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Rip it up & starting over in long-term care

Rip it up & starting over in long-term care July 29, 2020
long term care

Date: July 29th 2020
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    Transcript

    Rip it up & starting over in long-term care

    Irving Stackpole

    What I hope to do is I hope to cover some very broad topics within long-term care and focus on the current situation. How we got here, talking about the components of long-term care structures, programs, technology and information. The means of production, which is the human resources and the culture, outcomes and economics. The timing of this really couldn’t be more propitious. Just last week, The Economist published an article about how the pandemic as showing has shown the ugly side of long-term care.

    Technology

    A disproportionate number of illness and injury have occurred inside of congregate long-term care operations, both in the UK and the US. Even home care and other types of long-term care have been shown to be places where consumers, patients, individuals are at risk. This is an extremely timely topic and one that’s being discussed in different ways, in different places. My hope is to take a broad view to deconstruct the sector and frankly, just start a dialog. I don’t necessarily have any answers. I don’t have any solutions. These ideas have been circulating, rattling around for some time. I don’t think I’m going to talk about anything that’s fundamentally or profoundly new. I do believe that we are in a position to start a dialog which can have significant change in the situation currently is nothing short of a crisis. A crisis is defined as an event with an adverse impact on the organization customers, consumers, employees and the brand.

    The brand long-term care is under siege right now, and we have to we have an obligation to undertake a serious assessment of how the public sees us. Whether we are fulfilling the trust that families and the public place in us for the fulfillment of care, nurturance and socialization for the most some of the most vulnerable people in our society.

    I was attracted to this quote by Margaret Mead, A small group of thoughtful, committed people can change the world. That’s the only thing that ever has changed the world. My hope is that that’s who we are. A group of thoughtful and committed people who have a real interest in this very complex array of services called long-term care. I’m at the point where I think we just need to rip it up.

    Technology

    I think that the current system that we have is so complicated, it’s such a patchwork quilt of dis coordinated, inefficient and too often ineffective services that it serves very few people, only those who are fortunate enough, well-informed enough to arrive at a place where a helpful person navigates them through. Only those people really benefit from all of what’s available. This is my arbitrary, deconstruction of the long-term care, I want to go over structures and by that, I mean property, plant and equipment, the original PPE. In every budget, there’s a budget line for property, plant and equipment. I want to look at the property, plant and equipment as it affects as it relates to long-term care. I want to talk about programs. That’s the soft side of long-term care, what the intentions are, what the structures are, the structures of fulfillment, who gets what and why. How are those programs organized? We’ll talk a little bit about that technology and information which is critical to success going forward in virtually any endeavor in the 21st century. I want to talk about the means of production, an econometric term which in this case is people. The people are the means of production and long-term care. Despite what you read about cute stories about Japanese robots, we want to talk about the culture of long-term care outcomes. Finally, the economics. Most conversations about change in long-term care start with economics, I think that’s just a terrible mistake.

    We should first design what we want and then determine what the way forward is in terms of economics, in terms of fiscal and in terms of policy. In terms of the structure and I will be focusing on this program for the most part on the United States. I’m doing a program next week on August 6th called Fawlty Towers. I want to focus on the long-term care, the original copy, most nursing homes in the United States were built between 1960-65. This was part of what was referred to what’s called the Hill Burton Act, which made a guaranteed capital available to build hospitals in rural America. It was an enormously successful program. Hill Burton hospitals are dotted all over the United States, some of which have been converted into long-term care centers, others into primary care centers. This program really made health care available throughout rural America. 70 percent of the hospitals in the United States are 70 beds or less.

    Few people understand that. Most of the attention, of course, is focused on the larger hospitals. In fact, most of the care, much of the care is delivered in small centers. Nursing homes in the United States were modeled on hospitals and many of them were built along the same models, which is why they have cinderblock walls where they have hallways with nurses’ stations while they look like hospitals that were built between 1960 and 1975. Then along came assisted living, which in the late 80s and early 90s offered a much more attractive model, a structural model for families and consumers looking for long-term care for whatever reason. Assisted living offered a much more physically attractive model structural model to many markets.

