Jeff Howell: 0:01
Welcome to Home Health 360, a podcast presented by Alaya Care. I’m your host, Jeff Howell, and this is the show about learning from the best in home health care from around the globe. Hi, everyone, and welcome to another edition of Home Health 360, where we speak with home care and home health leaders from across the globe. Dr Katy Lanz is a health care executive with over two decades of success building programs for community-based services. She uses her clean-ups experience, along with her national network of systems, health plans and funders and investors, to custom design clinical programs. She most recently served PCMA, a growing geriatric and palliative medical practice, as chief strategy officer and Aspire Health as chief clinical officer from startup. Through the acquisition by Anthem, her firm, topsight Partners, is a boutique clinical design advisory partner that supports multi-stage organizations hoping to create, evolve and scale clinical services, and you can find out more at topsightfirmcom. That’s T-O-P-S-I-G-H-T-F-I-R-Mcom, and she’s also the co-author of a position paper called Transforming Serious Illness and End of Life Care in America. So if you just Google Transforming Serious Illness and End of Life Care in America, i added Katy’s name as well, so that’s K-A-T-Y-L-A-N-Z. You’re able to download. I think it’s a 17-page PDF that I read before this episode. I thought it was super informative. Katy, thank you for spending time with us today.
Dr. Katy Lanz: 1:50
I’m thrilled to be here. Thank you, Jeff.
Jeff Howell: 1:53
So this position paper this is going to be a bit of a deep dive for us today. Give us some background on when and why you co-authored it.
Dr. Katy Lanz: 2:02
Oh gosh, i’ll just. I think a little on me might help understand the background, but I’ve been in this field an industry of hospice and palliative care and really geriatric medicine for over 20 years. Something that bugged me, let’s put it that way is that we were having a hard time proving the value of what we do and the interdisciplinary approaches and how we have significant cost avoidance and also may need because of the way that the benefit was designed back in 1985 and the way that our patients have changed over the course of the last 10, 20, 30 years. How many years is that now? Geez, i don’t even know, but we now make people live longer and better, with more quality of life, and so how do we demonstrate the value of that And so this particular, because I’m on the board at the National Hospice and Palliative Care Organization and we were talking about similar things how do we demonstrate the value and also showcase to the industry be it home health, anyone caring for people in the serious illness realm how do we showcase the value of what we do through the unit economics and the way other people are doing it, maybe in the private sector, maybe in the government and what the demonstrations are done, and how do we get paid for what we do? by demonstrating our value. So that’s why I’m interested in it, because I want more people to have it, jeff.
Jeff Howell: 3:23
Yeah, sure, the paper talks about how valuable the hospice model is, but it does need to adapt to these diversifying needs of patients and caregivers. What would you identify as needs that are actually new for both patients and caregivers these days?
Dr. Katy Lanz: 3:41
Needs that are new. We are able to identify people who are likely, mortality data and risk stratification. We’re able to identify people who are likely to pass away in the next year more readily today than we were even 10 years ago. There’s algorithm support. There’s companies that build data, data science and artificial intelligence to help us clinicians figure things out. What’s great about that is that we now can have people utilizing the benefit longer. Sometimes the issue is that as a group, we don’t necessarily have the capabilities to anticipate a lot of the crises that might happen and create plans for those. When people aren’t dying, they might have still seeking some curative therapies and or might be responsive to some curative therapies, and so I think what’s needing to adapt a little bit is our ability to anticipate things and have better conversations about what people want, not just medically, also financially, legally, spiritually and really, in fact, i think the benefit itself might be a little bit overmedicalized, as the nurse practitioner, and I think sometimes people further upstream might need more anticipation, and that leads to less stress, more confidence for families and more days at home, which the data says people want, and so I think that’s what we’re seeing in terms of what needs to adapt, and I also think we need more personal care services in order to stay at home. People don’t always need a nurse, they need a caregiver, and we need government benefits to support that, and or we need personal care benefits that support that, and if those are, what is bending the needle and allowing people to be more comfortable at home? I’m hopeful to see that.
Jeff Howell: 5:24
I’ve always felt Medicare advantage is a tip of the cap to just how important personal care is in the entire continuum of care.
