The COVID-19 pandemic has pushed hospital system capacity to the breaking point in some parts of the U.S., and wrought particular havoc in the skilled nursing setting.
All eyes have been on the health care system, with a particular focus on ensuring hospital capacity: Calls to stay home and “flatten the curve” often come with the explanation that those steps are vital to prevent the coronavirus from completely overrunning the nation’s hospitals.
But Randy Oostra, the president and CEO of ProMedica Health System, is not so sure that hospitals alone will be the answer to the cracks in the foundation of U.S. health care, which the novel coronavirus has dramatically highlighted.
His perspective is unique; ProMedica in 2018 acquired the operations of prominent nursing home chain HCR ManorCare, and went to work reinvesting in the network of 171 SNFs and other senior care facilities.
That gives Oostra a wide-ranging view of the COVID-19 national emergency. On April 22, he joined Skilled Nursing News’ “Rethink” podcast to talk about how the health care system in the U.S. is coping, what ProMedica and ManorCare are doing to share resources, and what has to change about care delivery and infrastructure.
How would you assess the response of the U.S. health care system to the COVID-19 situation thus far?
It’s probably multiple answers. Our organization is kind of a traditional delivery system, with employed doctors in hospitals in, traditionally, northwest Ohio, southeast Michigan — and a health plan, which is in multiple states. And then now, of course, with the purchase of HCR ManorCare, we’re in 28 states, and so state by state, we’ve seen kind of a different sort of response.
We’re working with multiple states, multiple governors, multiple ideas and regulations and how they’re working. Nationally, I think what we’re seeing is again — in some ways as much as we want to criticize, we’re probably doing as good a job as we can. I think the idea that our stockpile should have been created and more up-to-date, I think that’s valid. I do think we’ve made a lot of mistakes in testing early on, and we’re paying the price for that.
But I think in the markets that we serve, we see some markets where things have stabilized and are going down. So that’s positive. And then we’re in other markets where we’re still caught in the eye of the storm, and a lot of activity and a lot of hard decisions about care are being made.
I think what you look at is the lesson here, and the lesson that strikes us, is that the health model in America is broken, and we’ve had the wrong priorities for a long time. And I think what we’re seeing now is this idea that we need to change our priorities.
So what does that look like? What needs to change?
You hope we’re going to change, and what you worry about is we’re going to just stay with what we know. Everything we know about the American health care model was broken. In just a few years, we’ll be spending $6 trillion, over 19% of the gross domestic product, on a model that’s broken, that doesn’t work anymore. It was a model that was created [as a] very hospital-focused model. Then we look at the unaffordability of bankruptcy being caused by health care, the number of seniors filing bankruptcy, reports about people not being able to access care.
We have this high-cost model with lots of waste in it, with a country that has maybe not the outcomes we want — in lower life expectancy.
Then when you look at the demographics. We have great caregivers, I think we see that, but the model doesn’t work. So we need a model that’s much more based on taking care of seniors, much more based on looking at social determinants of health, what it impacts people daily in their lives. I think we’ve seen that, as people with social determinant issues are more negatively impacted by COVID.
And then our complete lack of investment in public health. The only way those things happen is: The model has to be changed. One of the things that we’ve been talking about for several years, kind of rattling around Washington, D.C., talking about a national commission on health. The idea there is to create a new model for the future, and that we would pivot to something different over a period of time. We’re hoping that what comes out of this is that kind of focus.
How is ProMedica putting that into practice with ManorCare? Do any of the steps change now that COVID-19 is here?
I think the priority of senior care, at least nationally, should rise here. It’s been obnoxious to see how the country’s responded to the people providing care in nursing homes and senior facilities across the country, the level of arrogance.
We’ve created a situation from a reimbursement standpoint that we’ve made folks working in senior facilities a punching bag for the media, for plaintiff’s lawyers, for government officials; Medicaid continues to cut them. We’ve layered them with with tons of bureaucracy and regulations. Even now, you know, this demand for transparency, and [in] a lot of states the idea that the hospital is going to come to the rescue — but in the past, they’ve largely ignored the whole industry.
When you begin to think about the changing demographics, how we want to age as a country, and how we want to provide services for seniors, this has to be a time that we change. And hopefully we will look at this and change as a country.
