October 31, 2024 • 33 mins
How can senior housing operators position themselves for success in the evolving healthcare landscape? Hear insights on this and more from Dianne Munevar, Vice President of Healthcare Strategy at NORC at the University of Chicago. In conversation with Lisa McCracken, Dianne shares her professional journey and her passion for developing public policies that improve the lives of vulnerable populations, particularly older adults.
The discussion centers on the groundbreaking research conducted by NIC and NORC, including the Forgotten Middle study and the "value of senior housing" research. Dianne highlights key findings from these studies, such as the impact of senior housing on residents' health outcomes and access to care. The podcast also explores the challenges facing the aging population and healthcare system, and the potential role of senior housing in addressing these issues.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Lisa McCracken (00:03):
Hi everyone.
Welcome to the NIC Chatspodcast. I am excited for our
guest today, who is someoneI’ve had the opportunity to
work with a lot in the pastyear, Dianne Munevar, Vice
President of healthcarestrategy at NORC at the
University of Chicago. Diane,welcome. We've had a lot of
conversations, but this is ourfirst formal podcast.
Dianne Munevar (00:28):
I know. I’m excited. Thank you, Lisa. Hi
everyone. It’s great to behere. It’s my first podcast, as
I was telling Lisa, so I hope Iget invited to more.
Lisa McCracken (00:40):
You and I have conversations all the time, but
this is our way to share someof the enlightening
conversations that you and Ihave with our audience. Before
we jump into all the fun NICNORC stuff and the research
we've done, where we are going,and what it all means, I’d like
to start with a little bit of abackup in terms of who we're
(01:02):
speaking with. I would love tohear a little bit of your
background. I'm always curioushow people got to where they
are professionally. What didyou do before NORC? How long
have you been with NORC? Just alittle bit of your journey
professionally to this point.
Dianne Munevar (01:20):
Great, thank you for being interested. I'm
actually going to go back intothe journey a little bit and
then quickly get to the morerecent. I went to college
seeking a degree ininternational relations and
Latin American studies. Ithought I would travel the
globe and solve largediplomatic crises. I even
thought of myself as maybebecoming a spy someday. I
(01:43):
graduated from college and wentto DC, and in those first two
years, I pivoted and becamevery interested in US social
policy, particularly issuesthat impact some of our most
vulnerable members of society.
I had, and continue to have, apassion for developing public
policy that improves the livesof women, children, and older
(02:06):
adults. I went back to schoolto study public policy and
graduated from the HarvardKennedy School with a Master's
in Public Policy. My focus wason welfare, labor, and
education. Honestly, what Ienjoyed most from my grad
(02:28):
school studies was notnecessarily any one content
area, but a lot of the stats,econ, and econometrics classes.
What I enjoyed was figuring outhow to take big problems and
solve them using data andresearch methods. I ended up
with a toolbelt of research anddata methods. After grad
school, I began my career atRTI International, focusing on
(02:49):
issues related to post-acutecare. I spent three years
learning about the Medicarepayment systems for post-acute
care providers, which includedLTACs, SNFs, and home health. I
became very familiar with theMedPAC May and June
encyclopedia booklets about thepayment systems, and I fell
into the content area and lovedit. I ended up traveling the
(03:23):
country doing a lot of primaryresearch to support a CMS
project called the Post-AcuteCare Payment Reform
Demonstration, or the PAC PRD.
I became so interested, and Iwould say borderline obsessed,
with PAC research that Ithought, "This can't be all of
healthcare; there must be moreout there." So, I left RTI and
went to Avalere Health tobroaden my horizons. I spent
(03:47):
seven years at Avalere learningmore about how to take research
and apply it to solvereal-world problems for
commercial clients who expectresults in less than three to
five years—more like three tofive months—and how to be a
consultant. To me, that meansfiguring out how to do the
(04:08):
research effectively. How do Iconnect the dots? How do I tell
the story as quickly aspossible? They probably need it
for very timely advocacyreasons. Since 2010, for 14
years, that's what I've beendoing. I really love keeping
(04:33):
abreast of what's going on inthe industry. I love working
with clients, hearing what theyare asking, and figuring out
what they are not asking butwhat keeps them up at night.
Then, I combine the data, themethod, and the team to tell
the story that helps them.
Lisa McCracken (04:55):
Yeah . Very cool . So that's a good idea .
There's 100 percent of the workthat comes from your team in
the mostly post-acute seniorspace. You mentioned earlier
women and children as a passionof yours. Do you dabble in that
anymore?
