SHN+ Report: The primary care opportunity in senior living

In this report you will learn:

• How senior living can become the power player of primary care — including the value of primary care at home and how medicare advantage and consumer demand are key drivers.
• Strategies for senior living — and the future of senior living’s primary care collaborations.
• The new disruptors and disruptions — how primary care providers become MA plan creators; and the role of major insurers.

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Health care costs for seniors are soaring, health levels are plateauing and experts across the care continuum are searching for fixes to both. The answer will be found by going back to the basics. And senior housing might hold the key.

The “basics” in question is primary care. Along with the actual medical care provided, a primary care visit creates the foundation for a senior’s good health by building a relationship between the patient and the primary care provider, thus preemptively preventing health events that can send a senior out of their home and into a hospital.

With the continued growth in value-based care, largely through the implementation of Medicare Advantage plans, everyone involved in the care journey for seniors is getting preemptive. The result is a renewed focus on primary care, with senior housing as a powerful hub. As 2019 takes shape, the collective realization among senior housing providers, insurers, health systems, seniors and their families of the role senior living can play in delivering this care will dramatically shift the power structure in the care continuum.

“Where this is going is keeping everyone out of the hospital in the first place, and that goes directly to partnering with primary care providers,” says Andrew Carle, president of Carle Consulting LLC and adjunct professor at George Mason University. “This represents not only a major opportunity for senior housing, but a unique one (…). For us, it’s about transitioning from being viewed as a post-acute provider to being both a pre-acute and post-acute provider. We can hold the power position on the priority pre-acute side, and we’re uniquely positioned in the entire health care continuum to do that.”

How senior living can become the power player of primary care

Seniors are going to receive primary care. The question is where.

A 2016 report by the Health Care Cost Institute found an 18% decrease in office visits to primary care physicians between 2012 and 2016, and a corresponding 14% increase in visits to all other health providers, namely specialists and the ER.

When it comes to seniors specifically, they face two large burdens to primary care that younger people do not. The first is the difficulty of travel. The second is the increased need for primary care overnight outside of office hours, due to the risk of falls.

MEDICARE ADVANTAGE AS PRIMARY CARE DRIVER

“For young, healthy people, nine out of 10 times, (primary care visits) are wellness visits,” says Cindy Longfellow, vice president of business development, sales and marketing at Juniper Communities in Bloomfield, New Jersey. “But for seniors, the focus of primary care is chronic care management.”

About 75% of people 65 and over have multiple chronic health conditions. The diseases defined as “chronic conditions” vary depending on the source — the Center for Disease Control (CDC) lists 22, while the Centers for Medicare & Medicaid Services (CMS) lists 18 — but in general the term applies to severe, persisting conditions, everything from hypertension to arthritis to dementia to ALS.

As people age, these conditions multiply: experts interviewed for this report said that the seniors in their populations lived with four to eight chronic conditions. Bluestone MD in Stillwater, Minnesota, gave the highest count with an average of 8.75 chronic conditions per patient.

These numbers are significant because on average, Americans with five or more chronic conditions spend 14 times more on health services than people with none. Increasing the frequency that a given senior meets with a primary care physician can improve that senior’s health, because the primary care physician comes to understand exactly how each chronic health condition is impacting the others.

Chronic health conditions, from AARP:

Yet increasing the frequency of doctor visits in a fee-for-service marketplace puts further economic strain on a fattened Medicare system. From 2007 to 2017 alone, Medicare expenses rose from $425 billion to $702 billion. Overall, fee-for-service health care has sent cost skyrocketing ($3.3 trillion, or about 18% of the GDP) without making people healthier.

Enter Medicare Advantage.

Perhaps as a direct result of these rising costs, the number of Medicare Advantage plans tripled between 2004 and 2017, from 5.3 million to 19 million. The Congressional Budget Office projects 22 million Medicare Advantage enrollees by 2020 and a whopping 41 million by 2026.

The main cause for the boom are the advantages that Medicare Advantage plans offer the consumer, the provider of the plan and the health system at large.

However, in order for a private insurer to have success with MA, it needs to be able to manage its population. That means it needs peak efficiency, communication and coordination particularly at transition points in the care cycle between home, health care setting and home again.

Senior housing helps both. The increased face-to-face meetings that occur in a senior living community between a resident and a primary care physician improve outcomes while reducing cost. Organizations creating these opportunities are producing the data to support their impact. In its 2017 Connect4Life report, Juniper Communities showed that when primary care services are consistently offered in senior housing, hospitalization of high-risk patients drops nearly 40%.

