Anne Tumlinson

Scott
I'd like to welcome everyone to our newest episode of Verse the podcast sponsored by By VIUM Capital. I'm very excited about our guest today, Anne Tomlinson from ATI and IT Advisory. And Anne we've been friends for a long time, worked in a lot of different roles together and in different factors of our careers. But I'm really excited for our conversation today to have you on. You know, for our listeners that'd be really good for them to hear a little bit about your background, a little about ATI advisory, what kind of led you to form it, and then also how you work with your clients right now.

Anne
Great. Thank you. I'll try to keep this short. I have been in consulting for a long time, and I was at another firm for many years, I loved Avalere Health and grew a practice group there focused exclusively on post-acute and long-term care, which was wonderful. That is a larger organization with lots of other areas of focus. And I just decided that in 2014, I was like "You know, it feels like the time is right" to start a firm kind of whose sole focus is going to be around helping public and private leaders in developing solutions oriented around the growing complexity of need in the population around healthcare and social services. So taking everything that I had done before, but then building it out and really shining a light on it and creating a focus. So post-acute and long-term care is foundation of it, but now we've really built out capabilities around Medicare advantage, value-based care, we even have a prescription drug pricing group. We work with states, we work with foundations but the core in my area of expertise that was the foundation of all of it is in post-acute and long-term care.

Scott  
You've got a great team there. I know Fred Bentley, joined you recently. Tell us about your team and how many people are on staff.
Anne
We are at 25 people now, I think, maybe even 30. It's at that point now where I'm sort of losing track and we are organizing three, three pillars of work. And Fred is now leading the post-acute and long-term care work, which is phenomenal. I'm so delighted to have him. He sits within our Medicare group that does value-based care. We do PACE. If you're familiar with the PACE program, we're doing a lot of work operationally helping organizations set up PACE programs. We work with primary care groups, especially those who are now looking at assisted living and skilled nursing as places where they wanna focus their practice within value-based. We have a Medicaid long-term services and support and program integration group. It's also about 10 people. And then we have our prescription drug pricing, which is just two people right now but growing.

Scott
That's exciting. Thanks for giving us the background. It's been exciting for me to see you grow your practice and all the ways you work with your clients.

Anne
It's so fun. It's really fun to build something. It's been really gratifying.

Scott
Let's just jump in the topic today, which is value-based care. It's hot topic, as you and I just came back from the ASHA Spring conference, felt like every discussion panel was revolving around value-based care. You led a very interesting discussion on value-based care one breakout session. But I guess for our listeners who maybe aren't familiar with value-based care, I feel like you can define it lots of different ways depend on the context, depend on the component of the healthcare sector. How would you define it in long-term care?

Anne
I think having, a grounding in what it's intended to do is very important. So value-based care, at its essence is reforming the way that we deliver healthcare with the goal of getting much better outcomes for the unit costs of service. I'm sure everybody who's listening has heard people say volume to value a hundred million times, but it really is getting away from the primary financial reward in healthcare being based on the number of units of service that are delivered to what those units of service actually deliver in terms of value. So that's kind of the underlying definition. What's value-based payment then is that financial arrangement, the contract, the payment arrangement that actually aligns with the higher value of care. In senior living and skilled nursing and really any setting of care it's taking some group of services or maybe all of the services for a population and saying okay the entities at the heart of delivering that care, the providers themselves are going to now be held accountable for the costs of a chunk of services or all of the services. We have a phrase we call total cost of care risk, which just means that a provider organization is sitting there essentially responsible if somebody goes to the hospital or the emergency room, ultimately they're accountable and at risk for the actuarial risk, essentially for that. Value-based payment doesn't have to be that extreme in terms of risk. It can be as small as we're going to reward you financially if somebody gets a higher rate of vaccinations for the flu, or if the wait times are lower in terms of the fulfillment at the service itself. There's a very broad continuum. I think in the way we tend to talk about it in facility settings like assisted living and in skilled nursing is you have a resident population that lives there and they are using a lot of healthcare, and that healthcare largely is being delivered in a fee for service type of volume-based environment. What we wanna do is begin to migrate some of that into financial relationships with healthcare providers that interact with them on a regular basis, say primary care providers or pharmacists, or it doesn't have to be primary care management organizations. Essentially take responsibility for delivering, keeping them out of the emergency room, keeping them out of the hospital, and helping extend their life and their quality of their life. That can happen when you change the way that you pay for those services. So the incentive is to spend more time with them understanding their needs you know, doing medication management, preventing them from going to too many different specialists that they don't need to be going to, working with the family. It's hard, value-based care is hard. It's harder than volume-based care to deliver but there's an enormous amount of value to be extracted from those settings, because we have been really inefficient in the way we deliver healthcare, particularly to that population that's living in facilities.