Dianne Munevar (05:08):
Our team in healthcare strategy is about 20
individuals, and we have fiveverticals or hubs. Senior
housing and healthy aging isone of them. We also have a
Medicare space, Medicaid, wheremore of the maternal health and
children's health work islocated. Then we have
prescription drugs and healthsystems. I sit as a VP over all
(05:31):
of them, but I focus a lot ofmy time on senior housing and
health.
Lisa McCracken (05:39):
That's fascinating because I want to
come back to some of that. Wedon't function in silos and
bubbles, and I think yourexposure and your team's
expertise in some of thoseareas has definitely helped us.
As NIC has taken the researchwe've done with all of you, we
try to connect the dots—whatdoes this mean, and how do we
move it forward? You talkedabout some of your passions,
and I've observed yourcommitment to identifying
(06:00):
solutions, alternative models,and answers to some of the
challenges in our healthcaresystem. Can you tell me a
little about your commitment onthat front and maybe share some
of your vision? I've noticedthat when we've processed some
of the findings, you oftenspeak as if you have a vision
of where we could go. So, justshare a little of that with us.
Dianne Munevar (06:38):
Thanks, Lisa.
That's so funny. It's spot on.
Even the looking out, there's atree right outside my window,
and I spend so long looking atthat tree and being like, but
what's the ideal? What couldwe, what do we have the
capability to do? What's ourcapacity? I think I talk a lot
about what's the north star,which is the potential impact
(07:00):
that we can make. I think thatcomes from earlier in my
career, when I was reallyinterested in research and
applying the right methods andcreating this toolbelt. A lot
of health services researchersspecialize in the data and the
best research methods, andthat's amazing. I want to
leverage all of that, but Ialso want to ask, "Yeah, but
what's the so what?" Why doesthis all matter?
Lisa McCracken (07:38):
People like us need the "so what." I mean, we
need to know your team's gotthe numbers, but the "so what"
is a big deal for us and ourconstituents.
Dianne Munevar (07:45):
Right. I absolutely need to know that
the research we produced is notjust sitting on a shelf like it
used to when people printedthings. I don't want it to sit
on a shelf, in somebody'semail, or only be posted to a
website and not get any clicks.
I want to know that apolicymaker has picked it up
out of their email or off theshelf, and they're considering
(08:06):
it, and that it's going all theway up to help people make
decisions. That could bepolicymakers, business
strategy, or even MA plans thatare really thinking about how
to take this research and makeit actionable.
Lisa McCracken (08:29):
Right.
Dianne Munevar (08:30):
Yeah.
Lisa McCracken (08:30):
So, speaking of a hot topic that's very
important to us, we've reallytried to advance some
conversations to make theresearch translate into not
just actionable insights, butactual change in our sector. We
partnered with all of you in2019 and really led the
conversation around what waslabeled the forgotten
middle—the middle marketresearch. We know that research
(08:53):
has continued on our end andyour end, and we've learned so
much since 2019. That was justsome initial groundwork around
definitions and what we mean.
I've been with NIC for a year,so I wasn't around in 2019, but
I was a user of that report.
What we're most proud of is theconversation it has started;
awareness around the middlemarket and middle-income older
adults has skyrocketed. We'rein a much different place than
(09:14):
we were, but we still have aways to go on the vision, or at
least accomplishing some of thevision. When you look back on
that body of research and thattopic in general, what stands
out to you most? And where doyou hope we'll be in 10-15
years?
Dianne Munevar (09:51):
That whole research, which we've actually
continued, every year weproduce some type of
policy-relevant, timely updateto that work. And actually, I
think I mentioned this to youearlier. You and I were on the
NIC Fall conference stage thatMonday morning or Monday
afternoon, and probably 30minutes before we walked up, I
got an email from our team thatwe had just published three
(10:14):
more chart packs on the nearduals, which is a follow-up
study from the forgotten middlework. It's really exciting. We
just keep doing that work. Thething that has stood out to me
the most is, and thiscontinues—I just had a
conversation yesterday aboutthis topic—we often talk about
the middle market, theforgotten middle, and near
(10:36):
duals in these technical terms.
