Host of Payment Matters
On this episode, Jeff speaks with Dr. Jay LaBine, Chief Medical Officer at naviHealth. They discuss the impact of the COVID-19 pandemic on post-acute care and long-term care facilities.
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Jeff Lin: I have a great guest for today’s episode – Dr. Jay LaBine. He’s the Chief Medical Officer at naviHealth, a company that partners with health plans and providers to deliver a better healthcare experience for seniors, particularly in the post-acute care space. Jay, it’s great to have you as a guest today. For our listeners, please tell us a little bit about your background and experience.
Dr. Jay LaBine: Jeff, thanks so much for having me. I’m really looking forward to this conversation. My background is that I trained as a surgeon in Michigan. I did kidney transplantation, general and trauma surgery. In fact, Jeff, I did my trauma fellowship in the area around California where you are, in San Diego, California. I then spent 15 years doing my clinical work as a surgeon. I’ll tell you this, though, it’s there where I really got interested in senior care, especially complex seniors. The dialysis population is high-need, complex and those that are in end-stage renal disease are really complex patients.
Then about 10 years ago, I transitioned to become Chief Medical Officer of a health plan here in Michigan. It was focused on the Triple Aim and value-based care, population health, but always had that focus on seniors. Two years ago, I joined naviHealth, which, as you explained, helps seniors navigate from hospital through post-acute care and their recovery, then back into home. Frankly, it’s really a challenge, but we want to make this experience better for seniors so that they can have more days at home.
Jeff Lin: That’s an important aspect. With the pandemic that’s occurring right now, we’re hearing of a lot of impacts to post-acute care facilities. Given your current role, what’s your perspective about those impacts and what are you doing to support seniors that are in long-term care facilities or nursing homes?
Dr. Jay LaBine: I’ve got to tell you – with the COVID-19 pandemic, when it first started, I heard the words historic and unprecedented all the time. And, in fact, it’s true. This is an unprecedented time, not just for the nursing homes, but for all of healthcare. It was like the worst effects of this pandemic have hit our frail elderly. As you know, over 40% of all the deaths are in the nursing home population and with frail elderly. It’s especially in those that have complex, comorbid conditions. People of color have been hit in a disproportionate way as well. So, Blacks, Hispanics and Native Americans.
Our entire healthcare system was tested in unimaginable ways. But for nursing homes in particular, this was a setup. Think about it – frail, elderly, with comorbid conditions, in close proximity with staff that had a very heavy load. This hit nursing homes very hard.
Jeff Lin: As you noted, that’s a recipe for quasi-disaster. It’s a scenario which is really impactful to those long-term care facilities. It’s hard to social distance when you have this segment that’s really susceptible to disease. How do these facilities cope? How do you mitigate the risks and the impact to individuals that are in those facilities?
Dr. Jay LaBine: Part of this is to understand what were the challenges before COVID. We knew that there were challenges in senior care pre-COVID. Some of these challenges are well known. We knew the baby boomers were aging into Medicare at a rate of 10,000 per day. We also know that frail elderly that are in nursing homes were having more chronic disease. The nursing homes had to deal with a larger, aging population. For example, the Kaiser Family Foundation predicts that by 2050 we’ll have quadrupled the number of 100-year-olds and 90-year-olds in the US. So, this was already coming into nursing homes pre-COVID.
So, what are some of the things that the nursing homes were challenged with pre-COVID? It was the investment into the care model. How could their care model get improved when the business model wasn’t completely aligned to optimizing the care model? This was a major pre-COVID challenge for nursing homes.
Jeff Lin: When you say care model, I’d love to double click on this. Is it where care is being administered? Maybe it’s not in the facilities of the nursing homes or the long-term care facilities. Where is that shifting? Or is there a plan a shift where that care is being delivered?
Dr. Jay LaBine: Yeah, one of the challenges for the nursing homes and residential care is going to be how they can innovate for the future. But also, how we as a society are going to invest in this care model. There are clear flaws that were exposed with the COVID crisis. Number one was that there was a lack of PPE, personal protective equipment, for nursing homes. This led to this infection spreading in some clusters in nursing homes. There was inadequate testing available initially. There was, in fact, overburdened staff and I’ll tell you this, that during the COVID crisis, there have been heroic efforts by doctors, nurses and nursing home staff, but the system just wasn’t in place.
Investing in the care model is one part. The second thing, though, is that we know that we need more transparency into the choices that seniors make when they’re leaving the hospital and going into a nursing home. This transparency should be evident in both the outcomes that occur in the nursing homes, but also the costs to do that. The more transparency we can get into costs and care, the more the nursing home industry will continuously improve to better the choice that the consumers make, that the seniors make, and they’ll want to be chosen preferentially over others. Those are a couple of things that need to happen to help with the care model and nursing homes.
Jeff Lin: You talked about investing in the care model, and also transparency and choices. I think in both aspects there’s a potential for costs, right? You alluded to burdened staff, lab testing and other things. So, cost is a big factor in this. Without just lightly adding staff or adding resources across the board and making it more expensive, what digital or any other scalability technology solutions could help to deliver better transparency choices or improvements in the care model?