Miami-based ChenMed is a 34-year-old concierge VIP primary care provider for patients of low-to-moderate income; its data shows a 28% reduced cost of primary care created by increasing patient-doctor contact. The company, which does not work with senior living but selects clinic sites based on senior populations, averages 208 minutes of face-to-face time annually between patients and doctors, with the U.S. average at 20.3 minutes.

Bringing primary care into senior housing also improves the other challenge for Medicare Advantage, which is population management. Senior housing gives plan providers a total view of each patient. Health care providers are paying increased attention in 2019 to each patient’s social determinants of health, which the CDC defines as social environment; physical environment; health services; and structural and societal factors.

Senior living operators naturally have all of this information. They know each patient’s entire health backstory, including family history. They know the patient’s diet and exercise schedule. With smart technology, they often know to the minute how much sleep the patient gets.

Senior living operators also manage one of the most dangerous times for a senior: night time. The risk for falls is higher and the chances of a disconnect between the resident and a doctor or nurse is greater. When senior housing operators bring primary care onsite, they can mitigate those overnight risks for payers.

Such was the case at Village Shores, a memory care community in Richfield, Minnesota that partners with health provider Lifesprk of the Twin Cities, Minnesota, to bring primary care onsite. A 93-year-old resident with advanced dementia was found by a caregiver sitting on the floor by her bed. The caregiver called the Lifesprk-hired Life Care Manager (LCM), putting into motion a care delivery process that succeeded due to the personnel onsite and the staff’s knowledge of the resident.

This included x-rays and pain medications, along with a meeting with a nurse practitioner. All of this was done onsite at Village Shores — not only did the resident never need to leave her home to go to a hospital, but she had lunch that day in her usual spot with her friends.

“(Her not going to the ER) saved the system a ton, and saved her and her family the trauma of being put in the hospital and potentially running into other concerns — like infections, delirium, and all sorts of stuff that people can have in the hospital — and we were able to seamlessly coordinate that care in the senior residence, which is awesome,” says Joel Theisen, CEO and founder of Lifesprk.

“The family loved it … and the real estate owners loved it, because why wouldn’t they? They don’t have people leaving. It creates a huge differentiation for them to be able to tell these stories about how ‘We can bring everything to your mom, including primary care.’”

CONSUMER DEMAND AS PRIMARY CARE DRIVER

Seniors move into senior living communities in large part for a lifestyle of convenience, socialization and safety. There is convenience for the resident, but also for the family members, who surely expect to reduce the time they spend coordinating their loved one’s care.

Too often, these family members are met with a rude awakening.

“(Families) say, ‘We’re paying all this money for senior living, why am I still in charge of everything?’” says Anne Tumlinson, CEO of senior living consulting firm Anne Tumlinson Innovations, which partnered with Juniper for Connect4Life. “(They are) scheduling doctor appointments, transporting (their parent), educating staff on medications, running records down … and the (resident) is on a round-trip cycle to the emergency room.”

When senior living moves primary care onsite, they have the advantage of eliminating these challenges to the families. The transportation is gone. The need to educate staff on medications is gone after the initial resident intake. And the round-trip cycle to the ER is gone, replaced by only the most essential ER visits after all options are explored and executed onsite.

What remains is a wholistic system of health built around a resident, starting with primary care, that reduces or potentially removes an enormous burden on families. Since partnering with Redwood Health Partners in 2015, Juniper Communities has seen a 27% reduction in move-outs.

“We’re one of the few providers that really said, okay, the (Affordable Care Act) is here to say,” Lynne Katzmann, founder and president of Juniper, told Senior Housing News in 2017. “Having primary care onsite made sense.”

THE VALUE OF PRIMARY CARE AT HOME

Between an all-around increased emphasis on aging-in-place and CMS adding for 2019 the state-by-state possibility of non-skilled, in-home care covered under Medicare Advantage, senior living operators are in a unique position to foster care options in senior housing, which more and more will be considered “home” for seniors within the context of health care.

As primary care in senior living becomes more prevalent, the amount of data showing its impact will increase. And if the results continue like what we are already seeing, senior living operators should see their leverage expand.

“We have good evidence to suggest that when people get good integrated primary care at home, they stay out of the hospital,” Tumlinson says.