However many times, two toeight times the federal poverty
line. I honestly don't evenknow what that means. That
(10:56):
feels like it's at arm'slength. What stood out to me is
when you actually translatethis into real, normal person
terms, the forgotten middleactually ranges from $27,000 a
year to $103,000 a year. I thengo and translate that again. I
think, well, so what? The "sowhat" is that I think about
(11:17):
recent college graduates, andin that first year after
college, many of them areprobably making more than
$27,000 a year, and some makeover $103,000. Now we're
considering the 16 millionolder adults who make somewhere
between $27,000 and $103,000and the 11.5 million who, based
on their income and assetportfolio, are not able to pay
for senior housing if theysuffer even one debilitating
(11:42):
event. It's that translation towhat does that number actually
mean to a person that standsout to me and continues to
drive me to find solutions thatmeet their needs.
Lisa McCracken (12:03):
Well, I know when developers and operators
talk about developing a middlemarket community and product,
there's always thatconversation around whether to
advertise as middle market. Isthat a label we use, or does
the customer, the consumer,know they're middle income or
middle market? It varies somuch depending on where you
live. It's interesting becauseI think this middle-income
group has really gottenattention across a lot of
(12:25):
different age groups, andactually, the whole workforce
housing topic is really thatmiddle-income cohort. One of
the things we've been pushingat NIC is that the older adults
in workforce housing are justan older version of that same
cohort. We've been talking alot about affordability, and
you mentioned the near duals,and I want to talk a little bit
(12:46):
more about that. But it'sincreasingly clear that this
middle-income group is notmonolithic. We are increasingly
breaking it down into the nearduals, the middle-middle, and
(13:06):
the upper-middle. Now, how dowe define some of that? Some of
that gets a little trickier.
Talk a little bit more aboutthe near duals work. You've
done that, and the ScanFoundation has been a big
supporter of this research anda partner to all of you and to
us too. First of all, definethe near duals so we understand
what we're talking about. Anyinsights from that work?
(13:27):
Finally, I'll come back and askyou where people can access
this. I know it's a little morepublic now than what we
referenced with the hard copyreports sitting on the shelf
back in the day. So, nearduals—how do we define it, and
what insights do we have intothat group from the research?
Dianne Munevar (13:55):
If you think about the forgotten middle,
$27,000 to $103,000, the nearduals are the lowest income
strata of the forgotten middle.
They're at the lowest end ofincome and assets. We've
labeled them near duals becausethey look like dual eligibles
(14:16):
in terms of being eligible forMedicare and Medicaid, but they
also have similar health andfunctional needs as full duals.
Their income and assets areadjacent to full duals. To
define it more specifically,similar to what I said about
the forgotten middle, they haveincome ranging from $11,000 per
(14:36):
year to $28,000 per year andassets of up to $26,000. Assets
meaning the value of theirhouse is $26,000. I keep
thinking of a college graduate,and now I’m like, oh, this is
like a summer internship.
Lisa McCracken (15:06):
Right, right.
But now most of them arerenters, correct? I mean, home
equity is not a big portion ofthe near duals.
Dianne Munevar (15:13):
But they are still using that to cover food,
to the extent that they needtransportation, and healthcare
services copays because theyaren't eligible for the
Medicaid safety net. That's thechallenge they have—they are so
similar to full duals, but theydon't have access. They're not
(15:34):
eligible for that Medicaidsafety net, so they just keep
bobbing at the surface, gaspingfor air for services that they
just don't have access to.
Lisa McCracken (15:50):
Off the top of your head, do you have any
numbers in terms of magnitude?
How many seniors are we talkingabout here in the near duals
category?
Dianne Munevar (15:57):
Oh, gosh, I don't have the number in front
of me. I don't remember either. I don't have the number in
front of me, but one of thequestions you asked me when we
started talking about nearduals is where can people find
this information? Yes, and thisparticular number would be in
those. Our website has a spotfor all of the forgotten middle
research, and all of thesechart packs have been posted
(16:20):
there. I can follow up with youand send the link out so we can
put that in. We recentlytransitioned that work from
being about research to nowpolicy recommendations. Lisa,
you were on our advisorycommittee for that body of
research where we started toshift and pivot to think about,
okay, how do we find thesesolutions? They can't be
(16:43):
siloed; it can't be justhealthcare or housing. It has
to be a combination of both.
We've come up with five policysolutions that would support
the needs of the near duals.
That also came out last Monday,and all of that will be
showcased in a webinar later inOctober, which we can also post
when this podcast comes out.
Lisa McCracken (17:14):
Yeah. And we can work to get that
information back out to ourconstituents too. Okay, let's
pivot—the middle market stuffwe could talk about forever.
But we have also spent over ayear on a four-part body of
research that we have used theumbrella term "the value of
senior housing." Can youbriefly summarize what that was
(17:37):
for our listeners and what someof the key takeaways were from
that body of work?