Dr. Katy Lanz: 5:32
It totally is, and it’s how we maintain our dignity. And it’s such a personal thing too, just even having people in my home to help care for my kids. It’s really hard to find, and so I’m hopeful to see not only the benefit change around that, but also the vocation of caregiving and or supplemental benefits to help families, like other modernized countries have started to do So. That’s what I’d love to see, but that’s just a pipe dream, yeah.
Jeff Howell: 5:59
Your position paper doesn’t really see a future in fee for service for the hospice model. Can you give us a sense on why you feel that this model is broken and what’s the better path?
Dr. Katy Lanz: 6:11
I think we all know and it’s. We hear a lot of people talking about fee for service as transactional medicine and transactional services, and unfortunately we don’t just cancer. When people are dying from cancer, we generally know they’re doing OK and then they decline pretty rapidly. But a lot of the diseases that we die from heart disease, lung disease, others they take a little bit longer and they’re not a straight path, and even Alzheimer’s disease could be a very long path. And so with that path we have intensity of need when we need it And we’re going through some periods where we’re doing. OK, and fee for service and being accountable is only transactional. Through those crises It’s not actually incentivized to help people out of the system, and so I think that it’s better. When people assume risk meaning and I’m just going to break this down a little bit because nobody ever really broke it down to me And so when people said assume risk, i was like what does that mean? I don’t want to be risky From a clinician. I want to live by the standard protocols. But let’s say there’s $10 that the health plan pays for typical care for people, any health plan And I’m a provider group hospital health, whatever it is and I want to help assume some of the risk for my patients longitudinally, not just through that episode of care which is fee for service, and get paid for it, but maybe actually assume some of their needs until they die Okay, and that is we could even say, their total needs, which would be total risk. So what we might say to the health plan is okay, for that $10 that you usually spend, i want to be paid. Potentially, if I spend only $6 compared to usual care, which is $10, let’s split the $4. Sure, and you pay 20% of that or 50% of that savings. That might be one example of how risk sharing pools are, and so the cool thing about how that translates into business is that, as a clinician, i’m more focused on the things that we just talked about. I’m more focused on anticipating crisis, making sure that people can stay home, making sure that people have their personal care needs met, that their goals of care and what they really want established, versus responding to a crisis and then coming in for home health or coming in maybe in the last three weeks of their life, and so I love this idea. The government loves this idea. We’re seeing the trends with ACO, reach. We’re seeing trends with Medicare Advantage, carvins and even companies like I helped work for Aspire Health and others that are assuming risk with a lot of the Medicare Advantage plans. So we also know that there could potentially be the carbon, and when people say what is a carbon? And right now, when people are dying on Medicare Advantage which about over 50% of Americans are on Medicare Advantage once they go on to hospice they flip onto the traditional Medicare benefit. But in the event that Medicare Advantage started dooming some of that care until people die, that would really change the landscape for the national benefit as it currently stands. And I think that the future for the hospice service model is not just that it’s transactional and waiting for people to really get to this point of decline. I’d love to see the benefit involved into something that’s more dose, escalated and anticipatory and more like a serious illness population management platform or benefit that escalates up when people are sick and maybe down a little bit when they don’t have as many needs, and that would really attend to the needs of most Americans and how they are chronically living and dying in America today.
Jeff Howell: 9:46
I’ve never thought of value-based hospice care, because it’s really the last six months of life right Where I’ve always equated value-based with home health and it strikes me as like fee for service. Really, there’s no incentive at all. It’s like being an hourly employee, right? Someone needs some care, we’re going to go deliver that care, we’re going to get our fee, and there’s no incentive for any innovation. Providers that are competent in communicating value, especially through KPIs, will be best positioned to enter value-based arrangements. Give us a sense on how sophisticated is the reporting out there right now at the top end, and then what does it look like for the average provider?
