Robert (Bob) Kramer has many important things to say about the future of “seniors housing”. The current role of the boomer in this arena is often recent or current experience choosing and managing their parents’ assisted living facility residence. Not that long from now, we boomers will be making choices for ourselves.
Listen to Bob’s advice about why we must retire the second half of the twentieth century concept of “retirement.” Why you want to avoid assisted living facilities that routinely send their residents to the ER and much more.
Bob refers to several pioneers in the field of assisted living, medicine and agism. I include notes about them below this transcript.
Full Transcript Bob Kramer on Boomers and Older Adult Housing
Linda: Hello, I am Linda Sherman, @LindaSherman and @BoomerTechTalk on Twitter and I am so delighted this morning to be with Bob Kramer who I heard speak yesterday at Boomer Business Summit and is a complete genius in my opinion; so I’m excited to have him share his thoughts with you, and I’m going to let him explain where he works and a bit of his background to you.
Bob: Thanks very much Linda and thanks for the opportunity to be with you and your viewers today. I am the founder and now strategic adviser at an organization called NIC – the National Investment Center for Seniors Housing and Care; now that’s a mouthful but we’re 501C3 and our mission is to enable access and choice for America’s elders to seniors housing and care and we do this in a rather unusual way, by providing data analytics and connections to educate and bring together providers of capital with providers of housing and care for America’s elders.
And so we are the leading provider of data to the investment community that invest in companies that provide service enriched and care enriched housing and healthcare for America’s elders.
Linda: Great thank you so much. So one of the first things I would like to talk about is the promise to the adult child taking care of a parent of the healthcare system and what you think about that.
Bob: Well I think that it’s important to understand that much of what is today viewed as private pay seniors housing; meaning that you pay out of your own pocket, as opposed to for instance, the government reimbursed program like Medicare and Medicaid. The promise there really started with the– usually the first born adult boomer daughter because in the nineties, those daughters were in the work force and they looked around when suddenly their parents, more often than not their mom, needed care. In the past they would have provided that care; they would have been staying at home providing that care, now they’re in the work force.
But they looked around and they saw the skilled nursing properties in the early nineties and they basically said, ‘hell no I’m not going to put my mom in a nursing home; I couldn’t live with myself.’ And so suddenly assisted living came along and there were wonderful pioneers in that field, Keren Brown Wilson, Paul and Terry Klaassen, but what they provided was a residential feel property with carpets, not linoleum, with gorgeous foyer entries with two and three story atriums and sweeping staircases and residential style furniture and so forth; and it was very attractive.
The promise really was that this is a home-like residential atmosphere and we will provide that personal care, not healthcare but assistance with activities of daily living; bathing, grooming, eating, so forth for your mom and your dad; and it was a wonderful promise and I think to a great extent, in the early days of assisted living, we really delivered on that. I think the challenge has become increasingly that as healthcare has gotten all the more complicated, the adult child oftentimes is left feeling like, ‘I’m still the ultimate accountable care organization myself. I’m expected to be an expert; I have to coordinate all the different healthcare providers, I have to make sure they all have mom’s information, and I also have to figure out who pays for what. I’ve got to go through all the different bills – what Medicare paid for, an insurer paid for, or Medicaid. All this, plus I’m still getting a call at 2:00AM when mom has a fall and the community sends her to the emergency room.’
It’s basically a sense of, ‘gee this isn’t right, we’re paying this money but I’m still running around trying to be an expert on all these health care and life issues.’ So I believe you are increasingly going to see senior care providers who increasingly realize this, are going to start delivering on that. For instance right now there are certain companies that are starting to promise that if your mom or dad or loved one has to go to the hospital or just to the doctor’s office, we will send a staff member with them, so that you don’t have to panic that you’re getting that middle of the night phone call and you have this vision of your elderly mom or dad suddenly all alone in this scary place, especially when you live out of town but even if you don’t.