Dianne Munevar (17:43):
Absolutely.
That body of work looked atpeople who had recently moved
into senior housing between2017 and 2019. We focused on
that period to avoid theimpacts of COVID, which took us
all for a loop. We looked at2017 through 2019 and the new
move-ins, and we studied whatfrailty looks like in the two
(18:03):
years following the move-in.
What we found is that frailtyactually increases in the first
three to six months aftermoving in, which makes a ton of
sense. It's a frail time for anolder adult and their families
to make that decision to movein, usually after some
debilitating events, so frailtyis high. W hat we also found
(18:42):
was that at about six months,frailty had peaked, and then
residents began to stabilize inthat new setting. They started
to see the physician moreoften, and their chronic
conditions were being activelymanaged. They had more access
to rehabilitative care. We callthis the "mountain effect,"
where frailty increases andthen comes down at the
six-month mark. We also lookedat access to primary care
(19:05):
services and found that accessincreased in the period after
moving in. Two things stood outto us about access to care:
more people were accessingprimary care after they moved
in. Prior to moving in, 70% ofthose individuals had seen a
primary care physician, butafter moving in, it was 90%.
Lisa McCracken (19:36):
Yeah.
Dianne Munevar (19:37):
The other thing that we found was that the
higher acuity property typethey moved into, the greater
the number of visits, whichmakes a ton of sense. But what
we liked to see was that thosevisits were more often
happening in the residents'homes.
Lisa McCracken (19:56):
Right.
Dianne Munevar (19:57):
But the doc was coming to them, giving them
more access to see the doc. Andso there was more active
management of chronicconditions.
Lisa McCracken (20:04):
Which we know is a big barrier for people
living in their own homes.
Getting to that, thatpractitioner.
Dianne Munevar (20:10):
Right. So we wrapped those up in 2023. And
then we came into 2024, lookingat longevity and health
outcomes. With longevity, westudied things like mortality
and more specifics related tolongevity—how long people lived
in that two-year period. Welooked at things like, assuming
(20:32):
you were living those twoyears, what percent of that
time were you spending at home,like in your own bed, versus in
a hospital or a skilledsetting. And what we found was
that senior housing residentswere spending more time in
their own bed as opposed to inthe hospital or in SNF.
Lisa McCracken (20:58):
Compared to
Dianne Munevar (20:58):
To the people living in the community. Right?
So, non-congregate individuals.
And then we also looked atthings like the number of days
on antipsychotic medication. Wefound favorable findings there,
showing that senior housingresidents were spending less
time on antipsychoticmedications.
Lisa McCracken (21:18):
Right. Right.
Dianne Munevar (21:20):
So all great. I think what we also found was
that they were receiving morepreventative and rehabilitative
care than people living in thecommunity, which picks up from
the access to care study, butthey were also seeing more PT
and OT and such.
Lisa McCracken (21:36):
So I know one of the things that did come out
of that research, in general,on average, and there's great
variability across thedifferent communities, but on
average, we also know that weare much more likely to send
residents to the emergencydepartment than their peers
(21:57):
living in the non-congregatesetting. That utilization was
much higher, and I don't thinkthat came as a surprise to
anyone, but it's something weneed to continuously have on
our radar and figure out what'sdriving it. How can we bring
that down? Some of that is riskaversion, some of it is
policy-related, and some of itis just not having full
insights. If you find someoneon the floor, did they really
(22:18):
fall, or did they laythemselves on the floor?
Nonetheless, that's one thatalways jumps out to me, and I
think there's more room topursue. Knowing all of the
research we've done and thequestions we're asking today,
because there's always moreresearch to be done, what is
the "so what" with that body ofresearch? Great, Diane, that's
interesting. People livelonger, generally with better
health outcomes, but tell uswhy we should care about that.
Dianne Munevar (22:53):
Yeah. This is such a good question. It's a
very big question. The reasonI'm pausing is that I think
it's really important to pausefor a moment and reflect on
this moment in time, becauseright now there's a multi-part
crisis happening in aging, inolder adults, and in healthcare
more broadly. First, we'reseeing many more older adults
(23:15):
who are aging and living waybeyond what we ever expected a
hundred years ago. While that'sfantastic and demonstrates
where we've come in terms ofmedicine over the past hundred
years, people are coming withmore chronic conditions, higher
rates of dementia, and allsorts of issues. There's a
(23:38):
shift in demographics. Second,healthcare costs are not
getting any less expensive;they just keep getting more
expensive.