The Connect4Life model provides integrated, onsite primary care — as well as comprehensive therapy and pharmacy and lab services — to residents of Juniper Communities who are Medicare beneficiaries. The health outcomes were remarkable for the Juniper population compared to all Medicare beneficiaries, especially considering that the Juniper population was much older: 73% of residents were 85+, compared to only 11% of Medicare beneficiaries.

Among the standout metrics culled from this delivery of onsite primary care:

• Juniper’s hospitalization rate was about 50% lower than a similarly frail population in senior housing
• Juniper’s re-hospitalization rate per 100 hospital admissions was more than 80% lower than a similarly frail Medicare population in the community
• Juniper’s re-hospitalization rate per 100 hospital admissions was more than 65% lower than the rate for all Medicare beneficiaries

Other organizations innovating with primary care delivery to seniors boast similar success stories. ChenMed’s data shows reduced rates of hospital admission by 50% among its seniors. Ohio Living’s work in Toledo has a hospital re-admission rate under 3.5%, compared to the market average of about 18%.

The insurance giant Humana is also on a value-based journey, with powerful outcomes. Here is the data Humana compiled in 2017:

Prevention, outcomes and utilization

The results below show the percentage difference between Humana MA value-based agreements and Human MA fee-for-service.*

“I would say primary care is at the core of what we do,” says Dr. Roy Beveridge, chief medical officer of Humana. “Five to six years ago we were an insurance company with some clinical attributes. I think where we are at this point is a health company that is focused maniacally on primary care and on our members, with insurance as a backbone.”

STRATEGIES FOR SENIOR LIVING

With its ability to manage a senior population and effectively deliver it to a payer, senior living can position itself as not just a post-acute setting, but as a powerful pre-acute actor. To execute on that opportunity, senior housing operators can follow one of two models:

• Create an in-house primary care office
• Partner with outside PCPs to bring them on campus

Both models for bringing primary care directly to seniors all follow the credo, “Meet them where they are.” The difference is in how people execute on the idea of “meeting them.”

An in-house, onsite primary care office is the purest form of that “Meet them where they are” idea, and the most comprehensive. Among the leaders in this space is Catonsville, Maryland-based Erickson Living, which operates 19 communities, most of which are CCRCs of 1,000 units or more. In 2018, Erickson announced that its revenue had hit $1 billion for the first time ever, leading to increased development opportunities.

The company is using the benefits of its scale and revenue to provide wrap-around services to residents, including Medicare Advantage plans and primary care physicians. Its MA plan, dubbed “Erickson Advantage,” serves more than 4,900 members. A whopping 90% of its residents, meanwhile, use Erickson’s doctors in onsite medical centers, with 32,000 same-day appointments provided in 2018.

“These are our doctors, not contracted doctors,” Dan Dunne, Erickson’s director of external communications, told Senior Housing News in December of 2018. “One of the differentiators when people visit our communities is, they want to know medical care is available, and to have it right on campus is a factor for them.”

Erickson residents using the operator’s onsite doctors see the physicians in the medical centers. The same goes for Juniper Communities. Its partnership with Redwood is one both in care and architecture. Every Juniper community has a physical clinic space, and when they revamp, retrofit an existing space to transform it into a clinic or build a new clinic, they work with Redwood on the design to ensure that it meets Redwood’s needs and standards, along with their own.

“To the degree possible, we encourage our providers to see our juniper residents in the clinic setting,” Longfellow says. “The doctor doesn’t go to your bedroom, he doesn’t go to my bedroom; we go to the clinic. And our residents can do that when it’s there in their home.”

Presbyterian Homes & Services (PH&S) does the opposite. Based in St. Paul, Minnesota, PH&S is a non-profit, faith-based organization serving 25,000 seniors, mostly in 46 senior living communities in Minnesota, Wisconsin and Iowa. It has a range of primary care partnerships and arrangements, starting with its work with Optage Primary Care, which began in 2011.

Residents of PH&S are renters, and along with a meal plan they can also purchase a variety of care and medical packages from the operator. The medical package can include anything from assistance setting up their medication, morning and afternoon checks from caregivers, bathing and monitoring vitals. The medical package can range from $800 to $1000 per month on the low end to up to $5,000 to $6,000 per month. PH&S also manages each resident’s Medicare package.

“So we’re managing two levels of benefits for people,” says Mike Bingham, Vice President of Optage, the home and community services division of PH&S. “If the primary care isn’t integrated well to the care at the site, it can feel fragmented to the family.”