Scott
I heard you on the panel at ASHA Spring Conference a couple of weeks ago. This is not a new concept, right? I mean we've been trying to elevate value-based care and value-based payment for some time. And so say little about the history dating back, I think probably, maybe several decades even, right?

Anne
It's really for people who are listening and who are familiar with the program for all-inclusive care for the elderly or pace, that really was the first ever value-based payment arrangement, I think in healthcare. Maybe actually I would even argue that the DRG  the diagnosis-related group) payment to hospitals. It's crazy to think about this now that we used to pay hospitals on a cost basis. They would just say, here's so much it costs. Medicare would just be like, ok, here you go. That we moved into a prospective payment system where we say to the hospital and say, look, all right, everything that happens within this hospital is now your responsibility. We're gonna tell you how much we're gonna pay for it, and then you have responsible for delivering that and eventually build quality measures into that and things like that. It is risk-based payment, you know, measuring quality, holding providers accountable for care. We've been doing that since the early eighties. Then the ACA passed in 2009, and that kind of ramped up the visibility of it because we now created the Centers for Medicare, Medicaid innovation within CMS, whose job was essentially to really develop out and test these various models. While CMMI was doing that Medicare Advantage, I would encourage your listeners to think about this in two buckets, in a way. We have kind of half of the Medicare population that is getting their healthcare through the traditional Medicare fee-for-service program. In which there are these demonstrations running with ACOs. You've heard of Accountable Care Medicare Shared Savings Programs. There used to be a sort of rebuttal payment, lots of things going on over there. Then over on the other side, there's Medicare Advantage, and enrollment in Medicare Advantage has been growing really quickly. These private insurance plans were essentially capitated for all of the healthcare costs for the people who choose to enroll in them. They are payers who have been now engaging in value-based contracting with providers. The Medicare Advantage program and payments to care organizations that are not value-based care, that are just the delegation of actuarial risk and the Medicare program to private insurers. They are then in the same boat as CMS. They're just paying bills and mostly they're paying on a fee-for-service basis. But increasingly they have been engaging in probably ahead of now CMS and actually enabling this rapid growth in investment, in these primary care organizations that are very tech-enabled and really capable of taking on an enormous amount of actuarial risk for the populations that they serve. If you're familiar with Oak Street Health is a good example of one of those. Village MD is one that we've heard of in our space quite a bit. Aspire, which was not a total cost-of-care model, but it was palliative care at home. Landmark Health, all of these venture-backed private equities backed arose out of actually responding to the needs of these Medicare advantages plans for better management and better kind of cost controls. So we accelerated ahead of CMS in that sense.

Scott
That's fascinating. Thanks. Let's jump right into the operator side because we have a lot of listeners here probably thinking, okay, I'm curious about value-based care, about value-based payment as a SNF operator, what are the benefits? And how does someone start going down this path?

Anne
I would say on the SNF side, it's tricky. Because on the one hand there's an enormous amount of opportunity for savings in the resident population because right now, on average, the skilled nursing facility sector is hospitalizing their residents at a rate of 700 per 1000. Just as a benchmark in the regular Medicare population, it's like 300. We know that when the long-stay resident population in a skilled nursing facility is managed with a primary care intervention, we know this from data from Optum, that we can actually get that hospitalization rate down to 300 per 1000.