    Indeed, assisted living has proliferated throughout the United States. Since the 1960s to 1975, with the exception of assisted living, there’s been little or no reinvestment in the physical structures of nursing centers, congregate care nursing centers in the United States, the capitalization model in the sector. Remember this 15 thousand of these nursing centers around the United States? The capitalization has been fundamentally extractive. We’ll talk a little bit about that when we get to the financing matters. The capital that’s been created based on the property, the value of the property, the value of the betterment, the building on the property, the capitalization has been extracted. The money hasn’t necessarily gone back into the buildings. It has in some cases, but far too much of the money has been removed or extracted for other purposes. Also, it’s important to note that when Gilberton came along and nursing homes began to proliferate, Medicare supported paid for some parts of long-term care. It has long since Medicare has long since left the playing field and now provides only about 10 to 12 percent of the payments for consumers in nursing centers in the United States. These are primarily short-stay rehabilitation consumers, as many of you in the business understand. This gets to the heart of one of the financial flaws, one of the weaknesses in the long-term care model in the United States. The difference between Medicaid funding means tested. That’s supported by both the state and the federal government and Medicare funding. I’ll talk a little bit about that when we get to the economics and what’s wrong with that model.

    The result what we have now is basically yuck. I’ve been I’ve personally been in about seventeen hundred nursing homes around the United States, give or take a hundred or so. I have to tell you that the vast majority of them are not places that I would want to stay.

    Technology

    The model that I often ask people is, would you stay at a Hilton or a Marriott that hadn’t been renovated, significantly updated, upgraded in 40 or 50 years? Of course, you wouldn’t. Well, this is where we have basically relegated the oldest, poorest and most vulnerable individuals in our society. What do we need? I deconstructed the property, plant and equipment and it painted the picture based on how I see it. I know there’s exceptions to the rule, but I’m saying on average, it’s pretty grim.

    What do we need? Well, first of all, we need a wide array. We have basically created we created back in the 60s to 70s, we created this cookie cutter model and in fact, assisted living, followed closely in nursing homes, footsteps, I would argue, and created a cookie cutter so that what one assisted living residence in in Massachusetts looks very similar to another assisted living residence in Southern California. What we need is we need a wide array of property, plant and equipment. We need large places like newer college dormitories that have extremely attractive common spaces. I’ve been watching with a great deal of interest the war between colleges and universities of building nicer and nicer student dormitories and student union buildings. This has been an arms race between colleges in an attempt to make Georgia Tech more attractive than the University of Virginia. Millions, hundreds of millions, if not billions in the small billions have been spent building this infrastructure, which is probably going to be used with great caution in the near future. For seniors housing, we need large we need large properties because some people want large properties, large spaces. We also need medium size like Ale’s and suburban areas.

    The average assisted living residence in the United States has 70 units. They look you can spot them. If you looked as many as I have, you can spot them from the side of the road. We also need small places like mansions for small groups of related and unrelated individuals. Think of a naturally occurring retirement communities as well as just think of the Golden Girls. That’s the model. There was a famous New York Times, I believe it was the New York Times article about this shift in the physical environment, the physical structure for aging, aging in places that is the term. In seniors housing the supply studies have used benchmarking as a model to determine what the physical plant and the fixtures and the Infrastructure features should be like in other words, benchmarking is a process where we look at a marketplace area and we say what is currently in that marketplace area? What supply is there? What are they offering? At what price point?

    We are being the party that’s interested in developing a property in that marketplace area, we say, OK, here’s what we need to do in order to compete. Well, that’s a benchmarking approach. Rather than a qualitative or quantitative approach to say, what do the consumers in that marketplace area want? What do they need? What would they like? What would differentiate us? From the competitors, rather than anticipating. We should be expecting, in other words, rather than saying maybe I misspoke rather than saying this is what everybody else has done in the past, we should be looking forward and saying, how can we insert something into this marketplace area that will meet some demand now but will really fulfill on a latent demand going forward?