Dr. Katy Lanz: 10:31
You know that it’s. The data is good. I think that we are now evolving to a better platform for providers to be able to readily utilize that information and do something about it. Data is nothing if you can’t manipulate it into a workflow that works for providers out in the field and that they’re incented to not have to take more time to do things on top of what they’re already doing. The actual tools that are out there on the top end risk stratification is pretty darn good. We can identify people’s risk for hospitalization, people’s risk for mortality, functional decline all days, at how likely are they be able to stay home. That’s great. How do we translate that into Things that are taskable and actionable, into the systems that people utilize? I think that we’re also seeing a lot of great information that comes from claims data. Right, so claims is doing whatever. Whenever somebody submits a bill, we can see what, be it for a wheelchair or for, i don’t know, let’s say, copd. We can look and say, okay, they have COPD, and now they’re wheelchair down. Okay, something, they’ve got a significant decline. But what’s not happening is patient reported information as well. There are some companies evolving that are bringing that in and it’s and I’m loving to seeing that They also are not as closely integrated into some of the EMR systems and the monopolies that we use between like home care, home base or lots of the larger EMR systems. But, I think the functionality improve. What providers want out in the field is something that they don’t want to have to open three dashboards. They maybe want one or two that they can work off of to plan their day and schedules at such. But I think that right now, artificial intelligence is great and we’re seeing more competition, which is good. I would love to challenge those innovators to really think about how they integrate that into the workflows of the people using them Not just home care, or I should say that home care business, or not just hospice, but population platforms that really allow us to manage people across the continuum and assume some of that risk that we talked about.
Jeff Howell: 12:38
And totally how the explosion of chat GPT has really raised the bar for the entire AI space. Everyone’s talking. Did you know that they went from zero to a million users in five days, or something like that? It broke every record.
Dr. Katy Lanz: 12:55
I’m not surprised, yeah, and I believe that the post-war generation and the burn the bras generation is about to burn their depends. They want to hit their voice involved in the care. They want choices right. I’m not surprised that it’s blowing up.
Jeff Howell: 13:11
What about the on the hospice side of things? there’s one company that I remember I’ve had them on the podcast and they talked to me about. They can predict a death in hospice to the day with something like a 99.9% accuracy. Curious if you see that, and when I heard that I thought this is the pinnacle of what the industry should be about is predicting these health events, and I’m just curious, like what you’ve come across that would be in that same ballpark.
Dr. Katy Lanz: 13:42
Not a lot, and I think that even the best algorithms out there in terms of prediction for hospice eligibility and or risk of mortality are somewhere between the 70 to 80% zone. Now, when people’s vital signs are changing, they’re completely immobile, they’re no longer eating and drinking. It’s a little easier to quote predict death, but it’s going to be within days, maybe weeks, right, and that becomes more statistically accurate And we see those go up. But when we’re talking about avoidance of crisis and comfort and confidence of families, you can’t do much in those last few days. As clinicians, we need to be able to intervene. I’d love to be able to intervene at the time of the diagnosis. If your loved one is diagnosed with Alzheimer’s disease, that is a terminal disease. At some point they’re going to stop eating and drinking if they don’t die from some other acute cause And they are going to have to make decisions about where they live and the type of care that they receive. And those decisions need to be made ahead of time, while they still can, and those escalated as they get sicker, to avoid both the expense and the suffering. So I love that, so accurate. But then what are we going to do about it? Okay, they’re dying at this point, but we do need to get them the support of the hospice benefit. I’m sorry, i’m tangentially. The NORC, in March this year just came out with a study and NHPCO published it that it was done by the University of Chicago as well. They could basically hospice contributed to 3.5 billion in savings for Medicare in 2019, while providing multiple other benefits. But what the study actually showed is that it’s not as effective in the last few days of life. It really becomes better for families and more economically. The savings actually occur when you get involved 15, 30, 45, 250 days ahead of it. That’s when you really see less suffering and less spending Right.
Jeff Howell: 15:42
And that leads me into my next question is that the paper talks about the need for reducing care transitions and handoffs between different programs, and it didn’t go too much into it, but I’m assuming that what you were getting at there was providing the disjointedness of the whole continuum of care, and how do you think we can achieve a state of fewer handoffs?