I think that really addressing meaningfully the promise that adult child is looking for us to deliver on, and executing on that, is absolutely necessary. It’s about being that coordinator for all of that care. For the residents it’s about quality of life and that means I’m not defined by my chronic conditions or my ADL [Activities of Daily Living] needs; I’m defined by who I am positively as a person.
We’re going to see major changes coming like that in the field. I’m excited by that; but it’s also absolutely necessary, especially for the higher end product. You’re going to have to start doing this or you won’t survive. Boomers just won’t put up with it and that partly relates to the fact that boomers have gotten a lot of experience with the issues of aging and care because of looking after their parents. They have some pretty definite ideas of what they want for themselves and it isn’t what they see out there for the most part today.
06:22 Linda: One of the things they may want is in-home attention and I’d like for you to address that and the downfalls of going to the hospital.
Bob: Well I think we would define home as where elders, especially frail elders, live, function and seek to thrive every day. That last part is really important. They live there, they function there and they seek to thrive every day. Home isn’t necessarily the place where you’ve lived for 40 years because aging-in-place can be a trap. You want to age in the right place. If you’re 65 and your neighborhood’s relatively intact and you’re mobile, you want to stay there. You’ve got your friends there, you’ve got your network. But if you’re 89 or 92 and most your friends have died and you’re no longer mobile, your home could be a trap and it may actually be the worst place in the world for you to be aging.
But let me address, related to that, your question with regard to the hospital. One, our whole health system’s built around a rescue model of medicine, as Atul Gawande himself trained in it as a Harvard surgeon. Ultimately it’s all about acute care. We send you to the hospital and to the specialist doctor to be cured, to be fixed. What we’re now seeing with many elders, is their issues are proper management of chronic conditions. They can still have a healthy lifestyle while they have these chronic conditions. Some of these limitations and what are called activities of daily living.
For those folks, especially frail elders, the most dangerous place in the world is to be sent to the emergency room of a hospital. The second most dangerous place is to be admitted and the third most dangerous place, when something’s wrong or they have a flare-up in some condition, is to be sent to the waiting room of their primary care physician for two to three hours. If they weren’t sick before they went there, they will be sick after being exposed to all the germs in the waiting room.
A health system built around the rescue model, where you go to be fixed, does not fit the reality of the healthcare prevention and wellness and maintenance needs of the average elder person. In the future what we’ll see, and what we’re only just starting to see now, is that Boomer consumers will demand, technology will enable, and payers will pay for bringing the health care to seniors where they live rather than taking seniors to healthcare, which is not good for their health
We can save dollars because we can avoid ER visits, we can avoid hospital admissions; the most expensive place in the world to receive care. In the latest study, 19 percent of all ER visits come from nursing homes. They’re the largest single sender, other than the home.
Depending on which study, in anywhere from 50 to 80 percent of those trips the individual did not need to go to the ER. Now having said that, they do need a qualified expert in emergency medicine to figure out whether or not indeed in some cases they do need to be at the hospital. But what’s happening now partly for liability reasons, partly for staffing reasons because the falls seem to happen at 2:00AM in the morning, is that the immediate response is either to send people there or for the person themselves; ‘I’m falling, I’m all alone I call 911’; and 911 comes, the emergency, the EMTs and the paramedics and they take me to the emergency room.
I think we see a number now of innovative programs. The government, both federal and state, is moving to get out of holding the liability of the exposure for healthcare costs by going to capitated risk plans and whoever has the responsibility, for instance Medicare Advantage plans, managed Medicare. If they see an innovative program that can properly manage an individual’s health and chronic conditions without always sending them to the ER and the hospital, they are going to be very interested, because usually, frail elders going to the hospital can -not always – but more often than not, be the beginning of decline rather than the beginning of recovery.
