In mid-January, as some senior living providers had yet to even begin their first vaccine clinics, Marquis Companies had already held two at its 28 senior housing and care communities.
Much of that had to do with the fact that the Marquis Companies umbrella includes a long-term care pharmacy called Consonus Pharmacy, and having that capability was a driving force behind the speedy completion of the company’s clinics.
In fact, Marquis has diversified across the continuum of care, and also is a payer through its Medicare Advantage plan. Becoming a population health company has brought benefits to Marquis, and the organization is still expanding its capabilities and seeking to more closely and effectively manage care for its residents and beneficiaries — something that Fogg believes few managed care companies actually do.
Looking ahead in 2021, Fogg sees signs that assisted living providers are poised to start realizing more pent-up demand, provided that case counts don’t spike again and lead to more lockdowns or restrictions.
“As soon as the consumer marketplace feels comfortable, I think you’re going to see that come back really fast,” Fogg said. “But it’s got to get to a point where the consumer understands what’s happening and that the risk is gone of outbreaks.”
On why Marquis became the diversified company it is today:
If you go back into the ‘90s, we started in Oregon, and the Medicaid rate system in Oregon was one of the worst in the nation. As a matter of survival, I started diversifying into rehab, later pharmacy, just as an economic driver. And then the Affordable Care Act comes into place, and now all of a sudden, the ability to manage post-acute care episodes becomes really critical.
In order to do that, it was very helpful to have a network of services. So, today, we break up that network into our facilities — skilled, assisted living, a little bit of independent living, and some memory care — and our home health care. And then we have a managed care division, where we actually have a Medicare Advantage I-SNP and our own physician and advanced practice services.
And then to complete that, we also have our ancillary services, pharmacy and rehab, and we’re going to be going into the diagnostic side.
The ability to control and manage all of those services together, and to be able to get the leaders working together in a manner that helps people live the best rest of their lives, is a really cool thing from my perspective, because we eliminate a lot of the dysfunction between a lot of those areas. And by being able to have leaders across those services working together for common objectives, whether it’s quality objectives or whether it’s having an understanding of the financial levers, it’s been a really cool thing for us.
We’re a population health management group — and by the way, I steal a lot of my stuff from the book Being Mortal by Atul Gawande — and we manage two populations. We manage a post-acute care, post-acute episode population, and we manage people within long-term care settings.
Whether we’re providing post-acute care in a skilled nursing facility, long-term care in skilled or assisted living, home health care, private-duty, whether we’re doing an I-SNP, whether we’re providing the physicians the drugs for these environments, rehab — that’s what we do. We’re managing that population and anything that enables us to do that and achieve the triple-aim goal of creating efficiencies, better customer experience and satisfaction, and better quality outcomes, we’re going to probably try to own it ourselves and do it ourselves.
How Marquis has fared during the Covid-19 pandemic:
To say it’s a challenging year is an understatement for everybody.
We certainly had our outbreaks, we had our challenges. I think that we felt like we threw every resource possible at it. And even then, when we were in communities with high case counts, we couldn’t keep it out of the buildings. It was incredibly frustrating.
I think that the mental, physical and emotional toll that it took on leaders and staff was probably the biggest challenge. I, frankly, can’t even imagine if the vaccine had not come out when it did. People are getting near the end of their breaking point, and it couldn’t have come at a better time, from my perspective.
I think the thing that I am most proud of is that we made a decision early on to have our home office and all of our support services come to the office every day. There were certainly a few people who had health risks that did not, I’d say 95% of our staff came physically to the office. And I’m proud of that, because it was hard for me to justify why we’d have all of our people go into the facilities, or therapists going into rehab clinics, or pharmacists coming in, home health people working in the homes — and yet we couldn’t come to the office.
And the benefit of that was much more timely decision-making. We were able to adapt to the millions of changing regulatory things, so I’m quite proud of that.
I think that some of the fiscal decisions that we made over the last 30 years put us in a position to have the financial tolerance to be able to get through a “black swan” event like the Covid-19 pandemic. Our leaders and our staff were rock stars and champions.
I know we’re not completely out of it, but to already see [Capitol Hill] judging and attacking our profession is very hard for me to stomach, emotionally. Knowing the sacrifices and the things that our profession endured — I understand the world we live in and the politics of it all — but it’s like, none of you could have endured what my leaders deal with, none of you could have endured what our staff dealt with, you would quit. And it’s a lot easier to be the Monday morning quarterback, but it makes me angry.