    I say here that what can the investors extract versus what they can contribute too often? The question I get when retained to do a market study is, we want the highest and best value. In other words, they want to see what they can get out of the marketplace rather than looking forward and saying what are the values? How can we brand our building around values?

    What do we need? We need telecommunications and information, infrastructure, the and the access to capital. I will talk more about telecommunications and information infrastructure; basically, long-term care is the land that modern telecommunications left behind. It’s just it’s a should be a national embarrassment, almost bordering on a disgrace that billions, have been spent on health information technology for hospitals and doctors’ offices. Precious little has been spent. Nothing, practically nothing has been spent in long-term care. It’s just it’s wrong and it needs to be changed.  While I may not have the answers, I know it needs to be changed. I’ve got some suggestions about how we can begin the conversation and then access to capital, which I will talk about when we talk about the economics. That’s what we need to begin to fix the structural problems, the property plant and equipment problems in long-term care.

    I would just leave this particular topic by saying who on earth wants to go and spend two to four years living in a nursing home? Most of us do not. OK, why don’t we get what we need? Well, first of all, access to capital. I’ve talked about needing about the Hill Burton Act. We need a new federal Hill Burton act that makes capital available to investors who are willing to make a commitment to a marketplace area for some durable period of time. The market has been too busy eating each other’s lunch. Assisted living competes with nursing, nursing competes with the Alzheimer’s centers. We’ve been too busy whining. Complaining about Medicaid won’t pay for this. Medicaid won’t reimburse us what we need. Personal care aides are. We have a program. We have a reason for bringing issues to government. We have reason for bringing issues to policymakers. We recruit the academics in legitimate studies that prove our points. Or just please don’t whine. It’s an issue. It pays to confuse the consumer. One of the issues at the core of why long-term care is such a mess in the United States is that we have not educated consumers about long-term care in the United States. I would say in the UK as well, although in the UK there are some advantages that we don’t have here. It pays to confuse the consumer. It pays we put home care, private home care against private assisted living.

    We pit memory care properties against nursing centers. We do it all the time. What that does is it confuses our publics so that they don’t understand what their legitimate choices are in the marketplace. This brings me to a question that has rattled around for some time inside of my head, and I’ve read a little bit about it, although not enough, I don’t understand why providers don’t bargain with state and federal agencies together. The organizations, the membership groups in the sector have been asleep at the switch. I’m sorry, I have great respect for the American College of Health Care, the leading edge, the American College of Health Care Administrators. I have great respect for all of those leaders. But I don’t understand why. There’s no effective negotiation between providers and state governments and between providers as groups like unions, providers and the federal government, certain of the programs that we’re that we need can only be accomplished through federal. Effort and why we aren’t pushing for this is, I think, a lack of leadership, frankly, and a lack of bold visioning, which only appears from time to time.

    I understand the role of the real estate investment trusts are an animal of the Internal Revenue Service code, and it allows investors to extract a reasonable, manageable income from investments in the real estate. I just don’t understand their legitimate role in long-term care in the property, plant and equipment they are. They have proven to be a very unappealing bargain going down the road. I was active in long-term care, have been active in long-term care since 1985. I remember what happened following the Balanced Budget Act, the BBA in 97, and how many of the operators of long-term care were in receivership, effectively in receivership and they got saved that time. They’re not going to get saved this time. Rates are an animal of the investment world and I don’t know that they have been properly engaged in the creation and management of capital needed to build effective structures in long-term care.