Dr. Jay LaBine: That’s a really great question. For high-need seniors who need care and need to recover and then get back to the community and independent living, there are ways that we can do that without residential care. This is where innovation and engaging in innovation can really help the senior care models.
Here is one of my favorite examples. We know that home-based medical care or home-based primary care is a great care model for complex, chronically ill, frail seniors. There are a number of models out there that are actually delivering the same level of care as you would get in a nursing home, in a person’s home. Think about it – if I’m 93 years old and I have diabetes, heart failure, I’m frail and I have decreased mobility, it’s hard for me to even get to my doctor’s office. There are a number of models that have been shown to be very valuable for these types of patients. You deliver the care to their home, and it actually decreases the number of times they’re hospitalized and therefore decreases the amount of time that they would spend in a nursing home.
Jeff Lin: In the broader consumer economy – let’s call it the on-demand economy – I can pick up my phone and order any food that will come to my house. Or have an Uber come. The analogy here is that on-demand care – meaning these consumers are at home – and home-based primary care is a better care model for them. That’s great to see.
In terms of innovation, that’s a great transformational component. What aspects of technology, data or analytics do you see playing into this? Telehealth is transforming the other segments of healthcare. Where do you see technology playing in this segment?
Dr. Jay LaBine: Yeah, I think it plays a really important role. I’ll just say this – pre-COVID, there was a lot of concern about the adoption of virtual visits or the adoption of technology. It especially came up with seniors. How many seniors will adopt this? Will they feel comfortable with a virtual visit? I’ve got to tell you, in 10 weeks of COVID we’ve seen telehealth adoption skyrocket. The pandemic basically pushed telehealth 10 years into the future in about 10 weeks. In fact, I just saw that for the week ended April 18th, there were 1.3M Medicare virtual visits, versus a month before that – pre-COVID – in the same week there were 11,000. Astronomical, the amount. I’ll tell you this too – providers were also not engaged in telehealth virtual visits. Jeff, I’m sure you’ll understand this, but part of it was that there wasn’t a payment model that adequately incentivized the providers to get on board with telehealth technology. I think telehealth for senior care will be a really important advancement.
I'll just say this – pre-COVID, there was a lot of concern about the adoption of virtual visits or the adoption of technology. It especially came up with seniors. How many seniors will adopt this? Will they feel comfortable with a virtual visit? I’ve got to tell you, in 10 weeks of COVID we've seen telehealth adoption skyrocket.Dr. Jay LaBine, Chief Medical Officer, naviHealth
Jeff Lin: Those are amazing stats. In the banking world, I’ll create the analogy here, which is that after 9/11, check processing stopped, because checks couldn’t go to all the Federal Reserve branches. Out of 9/11, it created a need to make check processing electronic. It may sound basic now, we think checks are just getting done automatically, but that was born out of 9/11.
In a weird way, COVID is also transformational. If there is a vaccine, and hopefully there is a vaccine, where do you see this going? Do you see us staying the current course in terms of technology innovation and the use of virtual visits, or do you see us scaling back?
Dr. Jay LaBine: No, I actually think that there’s no turning back with some of the digitalization that has been adopted. In fact, there is a MedPAC meeting just this week around looking at how the payment model moving forward is going to support telehealth for Medicare. As you can imagine, there’s a lot of discussion about the expanding access and paying for telehealth virtual visits, versus the potential deep costs associated with that or the excessive use of telehealth. And then, where do you set the payment rates so that you get really good adoption? This is being discussed as we speak, Jeff. I do think that there’s no turning back and seniors, in particular, are finding it very comfortable to use virtual visits.
Just a cautionary note, from a physician’s point of view: I think we still have to test out what types of visits are best for telehealth and when to escalate that to an in-person visit so we’re providing the highest quality of care and safe care for people and that we’re not missing anything. I think that still is an open question that we need to have our medical community invest time in.
Jeff Lin: You’re talking about how we’re at, call it the new normal. You said that seniors are adopting technology. There have been a lot of naysayers out there. Do you have any insights in terms of how well seniors are adopting technology or adopting these new ways to consume care?
Dr. Jay LaBine: One of the concerns that’s being raised is whether it’s being adopted equitably. Meaning, we’ve always felt like access to physicians and access to the healthcare services through telehealth is really important to, say, rural areas where access is limited. We also know that if you’re poor or have no access to high-speed broadband internet or a smart phone with cellular data, that it’s going to be challenging for you as a senior. And then there are going to be some seniors who are isolated that may not be able to use this type of technology. So, there’s still a lot to be worked out with this telehealth care model, because of these concerns around whether it’s going to be equitable access. The fact that there’s broader acceptance, that we’re not turning back from the digital connectivity, is a really positive development.
Jeff Lin: Yeah, it’s interesting. I never really thought about how you number one have to have broadband and number two, you have to have some digital tools: mobile phone, desktop, whatever the case is, to access this new type of carrier.
We alluded to this earlier, but we didn’t talk about it in depth. What can you tell us about naviHealth, and what exactly they do to support these post-acute care facilities?