Now pessimists would say we’re not. Sometimes when we look at these things, we get the same people that that are vested in the current model, that [say]: “We’re going to get them to change the model,” which they never will.
But hopefully, we see people that that step back to us and say: “We need a rebalancing here of the health care model.” And again, spend a lot more time and resources, a lot more respect for the elderly, and a lot more respect for people that have significant social determinative issues and public health issues — and make those investments.
The point about investment is interesting because of the Medicaid shortfalls; one of the earliest things I had someone tell me when I started covering the industry was that it’s hard to find a nice hotel at some of the Medicaid reimbursement levels. And that’s without complex medical care.
Yeah, and that’s the frustrating thing here. I’ve been on some calls, especially with hospital people, and just the level of arrogance and looking down at people that take care of millions of residents every day in a really respectful, great manner — and all of a sudden, they’re gonna rush to tell them how to do their job, to people that have been doing it for decades, if not years. And, you know, the idea that they can do it better. It’s like: These are the many of these same folks who prefer not to take care of Medicaid patients, and somebody who won’t take care of Medicare patients.
Think about how we judge society. It’s how we treat our folks that are in their most times of need, and we think about fragile seniors and how we invested or not invested. It almost argues, and sounds kind of harsh, but it’s almost a form of abuse that we have not made the kind of investments that we should — and we’ve sat back and let the model just go forward, and there seems to be no momentum, or even thought about changing it.
We tweak it, and we’ve got new buzzwords, and for a while we talk about value-based care — and value-based care didn’t really do anything to the cost-curve. The Affordable Care Act provided a great level of increased access, but the costs went up. So really, we don’t have a plan to change the model and direct resources towards senior care or social determinants or public health.
And the idea that you would do Medicare for All, it’s like: Let’s take this broken model and just give it to a lot more people. Again: Before you do that, let’s change the model. I think that’s what we’re hoping will come out of this.
So how is ProMedica working with ManorCare to change that model?
We’ve got religion, if you will, over the past few years, and we think a lot about how we deliver care in the future, what our facilities will look like, how do we provide care. We all want to stay at home as long as we would like. We spend a lot of time looking at hospital-at-home type services and developing that. We’ve got some pilot areas that we’re launching as we speak.
So we think there’ll be a lot more technology — call it what you want, telehealth — put into homes. We’re spending a fair amount of time on that.
We’ve also been pretty successful early on in providing access to our doctors into our footprint. So you may have a doctor in Toledo, Ohio, talking to a nurse in a skilled nursing facility in Naples, Fla., and can access that consultation 24/7. Because we have all that under one umbrella, we’re able to connect clinicians to people that are working day-to-day with people. We’ve been spending a lot of time on that: How do we make clinical connections to provide them more robustly? How do we think about providing hospital services at home?
And then on the other piece, we’ve done a lot to begin to address social determinants of health for a lot of our residents, starting initially with food at discharge, and also beginning to bring a lot of our social-determinant work into the HCR footprint as well.
It’s early on yet, but we think a lot of those areas make a lot of sense. We firmly believe a lot of health care will be delivered more and more to a consumer at home. In kind of the first year and a half of our marriage here, that’s what we’ve been focusing on.
Then, obviously, comes the COVID-19 situation. Has that given you any new insights into the social determinant side, or has anything come up that you weren’t expected or surprised by?
You know, I was talking to a gentleman this week, a business owner, and he was talking about — this is going to sound terrible — all the positive things that have happened [from] COVID for him and his company. A lot of it was the type of things that we’re seeing in health care. It’s the advancement of technology, learning the new ideas, and learning that we haven’t learned before.
Then also the appropriate setting for people and where they work from. So for us, we’ve been all talking about telehealth, being able to talk to patients online, having physicians participate in that. We’ve seen, and I think this is true, probably in all systems in the country, that’s exploded. Doctors who in the past were hesitant, because they grew up in a model where they had to see every patient and that was part of what they did, now all of a sudden realize they can communicate online with folks on a video chat or talk with them.
I think what we’re going to see is that ability to really advance that. That’s going to be great when we think about delivering more services on a home basis and actually into senior facilities; we’re going to have a lot more positions that are going to be very, very quickly adapting virtual options.