On the benefit of having senior housing and a health care pharmacy in the same company:
Our long-term care pharmacy division was one of only seven long-term care pharmacies in America to get the vaccine.
Again, the combined efforts of those pharmacy leaders being champions, and understanding how critical it was that a long-term care pharmacy that understood the population and the facilities would be the one to actually bring it to the facilities, as opposed to relying on a retail pharmacy — it was the driving force for us to say that we can get it to our buildings faster, we can get it to the buildings more effectively.
It wasn’t so much that the facilities benefited from the pharmacy, it was the pharmacy benefiting from the fact that it’s so closely aligned to a provider group that it gets the customer perspective every hour, every minute, every day. And that’s what enabled us to affect a distribution plan that got vaccinations started on December 21. We completed 50,000 vaccinations over the phase-one process. It was just a massive, massive team effort on [the part of] the pharmacy. For a long-term care pharmacy, when you don’t often see the faces of the customers, and then you go to a clinic and people are cheering, crying — it really reinforces the meaning or purpose of what they do.
On what advice Fogg has for other providers going through their own clinics:
Consent rates with staff are obviously the most critical goal that you need to have.
We have [as of late March] about an 82% consent rate, and I think it’s getting as much information to your staff before the clinic from people that they trust, and to help them understand why the consent rates are very, very important to the people we serve. I think if you can do that, and you get leaders in facilities who are very, very supportive of the vaccine, you will see your consent rates higher. We utilized medical directors, our company’s nurse clinical teams and operations people that the facilities were used to seeing all the time. We try to use trusted faces with real messages and didn’t try to force people.
We didn’t create any negative disincentives. We just said, make an informed decision, because there’s a lot of disinformation out there. There is going to be a group of people that are just so adamantly opposed to it that spending time in debate isn’t worthwhile. Spend the time on informing people who are open to the information.
And by the way, if I could just say, [Covid-19] cases are down 96% [in skilled nursing]. I did see that. That’s awesome. It’s working beyond anything we could have ever imagined.
[Regarding a vaccine mandate], on a personal level, it doesn’t feel right to me. But if it was going to be mandated, the federal government would need to mandate it. There’s a lot of ambiguity on an employer’s ability to even do it. And there would need to be a clear federal requirement that would reinforce employers’ decisions in order for it to actually be effective, in my opinion.
On acuity levels and needs-based demand during the pandemic:
I think that the average acuity level has risen because the lower-acuity people during Covid-19 — their families, their spouses, their kids, their responsible parties — made sacrifices to not bring them into the facility during Covid. They spent dollars on private-duty home care, home health services, they made personal sacrifices and became caregivers, they did things to keep those folks from being admitted to the facility. That is what then created a higher average acuity level.
The admissions we got were truly the needs-based admissions. In fact, depending on your region or state, if you saw 16% to 22% reduction in your post-acute care population, it’s probably a pretty good indicator of … the true need versus maybe not. It’s kind of interesting when you look at policymakers and you hear discussions around trying to do skilled at home, things like that. [And] how much of that could you do? Maybe 16% to 22% is kind of an answer. That’s what we saw when people were willing to make really big sacrifices. That was the amount that the need overrode the demand.
On the prospect and timing of a recovery this year:
In December, when Covid was going crazy, even though the vaccine was there, the hospitals had some of their highest Covid-unit occupancies. Our perception is that the hospitals, as they close those down, they began to really escalate the pent-up demand for elective surgeries. I don’t know when that pent-up demand goes away.
I separate this into three groups.
I believe that the post-acute care admissions will go back, I think there’ll be a little bit of increase as the pent-up demand for the elective surgeries gets satisfied, and that the post-acute care admission rates will go back to where they were pre-Covid.
The facilities that are the nicer facilities that have better quality, that better reputations will recover faster than the older, more challenged buildings. I think, though, that the long-term nursing facility loss in census could be a new normal, that if you were in a building that had a large erosion in your long-term living in the nursing facility, I think that’s going to be a much more challenging recovery scenario. And we’ve essentially done planning and re-budgeted in those environments to say, how are we going to operate this building if it lost 15 to 20 residents, what’s going to change?
And then there is the assisted living or the community-based care environment. And again, I think that those folks will recover … and I think you’re going to start to see that bounce back more quickly. It’s that long-term living nursing facility that I think is going to have the permanent, damaging impact to occupancy.