    So now I’d like to switch over to programs, the soft side of long-term care. One of them is where you are, where the consumer is or where the provider is, and the other is what the need is. So, there’s both locations based, or geography based and need based. Some of these are located in the community, the agencies for services in the communities, the area, agencies on aging. Some of these are home based home care, home health care, home and community-based services, which are all different, receive their funding through different channels. There’s congregate care versus domiciliary or home-based care, and then there’s nursing care. The complexity of this is overwhelming. I receive calls on a regular basis from friends and family who know that I’m in the business saying we don’t understand. There is a point at which I don’t either. It got this complicated because we were busy trying to control gaming of the system. We lost touch with who is at the center of the system, the consumer at the center of the system and the family trying to do what’s right for the consumers.

    Technology

    What do we need? First of all, we need screening and triage. We need objective evidence-based criteria to guide decisions about the location and the type of services that consumers should receive and for which they will qualify. What I mean by that is fit the person to the program and not the program to the person. We have perverse incentives in the current system that forced providers to compete with each other and we need clear choices. Credit default swaps are simpler than the choices that families have with regards to long-term care. These should be three basic operating principles for long-term care going forward that would sweep away much of the enormous complexity in the system today. Technology and information, what is the status of technology in this sector? Well, there is no one status of technology in the sector. It’s a mess. The technology that is available has been adaptive, attempting to create reports and records that fulfill regulation. Well, I got to tell you, that’s backwards.

    That shouldn’t be the way technology and information flow work in the system. 60 to 80 percent of every budget in every operating congregate operating center and even more in-home health agencies, its staff is the means of production. Does the technology render the staff more efficient? In many, many cases, it does not. The tragedy of this is that subsidies have been flowing for health information technologies in the health care and medical realms. Only a few drops have reached the long-term care sector. It should be an embarrassment. It’s an embarrassment in in the case where the operations are not efficient and don’t meet the needs of the consumers. It’s an embarrassment when families can’t get answers about the status of their family member, when they can’t get into the building. That’s a technology and information floor.

    My bottom line here is that we as a country should be just mortified that Kroger’s knows where all of its tomatoes are. We don’t know where Maria or Zhao are in order to take care of Mrs. Stackpole, my mother, in a long-term care center. It’s just it’s outrageous.

    Technlogy

    What do we need? What we need to make the choice really clear, are we going to take care of our tomatoes better than we’re going to take care of granny? Now, there is this legacy of personal emergency response systems. For a long time, you know, the ones I’m talking about, the lifeline etc. For a long time, these were legacy systems that were hospital based because they were built on old communications infrastructure. What we need is we need an internet of long-term care. We need electronic, real electronic health records and not software packages that are designed only to produce reports that fulfill on a specific financial federal reporting or state-based reporting requirement. We need interoperability and we need something that looks like ambient assisted living. The term refers to supports for individuals to live in congregate environments and who are nevertheless have varied needs and varied requirements.

    I’m not a technologically sophisticated person, this the lack of technology in the sector drove me in 2014 to look into creating a very simple system using existing technology. Wouldn’t you know that I’ve discovered that there was nothing available technologically information systems based that could be put into a congregate care building, whether it was a nursing home or an assisted living residence that could track where people are VCP, the consumers, the residents, the people we’re caring for. There was no system.

    I put something together and wouldn’t you know, it just got a patent because nobody else has done this. Nobody else has done this because we as a sector haven’t demanded it. We haven’t demanded it of the technology companies, the big technology companies, and say, how come you can track these things for Kroger’s, but you can’t track them in a long-term care center.

    Let’s go to the People the Economist article that I referenced at the beginning talks about who cares? That was the subtitle in the article. There are both unpaid and paid caregivers. I would offer the challenge, who wants to work in long-term care? There’s lots of research to show that most people don’t want to work in long-term care. My company did a research project years ago for the Massachusetts Medical Society. We surveyed over six thousand doctors and quite accidentally we were asking a different set of questions. Accidentally we discovered that those doctors who work in long-term care. Have a lower esteem than doctors who work in virtually anywhere else, in other words, working in long-term care can be damaging to your self-esteem and your reputation among your colleagues. Why? It’s because we have treated long-term care as a stepchild. It’s a second thought in virtually everything when we set up the information systems incentives back many, many years ago under the Affordable Care Act. long-term care was explicitly excluded. I say to the leadership in the sector, where were you?