Dr. Katy Lanz: 16:04
I think it’s networks. There’s a couple of ways. One is really aligning closely with primary care providers, using these algorithms to trigger identification for people who are going to decline, and creating some type of bundled network that shares in the savings when they do well, i think that’s the ultimate pipe dream, right. And or owning services or large conglomerates that really focus on the serious illness population. But it’s really hard when, let’s say, i’m a patient and I’ve got my PCP who doesn’t come to the home. He orders home help for me. I get it for three weeks. Let’s just say, and now I’ve got nothing, i fall, go into the hospital and now I’ve got pneumonia. I get another episode of home health and they send me to long term care And then each one is a transactional fee for service type of thing. But when we actually assume the risk and we’re part of avoiding those types of things that happen to me, then things change And so the pendulum is swinging back towards primary care, assuming a lot of that risk, and I’m so glad to see that. Home health, hospice, all of these services were born out of a service to the actual primary care providers. That’s how we were born, as a subspecialty and or support service for people in crisis in their homes, and I am so glad to see that partnership. Rather than building providers on top of primary care, i think that we should enhance what primary care can do through data and networks to allow people to stay at home as long as they can. Yeah, long winded answer there for you, but I like it though.
Jeff Howell: 17:44
And what other trends do you see happening?
Dr. Katy Lanz: 17:46
I’m seeing a lot of MSOs form MSOs, managed service organizations, and what’s happening like a large primary care at risk group, let’s just say, like a GenMed or a Oak Street or Village MD. They take full risk, meaning they say to a health plan, i am gonna, if I don’t save money for you by doing this population management care, i’m gonna write you a check. They’re really worried about this and this population that is homebound, and so they’re looking for groups that can service large portfolios of dense populations where they serve and or on the map, and I see some groups forming managed service organizations that will get those contracts with those types of provider groups and then connect and build a network of hospices, home health, personal care, you name it And that’s really cool because they’re using workforce strategies that already exist in the markets where they serve. You’re already seeing also, as well, a lot of ACO formation and accountability. So the ACOs are driving and wanting to pick their own networks And I’m cool with that because you know what it’s gonna do. It’s gonna improve how we perform and the instill what is AFI for service industry in both here and hospice today.
Jeff Howell: 18:58
Are you seeing much? are you familiar with the Burtzorg model?
Dr. Katy Lanz: 19:02
No, tell me about it.
Jeff Howell: 19:03
Yeah, i’ll probably hatch at this, but it Burtzorg, is B-U-R-T-Z-O-R-G, something like that And it’s I think it’s a Danish care delivery model which is really community-based. And if you just break it, imagine every neighborhood had a primary care doctor whose clients were geographically based, and then you have the whole everything that you would need in one community is really there. And because the biggest challenge with home health is the geographic spreading out And obviously there’s a caregiver shortage, but also it’s exacerbated by the fact that caregivers tend to make more money when they’re in buildings And it’s one logical destination for them, and one of the big challenges about delivering home care is the caregivers and nurses and clinicians that have to go from place to place. However, the overwhelming demand is everyone wants to age in place and it’s expensive to deliver care and buildings.
Dr. Katy Lanz: 19:59
It really is. But if you here’s the thing if we actually completely deconstruct the benefit, it’s expensive today And we actually give people what they need instead of this bundled thing that is guaranteed. People might not need nurses. They might actually need a social worker and a personal caregiver. They might not need a doctor, they might need a nurse. And so with the cool thing about these contracts, when you’re assuming full risk, is that you don’t have to go by the same governance and standards that home care and or hospice require. So, for example, Aspire Health, we built our own clinical model and we consistently evolved it the whole way through to help people stay at home. The nurse practitioner was present because it was a person that we felt like was really important in the goals of care and management, medication and some clinical things. But what we found over time is that people really needed social conversations and people really needed a little bit more goals of care and anticipatory planning around the hard conversations with their family about what they really want and need when they decline, if and when they decline. I think that’s the cool thing about deconstructing a lot of this fee for service is that we can get really creative and then it’s less expensive, and it’s actually what people need.
Jeff Howell: 21:11
And I think what ties into that is what you touched on earlier was future patient enrollment driven by algorithms and networks instead of provider relationships and marketing. How much of this are you actually seeing in today’s world?