The pent-up demand, I would expect to [arrive] for the assisted living environment [in] the next 90 to 120 days, if it’s there as visitation is reestablished and group dining and activities and life goes back to normal. As soon as the consumer marketplace feels comfortable, I think you’re going to see that come back really fast. But it’s got to get to a point where the consumer understands what’s happening and that the risk is gone of outbreaks.
When that happens, you’ll see that recovery, and we’ll be able to then really understand, what was it? Are we getting a 5% [occupancy] recovery? Are we going to 10%? Or are we going to 15%? I do not know.
On the skilled side, I think the question that I have is, when do we go back to normal admission patterns, and how much of what we’re seeing today is actually just that pent-up demand for the elective surgeries? I don’t know how long that would be — that can be June, July, that those are exhausted. One of the drivers that I look for is that physicians have had their economics damaged, surgeons have had their economics damaged, and they’re going to want to get as much done as they possibly can do as well.
On the use of technology, such as telehealth, during Covid-19, and whether that represents a new normal for the industry:
There were a lot of emerging services and companies — early stage — who tried to use Covid to raise capital or to justify their business model. And there are many of those that I do not think are going to be sustainable in a post-Covid world.
My brother has a lovely saying, which is that economics drive behaviors. And so, you hit one economic factor of, if there’s a payment source for telehealth for a physician or an advanced practice professional, you could see it get utilized on an ongoing basis. But at the end of the day, telehealth is going to have to create efficiencies or enable productivity or to save dollars.
My model of care is that we employ our own physicians and MPs and PAs. They’re in the facilities a half day to a full day, every day. The need for telehealth for them is not huge.
However, we serve assisted living facilities where if somebody falls at 10 o’clock in the evening, and they need to be assessed instead of sitting in the emergency room, it would be better to use telehealth to have somebody do an assessment. And so there could be things that come out of this. You can see behavioral health experts and clinicians use telehealth more effectively, wound care — there are certain specialists that I think it could be really good for, but not in terms of broad adoption.
On whether senior living providers will continue to utilize new payment sources to fund services:
I would say the litmus test is, does it achieve the triple-aim goals? Is it creating efficiencies? Is it improving customer satisfaction or experience? And/or, is it improving care and quality outcomes? If it is, I’d say any of the options, the flexibilities to get better outcomes in a more effective way, is a really good thing. And so I’m, I’m completely supportive of it.
I do expect more creativity in those areas. We talked about this idea of skilled at home. And as we said, maybe 16% to 22% of the discharges might be able to do it. But I can tell you, I’ve done the math, and all of that hinges on an individual and or their family being able to pay for private-duty home care, to support the person in the home.
Now, Medicare Advantage says you have the option of supplementing it with private-duty home care, and if it can be done more cost effectively than an inpatient SNF post-acute care stay, then people would affect that because the person might be happier in the home. If the care outcomes are equal or better, that’d be good. And then if the cost is lower than going to the skilled facility, then that might be a sustainable change, that could happen for a small part of the population we serve.
On Marquis’ growth plans in the senior housing space:
In terms of our senior housing, we take a very slow-growth methodology. Most of our stuff is new development. I want to have a product that the boomer consumer wants to be at. And I believe from a competitive standpoint that not only can you differentiate yourself with the consumer market but even with the workforce, with brand-new facilities or newer buildings. Our general approach is that we look for environments where we can build new skilled and assisted living and independent living capacity.
So, it’s a much slower-growth approach. The facilities are quite challenging from a leadership perspective, and not outpacing our ability to develop leaders is really important to us. Big picture from our perspective is to continue to become experts on being able to manage the populations that we serve, and to take and control the environments that they’re in to the extent that we can, and the services that are provided them, so that we’re getting, again, the highest outcomes, customer satisfaction and most efficient use of resources possible.
And [we’re] developing a technology platform that enables us to know where our managed care members are at all the times and to get alerts if there’s any changes in conditions so that we can get the right person or clinician to intervene or to take action when it’s needed.
One of the things I learned when we got into the Medicare Advantage space was that the managed care companies don’t manage care, they look at 90- to 120-day claims data and look at the cost of that claims data. And then they try to take actions to reduce those costs, but they’re not really managing the care. They outsource that to PCPs and other groups.
To really manage care, you’ve got to be in the right place at the right time to help stop negative outcomes and/or costly events. So creating a technology platform that enables us to do that and to be able to interface with all of our network of providers, whether we own them or don’t, and to be able to get the right information to the right people the right time, that’s kind of where my next passion is going to be so that we can truly truly change the way that we serve our populations.