    Use is meaningless unless it includes long-term care. What are the sources of people, what are the sources of our staff today and what are the sources tomorrow? Well, this is what it is today. This is from the Kaiser Family Foundation.

    We can see that it’s a moderately sized labor force, 4.5 million. This is where they work and will send these slides out afterwards. This is where they work, and I will tell you categorically that they are overwhelmingly women. They are overwhelmingly asset limited income constrained and employed. In other words, they’re on the brink of poverty and many of them and we can’t even really identify how many of them. Many of them are foreign workers, which is why the home care leadership, to their credit, and others leading edge and the American Health Care Association spoke up when the current administration threatened to shut off the availability of foreign-born workers to the sector. It’s critical that we support, nurture and protect them.

    What about the future? What’s plausible? There really are people who want to work in long-term care. We’ve done tens of thousands of surveys and we know that there are people who genuinely want to work in long-term care. They have a specific psychological and behavioral demographic profile. We know that they’re there. We need to get to them and we need to work together to remove the stigma associated with working in long-term care. That’s that alone could be the subject of a webinar and a vigorous conversation. We need a federal long-term Care Jobs Act. We currently have roughly 17 to 30 million unemployed. Some portion of that unemployed pool would be very suitably screened and retrained for long-term care. We need better pay, and that means subsidizing salaries and creating incentives, retention incentives. This is nothing new. It’s been used before, too often with mixed results. It could work and it would encourage the sector to employ new, different and frankly motivated employees to work in the sector.

    Culture, well, this picture says a lot about the culture in long-term care and culture, as many of us understand is the unwritten rules that guide behavior and culture is not sticking a potted plant in the corner of that hallway culture is changing the attitudes. Of the people inside so that it shows on the outside and famously, if you want to understand the culture in your organization. Listen to what happens to call bills if call bills are left ringing, there’s I would challenge that you have the right culture in your congregate care center among home care workers. Culture has to do with loyalty, engagement and commitment. There are very good ways to measure these things. I would encourage us all to look at culture. I think we need a concerted effort at a change in culture and nothing short of ripping it up and starting over will do outcomes.

    Outcomes is extraordinarily important in long-term care in the United States. These outcomes are very often measured as clinical results, and some of these measures have gotten progressively more sophisticated. The new reporting requirements are heavily focused on clinical results and pretty good, pretty interesting approach to outcomes. However, the myth that quality is somehow measured by these outcomes has to be blown up. We need to start over again. First of all, quality is the degree to which it’s services free of defects. I didn’t make that up. That’s W. Edwards Deming, the father of quality, the QR P program, which is part of the new reporting requirement for CMS, the agency, the regulatory body in the United States. QR only has half of the equation. What we’re not looking at and what there’s no systematic and serious way to look at. Across the board in the United States is consumer satisfaction, and these are the core questions, is this what the consumer wants?

    Tecnology

    Is this what they need? Is this what their families want? Until we can really answer that, we can’t know what level of quality because quality is what these the defects in quality defects in the service are driven by dissatisfaction among the consumers, not a not and a loss of weight or failure to improve the decubitus. The issue is, are that is this what are we giving the consumers and their adult advisers what they want? If they don’t know what they want, if they don’t know it, why aren’t we teaching them? Instead of complaining about the lack of Medicaid funding, my prayer is that we can launch a campaign to teach families to teach the public about long-term care.

