The era of siloed post-acute care appears to be waning. The federal government is pushing for coordinated services and different types of providers are adapting by partnering up—or trying to control more parts of the continuum themselves.
Marquis Companies is a striking example of the latter approach. The Milwaukee, Oregon-based organization offers home health care, post-acute rehabilitation, independent and assisted living, memory care, and other services in five western states. It also is the parent company of Consonus Healthcare, which offers consulting, rehab, pharmacy, and other services.
The company initially began to diversify to limit its exposure to Medicare and Medicaid reimbursement changes, but now has fully embraced the strategy as being aligned with the direction of health care generally, according to CEO and President Phil Fogg Jr.
“We’ve created a post-acute care network or health system,” he told Senior Housing News. “We’re really trying to lower the cost of care for whoever the payer might be … and achieve the greatest functional improvement for the clients and population we serve.”
Fogg recently spoke with Senior Housing News about being both a care provider and manager for a whole patient population, why assisted living is behind the curve, and some of the tough calls to make in the new world of senior care.
SHN: How long has Marquis been around and how has it changed in recent years?
Fogg: I grew up in long-term care, and I started this company in 1989. We started to build our organization and we migrated into other services besides skilled nursing, developing assisted living facilities, home health, and home care services. We now do institutional pharmacy services, serve 20,000 residents in long-term care, and do institutional contracts in rehab for skilled and post-acute care. We do that in 95 facilities.
Over the last five years, because of the Affordable Care Act and the impact that many of the laws had on our areas of service, we had to develop new capabilities to manage care. Our focus has been on managing a very specific population, which is post-acute care episodes.
So, to be able to do care management effectively, we’ve developed our own physician services, [introduced] liaisons into hospitals and SNFs, and changed the way we’ve done home health and home care. We have a full-time staff person dedicated to developing our disease management within skilled and home health. [We have to] manage our relationship with payers like Medicare Advantage plans, really improve the episode of care, and reduce readmissions.
SHN: In addition to the staffing changes, I assume new technology has been implemented to help manage this population?
Fogg: We’ve built a robust data analytics solution that allows us to manage pay-for-performance … manage readmissions, length-of-stay, utilization, look at our 5-Star quality indicators, functional improvement within self-care and mobility. [We believe we are] one of the most progressive with data analytics.
We’re really trying to refine and focus on our post-acute episodes first, but also we’re going to focus on the long-term living segment. How do we deploy telehealth or remote monitoring for patients who discharge from skilled to home or community?
Right now, we’ve got the PointClickCare EHR solution in our facilities. It allows us to pull out general population characteristics. At this time, there’s not a tremendous amount of population management, but we’re trying to develop the programs to help our population remain at its highest functional level, building it around physical health, mental health, all components of health. Our goal will be to measure and score our populations in all our facilities to see what’s happening, what’s the rate of improvement or decline.
SHN: I’m curious about assisted living. Because it’s mostly private pay, assisted living has been left out of a lot of the new health care partnerships that are formed largely around Medicare payment incentives. Marquis has four assisted living communities. Where is assisted living in this new, more integrated post-acute landscape?
Fogg: Assisted living is behind the curve.
Assisted living, as you probably know, is an ambiguous term. There are states that have very mature community-based care and assisted living environments, and some where assisted living is fairly new. You can see a much different level of care needs in different states.
Having said that, I think that AL is going to need in the future to manage outcomes, maintain the health of the population they’ve got, and stop unnecessary hospital readmissions in the same manner that now the skilled environment is doing. I think you’re going to need to have EHR systems to manage that population, and I think additional resources need to be applied to those populations in the same way we’ve built capabilities in skilled. You’re going to need physician and primary support that is more than what is there today.
Also, you’ll need disease management protocols … how are they managing chronic diseases and osteoporosis and impairments that, if not managed correctly, will cause decline and residents will not be able to live independently in an assisted living environment? I think population health will be a big thing and economics will drive behavior. I wonder how much the behavior change will occur without broader policy changes. Right now the incentive is that [assisted living providers] don’t have population turnover. That’s your return. You have to look at the cost of investing in these capabilities.
SHN: You don’t have population turnover, until the residents can no longer afford the assisted living setting.