Again we’re talking about managing chronic conditions. We see flare-ups of chronic conditions but they don’t necessarily need an ER visit and a three or five day stay in the hospital and that’s the system we have right now. It’s encouraging that, for instance, CMS is now allowing more flexibility to both Medicare Advantage plans to not have to have what’s called a three day stay in hospital for Medicare to pay for something. CMS is also providing flexibility to Medicare Advantage plans to be able to pay for home improvements like accessibility features and wheelchairs and ramps, so that people won’t fall, so they can successfully live in whatever setting they’re in. Because Medicare is realizing this can save money, it’s better than having a person fall, broken hip, goes to the hospital, has surgery, goes through rehab and often never recovers quite the mobility that they had before.
Linda: On the Medicare Advantage and the CMS saving costs, could you talk about choosing the community, the particular facility that you’re in affecting that.
Bob: Yes, I think it’s an interesting phenomena. It’s only in sort of a pilot stage but I think it’s inevitable we’re going to see more of this in the future. Thirty three percent of seniors, 19,000,000 seniors 65 and older are now in Medicare Advantage plans. That number is projected to grow by many, to as much as 50,000,000 by just 2025; and another 22 percent of seniors are in some form of population health management payment model.
What we’re seeing with this is increasingly those payers have an incentive to pay for things that can provide better outcomes for you. What does that mean for, say, living in a retirement community, assisted living, or what’s called a life plan or CCRC? Well, I think in the future what it’s going to mean is; let’s say Mrs. Jones is an 89-year-old widow and she lives in an assisted living community; in the future, I think she’ll move into that assisted living community A, let’s call it.
She’ll notify her insurer, her Medicare Advantage plan or in some cases today it might be a Medigap plan and she’ll notify them and then they’ll say, Mrs. Jones thanks for letting us know about your new address, we hope you’ll be really happy in your new home, by the way, you have a history of the following chronic conditions, they’ve often resulted in your needing emergency room and an acute care hospital; we want you to know that should you need to visit the emergency room or the hospital, this’ll be your co-pays, these will be your deductibles whatever; and she’s in sticker shock.
14:44 And then they say oh and by the way, should you be interested, if you were to live in assisted living community B which is two miles away, we waive all those co-pays, we waive the deductibles and we actually also will cover three additional services that we think will actually help you to better manage your chronic conditions; preventive health measures, basically.
What they’re doing is incentivizing her behavior. She’s free to choose where she wants to live but they’re making it very clear they prefer community B. The difference they see is, in assisted living community A, they see high ER utilization and high hospitalization rates; for them that’s a lot of costs. In assisted living community B, they see better health outcomes, less use of the hospital, less use of the emergency room. In the future, you’ll see managed care providers increasingly influencing consumer behavior by incentivizing one setting as opposed to another. Medicare advantage plans or what’s called managed long term services and supports on the Medicaid side will see that there is good chronic disease management that doesn’t always just say our immediate fall back strategy is the hospital. That’s not only the most expensive option – but quite frankly for the frail older, who has multiple chronic conditions, as I said earlier it’s the most dangerous place, it’s not healthy for them to be sent to the hospital.
There are certain exceptions clearly; there are times when the hospital is absolutely the place to be but for four out of five cases, I would say as a rule, there’s no need for the person to be there. With advances in telemedicine and other technology, plus, I think, the Boomer consumer demand and more transparency around our healthcare, that’s going to be the future.
Linda: How will the boomer be able to research which facilities have those ratings so they’re able to get that benefit from their provider?
Bob: We’re not there yet, to be blunt..
Linda: In your imagination in the future, you think there’ll be a database?
Bob: In the future I think there’ll be information on that. I think it’ll start with communities themselves being proud of their results and advertising it and therefore forcing competitors to up their game and improve their results so they too can claim them. In other words, saying, ‘you know we don’t think it’s good for our residents to have to have a revolving door with the hospital, we do everything we can and here is the data to show it; to keep our residents out of the ER and the hospital except when it’s absolutely medically necessary.
