Anne Tumlinson, CEO, ATI Advisory

As the CEO of ATI Advisory, Anne Tumlinson continues to set the course for aging policy on the national stage. She founded ATI Advisory to drive reform of health care, long-term care delivery and financing for the nation’s vulnerable aging population. Tumlinson also founded Daughterhood to connect family caregivers, providing them with a platform to share support and information.

Through the Vision Series, Tumlinson shares her vision for an idealized health care system that utilizes technological innovation to assess and address the needs of individuals and their families. She explains how it can be achieved by integrating our health care system, focusing on value-based care, changing payment incentives, and introducing new infrastructure to serve our communities. This is a future where health care is no longer fragmented, resources are accessible and everyone knows exactly where to go when their aging family members need services or medical treatment.

To start, this is the Vision Series. Tell me about your vision for a health care system that’s really equipped to serve the aging population.

We (I say we because it’s the team that I work with) have been imagining an ideal future state that has two components to it: One is that we’re really fully serving older adults in what I call a “health care hub.” From a health care perspective, when it comes to medical care and clinical care, we have to be a lot more integrated in the way that we address the needs of older adults.

What I would like to see happen as a result of changing payment incentives, and value-based care, and risk-based payments, and things like that, is to begin to concentrate the sum total of health care dollars into population health/public health hubs that really are responsible for assessing individual needs, goals of care, and directing the health care dollars in a way that best serves the needs of the individuals and their families.

It looks a little bit like we’re inching our way there with some of the more innovative enhanced primary care models that you see cropping up in places like Oak Street Health and Iora Health. I think those are good examples of what it can look like, but we need [more of] that model. My vision is for that model to scale and to be the norm and not the exception.

We also have to have what I would call a community-level resource. That is, every community has one, but it’s a new piece of infrastructure that the government invests in to really support older adults and their families around their needs for long-term services and supports, assisted living home care, meals, groceries, and all of those things. It’s important for health care providers to be on top of those needs, but I think the challenge for families and older adults is that they can’t. There isn’t a single place to go.

When functional decline or cognitive decline is on the horizon, there’s no single place for someone to go to get their needs assessed, determine what services are needed, where to get those services, how to interact with that service system, or how to get things set up. The No. 1 thing that I hear about in the work we do with Daughterhood is, “Where do I go?” This isn’t so much about health care as it is about, “My mom, she’s showing signs of dementia, and she lives alone, and I don’t even know where to go.”

That comment is really a reflection of just the lack of infrastructure, the lack of a system that we can deploy to help people when they get to that point. Everything needs to be less fragmented and more integrated in the health care delivery systems through these medical service hubs, and then, in addition, we need community-level infrastructure and a system to support people, especially when they get to that point where they need ongoing home care, senior living services, or things like that.

My vision is that in the future, if your parent is having an issue or your spouse is having an issue, or you’re having an issue, you know where to go. We have senior centers today, but they’re not really funded, and nobody knows about them. My vision for this place is for it to be well known and well understood — the equivalent of our educational system, or our prison system, or our transportation system, or postal system.

In this vision, on the health care side, you’re not just standing all by yourself at the point of discharge from a hospital, holding 12 medications, going, “I’m in charge of all this medical care now.” You’ve got a team and they’re supported by the funding that’s flowing through that team instead of just all these individual providers.

Could you see these two components, the health care hub and this more social-oriented place to go, actually being the same place?

I have thought about that a lot. I think it’s up for debate. It’s something we should be talking about. At this moment, I think they have to be different, and here’s why: I think the private market can work in these health care hubs, but I don’t think it is reasonable to ask them to also be serving this other purpose, which is very labor-intensive. It would be like asking a car manufacturer to build the interstate highway system.

We need private sector innovation in primary care, or technology, or housing, but we’re missing that interstate highway system; the sort of government role that says, “This is like the entry point into a system particularly when your needs get incredibly complex and you need access to long-term service support.”