Anne  
You know why because you should be at the general population or below because you can skill in place in a managed care contract. So there's theoretically the skilled nursing facility is a setting in which we should be able to provide a lot of care that intervenes in emerging conditions and emergent situations before they become emergent. And also where we can address emergent conditions in real-time by skilling in place. So that's a lot of money. Hospitalizations, like, 10,15 to$20,000 per stay, and then you're coming back anyway. It's a lot of money. The trick is that is for the skilled nursing facility to be ready to, and able to benefit from the savings that accrue to kind of stopping that churn through the hospital at a level that actually is higher than the money that they make. When people are coming back through a shorts day, when their residents are coming back through on a skilled stay. And the reason why it's challenging is because you have to bring a lot of capabilities to bear through partnerships with primary care organizations. Those primary care organizations are part of ACOs or they're part of Medicare Advantage plan contracts. if you think of it is that savings have to kind of be shared across a number of different organizations. That's when we struggle a little bit sometimes to find enough savings that it actually rewards them for stopping that turn. That's a challenge.

Scott
You said something interesting like, they need to be ready. If I'm a CEO of a larger regional skilled operator portfolio, what are those first steps to become ready?

Anne  
I'm gonna start at the most basic level. You really do have to educate yourself. What I am seeing is that I'm seeing a lot of operators jumping into it's like the first organization that kind of comes across their path and pitches them on a partnership. And they leap in and it's very important just to start having the conversations and educating yourself with as many different solution providers out there as possible. The biggest one is Optum, talk to them. But talk to others as well because there are a lot of different ways you can go about doing this and a lot of different types of arrangements that you can enter into. I think just educating yourself is a really important first step. And just having those conversations. The other thing though is that you do, in order to really benefit financially from the value-based care that would be delivered in your building, you have to be ready to take on some of that risk. You could look at this in one of two ways. You could look at this as like, we're gonna bring value-based care into our building. We're not gonna take risk, but we're gonna improve care for our residents and we're gonna perform a lot better now on all of our quality measures. And this is the right thing to do. We're gonna find a really good partner and we're gonna get paid for some of the upside, a small amount of money for the value that we're creating, but we're not gonna take on a lot of the risk. That is great. The other option is if you really wanna benefit in being kind of a population health manager for your resident population, you have to be ready to take on some of that downside risk. And you don't have to become a Medicare Advantage plan to do that by any stretch, but you do have to enter into a partnership with a primary care organization that has those risk-based contracts and can share in that risk and the savings with you. And those are the organizations that you have to get to know slowly over time and my main piece of advice is don't just jump into something.

Scott
Really spend the time to educate yourself and your team. How about on the assisted living side? Cause I think a lot of people don't realize there are some incredible opportunities for value-based care and outcomes for senior living and assisted living. So maybe say a little bit about what you're excited about on that side.

Anne  
I'm really excited about that side because unlike skilled nursing where it's really complicated, in some ways skilled nursing is a really easy population to manage because it's such a controlled setting and people are at a point where they need so many interventions. But on the other hand, it's complicated because of all the conflicting financial incentives, not the case in assisted living. In assisted living is kind of a different set. The challenges are really just persuading the population in your building to participate in whatever the program is. But there's no financial downside at all. To me, this is where kind of the really exciting opportunities are because, you know, increasingly the primary care organizations that are specializing in being in assisted living are expanding there, how do I say this? They're expanding the way in which they can bring that value-based care to the building. It used to be not that long ago that the only way you could really do this in a building is if you enrolled all of the residents into a special managed care plan called an IESNP. And that was hard because many residents don't wanna do that. So you're kinda stuck. But increasingly now these primary care groups are coming with accountable care organizations and things like that where your residents don't have to switch plans. They essentially just begin to enter into relationships with these primary care physicians and use the services on-site. They just get naturally aligned to these ACOs and then the kind of financial incentives are all aligned.