17:41 But no we don’t– every time there’s a situation, we don’t immediately resort to the hospital. And rather, we are trying to actively manage and coordinate your care; both your personal care activities of daily living but also your healthcare because we recognize that by doing that, we’re going to enable the best outcomes because longevity ultimately can be scary to folks; what they want is a health span that is longer.
The thought of living 40 years with massive numbers of chronic conditions and functional limitations is not going to be attractive to most people. But the thought of successful aging, as some people say, is to live long and die short. That doesn’t mean you won’t have chronic conditions, but you will be able to manage those and continue to have a fulfilling life style and engagement, without feeling like your whole life is defined by these care needs. There’s no need for that.
Linda: And those facilities that get those benefits with the lower costs from the CMS are also probably providing stimulation like music and tactile and other things.
19:03 Bob: That will be, increasingly. I think that’s another good point that you raised Linda and that is that in the future if people aren’t going to be defined by the care they need then that means that we’re going to have to recognize that, in the future, aging itself and retirement itself is going to be about connection and purpose and engagement. Right now, we’ve accepted and we’ve sort of given to the greatest generation a rather– well let’s call it not a very optimistic and not a terribly positive view of retirement and aging.
We talk about the twilight years or the golden years but what we’re really saying is what I could call the declinist view of retirement and aging. What do I mean by that? Well the word retire, if you look at the French and the Latin derivation, literally means to go away. And so, in some sense literally you retire, you lose access to the office, to the office internet, you’re disconnected and you begin to disengage. And oftentimes the picture is kind of a slow decline where you have this bucket list and you hope before your physical and mental health deteriorates too much, you can fill as many items on your bucket list.
20:26 Well the reality is, that might make sense if there was this five year period between retirement and death or total disability, but the reality is many people are going to retire as boomers, they’re going to retire the first time in their sixties and they may have 30 years, they may have a third of their life. The average boomer will have a quarter of their life ahead of them after the normal age of retirement; many will have a third of their life.
My father-in-law, greatest generation, he took early retirement as a school teacher in New York at age 62 when he had a heart attack but he passed away at 93, so he lived for 31 years after he “retired”. Well as Laura Carstensen at the Stanford Center on Longevity likes to say, “retirement is not good for your health,” if retirement means this declinist view. The priorities in retirement communities serving the greatest generation are really safety, security and comfort. It’s formed around “three hots and a cot.” Both my father and father in-law served in the army in World War two and my father in law used often to talk about the relish with which you anticipated three hot meals and a cot. If you’re on the front lines, three hots’ and a cot was pretty special.
Compare that to the boomer experience. Their form of experience was college, not exactly with a sense of gratitude for three hot’s and a cot. When you compare that, the declinist view where basically retirement and aging is a time when you disconnect, you disengage, you decline and the ultimate form of disappearance was just death. There, aging is seen as the problem; it’s a disease to be avoided, it’s a really negative view of aging and of retirement. The retirement communities were separated; to a certain extent, they were aging ghettos; what do I mean by that? I don’t mean that they were bad at any means but what I do mean is that other than staff and family members, no one had a reason to go there except for maybe the church or synagogue group that came to visit on the weekend. I don’t think boomers are going to want that.
They want to be integrated with where the action is, not separated. Their view is what I would call an engagement view of retirement and aging. I’m often asked, ‘what’s the future of seniors housing care going to look like?’ and I’ll say, ‘well I don’t know for sure because I think it’s going to be an enormous variety.’ But these things I do know: Boomers won’t be called “seniors”; they hate that phrase, that reflects their parent’s notion of retirement and of aging.
