It could be time to scale up
December 2021 – Repertoire Magazine
Family doctors have traditionally taken the lead in managing care for senior patients. After years in practice, their patients tend to grow older along with their doctor. Together, doctor and patients learn how to navigate the complexities of caring for seniors, with their comorbidities, challenging living conditions, immobility, frailty and even dementia. But today, as baby boomers enter old age, a number of companies with regional and national aspirations are increasingly tapping into this market.
Regardless of who is delivering the care, future providers of geriatric medicine will most likely operate in a capitated, or value-based environment instead of fee-for-service. And Repertoire readers will be challenged to help them deliver compassionate, patient-centered care in a cost-effective – and profitable – way.
“Geriatricians have deeply studied the diseases that affect older adults and how they manifest and react differently to treatment as we age,” says Scott Weingarten, M.D., chief innovation officer for SCAN Health Plan, a not-for-profit, Medicare Advantage health maintenance organization based in Long Beach, California. “They understand how, as patients age, their needs expand beyond just treatment for physical health, into mental and social limitations, and they work collaboratively in teams to solve these many issues.”
Specialists in seniors-based medicine also have learned to balance treatment for disease with patient quality of life and function, and they weigh the pros and cons of intervention, he adds. “Geriatricians are trained to avoid care that may lead to unnecessary procedures and medications in elderly patients, and they are focused on the trade-offs between the harms and benefits of each diagnostic test, procedure, and medication.”
A growing demand
The statistics point to the difficulties – and the opportunities – facing primary care for seniors today. The increase in the number of older adults in the United States is unprecedented, according to the Centers for Disease Control and Prevention. In 2016, 49 million U.S. adults were 65 or older, representing 15% of the population. That number is expected to reach 71 million by 2030 and 98 million by 2060 – when older adults will make up nearly 25% of the population.
Age brings a higher risk of chronic diseases such as dementia, heart disease, type 2 diabetes, arthritis and cancer. In 2019, healthcare and long-term care costs associated with Alzheimer’s and other dementias were $290 billion, making them some of the costliest conditions to society.
There’s another problem. The demand for geriatricians is expected to continue to climb, but their numbers will not keep pace. By 2025, demand is expected to outstrip supply by five times (i.e., an estimated 33,200 geriatricians will be needed, but only 6,230 are projected to be practicing), according to the Health Resources & Services Administration.
The family physician
“Even if I hadn’t started out taking care of older patients, my younger patients have aged with me,” says Donnie Batie, M.D., a family physician and board-certified geriatrician in Baton Rouge, Louisiana.
Batie started his family medicine practice in Baton Rouge 40 years ago. He was drawn to caring for the elderly when he was still young, following a six-month stint after residency. In his own practice, he found that his younger patients brought with them their parents and grandparents for care. As they did so, he became more engaged in geriatric medicine. When the exam for certification in geriatric medicine was first offered in the early 1990s, he wasted no time becoming board-certified.
Family practitioners are well-suited to care for seniors, he says, given their lifelong relationships with patients and families. “Family practitioners recognize that death is as much a part of the practice as delivering babies,” he adds. “We are comfortable with palliative and hospice care, nursing home care and team-based care.”
There’s another thing about caring for seniors. “At age 50, a person may take two medications, but after 10 years, another two or three might have been added. So we are trained to look at our patients’ bag [of medications] and eliminating as many as possible” to avoid harmful drug interactions.
“We’ve always had complex patients, but haven’t been paid adequately to care for them,” he says. “It’s next to impossible to care for an 80-year-old person with multiple chronic conditions in a 15-minute office visit.” Value-based care, as opposed to fee-for-service, is probably the best way to make such care viable in the future, says Batie, who participates in an accountable care organization for Medicare patients.
Big players
At the other end of the spectrum from the solo practitioner, a growing number of public and private companies are zeroing in on senior-based care. In 2021 alone:
- Humana announced a new brand – CenterWell – to describe its services, including senior-focused primary care facilities that had previously operated as two entities, Partners in Primary Care and Family Physicians Group. (Humana’s Conviva Care Centers subsidiary, which operates senior-focused primary care centers in Texas and Florida, was not affected by the rebranding.) Humana expects to have close to 200 CenterWell and Conviva clinics by the end of 2021 or early 2022, with further expansion planned.
- SCAN Health Plan made plans to launch its geriatric primary care program in Los Angeles County in March 2022.
- Miami-based CareMax – a provider of value-based care to seniors – signed an agreement with national health benefits firm Anthem to build medical centers in Indiana, Texas, Kentucky, Wisconsin, Georgia, Connecticut, Virginia and other locations.
- Jacksonville, Florida-based GuideWell made a “multiyear strategic investment” in its PopHealthCare subsidiary, which provides home-based primary care services to vulnerable seniors and adults.