    Finally, economics. There’re direct and indirect costs associated with providing long-term care. long-term care in the United States has been shortchanged for 30 years. You can’t have an entire sector. This is a sector. This isn’t a business or, you know, this is an entire sector that’s been operating now at or near the margin. So that recently with the with what’s occurred because of covid that have been operating at a loss, the examples of this are clear and powerful. The system has been shortchanged for 30 years. Medicaid can’t afford to pay for the long-term care that it’s covered. Beneficiaries require period, paragraph and Medicare back about 30 years ago. They they’re only paying a pittance. Many think that the government will pay for it. Paradoxically, the part going back up to this one, the part that Medicare does pay for, subsidizes the part that Medicaid shortchanges in many cases. Without those Medicare beneficiaries, long-term care providers are going broke. The public thinks that the government will pay for it.

    This notion persists, which is one of the reasons why long-term care insurance, such as it is, has failed, hasn’t exceeded 11 point something, percent penetration, because why do I need it? The government’s going to pay for it. Then there’s the almost five hundred billion in value in unpaid care that’s provided. In other words, this is a superior good a superior value delivered to this long-term care system free of charge. Five hundred billion in value delivered by non-paid caregivers. There’s waste in the system, maldistribution, lack of collaboration and fragmentation. Cooperation is hard to come by. Collaboration is extraordinarily difficult to achieve. An assisted living provider client and a home health care client of mine. I wanted to put them together and the lawyer said we couldn’t because of some fear about stark regulations. Well, those are the realities on the ground and those don’t make any sense, just doesn’t make any sense.

    Technlogy

    What do we need to get started? Well, we need a federal insurance for long-term care. This is not a new idea. This has been around forever. It’s forever. It’s at least 30 years. It’s always the bridesmaid, never the bride. It’s always part of some federal legislation or some federal program that doesn’t go forward for funding. We need a small increase in the Medicare payroll deduction and a small premium with the means testing on uses of Part A, part C and Part D, that’s the Medicare Advantage part is the Medicare Advantage program. That’s a profit laden juggernaut that’s rolling up more and more of the market. I got to tell you, don’t worry. All of the people that are participating in part a part of the party, they can afford a small premium, really, like they can do it. For this, we need to use this to fund private long-term care, the federal long-term care insurance, private long-term care insurance.

    A Federal based program and a private long-term care program, fully deductible and risk pools in each state and require the long-term care health insurance plans to spend at least one half of one percent of their premiums on education communications so that the public understands how to access the system, where to access the system. What’s the basic level of services that are on offer? What they would get if they topped up to a private long-term care insurance, this can be done.

    In conclusion, the current situation is a mess and there’s just no reason for it. We need a community. There is we need a community of action and an effective dialog. And we need to engage the leadership. I know them. I respect them. It’s time to take off the gloves and step into the ring. The world we’ve created is a process of our thinking. long-term care has been a process of our thinking and our defensiveness. We’ve got to protect this. We’ve got to protect. It can’t be changed without changing our thinking, and that is that’s the program. I’d be delighted to answer your questions.

    Questions and Answers

    Question: Does the profit motive negatively impact the long-term care open court system as there seem to be too many operators who focus on their profitability to the detriment of quality care?

    Irving: I don’t believe that the profit motive is necessarily a negative element in the development of an effective and efficient long-term care system. In fact, I believe quite the opposite. I believe without suitable profit incentives. Capital formation, investment, creativity is thwarted. There’s lots of good data about this, there have been attempts and this is some of the internecine stuff that I just. I hate to say this, I’ve used it myself. I’m embarrassed to say this, not for profit side points to research that says the not-for-profit long-term care providers provide higher value than for profit care providers. Then there’s another research to show. The for-profit providers provide very comparable and, in some ways, better services or outcomes or satisfaction or some other metric. I think competition is good, that kind of competition is a waste. So, no, I don’t think that profiteering, profiting is a bad thing. Profiteering is and profiteering is when money capital is extracted from a building or from an operation and doesn’t somehow, beyond a reasonable profit, go back into or be reinvested in the system. Now, there are ways to manage profit in the sector.