Secondly, many boomers, most boomers won’t retire, they’ll “transition”. What do I mean? Well Hallmark now has transition cards. When you retire, you’re saying “I’m finished. I’m done.” Now I hope I have a few years to do the bucket list. When you transition, you announce with a sense of excitement what you’re going to do next because you’re not done, you still feel like you can contribute, you have a meaningful role in society. Marc Freedman of Encore.org likes to say that for boomers, ‘retirement will be one part purpose, one part passion, and one part pay check. For some, it’ll be just pay check because they need to keep working. For others, they’ll want the pay check. I think in the future, they won’t be called retirement communities because boomers won’t for the most part move into anything with the word senior or retirement in it because that’s anachronistic, that’s their parents notion.
I think a third to a half of the residents of these communities in the future will be working. It will be totally different. I also think these communities in the future will be known by what the residents do, not what they did, because it’s about engagement, it’s about connection. All the studies now show two things. One, that social engagement versus isolation makes a difference in your health span. You will live longer healthier if you’re engaged with people; and it is not surprising, you have a sense of purpose, connection, you need it. And the social isolation is bad for your health. Secondly, having a sense of meaning and purpose to your life is critical whether you’re 89 or whether you’re 19. But for the elders, some of the studies, such as Becca Levy’s research at Yale, show that positive attitude, a sense of purpose and connection and engagement, can add as much as 7 1/2 years to your life span. That’s huge, absolutely huge.
So again the social engagement, the sense of purpose and connection; I think in the future you’ll see communities that’ll be near colleges, they’ll be where the arts are, they’ll be more in the center of the action, but still with a sense that at 10:00 at night, I don’t want to be woken up by a big loud party. They’ll be much more integrated with the rest of the community and they’ll be known again: ‘gee your passion about education, well you want to go live in this community because these are people that have been movers and shakers in education, they care about education, they’re mentoring now, they’re giving back, they’re driving education reform. Or the arts: ‘you are going to want to live in this community because these people again, they support young artists, they’re major philanthropy support for the arts in our city, and they really appreciate art’, whether it’s music or any of the arts.
Those are the types of communities you’ll see in the future and that’s just totally, totally different. That’s an engagement view of aging, where aging is not a problem, aging actually is where you combine knowledge with experience and it equals wisdom. You now know what’s most important to you, you now know what you really want to spend your time on. Maybe it’s something of passion: ‘I’ve always wanted to do X’ or it’s something of purpose: ‘I spent 40 years working at this job, I’m grateful for it, it paid the bills, enabled me to put my kids through college or whatever but now I want to do something where I feel like I’m really making a difference.’
And it’s working for not for profit, it’s mentoring, it’s caregiving, it’s whatever it is but it’s something so that when I wake up in the morning, I feel like I need to get up, I need to get dressed because someone is depending upon me’, we all need that. And I would argue and the research shows, we need that, it becomes even more vital to us and we have even more to give when we’re in our eighties and nineties, and in the future we’ll also be saying when we’re centenarians as well.
I think of that “engagement view” versus the “declinist view”: aging as a problem, it’s a disease. Aging really is a period, like fine wine, it’s aged. And now that experience combined with knowledge can produce genuine wisdom. Less time is wasted because you have a sense of, ‘I now know how I want to spend my time’. I think they’ll be purposeful, I believe that we will see boomer power.
And one other “E” word I should say, which of somewhat concern with the boomers is also their sense of entitlement. They will believe that they’re going to totally change the view of aging and my hope is that they will accomplish that. One of the best gifts the boomers could give this country, and for that matter all the developed countries, is to retire the second half of the twentieth century notion of “retirement”. It’s bad for people’s health, I said that earlier, but it’s bad for our economy. We can’t have people retire in their mid-sixties and expect that their savings or government support programs are going to support them for the next 20 to 40 years of their life. We’ve got all this terrific productivity that we’re basically squandering, and as a nation, we can’t afford that.
Linda: Wonderful. I think that’s very inspiring to everyone who is watching this. Thank you so much Bob. I really, really appreciate it.
