What is LeadingAge?
Alwan: LeadingAge is an association of 6,000+ members and partners that include not-for-profit organizations representing the entire field of aging services, 39 state partners, hundreds of businesses, consumer groups, foundations, and research partners.
In order to decrease medicaid spend, CMS is incentivizing states to enable potential long-term care (LTC) candidates to stay at home using technology. What are your thoughts on using technology to age in place? Is this effective?
Alwan: Technologies, like telehealth & RPM for example, can be very effective in helping older adults with chronic conditions improve their self-management skills, helping clinicians better manage their patients and improve their outcomes, by reducing hospitalizations, hospital re-admissions, and institutionalizations, hence supporting independence and reducing the nursing home room and board cost on Medicaid.
There are 6 states in the US that has Medicaid Waiver programs that covers telehealth services for dual-eligible patients who are not only covered by Medicare and Medicaid, but are also nursing home eligible! Please see CAST’s Analysis of the State Medicaid and Options Programs in terms of coverage of technology and technology enabled services. Kansas was one of those states that did a demonstration and then applied for and obtained a Waiver from Medicare for its Medicaid program to cover telehealth services. Please see Windsor Place’s Case Study in partnership with Philips in the following CAST Telehealth Case Studies (page 27). Details of the Kansas Medicaid Waiver Program can be found on our website.
Similarly, there are private Medicare Advantage (MA) plans, including ones for Special Needs Populations (MA-SNPs), that have flexibility to cover services that are not traditionally covered under regular Medicare program, like telehealth services.
However, I firmly believe that we need to get beyond the dual eligible population which is less than 20 percent of Medicare, and the Medicare Advantage enrollees, which again are probably less than 30 percent of the Medicare population. I believe it is time for CMS and CMMI particularly to should consider innovative care delivery models and modalities that are: a) proactive and preventive in nature, i.e. start in the home of choice, as opposed to a crisis like institutionalization/ becoming nursing home eligible, or start with a costly acute episode of care like hospitalization, b) that use technology to deliver efficacious interventions cost-effectively!
We know from the Chronic Disease Management chapter of the Aging Services Technology Study Report to congress that telehealth has a strong body of evidence demonstrating its efficacy. However, cost-effectiveness evidence is weaker; the strongest cost-effectiveness evidence comes from integrated care delivery systems like the Veterans Administration’s Health System, which is the most pioneering in terms of telehealth and RPM use in the use. This is because they are the care provider and the payer.
Most cost-effectiveness studies were conducted under prevailing reimbursement/payment models that do not have the right alignment of incentives that encourages providers involved to use the technology.
I remember doing a study funded by AHRQ in partnership with the School of Nursing at Wright State University to evaluate the use of telehealth kiosks. The study entailed the study clinicians, who were nurses from the nursing school, to get in touch with the primary care physician of every volunteered enrolled in the study to let them know about the study, get a base line of their blood pressure, and let them know that the nurses my call them or make a referral if the participant’s blood pressure was outside their own norms. Some physicians were reluctant to collaborate with the study team, because they perceived that telehealth would reduce in-person visits by the participants, and would hence cut into their bottom line!
Personally I believe that we cannot assess the cost-effectiveness except under appropriate payment models that correctly align the incentives.
How does the new HHS final rule supporting certified health information technology effect your target population / aging field?
Alwan: Well the long-term and post-acute care providers that provide most longitudinal care and support for the aging population were excluded from the CMS Health Information Technology (Health IT) incentive program, along with other providers like behavioral health providers, and cancer hospitals. The Health IT certification programs are primarily driven by the Meaningful Use criteria and have little relevance to long-term and post-acute (LTPAC) EHRs. While there are a few LTPAC EHRs certified under the 2014 Edition of the ONC Meaningful Use Certification program, I am not aware of any that have pursued the 2015 Edition!
The letter to Medicaid directors allowed states to use funds to engage LTPAC providers only in health information exchange, and only if that helps the providers eligible for incentives (i.e., hospitals and physicians) who serve the Medicaid population become better Meaningful Users. So again, this does not help LTPAC providers who do not have interoperable health IT to upgrade their EHR, for example. Also, LTPAC providers who do not serve Medicaid patients would not necessarily benefit from this “opportunity.”
LTPAC providers that have the scale, volume, market opportunity or resources have already adopted EHRs, but I worry frankly about smaller unaffiliated providers, especially those that are rural, remaining behind the Health IT adoption train. I hope that we, as a nation, consider grant, incentive, and other such programs to bring this key enabling technology to these providers who are at risk of becoming irrelevant in the information age!
What is the future of aging population? Any trends you can forecast/ are seeing on aging in place that entrepreneurs could capitalize on?
Alwan: Certainly the aging population is growing, and interest in aging in place is on the rise. Entrepreneurs should think about care modalities that fully support Thriving in Place of Choice, in other words supporting not only independence but also dignity, quality of life, safety, and social connectedness! If it is not good for me or my own parents, it’s not good!
The other important aspect is thinking of all the stakeholders, who need to be involved in the care process to build caring communities. It takes a village in aging services too; solutions that dump the care load and responsibility on the family caregiver alone are likely to fail. We need to think about professional caregivers and service providers and keep them in the loop. We need solutions, including technologies and models, that serve everyone’s needs and we need to engage them in the design process using a user-centered design approach. That is why LeadingAge launched its HackFest model where we embed on each participating multi-disciplinary team an older adult user, a care professional, and sometimes a family caregiver.