I just don’t think a ChenMed, for example, is ever going to be in a position to say, “All right. These are the 12 home care providers, and this is who we recommend, and this is how you bring them in, and here’s how you deal with the home modifications.” It would be better, I think, if we had almost like a shared services entity and a market that coordinates with all of the private sector entities, but serves as that central hub.

This actually is partly happening in Vermont right now with community health workers, where essentially, all of the insurers and Medicare centrally fund a community health worker function. Then those community health workers interact with an interface with physician groups. Sometimes they’re assigned to physician groups, but they’re not financed by or beholden to, or employed by [them]. They serve the community.

Those two things I think have to run in parallel. I always say it’s like, to use another metaphor, we see all of this venture capital being poured into – or attracted to this longevity sector now, and a lot of private equity, and venture capital in these primary care groups. I say it’s like everybody is running around making a whole bunch of Christmas tree ornaments, but there’s no Christmas tree.

A parallel is that we have FedEx and UPS because we have a United States Postal Service. Sometimes you need that fundamental system to be established. In this case, people understand that, yes, we should have mail. Otherwise, you’re not in a position to build off of that. Right now, there’s no distribution channel. It’s like creating an entire system from scratch every single time.

Even though we have lots and lots of aging tech innovation, they have no way to connect with those families and serve them because there is no system. It’s like trying to sell textbooks and everybody is homeschooling. I think we should let primary care do what it does well and it should absolutely be integrated with long-term care.

I know it focuses more exclusively almost on the lower income part of the population, but do you think PACE could become this center? Like a PACE Center could serve the function of the social piece, or is that more on the health care side?

That’s a good question. I think PACE does really serve that purpose that I just described on both sides, but there’s a question of funding. If you’re not a dual-eligible with high levels of need, if you are not on Medicaid, you really can’t access PACE. It’s very, very hard to access it as a private-pay person.

In PACE, long-term care is paid for. What I’m talking about is something similar to PACE in the sense that they can help you essentially assess and determine what you need and get those services in place and help you with the management of them. That feature of PACE is what I’m talking about.

How far do you think we are from reaching this vision or something similar to it?

I think that we’re closer than we’ve ever been.

In particular, with the [recent] rescue plan, I think there’s been a watershed moment where suddenly, and because we are in such a crisis right now with COVID, there’s an acceptance and a recognition of a different type of role for government; that its role can very much be to partner with the private sector; to make some of those down payments and initial investments in infrastructure that will then allow the private sector to flourish. I think we might see some early signs of that with federal investment this year, and an infrastructure bill.

On the health care side, I think we’re going to see a lot more aggressive experimentation and insistence on the part of CMS [that] health care providers will get more organized around taking risk, managing the dollars, and serving particularly complex care populations. I think we’re going to see an enormous amount of change just in the next five years.

There’s been a lot of attention on the concept of home-based care. There is a coalition that just formed to push policies to support things like hospital at home and this amorphous and undefined SNF-at-home model. Obviously, home-based long-term care will not work without a better infrastructure to support the families and the older adults who are living in single-family dwellings.

What I mean by that is that hospitals and nursing homes, and senior living to a small extent, do serve the purpose of having some infrastructure and systems in place. If you go to the hospital or you go to a nursing home or you go to senior living, you’re not going to starve. Your laundry is going to get done. There is a wide variety in terms of quality, but your basic needs are going to be met. They’re thinking about your needs. They’re making sure they’ve got the right people. All of those things happen in institutional settings. They don’t happen in the community.

I think there is a mismatch between the expectations that some of these innovative providers have about the opportunity to serve people at home and the ability of the families and those older adults to be cared for in a home setting without more support around some of these fundamental systemic needs that would otherwise be served in an institutional setting.

The last thing in the world that anybody wants to do is put more burden on the family. I think we have to have a really good understanding of what it means to turn somebody’s home into a hospital. It could be a great thing for some people, and it could be a terrible thing for some other people.

I think senior living has a really important role to play going forward in seniors housing, which is to be a stand-in, to some extent, for the infrastructure that’s missing and create those opportunities to bring hospital-at-home or SNF-at-home into their settings and make sure that it’s kind of potentially the best of both worlds.

