Episode 58: Mending Senior Care

Most people seem to agree that healthcare for seniors needs to be improved. Dr. Jay LaBine, chief medical officer at NaviHealth, is ready to answer the tough question, “How?” In this episode, you’ll learn about where higher quality of senior care needs to come from, how to demand more transparency for rehabilitative care, and the role that orthopedic surgeons can play in the post-acute stage.

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Full Transcript

Announcer: It’s time to think differently about healthcare, but how do we keep up? The days of yesterday’s medicine are long gone and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans, and many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together, and hear some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.

Michael: Welcome to the “Paradigm Shift of Healthcare,” and thank you for listening. I’m Michael Roberts here today with my co-hosts, Scott Zeitzer and Jared Johnson. On today’s episode, we’re speaking with Dr. Jay LaBine. He’s the chief medical officer at naviHealth. Dr. LaBine, thank you so much for coming on the show today.

Dr. LaBine: Yeah. Thank you so much for having me. Really appreciate it.

Michael: We’re looking forward to the conversation today. And so, we’re just going to dive right in. You know, in July, you co-wrote an article titled “Lessons Learned from COVID-19 – It’s Time to Reshape Healthcare.” And in that article, you stated that, “If COVID-19 has taught healthcare leaders anything, it is this, the very fabric and design of our current system is flawed. Understanding the challenges seniors are facing is vital when it comes to redesigning care in a post-COVID world.” Totally agree. We’re totally on the same page with you. So, now, we’re going to get into the hard question which is how do we do that? You know, how do we fix healthcare for seniors and what are those specific steps?

Dr. LaBine: Yeah. Thanks. I mean, I’ll just tell you this, that I remember when I first heard about COVID-19 pandemic, and I can’t tell you how many times I heard the term like “unprecedented.” Even now, it’s ongoing, right?

Michael: Sure.

Dr. LaBine: And, Michael, the worst effects of COVID have really hit the frail elderly. You probably know this, but over 40% to 50% of all the deaths occurred in seniors in nursing homes, especially those with a lot of comorbid conditions, you know. And as a surgeon, we’d always call, you know, folks with multiple chronic conditions like multiple medical problems and these are the folks that have really impacted the most, right? And I’ll tell you that the challenges that occurred, you know, that we’re experiencing in COVID actually began pre-COVID. If you think about the senior care challenges pre-COVID, the senior population, 10,000 people per day, were turning 65, right, because of the baby boomers. And then here’s really something fascinating. And we were talking earlier about this, but by 2050, the number of 100-year-olds and 90-year-olds in the United States is going to quadruple. I think that’s just an amazing statistic around what our medical community is going to be faced with as we move forward, right?

Michael: Absolutely.

Dr. LaBine: And to your question, you know, what is it that we need to do? I’m going to focus primarily around senior care and rehabilitation challenges for seniors. And so, this is something that, as you know, COVID really exposed, you know, the facility-based care and all of the challenges. I would say there’s three kind of aspects of this. First one is in the care model for rehabilitation, if you’re going to go from the hospital to a nursing home, you know. And this happens, I know your audience, there’s a lot of orthopedic surgeons, and neurosurgeons. But when they transition from the hospital into the nursing home, there’s really a challenge there in that hand-off. And I think investing more in basic safety, like personal protective equipment, testing how you can do safe touch in a nursing home, this is like really important. So, I think that would be my number one, Michael, on what we need to do for improving this senior care rehabilitation.

Michael: So, you said you got three steps there, or three kind of like aspects of that. What are those other aspects there?

Dr. LaBine: So, the other one is something that we’re really involved with, but I’ll put it under the heading of transparency for rehabilitation care. And this is really based on, we need to expose like the functional gain that occurs when you’re in a nursing home, getting rehabilitation, and then ready to go, is that we know that there’s huge variability in post-acute care. And in fact, as a physician who was doing rounds in the hospital, that was completely unknown to me. Like I had no idea if my patient was going to go to a really high-performing post-acute care nursing home, or if my patient was going to go to one that is really challenged and doesn’t perform as well. I think bringing transparency into those outcomes for rehabilitation is really important. But also more and more, right, it’s about, well, can they do it efficiently and can it be cost-effective? Because cost is playing a really important role in senior care.