Anne
So I'm excited about those. I think this is a population that is going to the emergency room in the hospital way too frequently. It's hugely inconvenient for families. There's so much we could improve on in terms of care management, medication management in the building itself can actually offer those services. It doesn't take that much to retool existing staff into becoming care managers. And then they are really offering an enormous amount of value to that primary care organization that's gonna come on-site and provide that.

Scott
To your point there. I think that's a really important thing for our listeners on the AL side to consider. I've heard our friend Lynn Katzman, say to AFL/AL providers, you are already doing all of this work in house, you just don't realize how much you could be benefiting through a value-based care experience it through a new relationship, and then to elevate your staff and your residents accordingly. So I that was really an interesting point you just made to highlight what I've heard Lindsay as well. Senior living operations already doing a lot of the work that could be done through a relationship like this. Is that right?

Anne
Yeah, and she's so positive about the sector and she and I get into arguments sometimes because I'm like, the operators are not doing what they should be doing, you know, and her point to me is always that there's so much that's happening inside these buildings, it's so valuable. And what she's talking about is re-engineering some of the processes and some of the job descriptions a little bit, so they're a little bit more oriented towards the healthcare management of the population. When you think about it, that's what residents and their families are really looking for. And one of the things that one of my panelists said at the spring conference, which I thought very compelling was Christoff from Kirana, and he said we're in buildings in your market. Increasingly families are making decisions about where to place their family member and when this is in place, and available, that's gonna be a market advantage. And I think that's true. I just speaking as a daughter myself, I feel I'm moving my mother actually into independent living this weekend. And I'm frustrated already that, when I said, where is she gonna get? It's like this health and wellness model, and it's very fancy, but can't tell me who's gonna provide primary care. They don't know. They're like, well talk to some of the other residents. Maybe they can recommend somebody. She's 82 years old, her whole life is managing her help now.

Scott
You're experiencing something, I know that a lot of people listeners are experiencing right now as sort of the adult child and the caregiver. I wanna get into a really interesting project that you've worked on in your own personal life and the side as well. But I think for the adult child who's really the client in many ways, I think for our listeners, they already know it all too well. I think in this world of value-based care, seeing it as an opportunity to show value, right? Seen it as a way to demonstrate that this can be more than just a care recipient, right? That they're residents that have lives and want to achieve outcomes and want to have their health improved. I think that's really exciting, but can be seen as a marketing opportunity to really show that there's more in a happy building than just residents being there.

Anne
Yeah. I completely agree.

Scott
Let's talk about the benefits of value-based care. Are there downsides?

Anne
There are downsides to everything. And there's actually a very heated debate going on right now in Washington among policy wants about whether or not value-based care even works. Honestly, from the perspective of the federal government saving money, we haven't really seen savings. We've seen a lot of primary care organizations make a lot of money and get really high valuations. It's like, at the end of the day when you capitate payment to an organization, you're changing the incentives now, potentially to stent on care. And some of your listeners may recognize this in the hospice benefit, for example, or home health where we're paying on an episodic basis or we're capitating payment, and then sometimes it's a little bit of an effort to get the providers to come out and do what they're supposed to do. So that's a little bit of an existential challenge with value-based care. I don't know that I see any downsides. From an operator's perspective, it's a big change. Despite what Lynn says and I agree with her that they're already doing it's still not nothing.

Scott
Their resource to be expended, staffing, you may need to realign. The new administration called a burden possibly, but maybe it's surmountable through IT, but it is a consideration.

Anne
Even families can get confused, I make a big deal about, oh, this is what families want. Well, sometimes what families want is for you to send somebody to the emergency room, right? Because they're scared. They're like, wait, why didn't you do that? And so there are nuances and complexities to everything, and I think this definitely qualifies.

Scott
In your crystal ball, where do you see value-based care going in the next 10 to 15 years? If we were to have this podcast 15 years from now, looking back, what role does it play in moving the needle on outcomes and improving quality of care? And, what kind of percentage of penetration are we seeing in terms of MA plans and evaluations? So what what do you see going ahead here?