For primary care delivery, the doctors at PH&S go room to room to see patients. In the communities that have a clinical space or some sort of doctor-friendly common area, the primary care physicians might set up there to prepare, but they still generally deliver care in resident rooms.

“Sometimes if the patient is mobile the patient can come and see them (in the care suites), but typically it’s more convenient to go right to their room,” Bingham says.

Bingham drives at one of the two key reasons why some senior living operators prefer to bring onsite primary care directly to resident rooms: it’s typically much easier for residents, who are often frail and struggle to travel.

The other reason ties to the focus on social determinants of health. Iora Primary Care builds relationships with senior living, and delivers care in resident rooms. They do so for two reasons. First, they don’t have the volume of patients at any one community for them to justify pushing for the construction of a medical center onsite.

But perhaps more pertinent is the information doctors get on a patient’s health determinants in the room.

“You can walk into a room and tell a lot in about 90 seconds about how a person is doing,” says Carroll Haymon, medical director of Iora’s Washington market, which consists of six clinics across the state. “If you wait for someone to come to you in an office, then what you’re getting is their presentation of themselves. We’re missing out on a lot of data when we do that. It’s the value of home-based care in any setting.”

Humana’s Beveridge agrees. He notes that there are more than 6,000 hours in a year, and seniors spend less than an hour or two in the doctor’s office.

“So if you want to think about impact and innovation, understanding what is happening with the patient at home for those 6,000 hours gives us the greatest potential for understanding what is happening with a patient’s health,” Beveridge says.

The question then comes as to whether primary care exclusively at senior living communities can be a sustainable model for doctors. That depends who you ask, but there are certainly physicians who have found success that way.

Bluestone MD is one, albeit at multiple sites. Founded in 2006, Stillwater, Minnesota-based Bluestone is one primary care provider that has seen success by catering exclusively to senior living, albeit at multiple sites. Using a a fee-for-service model, Bluestone works with 400 to 500 senior communities in three states. Most of its approximately 13,000 clients are residents in assisted living and memory care, with some in group homes.

Chief Clinical Officer Sarah Keenan describes Bluestone as privately owned with no investors, no debt, and 30% growth year over year since it was founded.

“I think where a lot of practices struggle is they are trying to do it in addition to traditional clinic-based practice,” Keenan says. “When you’re trying to do (onsite primary care for seniors) in the afternoon or on a Friday in addition to running a traditional practice, it is not a place where you can run a sustainable business.”

In Minnesota, Lifesprk is finding that the more partnerships with senior living communities, the better. Lifesprk is the contracted home care provider for each of its senior living partnerships, providing all health care services in the building. It currently has three such partnerships, all in Minnesota, with two more in the works for early 2019.

One of Ohio Living’s largest communities is Ohio Living Westminster Thurber in downtown Columbus, with about 500 residents. There is an onsite physicians office, and those doctors coordinate about 80% of the care for those residents.

“I know some physician groups that are literally closing down their offices because they have all the business they can handle in the communities,” Carle says. “Go where the patients are. … It’s in some ways more efficient for them than leasing or owning a brick-and-mortar medical practice.”

THE FUTURE OF SENIOR LIVING’S PRIMARY CARE COLLABORATIONS

Many senior living operators will view direct primary care in senior living, whether through a permanent medical team or outside partnerships, as revolutionary. Some operators, though, are already taking the next step by building for themselves ownership opportunities.

In October 2018, PH&S bought a 50% stake in Genevive, a geriatric medical care practice that basically does primary care house calls, but to senior living. PH&S bought its stake from North Clinic, and will partner with existing owner Allina Health, which owns the other 50%.

The deal, which took effect January 1 of this year, lets PH&S scale up, moving from 14 communities to now 75.

In concert with this arrangement, PH&S also contracts with three major insurers active in the Minneapolis area: Medica, UCare and Blue Cross Blue Shield. While Genevive patients can maintain their own insurance if they wish, they have to do their own coordination, which PH&S otherwise provides with its three insurance partners.

Therefore what PH&S is offering is total care coordination. It provides primary care services directly to seniors in senior living, manages the relationships and activity between the senior, senior living community and the insurer, gives the senior living community a sales differentiator and gives insurers an easily manageable pool of patients.

“The evidence would show that older adults who live in senior living communities who have the same needs as those who live in their houses have better health outcomes … and insurance providers know that,” Bingham says. “So the cost to provide care is less. Insurance companies want to get into these places.”