Do you think that that might be the biggest opportunity for senior living providers going forward, if they can execute on that opportunity? When you say it’s the best of both worlds, these are institutional settings, but they also are home settings.

They are both people’s homes and they’re institutions, and so they’re a step ahead already in being able to create this integrated system?

That’s it, yes. It’s almost like there are micro-level systems in place within these settings. There are many communities with many infrastructures, with many institutional types of functions, but they’re also people’s homes. The smart senior living providers or seniors housing providers are going to recognize that and really start to leverage that with some of these really innovative companies that are trying to do this more health-care-at-home approach.

The benefit to senior living is that then you have created a very attractive setting for the purposes of families, residents, and your referral sources and even potentially a source of revenue from some of these organizations that are happy to pay for space or happy to pay for some services. I think there’s a real symbiosis that’s possible, that we’re just starting to even remotely explore. I would say maybe only a handful of senior living organizations are even thinking about this, but the ones that are, are going to be way ahead.

Another big question. If you could change one thing about the current experience of aging in the United States, what would it be?

One thing? [Only] One thing? I’m going to give you two things.

One thing I’ve spent my career working on is an insurance system for the long-term service and support needs of older adults. There is a huge gap in the financial security of older adults. God forbid you should be diagnosed with early-onset Alzheimer’s at age 65; your options become incredibly small, really quickly in terms of how you’re going to actually pay for that care, and what’s required for you to become Medicaid eligible. It’s so devastating to the family, and often, it doesn’t produce very good choices in care.

If there was one thing I could change, either everybody would just have private insurance for this, or we would be in some kind of a social insurance model [to cover that] huge gap. That’s important, but it’s not enough.

We also have to have this infrastructure because even [having] the money to pay for services is not enough, if you’re having to set up and manage basically a mini health and aging services system in your home all by yourself. We’re not going to be using those dollars very intelligently if we don’t have a community-based infrastructure to support getting people connected to what they need when they need it.

Where do you see tech coming into play? Are there particular types of technology that you think are really critical or exciting?

I don’t think you can really do any of this without technology. It is not the solution to the larger systemic gaps, though it’s trying to be. I think that’s why a lot of the startups and entrepreneurs in this space are having a tough time [even though] they’re inventing some really cool stuff.

I love all of it. It’s enabling us to better understand the risks that individuals face for future health care expenditures, and it is helping us to better target interventions through artificial intelligence and algorithms. It’s critically important and is super necessary for technology to support and improve the way in which we communicate across sites of care and that care teams share information; [although] we have to obviously do a much better job of sharing electronic health records across settings.

Everything and anything we can do to support virtual clinical care, telehealth, virtual collaboration between clinicians [is a good thing]. In the case of an interdisciplinary care team that hangs out in-person at the PACE center, why can’t that be virtual? We can save a lot of money by creating virtual teams. I think there’s a long list of ways in which technology is enabling. What I’m frustrated about is that there’s no place to deploy it.

There are all these solutions running around like little ornaments and they’re looking for a Christmas tree [that doesn’t exist]. Technology has the most critical role to play, but it cannot solve all the problems by itself.

You talked about your hope that the new administration is moving toward creating some first steps toward this infrastructure that we need for aging services. If you could address a joint session of Congress tomorrow, what would you tell them about this issue?

This is the No. 1 economic and jobs issue. We can’t run an economy if every one of the workers is essentially running their own little individual health and aging system out of their home for the really rapidly growing number of people who are going to need that support.

We have a workforce that needs jobs.This is an incredible moment of opportunity. We have people who need to go to work, we also have people who need jobs, caregiving jobs can be good jobs. This is an issue of economic development.

The investment in this space by the federal government, both in terms of paying for services but also in terms of community-level planning and implementation grants and infrastructure grants will pay off tenfold in terms of just the economic activity that it will create. That is the message that a policy worker like me doesn’t have a ton of credibility around, but if somebody from Amazon delivers that message, that resonates across both sides of the aisle.

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