    The Affordable Care Act, in its original formulation in 2010, had an outstanding way of measuring this guarantee, a eighteen point five percent margin to health insurance providers that were willing to engage in certain risk pool activities. That kind of standard can, and I think should be applied, we love profit, we want to avoid and eschew profiteering.

    Question: How much of a role does ageism play in addressing needs? You gave examples of lack of esteem for those caring for elders, as well as a lack of federal policies to address native elders. But what about ageism?

    Irving: It is a cultural bias that we have that’s almost organic. It’s extremely difficult to fight against is a very funny in a very apt story in Daniel Kahneman book Thinking Fast and Slow about age bias. Age bias is with us. It’s almost an almost nothing you can do about it on an organic level. It’s the issue is when these. Personal biases, personal, behavioral, psychological biases become institutionalized. That’s where the danger is, and they become institutionalized in our names like Aged Care UK. Well, that says what it is you want to fight, and that doesn’t help. You’re fighting the thing that you’ve named bleeding edge.

    Ageism is a big issue. I think that. Age is less of an issue when the need arises, there’s a certain segment of the population who will always anticipate what they need. There’s another segment, a bigger segment that’s about 80, 20. 20 percent of the population will anticipate what they need and will look at things like long-term care insurance. They will anticipate there’s another segment of the population that will not look at what they need. For those who will look at it, our language, our messaging, our visuals, our what we say should be free and clear of messages about age for the rest of the population. It’s less relevant because they’re not going to come to us. They’re not going to look for us. They’re not going to find try to find solutions until they’re in the throes of the knee, at which point their age ism is less of an issue.

    Question: I think I like the idea of a federal job program. This would require high salaries. They are desperately needed. That will be difficult to secure. Do you have any recommendations on how to proceed with this great idea?

    Irving:  Well, yes, as a matter of fact, I do. I have tried to suggest this to the Blue-Ribbon Commission. In the federal government looking at long-term care and specifically with regards to the labor component of long-term care, which is of great interest to me, and I know it is to all of my clients and friends who are in the business. The first step is to assure minimum wage. A living what, living minimum wage? I don’t mean to scare all the Bernie Sanders supporters or haters out there, basically had the right idea. Minimum wage should be a living minimum wage. The difference between what we’re paying now, which on average is slightly under twelve dollars an hour. Sports fans, the difference between what we’re where we’re at now and what the. What the living minimum wage is, which in your marketplace, in each marketplace area it’s going to be different, is going to be different. In San Francisco, as it is in Sioux, Iowa. To fault, the difference between that needs to be where the federal government steps in and offers a subsidy and is a bunch of different ways to fund the pool that would be used to fund that subsidy.

    We need to get people up to that point for the retraining program. That would be a transitional or I see it as a temporary program which might run for two years. It might run for three years, it would offer an additional incentive or subsidy to the providers, to the employers to both recruit and retain these retrained, unemployed individuals. It’s a way of getting people from. Their role as a barista or from their role as an attendant at a hotel, leisure and tourism activities and get them into long-term care, suitable individuals, and to make their transition into long-term employment in those in those businesses to make that transition stick, to make it endure, to make it durable, sustainable.

    Question: The long-term care industry requires a blue ocean approach. However, who does not follow finance form does follows finance. Can you speak of any models that integrate the services support as well as payers in the US?

    Irving: It’s a terrific question and it’s a very specific question and it’s got a lot of layers to it. Yes, I think there are some examples in the US and they’re better examples internationally. The examples in the US are space programs. think the model for the snips, it’s a way to head into that situation where the form and money more closely match each other. That’s the generally that’s the right idea. The problem is that those are band aids stuck on something that’s so big and so dysfunctional at the core that we need to I think we need to rip it up and start again. I’d love to have a conversation offline with you, Kathy, about what successes have been and things like space programs that I snip and others. Where the problems come integrating in a particular geography, because that’s really what these programs are, these programs need to work in Cincinnati, they need to work in Austin, Texas. They need to work in the local marketplace area.