Fogg: I hear what you’re saying with the challenge. Will the cost structure that is necessary to support aging in place be sustainable or funded, will there be a private market or will there be Medicaid payments that will afford the cost structure to do that? I think that at the end of the day, if aging in place can be done more cost effectively [in assisted living] than in a skilled space, there will be value. But the million dollar question will be, will the cost structures to support the services be able to be funded by private payers or a state Medicaid system? Will there be a sustainable revenue model? Or by allowing populations to age in place is it an unsustainable model? I see the fear.
If I were a policy person, I would maybe want to broaden the definition of what the requirements are to fit in to an institutional special needs program [in Medicare Advantage plans]. I think that the traditional MA plans have a hard time with managing the populations that are in skilled or AL settings because they generally have agreements with primary care physicians in medical groups, and those groups are not necessarily the best way of managing the comorbidities in assisted living. I think we need to bring those services into the assisted living environment.
SHN: How big is managed care in your markets? Is that part of what is driving the evolution of Marquis?
Fogg: Just in the skilled environment, in our post-acute care, almost 60% of admissions are managed care, MA plans. There are other areas of the country where that’s less than 5%. In our environment, we have to differentiate ourselves with the ability to create value for MA plans with readmissions, length-of-stay, functional improvement and 5-Star quality indicators. And try to tell our story to the managed care provider to become a preferred or exclusive provider.
It’s very competitive. It’s a new world. Even managed care plans traditionally looked at things in siloes—their physician spend or SNF spend. One challenge is to look across the post-acute care episode and see this is what that cost of that episode is, and instead of saying, we want to reduce your SNF spend, look at the cost across the whole episode. Right now, they don’t have a way of measuring that but they’re all evolving.
SHN: In terms of driving cost down, home health would seem to be the lowest cost setting. Can you describe more of the changes you’ve implemented in your home health business?
Fogg: The first thing we’re doing is embedding transitional liaisons in post-acute care and hospitals. We have a few goals. One, as quickly as possible, plan the admission to the facility so we can start services within a day of discharge. That’s been a challenge, but we find that the initial visit is one of the key influences on whether there’s a hospital admission or not.
If someone is in a SNF, the liaison is working on planning the discharge immediately. Instead of getting the call a day or two days before, we get the call two weeks before. The second thing the liaison is doing is working with the patients who are appropriate for remote care management and setting up the equipment in the SNF with the SNF team. We want to get that in place and get that person oriented so when they get home they understand the equipment—blood pressure, sugars, heart rate, et cetera.
The home health team is getting the recovery plan, which is embedded in its remote care solution. In the home environment, we monitor for daily health evaluations. The goal with home health is again to stop unnecessary readmissions and get [patients] to the highest functional level. Right now we’re seeing rates of about 5% readmission from the home health environment.
SHN: So, there’s the technology piece, the staffing piece, are you doing anything else to help manage this patient population in the home?
Fogg: There are people who their whole life have come home, lay on the couch and gone to bed. They’ve got 60 years of lifestyle choices they’re not going to necessarily change. We need to get them to understand if they don’t want to lose independence, they need to make good decisions. I would tell you in terms of managing that population, [those are] some key things we’re focusing on now. It’s built around helping those clients make healthy choices, whether it’s medication, diet, exercise. You can imagine how difficult that can be for someone who is 84, but there’s a reality that hits them at this point and they can still make choices. It’s helping them understand what the impacts and risks can be.
SHN: In the typical model, home health might be competing with a rehab facility or a SNF for a patient. I imagine in shifting to the Marquis framework, it can be challenging to get everyone pulling the oars together?
Fogg: The challenge is to get all of these organizations with sometimes different economic drivers to work for the common goals … you can say, yeah, it’s too big of a challenge and we can’t get everyone to work together. We’ve found it’s more effective to fight through these challenges and make decisions about where margin might be and where margin might be reduced. Sometimes that might be length-of-stay in a SNF might need to go down three or four days and home health gets them earlier. I believe that if we move to post-acute care episodic payment, it’ll be one of the best ways to align incentives for providers to make the right choice in the aggregate.
My feeling: without common ownership of a lot of these services, it’s almost impossible to drive change because everyone is working in their own best interest.
Written by Tim Mullaney