Anne
Okay, I'm gonna make a very bold prediction. I actually think that the large payers like UnitedHealthcare Care, Humana, Aetna, CVS, will start to develop very specific products aimed at senior living that are, think of it as like, and not to get too into the weeds on how Medicare Advantage products work, but there's a lot Medicare Advantage plans can pay for that residents are paying for in their fees right now.

Anne
Like food, transportation, and ADL support. I think as these Medicare Advantage plans grow, they're gonna be competing for enrollment. They're growing off of a large base. They wanna keep growing. That's what their investors demand. They're gonna be looking in the nooks and crannies, and there's this whole middle market that we talk about all the time in senior living that can't afford it, but tends to enroll in Medicare Advantage at much higher percentages. I think that actually, it will be the Medicare Advantage plans that help to expand the senior living market by offering sort of more integrated products with senior living that phrase the cost for the resident and enables them and they'll be looking for partners. That's kind of what I'm, I'm working on right now and excited about and feel very passionate about. Because there's a lot of value leaking out right now. We're kind of double paying for things, between the Medicare Advantage, all the money that's going out of the Medicare trust fund, and then all the money that's going out, people's pocketbooks to pay for senior living. When you take that all in total, there are efficiencies to be had in integrating it. And that's what I'm excited about and working on.

Scott
I think, Anne, it would be really exciting for us, and I don't mean to look out 10 or 15 years, but to check in with you in the near future, just to kinda see where things are going. As I shared with you on our prep call for this podcast, we're gonna be going down a path here, our own, at VIUM Capital to highlight some work that's being done out in the sector right now. So our listeners can really have a great understanding from, you know, certain models, what works, what doesn't work. We're gonna talk leadership and big skilled, small, independent, owner, skilled regional assisted living, independent owner AL. Maybe talk to payers as well. Kind of just giving some real examples of what's happening in the front lines, really excited about that. Hey, we've just got a few more minutes and I just, want to pivot to something that I know you're very passionate about which is your daughterhood project. Tell the listeners a little bit about it. I'll tell you I'm really fascinated about the work you're doing. I got really excited about the podcast, in particular, I listened to several. I wanna share one of us from Patty Davis was absolutely fascinating, Ronald Reagan's daughter. I thought, boy, as a fan of President Reagan, and I was really lucky to meet him once a long time ago, I found her podcast to be incredibly fascinating, but incredibly relatable at the same time, even though she's the daughter of a former president. Tell us about your daughter, her project for our listeners.

Anne
Yeah, thank you so much. When I launched ATI, I launched Daughterhood at the same time. And with the idea being it's not, I'm tired of working on healthcare and healthcare policy and without understanding the ground level of what's happening. And so many times, people come, you know, everybody who's listening has had this experience because we're in the field. Your family members, your friends, they come to you, they have questions, they wanna know what they're supposed to do, and you realize you don't have great answers. So I think that you know, I wanted to try and take what I understand and translate it into something that could help caregivers and then kind of vice versa, be in community with them so I can hear from them. And actually, I had a really gratifying thing happen. Just highlighting that the president issued an executive order yesterday on family caregiving, and there is a provision in it about acute hospital at-home programs and making sure that there are considerations for family caregivers in that. And that was an idea that came from our community and Daughterhood. We took that insight over to ETI, we talked to AARP, and pitched them on a collaboration. We wrote a paper about family considerations in the acute hospital home, and it became, and it got into the executive order. So Daughterhood, I call it a laboratory or my sort of anthropology project. Now, having said that, so we have communities of caregivers all over the country, and we have a podcast and we have a blog, but we're getting ready to pivot it officially, create its own corporate entity as a nonprofit, get a 501 (c) (3) status. And we're changing the operational model to make it more scalable. We wanna reach more people. We want to take that one little thing we did and really amp that up. So we're, we're still working on it and it'll be more community-focused going forward.

Scott
Well, for our listeners, I encourage anyone who's in a caregiving role or in a future caregiving role to check out your podcasting resources. I know it's geared largely towards women and daughters, but I'll tell you as a son and as a son-in-law, as a husband, I found a lot of value as well.

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