    Too often the local circumstances allow them some to flourish and local circumstances and other places choke them off. They don’t get the traction that they need for a model. The German model is really pretty good. It’s a compound, social care model, health care model, and it’s in the health care and the social care this both private and public financing of this. They spend a fraction of what we spend on long-term care. They’ve got the data to show how well it’s like we don’t even have the data to show how well it’s like and generally it’s liked pretty well.

    Question: State legislators seem intent on purchasing long-term care with new mandates rather than supporting long-term care with new innovation and policies. How do we fast track the education of legislators about what is needed?

    Irving: Put their mothers in nursing homes. I’m sorry, it’s just. OK, it has been said, famously written, and I don’t think I think this is true. It’s been famously written that in the United States, with the exception of a nuclear reactor. There is nothing more heavily regulated than a nursing home. Now that we have a crisis in nursing homes in every state, now that we have a crisis, legislators and policymakers are going to revert to the dominant paradigm. They’re going to do what they’ve always done, which is to regulate there, try to regulate their way out of it. That’s not going to help. We have we don’t need another regulation which imposes an indirect cost on a system that’s running at a negative margin.

    That’s not what we need. We need legislators and policy makers to eschew that sound bite and to come into our buildings and see and smell what’s going on. We need policy makers and academics to go out on a day with a Haitian home care worker in Manhattan going through her daily rounds. That’s what we need to have happen.

    Question: Are you advocating for Medicare to be total payer for long-term care?

    No, I’m not advocating for Medicare to just step in and pick up the tab for long-term care at all. I’m suggesting. That we blow it up and start over again, start with. Systems that just I think it was, Kathy, you ask the question of put the preamble to the question about form and finance coughing fit and yeah, that’s a very good way to put it. And that’s what we need. We need a system that supports the needs of the individuals, the consumers and their families. Then we need creative ways to subsidize and support that. There are individuals who have the assets to pay for this and who would pay for it. We have an industry that’s mind boggling, it’s true. We have an industry. That is built on teaching consumers how to hide assets, so they don’t have to pay for long-term care. Now, some of these attorneys, some of these estate managers are my friends, I don’t bear them any ill will. Does that make any sense whatsoever? No.

    We have individuals, blessed individuals, who have the resources and have the assets so that they can afford to supplement top up pay for. We have other individuals who can’t afford, really can’t afford, and both of those people should receive what they need in a system where the outcomes are measured carefully, where the efficiencies are monitored intelligently, and where the person who can pay pays his or her fair share. The person who can’t doesn’t have to fret about it. I didn’t even talk about the bankruptcies and the rate of increase of bankruptcies among individuals in my age cohort, which, by the way, is approaching 200 percent because of medical bills. This makes no sense whatsoever. This is like the.

    Question:I’ve been researching the benefits of eliminate and eliminating phone medicine with virtual bedside visits, with an SNFs to prevent unnecessary and avoidable hospital admission covid and certainly help push this forward. I think every SNF should implement telemedicine. Would you agree?

    Irving: Yesterday A.S.A.P. and the simple technology that I referenced earlier on, which I got my patent is built around something equally simple. It’s just so simple. The stuff is out there, and we should just be bringing it on board with the appropriate precautions, with the appropriate measures, the appropriate policies and with the appropriate surveillance so that we know it is being used inappropriately. Nobody’s getting scammed. Nobody’s getting abused by it. Those the intent and the ability to do all of that is there. We can access it. Thanks. And I’d be happy to talk with any and all of you further about any of these ideas.


    Resources

    • Jan 28, 2015 – Long-term care (LTC) facilities (as defined by the ARRA) are facility types excluded from the incentives including skilled nursing homes, assisted … also a source of statistical inference when ‘meaningful use’ is assessed.

    Stackpole & Associates is a marketing, research & strategy consulting firm focused on healthcare and seniors’ services markets. Irving can be reached directly at istackpole@stackpoleassociates.com.

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