Dr. Jay LaBine: Yeah, like I said, at naviHealth, we provide both a clinical service and a proprietary data collection tool that helps to set the right expectations for a senior who’s transitioning from the hospital to the home. On the service side, this is a care coordinator – a therapist, a nurse or an occupational therapist – who will help to completely understand that person’s needs. Not just their medical needs, but most importantly, their functional and social needs.
Our tool, it’s a care planning tool called naviHealth Predict, uses a question tree. We ask questions that are hard to get from the medical record. It’s data that you won’t find in claims and you won’t find in a typical EHR. This is stuff like basic mobility. How far can you walk without assistance? Can you get up a flight of stairs? Generally, this is information that isn’t captured very well. We capture it in our database. In addition, questions like can you button your shirt or can you get to the bathroom on your own? All of this creates a score on functional status. We use that functional status score and compare people who have a best practice recovery to this individualized person. It’s about understanding the whole person and collecting data on that person so that we can set the right expectation for their recovery.
Jeff Lin: Got it. It’s really the personalization of care, to make sure that they’re mobile, they can get up. You’re capturing all this data, I assume from across the United States. Are you seeing any macro trends pre-COVID, during COVID? What’s the data telling you?
Dr. Jay LaBine: Yes. The first thing that this data helps us with is we can set an expectation and we can look at a nursing home and see what areas are important for them to focus on in order to improve in this functional recovery. Like did they hit the benchmark or not? That’s really important when it comes to helping manage seniors through that recovery.
Then also, how long did it take for them to get back to home? Because we know a lot of seniors are very uncomfortable when they’re out of their home setting which can lead to deterioration like delirium or even exacerbation of cognitive issues. So, this is one really important part.
The macro trends on this are that we’re seeing that hospitals and the seniors don’t really prefer to go into the skilled nursing facility. We saw a 20% drop in the admissions to skilled nursing facilities from the hospital during the COVID period. As you can imagine, Jeff, there was a lot in the news about infections and issues in nursing homes.
Jeff Lin: One of the things I want to tie this back to is that this data is so insightful, highly valuable to not only the facility but also to the actual patient that’s there. As these individuals are looking at solutions like this, is there an impact or value to the bottom line? Care is very important, but from a payment perspective or driving out inefficiencies that are in the market, is there some financial ROI or value being delivered by having this data?
Dr. Jay LaBine: Yeah, this is where the Triple Aim really comes into play. Our mission and goal, and I think the mission and goal of hospitals and nursing homes, is that we want to improve that experience. That’s where the care coordinators and understanding the whole person to improve that experience really makes a difference. But we also want to drive out, like you’re saying, the inefficiencies and make sure we’re hitting the same or better outcomes. But doing it while driving out the waste that can occur in the recovery period.
We use this to set the right expectation for a patient and their family, a nursing home and the payer who’s paying for these services. We share that information back, and what we are able to see is that we can deliver the same outcome and actually do it for a more efficient length of stay in the nursing home. Families and patients really appreciate knowing what to expect. So, staff can say, you will go home in two weeks instead of three weeks.
Jeff Lin: Sometimes people forget that while healthcare is about caring for the patient, it’s always helpful if you also deliver on the financial benefits.
Dr. Jay LaBine: One other point on the financial benefits. The cost conundrum is really everybody’s responsibility. Like we said earlier about seniors that are aging into Medicare and the Medicare system – and we know it’s going to be financially challenged, to put it mildly, as the baby boomer boomers age in – this is one aspect of optimizing care but doing it in a way that can preserve the Medicare system so that we’re not spending on low-value of care and we’re spending on high-value of care.
Jeff Lin: Yeah, it’s a targeted, laser-focused approach versus “spray and pray” and hope for some good results.
I always like to ask the big question, which is: you’ve had the experience of being a surgeon, working at a health plan and have had many different roles across the healthcare industry. If you had a magic pill for healthcare, if you could snap your fingers and change things – it’s broad question here – what would that be? What’s your magic pill for healthcare? No healthcare system is perfect, but what would be ideal for you? What’s your dream for healthcare?
Dr. Jay LaBine: You said it really well, that there’s probably not any one silver bullet for healthcare. I do have to say that the challenges for senior care that we talked about here are challenges the healthcare industry should really address. Meaning, we know that people are living longer. Our seniors, like my parents, are 80 years old and they’re going to need healthcare services. We want to preserve the system for them and we want to optimize the care model for them.
These challenges were present pre-COVID and they’re going to be with us whether we get a vaccine or not, post-COVID. What InstaMed is doing with understanding that payment matters, how we pay for the services, and how it aligns to optimizing our care model – we’ve touched on a few of them here – is probably the most critical aspect of how we can get our healthcare system to function better. Let’s align that business model so it drives the highest value care. Home-based primary care, like we talked about. Telehealth services that are done in a way that gives better access to care, but doesn’t require frail, elderly folks to come in to an office and spend a whole day getting there. Moving the care into settings where patients are most comfortable, whether that be at the home or at assisted living. Focusing on these challenges of senior care will really help our overall health system tremendously.
Jeff Lin: That’s great, Jay. As you noted, these topics are just going to become more and more important as the US population ages. Payments are going to be important and we need to drive the right ROI and value to everyone.