Ohio Living is also entering the world of strategic partnerships and creating MA ownership opportunities for senior living providers. In a move that could change the face of primary care in senior living, Ohio Living and Juniper are teaming up with AllyAlign Health (of Glen Allen, Virginia) and Christian Living Communities (of Englewood, Colorado) to form the Perennial Consortium, opening ownership interest opportunities to other senior living providers in Colorado and Ohio.

The consortium, which is on schedule to open in 2021, would create MA special needs plans (MA-SNP) allowing senior living providers to swap risk for Medicare dollars in exchange for a potential revenue stream. Laurence Gumina, CEO of Ohio Living, says that a key component to launching these plans is each provider’s ability to coordinate care for residents. The consortium will assess potential owners and then help those chosen to embed a uniform care model in each community.

Gumina sees primary care delivery as the foundation of the success of this project.

‘We believe very strongly that partnering with physicians to provide excellent primary care support to residents residing in our 13 communities is critically important for us,” he says. “We also believe that we need to partner with other providers and payers in more marketplaces, and also partner with large physician groups to coordinate efficient care. … This is an opportunity for providers, in my opinion, because we’re becoming more innovative in our partnership strategies with those that we serve at the right place, right time and right cost.”

THE NEW DISRUPTORS — AND DISRUPTIONS

What PH&S, Ohio Living, the other members of the forthcoming Perennial Consortium and others see is the need to take ownership, literally and figuratively, of primary care delivery for seniors in senior living. A variety of players are now tussling for control, with senior living at risk of losing this vital piece of the pie.

There are two main disruptors to senior living ability to control its primary care destiny. The first are venture capital-funded primary care providers that are launching their own MA plans and building partnerships with senior living.

The second are major health insurers that are realizing the power they can wield by controlling upstream dollars through downstream primary care delivery. Both offer senior living a vision of how to leverage strengths in the primary care game. And both have the potential to wrestle control of primary care away from senior living.

Primary care providers become MA plan creators

In the past eight years, a number of VC-funded care providers have popped up across the country, becoming a one-stop shop for seniors who want quality primary care bundled with a Medicare Advantage plan. These are standalone medical clinics that cater to seniors, bringing a host of health services to seniors, and offering transportation to bring seniors to them.

Investor dollars are rolling in. Since 2011, five of the biggest entrants have raised a combined $1.56 billion.

The oldest of the five is Iora Primary Care out of Boston. The company runs 31 clinics in six states, led by 14 in Arizona. It sees each patient a minimum of twice a year: once at the resident’s home and once at the Iora office.

“Primary care for seniors is primarily about building a longitudinal healing relationship with a human being and their families and their communities, that by definition is present over time, so that over time you understand this person, their values and challenges,” Haymon says.

Major insurers grab a piece of the primary care pie

On the other side of the spectrum from Iora and its ilk are the innovative moves being made by some of the nation’s largest health insurers. While the term “disruptor” popularly refers to new companies, the broader term is any entity that is disrupting an industry’s status quo with a new business model or new strategy. The moves made by Humana and Aetna to control the care continuum certainly qualify.

Both insurers are partnering under some arrangement with big box retailers, in hopes of coordinating care for their members by entering the primary care space. In November 2018, CVS Health completed a $69 billion acquisition of Aetna, with CVS declaring itself the nation’s “premier health innovation company.”

The same week as that merger, the Wall Street Journal published a report that Humana and Walgreens were in talks about taking equity stakes in each other. The move would formalize and deepen the flirtation the two giants began in the summer of 2018, when they announced a partnership to offer primary care clinics for seniors inside two Kansas City Walgreens stores.

Along with fulfilling the senior care “Meet them where they are” credo, the Walgreens partnership has another key benefit for Humana: it gives the health insurer a physical space where it can explore and test different approaches to delivering primary care to seniors, ones who just walk in off the street because they know Walgreens, not Humana.

“If we are going to try to continue to reduce the fragmentation and friction (in the senior health care ecosystem), then we need to have learning laboratories,” Beveridge says. “We need to be in places where seniors are, and seniors are in Walgreens. Seniors are interested in their health care. And we are doing small pilots with Walgreens to see how we effectively engage our members.”

Humana can then transfer those best practices into its home care work through its ownership stake in Kindred at Home, which sees more than 570,000 patients a day across 40 states. Humana has 3.5 million Medicare Advantage members, and it wants to keep them at home and out of high-cost hospitals as best it can. It does that through its Medicare-certified home care, which has to be delivered under the direction of a primary care physician.