And then the third aspect that I think is going to be even more and more important as COVID kind of rages on is innovation. And by innovation, I’m talking about look at what’s happened with telehealth during COVID. We’ve gotten 10 years of innovation in about 10 weeks. And the adoption of telehealth is one innovation that I think can help both like surgeons and physicians who need to do visits safely, they can certainly do telehealth. And we’ve seen a tremendous uptick in that. But I’m also talking about how we could do more rehab at home. I think that there’s a lot of advances now in the way we could manage people in their own home setting versus having them spend two to three weeks in a facility.

Scott: Yeah. You know, doc, I couldn’t agree with you more. Even from a pre-COVID perspective, I was talking to some of my parents and their friends, and they were talking about how great Uber was. You know, the ability just…they didn’t have to drive. They could get someone to drive for them. And there were a lot of services built around just making that easier, you know, for them to get from point A to point B. And then we started talking about, so Uber really doesn’t have a lot to do with medical care, but when you start talking about medical care, you do think a little bit about independence. A lot of people as they get older, like I just want to go home. They view that “nursing home” or that “rehab facility” as like the beginning of the end, so to speak. And there’s so much more that can be done at home because of innovation. How do you measure all that? Are you guys coming up with your own systems for that, or are you starting to work with other vendors and kind of review them as well or a little bit of both?

Dr. LaBine: Yes. God, I mean, I’ll just tell you this, that I have not met a senior yet who really wants to go to the nursing home.

Scott: Right.

Dr. LaBine: I mean, when that’s presented to them, they’re always like, “Hey, give me some alternatives because I really don’t want to spend two weeks, you know, outside of my home in the nursing home.” The problem was, you know, frankly, is that they really had to be there because there was just no other way. We didn’t have the infrastructure to take care of them, you know, at home. But that is changing. I’ll tell you this, like the ability to do more of that, we’ll call it sniff at home, rehab at home, there’s a lot of innovation that’s occurring. Our company naviHealth is investing in the ability to measure people and understand whether, hey, if you could get the same outcome at home with home healthcare and PT at home as you could in the skilled nursing facility, what would you choose? And we have a proprietary tool that helps with this decision-making.

Scott: I think that’s just amazing, you know, quite frankly. And we mentioned this before the podcast we were just talking a bit about, and you brought it up about just how many people are going to be “older.” You know, I think of a lot of my orthopedic surgeons that I work with quite a bit, neurosurgeons, ortho, etc., that’s an aging population, man. And many of them are in this age range, this “post-acute stage.” What is it, 65 to 70, right? So, what kind of role can an orthopedic surgeon take in this? You know, you mentioned as a surgeon, you know, you’d be like, “Okay, man, you know, I saved you. You’re done now,” right?

Dr. LaBine: That’s right. Well, I’ll just say this, like orthopedic care has made some tremendous advances in, you know, the last decade. I mean, the ability to now select people who could get their total knee done in a ambulatory surgery center and then stay in a hotel and then go home, that’s fantastic, right? I mean, we gotta really congratulate, you know, how advanced orthopedics has come. I would say that there’s certainly a number of things that orthopedic care could develop in their system that would really benefit seniors. And the first one is really around, like, I’ll call it whole person care. So, this understanding the entire person, because even though there are a lot of people who do have a really great home setting, we’re talking about social determinants of health, you know, like people that don’t have caregivers at home, people that, you know, are living in pretty bad situations. 

I think it would really help if in orthopedic care, that we understood more about these social aspects that lead to either really good recovery when you have a lot of support systems, but not really good recovery, actually poor recovery when you can’t follow your care plan at home because of these limitations. And, you know, one of them, Scott, is that you mentioned Uber, but Uber does affect healthcare because, man, if you can’t get to your doctor, that transportation…I mean, a lot of people just don’t show up, right? So, I think getting whole person care in orthopedics would be a really strong advancement.