- Miami-based Cano Health, a primary care provider for seniors, acquired University Health Care and its affiliates for $600 million, adding about 24,000 Medicare Advantage members to its rolls.
- In September, San Francisco-based One Medical acquired Medicare provider Iora Health for $2.1 billion.
Time well spent
Large companies hold some advantages over private practitioners, including more powerful technology solutions. For CareMax, for example, it’s CareOptimize, a software platform that aggregates a patient’s medical records from all inpatient and outpatient visits, as well as payer information, to form a single, longitudinal view of each patient, says Ben Quirk, chief strategy officer. That data is parsed and can be accessed at the point of care for use in determining care management plans and resource use.
Quirk has led initiatives in capitated, shared-risk and full-risk models for more than 15 years, and is continuing to do so at CareMax, whose physicians are rewarded based on health outcomes instead of volume,
he says. “They can take a different approach to care. It’s difficult for a primary care physician to see a mixed panel of patients. They have the same 15-minute slot for an 18-year-old with sniffles as for a 65-year-old [with comorbidities].”
Patient panels at CareMax are smaller than those in traditional primary care practices, he adds. But physicians are responsible for their patients 24 hours a day, seven days a week. “It’s not enough to offer advice when the patient is in the exam room. Our physicians are always available and accessible.” Patients have their physician’s cellphone numbers.
CareMax is accelerating the speed and geographies in which it plans to open medical centers for seniors – at least 15 in 2022, approximately 25 in 2023 and approximately 35 in 2024. In July 2021, the company signed an agreement with an affiliate of The Related Companies in which Related will advise CareMax on opening new medical centers nationwide, including but not limited to centers that are within and close to affordable housing communities owned by Related. (A global real estate firm, Related was founded in 1972 primarily as an affordable housing developer, owner and manager.)
Brick and mortar?
Given their more limited mobility, some seniors may be better served by home-based care than in-office visits. But that’s difficult in a fee-for-service environment.
“You have to consider transportation,” says Batie. “Whereas you can see maybe five or six patients doing morning home visits, you can see twice or three times as many in the office.” That said, he believes that, given the proliferation of home-based diagnostic tools, more home-based care may be possible, even for patients with chronic conditions, such as congestive heart failure, diabetes and peripheral vascular disease.
“Some elderly people have mobility restrictions, incontinence, transportation challenges and other reasons, and may find it challenging to visit a clinic,” says Weingarten. “In many cases, it may be better for care to revolve around the needs of the elderly patient rather than the needs of the clinic or healthcare organization.”
Says Quirk, “Our model is to envelop patients however they want to access care. As human beings, we like to congregate with others. That’s why some of our centers are more like senior centers, serving meals and offering interaction with others. But we think the home is equally important. As different conditions develop or mental faculties decline, we need to go to the patient in their home, particularly within 24 hours after discharge from the hospital.”
Humana spokesperson Cary Willis says the company sees both bricks-and-mortar and in-home care as important parts of an integrated system of senior-focused care. In March 2021, Humana completed its acquisition of Kindred at Home (KAH), which it says is the nation’s largest home health and hospice provider. That said, its bricks-and-mortar clinics are designed to meet the special needs of seniors, he says. They offer motorized exam chairs, family-friendly exam rooms, wide hallways, large windows that allow natural light, and, in many cases, on-site pharmacies and labs, and community centers, where seniors can socialize, learn new skills and exercise.
What’s next?
The opportunities to serve seniors are expanding. But the question remains, how motivated will young doctors be to do so?
“Young people like to take care of young people,” says Dr. Batie. “When doctors come out of residency, they tend to focus on a younger population. But as they get older, they find themselves taking care of older patients. Today, some are focusing on long-term practice, that is, caring for patients in long-term-care and independent-living facilities, which need doctors for their residents. Those opportunities are growing.”
Regardless of venue, it’s likely that senior-based care will increasingly be reimbursed on a capitated or value-based basis, not fee-for-service.
The approach promises more individualized care that is also more preventive, says Willis. And it works best when paired with Medicare Advantage plans, which cover most of the patients of CenterWell and Conviva, and which combine Medicare parts A (primarily inpatient care), B (outpatient care) and, in many cases, D (prescription coverage). “This pairing allows deep alignment on what matters most to patients – commitment to personalization and partnership in the management of the very complex challenges these patients face.”
It also promotes more cost-effective care, he adds. Medicare Advantage plans’ coordinated care approach has been shown to keep seniors healthier. Plan members with multiple chronic conditions experienced 23% fewer inpatient hospital stays and 33% fewer emergency room visits than those in fee-for-service Medicare. In addition, research shows that healthcare spending is 25% lower for Medicare Advantage enrollees than for enrollees in fee-for-service Medicare in the same county.