Lisa McCracken (23:59):
Yeah.
Dianne Munevar (24:00):
And then the third is that, due in part to
shifting demographics, we justdon't have the workforce to
address all of the needs thatthis older population has. I
think this actually presents amoment for senior housing
because you are taking care ofhousing, providing nutrition,
and providing socialconnection, and all of that
(24:21):
relates to healthcare. The "sowhat" is that there's a moment
to really demonstrate the valueof living in senior housing
relative to maybe aging alonein your own home and risking
adverse events. I think the "sowhat" is that we need solutions
at both the federal level andat the state and local levels.
(24:45):
Solutions need to happen. Theyneed to be small ones that can
be tested and also big,innovative, barrier-breaking
solutions. I think this is thetime for senior housing to
propose some of thosesolutions.
Lisa McCracken (25:14):
Y eah. Well, and speaking of timing, I know
you were at our springconference in Dallas this past
March, and we had Dr. MinaSeshamani , who's the director
for the Center of Medicarethere. That was really the
first time that our sector hasever had CMS at our conference
(25:35):
and really focused on seniorhousing. The nursing sector
often has more of thatinterface. But for us, it was
the acknowledgment of, "Hey, weshould better understand senior
housing." And as you said, whatis the potential role that
senior housing can play inaddressing some of these crises
that we're either in now orthat are just around the corner
(25:56):
for us? Did you see that as asign of anything? We took it as
a different level of opennessand an opportunity for us to
build upon. What was yourobservation from that time?
Dianne Munevar (26:15):
Yeah, my observation from that time, and
you all were, we also workedwith you to respond to that
RFI, the request forinformation about MA data.
Correct. And then it soundslike there was interest
following from that letter. Ithink you're on the radar, and
(26:38):
I don't mean that in the way,you know, having two kids in
school, I don't mean that inthe way that you're on the
principal's radar. I mean thatyou're on the radar to be
invited to the table to discusshow senior housing could help
manage the healthcare needs ofolder adults. I think it's
really important to take thismoment and to remain in a
proactive position. Right? Youall are asking the right
(26:59):
questions, in my opinion,you're funding the right
research to demonstrate thatvalue. And I think what we need
to shift towards now is reallyunderstanding what's driving
those favorable outcomes andwhat's driving some of the
questions that we continue tohave, like on emergency
department visits, what'sdriving that, and are there
(27:19):
public solutions that couldhelp make that a little bit
better for residents and forthe senior housing communities?
Lisa McCracken (27:34):
Right. We definitely need to get a little
more granular and answer someof these questions that, I
think, came out of theresearch. Clearly, it's a good
thing if people are livinglonger, they're getting access
to care where they call home,things of that nature. But
again, for those that are inthe 75th percentile and really
off the charts in terms of someof those things, what can we
(27:57):
learn? I think we've gottaunbundle that a little bit
more, 'cause I think it's naiveto think, I mean, the reality
is it's not gonna come out ofthis and say, "Oh, great, CMS
is seeing that senior housingpeople are living longer,
they're less likely to behospitalized, things of that
nature, so we're just gonna paythem more." That's not the
(28:20):
reality of it. Right? So, it'snot that simple, but we do need
to unbundle. Are there certainmodels, or are there certain— I
know we talked about primarycare, and there are a number of
operators that are reallydeveloping some robust
frameworks around that. And wehaven't really talked about any
of the healthcare costs, butthat's gotta be part of the
conversation too. What is thelens that CMS and payers are
looking through right now? Imean, honestly, you mentioned,
(28:43):
we mentioned Medicare Advantageplans. A lot of them are
hurting, quite frankly. So,there's— and this probably goes
to the "so what," but I thinkus identifying the value
proposition of what seniorhousing brings to the table for
the payers is huge. So, whatwould you say is top of mind
for payers right now, whetherit's a Medicare Advantage plan
(29:06):
or CMS?
Dianne Munevar (29:18):
I mean, it has to be reducing costs. Boom, it
has to be reducing coststhrough better outcomes. It's
reducing some costs on the PartB side, but it's really about
reducing those high-costevents—hospitalizations, ED
visits, stays. How can you makethat stuff go away through
better outcomes? How do youmake better outcomes happen
(29:42):
through more access to primarycare, good integrated primary
care, and also through morerehabilitative care? Helping
people with their functionalstatus, reducing falls, is
really huge. But I also thinkit's about ensuring that people
have the internal motivation tocare for their own health.