Dr. Katy Lanz: 21:27
a lot and, in fact, that I don’t know one risk-based company that doesn’t like algorithmically address, look at their patients and address their needs according to the algorithm, and so what I would say is it is important and identification of the patient is great, but then how you engage them, how you build their confidence and what you can do, that is really a hard skill, and then you also need to have, in my opinion, some physical services that go out to them. So things that are totally care management based, in my opinion, are okay, but they’re not going to bend the needle when people really get sick and, unfortunately, you’re not building trust in a patient’s home where they might call you in the same way that they would just having somebody over the telephone. So I think it’s the combination of the AI with human services that really and it doesn’t need to be a doctor, nurse, practitioner or practice actually I believe that those human services it might be an EMT that comes out and checks vitals, it might be a social worker, it could be anything that allows people to build trust in the home when people are likely to decline and are in crisis.
Jeff Howell: 22:36
The author of Sapiens talks about how AI is going to change so many professions, and what he talks about is how we’re one of the few professions where we will benefit from algorithms to connect patients with the right kind of care, but that we probably don’t live in a world where robots are going to be giving people bats.
Dr. Katy Lanz: 22:59
And would you want that, Jeff?
Jeff Howell: 23:01
No, who would? And particularly the burning bras generation. I don’t think they’re going to adapt to that very well.
Dr. Katy Lanz: 23:07
No, we want to be clean. Yeah, i think that there’s a lot of cool things that could happen, though, but it’s we aren’t designing a lot of the AI with the seriously ill in mind either, so I hope to see that change, and they’re the most valuable asset in America today And you’re speaking to somebody who is part of this group, but, i believe, are our caregivers in America personal caregivers, human services. I know that the private equity and venture capital worlds don’t necessarily see that, yet They’re starting to. It used to be tech right And data, and it’s easier. There’s less overhead and, to your point, less windshield time driving to and from each instance, but in the end, that’s who’s going to win, as people who are touching people and chain allowing them to stay home.
Jeff Howell: 23:53
Yeah, Yeah, there’s B2B, there’s B2C and we’re really in the P2P person to person kind of business. Katie, we’re bumping up against our time here. I’ll get you out of here. on this last question, give us a reason to be optimistic about the future of end of life care.
Dr. Katy Lanz: 24:08
I think it’s that the companies and a lot of the audience that is on this call if you were a caregiver yourself or if you’re a business owner owning and or servicing human capital, we own that most valuable resource. You are that most valuable resource. The next few years are going to be hard as we transition from this fee for service modality that we’re in and kind of transition to where we are thinking more about how we really care for people like we would our own loved ones and try to avoid things and keep them home. And so, having that skill set, you are so valuable and you are going to win And I think that’s the take home message today is you know how to care for people And as long as you know how to do that, you are going to have a job, you are going to have a business. Keep at it. Oh, and make friends with the networks, because they’re the ones that are going to decide where people go. So that’s, i think, that they’re looking to make friends. So that’s a number two on the list. There’s a reason to be excited about. This is because a lot of the networks are looking for quality groups to help them figure this out.
Jeff Howell: 25:16
Yeah, Katy, thanks for coming on today. folks, I’m going to give you a recap here. Again, it’s topsitefirm.com. if you want to visit Katy’s website, her paper is Transforming Serious Illness and End of Life Care in America. It’s the number one search result. You can find the PDF there. The number two result will actually be a YouTube video that you were in, with a couple of other people as well, that I was able to take a quick look at. So, Katy, thanks for coming on today and I appreciate your time.
Dr. Katy Lanz: 25:48
I appreciate it, Jeff. Keep at it. Thank you.
Jeff Howell: 25:52
Home Health 360 is presented by AlayaCare. First off, we want to thank our amazing guests and listeners. To get more episodes, you can go to alayacare.com/home health360. Or search Home Health 360 on any of your favorite podcasting platforms. The easiest way to stay up to date on our new shows is to subscribe on Apple podcasts, spotify or wherever you get your podcasts. We also have a newsletter you can sign up for on to get alerts for new shows and more valuable content from AliyahCare right into your inbox. Thanks for listening and we’ll see you next time.
