally have all of this information. They know each patient’s entire health backstory, including family history. They know the patient’s diet and exercise schedule. With smart technology, they often know to the minute how much sleep the patient gets.
“Today, the primary care doctors have been completely marginalized, because the health care system has moved to being specialty-based,” says Dr. Gaurov Dayal, president of new markets and chief growth officer of Miami-based ChenMed, a 34-year-old concierge VIP primary care provider for patients of low-to-moderate income.
“So when we (ChenMed) talk about primary care, we are going back to where you have a trusted physician — and I mean a doctor — who knows everything about you and is your partner in health and also in sickness,” Dayal said.
Senior living operators also manage one of the most dangerous times for a senior: night time. The risk for falls is higher and the chances of a disconnect between the resident and a doctor or nurse is greater. When senior housing operators bring primary care onsite, they can mitigate those overnight risks for payers.
Consumers are demanding that senior housing deliver and manage primary care
Seniors move into senior living communities in large part for a lifestyle of convenience, socialization and safety. There is convenience for the resident, but also for the family members, who surely expect to reduce the time they spend coordinating their loved one’s care.
Too often, these family members are met with a rude awakening.
“(Families) say, ‘We’re paying all this money for senior living, why am I still in charge of everything?’” says Tumlinson, CEO of senior living consulting firm Anne Tumlinson Innovations. “(They are) scheduling doctor appointments, transporting (their parent), educating staff on medications, running records down … and the (resident) is on a round-trip cycle to the emergency room.”
When senior living moves primary care onsite, they have the advantage of eliminating these challenges to the families. The transportation is gone. The need to educate staff on medications is gone after the initial resident intake. And the round-trip cycle to the ER is gone, replaced by only the most essential ER visits after all options are explored and executed onsite.
What remains is a holistic system of health built around a resident, starting with primary care, that reduces or potentially removes an enormous burden on families. Since partnering with Redwood Health Partners in 2015, Juniper Communities has seen a 27% reduction in move-outs.
Providing onsite primary care will inevitably add some complexity to senior living, with operators having to create examination and treatment space and find a good fit with a physician group or other clinical team as a partner.
But results like Juniper’s show that the pay-off can be significant, not only by helping maintain steady rental revenue, but by enhancing customer satisfaction and garnering more positive word-of-mouth.