And with changes to Medicare Advantage opening the door in some states in 2019 for MA to cover some non-skilled, in-home services, the circle of care for Humana is complete: it can bring primary care physicians into the home, keep costs low with Medicare Advantage plans, manage its population up and downstream and experiment with new techniques at its Walgreens clinics.

“The actual physical driver for so much of (our) implemented change is at the level of the primary care physician,” Beveridge says. “We strongly believe that the PCP needs to be the centerpoint of that health care continuum. What we see ourselves as doing is supporting that primary care physician. (…) That explains why we invested in Kindred at Home: it’s to get in and support our primary care physicians and help them take care of our patient — our member.”

Humana’s goal in all of this is to “reduce the fragmentation” of communication and care transitions between different care settings and different players, i.e. the insurer, primary care physician, family and patient. Medicare Advantage plans depend on, yet also foster, the creativity of provider. Humana’s range of partnerships and streamlined avenues represent new opportunities for that creativity, in part because their improved communication lets them remain a step ahead in terms of giving the patient what he needs.

“I think it starts with the sharing of information,” says Kirk Allen, president of Humana at Home. “A lot of times, insurers go into the home ‘blind’ after a patient is discharged. So one of the first things that we’re able to do with our relationship with Humana is send them a summary of that member’s care.”

Allen noted that what might otherwise be disparate pieces — the insurer, the home care agency, the health care setting and the primary care provider — essentially function with one brain. Allen and Beveridge note the value of sharing information and data around a patient, keeping the various parties updated on medications and health conditions and informing each other on what happened to the patient in the hospital.

This communication can then spur the creativity needed to deliver health outcomes to their senior members. If a senior needs telehealth, for instance, Humana can determine how to bill for it.

Humana’s Walgreens partnership continues to grow. It has four pilot markets up and running — Charlotte; Dallas Fort-Worth; Richmond, Virginia; Virginia Beach, Virginia — with a fifth to be announced. And though it has no official partnership with any senior living community, the home setting within senior living beckons.

“To my knowledge, we don’t have specific partnerships with senior facilities, but obviously many of our members live in those, and Kindred has a big footprint of senior living because they’re considered the members’ home,” Beveridge says. “When (seniors are) able to receive that care in their home … there is real opportunity for us to innovate there.”

THE FUTURE: get in or get out

For some, the notion of primary care delivery in senior living might be one without urgency.

For the experts in this report, the opposite is true: most believe that those not already thinking about how to bring primary care to senior living are behind.

“Right now, there is a very significant movement toward providing primary care at home in single-family dwellings,” Tumlinson says. Tumlinson notes the expansion of capital and policy and payment support being directed toward providing primary care services to people’s individual homes outside of senior living.

“So if you see yourself as competing against a person’s desire to stay at home, and one of the major trends in health is providing it at home through primary care and technology and telehealth and all of these cool new things, then you’re getting left behind as a senior living provider,” she says. “The home setting is going to eclipse your setting for sophistication for health care at home. If you’re not providing health care at home, you’re missing out.”

The key for the transformation is senior living changing its approach to the hospitality-health care split, embracing both — and branding itself as such. This will help health insurers, health systems and any other potential collaborator view senior living as a lucrative partner.

It will also help draw residents. After all, a senior living community is not just a senior’s individual home — i.e. her individual unit and everything in it.

It is her neighborhood, too. In that respect, the value of having primary care on-site is so logical that it seems almost too obvious. Just as residents expect their neighborhood to have restaurants, gyms, hair salons, swimming pools and even areas of worship, they are coming to expect their primary care to be there too.

Senior living operators in 2019 will have to face the question of who owns their residents’ primary care experiences. If the answer is not “us,” it will be someone else.

“That Medicare Advantage train has left the station, and we in the aging services side of the delivery system have been conditioned to being downstream of the payer,” Gumina says. He notes that he signs the MA contracts for Ohio Living, and the dollar amount of reimbursement is declining. He tells his board that in order for senior living to maintain its sustainability, it has to put more of its care outcomes at risk, with the reward being greater reimbursement.

“This can be done organically through Medicare Advantage plans — providing our own — or exercising leverage to partner with payers,” he says. “In order to mitigate that risk as we do that, the model of care and the coordination of care is, in my view, critically important.

“Whether we contract with physicians, partner with physicians, hire physicians — there is not one-size-fits-all — that physician partnership is critically important to our ability to coordinate care. As an industry, we need to get more aggressive.”