Bob: I’m happy to be here today. I’m glad you’re focusing in on this; I think this intersection of issues; technology is going to enable us to free ourselves and to free caregivers up to do the things we need to do, which is the social connection interaction. It won’t replace but it’s going to enable us to do better, the things we ought to be spending our time on.
Linda: Thank you so much.
About Robert Kramer and NIC from the NIC site
Mr. Kramer is founder and strategic advisor to the National Investment Center for Seniors Housing & Care (NIC), a non-profit education and resource center that serves debt and equity investors interested in the seniors housing and care industry. NIC is the leading provider of research as well as business and financial performance data on this sector for capital providers. NIC’s focus is to enable access and choice in seniors housing and care by providing data, analytics and connections that bring together investors and care providers. Mr. Kramer, a frequent writer and speaker on trends in seniors housing and long-term care, directed NIC from its inception in 1991 until July, 2017. A former county government official and Maryland state legislator, Mr. Kramer was a leader on health and environmental issues while representing the state capital of Annapolis in the 1980s. Mr. Kramer was educated at Harvard and Oxford Universities and also holds a Master of Divinity degree from Westminster Theological Seminary.
In 2017, NIC debuted NIC Talks. These are 12 minute talks on the future of aging. Twelve speakers answered the question: “What do you envision happening over the next 10 years that will revolutionize the aging experience of the first boomer turning 80 in 2026?”
The 2018 NIC Fall conference Investing in Seniors Housing & Care Properties will be October 17 – 19 at Sheraton Grand in Chicago. Registration opens late June. Seniors housing industry networking and educational event, attracting more than 3,000 industry stakeholders.
The Twitter handle for NIC is: @Natl_Inv_Ctr
Pioneers and Resources Referred to in Bob Kramer’s Interview
Keren Brown Wilson Ph.D
Paul and Terry Klaassen – Sunrise Senior Living founders
Dr. Atul Gawande
Reference to rescue model of medicine.
@Atul_Gawande on Twitter
Author of Being Mortal: Medicine and What Matters in the End
“Live Long and Die Short” is also the name of a book by Roger Landry, who spoke at Boomer Business Summit.
Marc Freedman of Encore.org
@EncoreOrg on Twitter
“If more people take on encore careers… the boomers who arrived on the scene by igniting a sexual revolution could leave by staging a give-back revolution. Boomers may just be remembered more for what they did in their 60s than for what they did in the Sixties.”
— Nick Kristof, The New York Times
“Dr. Becca Levy’s work on ageism
Dr. Levy’s research explores psychosocial factors that influence older individuals’ cognitive and physical functioning, as well as their longevity. She is credited with creating a field of study that focuses on how positive and negative age stereotypes, which are assimilated from the culture, can have beneficial and adverse effects, respectively, on the health of older individuals.”
Bob refers to a body of research on social isolation and health. I did an interview with NORC at University of Chicago researchers describing their research called NSHAP (National Social Life, Health, Aging Project), including a highlight of this topic.
What’s Next Boomer Business Summit Produced by Mary Furlong and Associates
Bob was one of three panelists in an excellent panel called “Analyst Session: The Intersection of Technology, Design and Longevity in Senior Housing – Today and 20 Years Ahead”
The panel was moderated by George Yedinak, Founder, Senior Housing News. The other two panelists were Donna Kelsey, CEO, American Senior Communities and Mark Johnston, SVP, Glynn Devins.
Mary Furlong and Associates’ next big event is the Silicon Valley Boomer Venture Summit – Investment, Impact, and Opportunity in the Longevity Marketplace, June 20 – 21st in Santa Clara.
Aging in America (AiA18) Hosted by American Society on Aging
I conducted my interview with Bob Kramer in the press room of the AiA18 conference.
“Over 3,000 attendees from across the nation and abroad attend the annual ASA Aging in America Conference conference to learn, network and participate in the largest multidisciplinary conference covering issues of aging and quality of life for older adults.”
The next ASA Aging in America event is April 15 – 18 in New Orleans.