Aging Expert Bob Kramer: Hospitals ‘Forced to Face the Fact People Don’t Want to Go There’

Bob Kramer was exposed to the aging industry in the 80s when he was serving as a Maryland state legislator. Kramer realized that the aging space was going to become more important — and that seniors would need more resources to be properly cared for in the future.

Some of the same problems that existed then still exist today, including a siloed care delivery system and a volume-based payment mentality. But COVID-19 could play a hand at changing that, with home-based care providers leading the way.

Kramer serves as a special advisor to the National Investment Center for Seniors Housing & Care (NIC), which he started in 1991. He served as the president until 2017, when he stepped into a role as a strategic director.


When COVID-19 arrived in March, there was a slew of new issues to deal with.

“COVID, on one hand, has made things more challenging because people are just overwhelmed with the pressures of the disease and how to address it for themselves for their workforce,” Kramer said during the Home Health Care News Capital+Strategy event. “At the same time, though, I do think there has been a propelling forward in terms of moving away from a silo- based approach.”

In April, Kramer launched Nexus Insights to facilitate discussion and debate on what person-centered senior care should look like to “rethink the aging industry.”


Working across the continuum of care to help break down those silos is a start. Doing so also encourages value-based care, according to Kramer.

Creating a home-based care environment that involves risk, where agencies are willing to bet on themselves and what they can do for patients, will help reshape the landscape.

“Part of what we see happening … is that we’re moving from a post-acute focus,” Kramer said.

Now, a pre-acute mindset is taking hold, which home-based care insiders have been touting in the past year. But Kramer prefers the term “peri-acute.”

“Peri-acute means we’re putting a moat around the acute care hospital,” Kramer said. “And your goal as a health provider, and particularly as one taking risk for the health care dollar spend for that individual, is to do everything you can to keep that plan member, that patient, that resident from having to cross that moat.”

Some of the provisions that the Centers for Medicare & Medicaid Services (CMS) has made during the public health emergency have played a hand in advancing the way home-based care is delivered.

Additionally, the Patient-Driven Groupings Model (PDGM) has moved the industry in the right way, despite it’s warts, Kramer believes.

If there is an incentive for home-based care providers to prevent those hospital admissions, which most already hone in on, the system will be more cost-effective and healthy for everyone.

“I think those that are most willing to break down silos are those that have the most incentive to do so,” Kramer said. “And the ones who have the most incentive are those that are holding some degree of the risk for the dollar spent for that individual.”

That would include insurance plans, Medicare Advantage (MA) plans, Medicare, Medicaid, LTSS plans, physician groups and others.

But it’s also about those who partner with them — and that’s where home health and home care providers come in. If value is prioritized, home health and home care providers will undoubtedly be more valued as well.

As long as they can prove their worth.

Home-based care providers stepping in

Family & Nursing Care, a home care company based in Silver Spring, Maryland, believes it can prove its worth. It has before.

Its census has been hurt since COVID-19 began, but it’s hoping its innovative partnerships — and the value they provide — can help bring it back.

“I think everybody’s hurting right now,” Mitch Markowitz, the VP of business development at Family & Nursing Care, said at Capital+Strategy. “I’m just so sorry that there are a lot of clients, a lot of family members who are taking chances with their loved ones, and they’re not getting the help that they need.”

Family & Nursing Care has partnerships with assisted living and senior living facilities, as well as hospitals.

Kramer believes the hospitals are the furthest behind when it comes to value-based, integrated care. But they are still the center of the U.S. health care system.

“Hospitals have been forced to face the fact that people don’t want to go there,” Kramer said. “They want to do everything they can to avoid it, which makes the hospital more seriously consider partnerships to deliver care out into the community and not always have a model that starts with an admission.”

For Family & Nursing Care, that means it has to show hospitals the way.

“There’s got to be something in it for the hospitals in order for them to make those partnerships worth it,” Markowitz said.

In Maryland, unlike the majority of the states, hospitals are also incentivized to keep patients at home. Home care and home health companies can help them do that.

“We’re helping facilitate these conversations in a different way than we ever had before,” Markowitz said. “And that’s probably what’s helping us work with these different types of providers.”

COVID-19 has, as Kramer put it, “propelled us into our future faster.”

As care becomes more integrated and value takes hold over volume, it will create massive tailwinds for the home care and home health providers who are able to make strategic partnerships and prove what they can do to keep health risks and costs down.

“Those partnerships, to me, are absolutely key,” Kramer said. “But none of this is possible if you can’t communicate the data about the individual quickly. That’s what one of the silver linings of COVID has been — it has forced us to enter the 21st-century world of digitization.”

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