Scott: Yeah. I couldn’t agree more. I think connecting the dots now that we’re getting a lot of these technologies that are starting to come out, you talk about telehealth, Apple just came out with a watch that’ll actually measure your oxygen levels as well as, you know, your heart rate. And I think the Android watches had that oxygenation level. You know, there’s so many more things that can be occurring right now and connecting the dots with all of this. That’s what really interested me about some of the things that, you know, your company is actually doing. It’s the measuring part. It’s going from beyond, “Isn’t it cool, that…” to, “Hey, here’s what we’re doing, and here’s what’s working, and here’s what’s not working, and here’s what we need to do to move forward.”

Dr. LaBine: Yeah. And I think that’s part of where…you know, when I said like transparency, part of it is understanding what’s really important to seniors who are getting procedures done or even being admitted for a lot, you know, medical conditions in the hospital. And then they have to transition, right, you know, back into the community. But if they’re not ready yet, this is really what we do is we identify those that are transitioning and with data, support that next step. And I don’t know if you remember this, but there was a time where like every total joint stayed at least a week in the hospital. Today, like they want to get their length of stays down to under two days, seniors, right? So, that’s quite a rapid transition.

Jared: It’s really interesting and it’s funny you say, I was literally just working with an orthopedic group last week, and they’re now touting same day, you know, you can go home the same day of your total hip or total knee. And I thought, man, like that’s really interesting that, well, first off, that that’s even possible. And second off, that that’s something that can differentiate them. And I think, you know, all that’s just part of this attempt to integrate the experience. I mean, recovery is very much a part of that and recognizing that more of the overall experience is going to happen at home is definitely a shift. And I know there are barriers that have kept that from happening in the past. And it’s not just COVID that has brought things to light in terms of how do we evolve the overall experience. I’m curious what other barriers are still standing in the way of reaching this desired care, that this whole new level that’s integrated all the way across the board, what other barriers are standing in the way still?

Dr. LaBine: Yeah. So, you know, I hate to say it this way, but payment model really matters when it comes to the barriers that need to be addressed. And I’ll give you the example of telehealth, right? So, when the COVID hit and they basically said, “Hey, you’ll get paid equal to a face to face visit with a telehealth visit,” man, there was this massive adoption. I just saw a statistic the other day that before COVID, they measured the number of telehealth visits in Medicare, and there was a total, for one week, 11,000. Then in the middle of COVID, I think it was in mid-April, there was 1.3 million virtual visits because now the provider, right, the doc was getting paid equal to a face to face visit. 

And, frankly, they needed to do this to keep their patients safe and their staff safe, right? So, the payment model, I think, is a real barrier that needs to be overcome. I’ll give you one other example of how, especially when we’re talking about seniors that are at the highest level of need. So, you may have heard of this high cost, high need, really a senior that is like 94 years old, has a walker, home O2, really needs more than what you could deliver in a primary care office, there’s a really great model out there.

And when I’m talking about innovation for senior care, it’s called home-based primary care. And in this home-based primary care model, instead of this really frail high-need senior coming to the doctor’s office, the doctor does a house call, right, like the old days and brings along either a med tech or someone and has a team behind him that can comprehensively take care of this really frail senior. And the reason this model is really valuable to the seniors is that so many seniors don’t want to get moved into a nursing home full-time. They want to stay at home, but it’s really, really hard to care for them. So, aging in place and being able to stay at home, this model of house calls has been shown, over and over again, to really have tremendous benefits both on the care side and on the cost side. The problem is we don’t have really good reimbursement models yet to incentivize those doctors who want to do this full-time.

Scott: Yeah. It’s interesting you say that. There’s a lot of…we keep hearing of a lot of really good ideas and thoughts on this show, and just over the years, in general, where, you know, frankly, the insurance companies have not caught up. It’s like, well, we’ve got…I mean, telehealth is a perfect example of, absolutely, it can be a very good thing. And you’ve got to trust the doctor’s judgment on so many different treatment options. Why wouldn’t you trust the doctor on whether or not it makes sense to be seen at home, you know? And you talk about COVID where somebody doesn’t want to come in and you bring up like, well, someone who’s much older, why do you want them to drive, get there, go through the pain and suffering, so to speak? And like when you’re 85 years old, it’s not an easy thing just to hop in and have a conversation about your diabetes.

Dr. LaBine: Yeah. Well, I’ve gotta tell you, I remember in my school in talking to some of the senior physicians, right, they used to do this all the time. They used to drop by and check on their patients. And so, that house call model is almost like a back to the future model, but it actually makes a lot of sense for the patients who have such a struggle. And their families, think about it. You’re trying to get your, you know, frail mom, grandmother, you know, loaded up in the car, drive across town, and then, you know, it takes a full day to just go to the doctor’s office. And then, frankly, when you get there, not a lot they can do, right? So, this model really…

Scott: Yes. Agreed. You know, it’s interesting because I have a son who’s in…going to learn osteopathic medicine and they are literally, they have like a ceremony for this particular school when you get started, “Hey, you’re about to be a doctor.” And that’s a big undertaking, you know. And they were literally begging them like, “We need more primary care guys and gals,” right? It’s like, “Please.” You know, and a lot of this is about that. We’ve gotten, so…you know, one of the barriers is just having enough humans, you know, to take care of people who aren’t specializing in a particular field. Wouldn’t you agree?

Dr. LaBine: Yes. God, you know, really, it focuses on this triple aim and I’m sure you guys have heard that before, you know. The triple aim really is better health outcomes, right, for people, for patients, a better experience with the healthcare system. So, it has to do with patient satisfaction, but also just a better experience overall. And then the cost of care. So, better care for less, right? That’s the triple aim.

Scott: Basically it.

Dr. Labine: Well, this is where, you know, this model that we were talking about for frail elderly and people who are really kind of in that stage of their life, it hits everything on the triple aim. It translates some of that learning, right, to how we can improve, going back to your first question around rehab care and facilities. Like it has to get to be a better experience than it is today. It’s not a good experience. We want to make it better. naviHealth really has invested a lot in improving the experience for seniors in this care transition and measuring it to the individual risk-adjusted measurement level so that we can show nursing homes who’s doing really well, best practice, and then who really needs to improve.

Scott: We’re getting close to the end, and you’ve talked about individualized care, which to me is very important. How far are we from just achieving integrated care, in your mind?

Dr. LaBine: It’s going to be a challenge. So, we’re very involved with, and I’m sure you’ve heard this before on your show, around the alternative payment models. So, bundled payments, especially in orthopedics, right, that was a really big thing. And, in fact, just recently, CMMI made an announcement that they’re looking again at mandatory bundled payments. When we talk about integrated care, we talk about, well, how can the payment model align with the care model of the integrated care, right? And if you move more and more towards these alternative payment models, what ends up happening is that the doctors, the orthopedic surgeons, they recognize that, “Okay, I’m going to be incentivized to make sure that this patient, if they don’t need to go to the nursing home, I’m going to be involved with that decision and say, ‘Hey, I think you can get the same result here at home. And then we’ll keep a real close eye on you for at least 90 days in your recovery. So, you’re not going back to the hospital with readmissions.’” So, that’s one example of like a payment model pushing us forward to a more integrated care model, that there’s going to be some headwinds to that because of COVID.

Basically, there’s a lot of, you know, health systems that took a big hit when we knocked off all the elective procedures and things like that. So, there’s going to be a little bit of a pause on investment into these kinds of models, but I do think where Medicare is going, the rest of the system really follows. And I think Medicare is committed to this payment model that will help with integrated care models.

Scott: I agree. I agree.

Michael: Yeah. It’s exciting as we’ve had the chance to discuss some of these different payment models through our episodes and really is exciting what’s possible with that. And you know, one of the things that we just hear over and over with this show is like, holy crap, this year threw us for a loop, and we’ve had to all adjust. We’ve all made these huge changes on what care actually looks like. And yes, there have been some major challenges, but, man, there really are some big opportunities in that. And I think that this conversation just continues to illustrate that. So, Dr. LaBine, thank you so much for coming on today. It really is wonderful. This isn’t a topic that we really had the chance to discuss on the show yet. So, thank you for really opening this up for us.

Dr. LaBine: Yeah. I really appreciate you having me on and thanks for the conversation.

Announcer: Thanks again for tuning in to the “Paradigm Shift of Healthcare.” This program is brought to you by P3 Inbound, marketing for ortho, spine, and neuro practices. Subscribe on iTunes, Google Play, or anywhere you listen to podcasts.