(30:03):
Something we learned from ourinterviews and conversations
with some of the Vanguardsenior housing communities and
Payviders is that they arereally thinking about what
internally motivates people andasking them, "Where do you see
yourself as a resident? Wheredo you see yourself, what do
(30:23):
you want to be doing in ayear?" And then creating a
custom plan for that.
Lisa McCracken (30:46):
And that's not easy work. That takes time and
commitment, but I think most ofthose organizations that are
really doing that type of thingsay it pays dividends. Not only
do they feel like, "Hey, thisis the right structure and
model," but it increasessatisfaction, improves
occupancy, and all of thosemeasures that we often define
success by. All right. I wantto ask one final question here
(31:08):
before we wrap up. All of thisresearch that we're doing is at
the big national level, themacro level, and we could
release another five reports inthe next year that's showing
this and that, telling thestory for senior housing, and
setting the sector up forsuccess. But at the end of the
day, this is very local. It canbe very local and very
regional. So, what's the callto action for the
(31:29):
boots-on-the-ground operators?
What can they be doing toposition themselves to be
stronger with all of this anduse this information to their
advantage?
Dianne Munevar (31:47):
Yeah. I think it's three things. I think
it's, number one, you need todo research, or they need to do
research that informs theirvalue proposition. Um, which
means like, get to know yourdata. Um, what are you doing
well? Where , what do you stillneed to work on? Honestly, you
know, not trying to , um, coverit up, but really understand
(32:10):
yourself, right? Um, or yourorganization. Two, develop
partnerships with therisk-bearing entities in your
market area so that you canthen align that value
proposition with what iskeeping them up at night. Like
what , where are their gaps,right ? Um, and then I would
say the third thing is don'ttake your eye off of CMS, you
know , um, continue to stayinformed of where they're going
(32:33):
, um, you know, where the windsare pointing. Um, and then try
to continue to keep thatdialogue open, which I know you
all are doing. So I would saythose three things.
Lisa McCracken (32:47):
Awesome, well we've got it all figured out.
At least a really goodfoundation! So this was great
and I appreciate your time. Wecould continue the conversation
but this was a nice 30 minuteoverview and primer for folks
who want to learn about thework we've been doing with you
and want to learn more, and itwas a good priming the pump for
what comes next. And we knowthere's plenty more to come
next and more research tofollow. Thank you all for
listening to the NIC Chatspodcast. This is Lisa McCracken
with NIC and thanks again,Dianne, for being our guest
today.
Speaker 4 (33:25):
Absolutely. Thank you so much, Lisa. Thanks
everyone for listening.
Hi everyone.
Welcome to the NIC Chatspodcast. I am excited for our
guest today, who is someoneI’ve had the opportunity to
work with a lot in the pastyear, Dianne Munevar, Vice
President of healthcarestrategy at NORC at the
University of Chicago. Diane,welcome. We've had a lot of
conversations, but this is ourfirst formal podcast.
Dianne Munevar (00:28):
I know. I’m excited. Thank you, Lisa. Hi
everyone. It’s great to behere. It’s my first podcast, as
I was telling Lisa, so I hope Iget invited to more.
Lisa McCracken (00:40):
You and I have conversations all the time, but
this is our way to share someof the enlightening
conversations that you and Ihave with our audience. Before
we jump into all the fun NICNORC stuff and the research
we've done, where we are going,and what it all means, I’d like
to start with a little bit of abackup in terms of who we're
(01:02):
speaking with. I would love tohear a little bit of your
background. I'm always curioushow people got to where they
are professionally. What didyou do before NORC? How long
have you been with NORC? Just alittle bit of your journey
professionally to this point.
Dianne Munevar (01:20):
Great, thank you for being interested. I'm
actually going to go back intothe journey a little bit and
then quickly get to the morerecent. I went to college
seeking a degree ininternational relations and
Latin American studies. Ithought I would travel the
globe and solve largediplomatic crises. I even
thought of myself as maybebecoming a spy someday. I
(01:43):
graduated from college and wentto DC, and in those first two
years, I pivoted and becamevery interested in US social
policy, particularly issuesthat impact some of our most
vulnerable members of society.
I had, and continue to have, apassion for developing public
policy that improves the livesof women, children, and older
(02:06):
adults. I went back to schoolto study public policy and
graduated from the HarvardKennedy School with a Master's
in Public Policy. My focus wason welfare, labor, and
education. Honestly, what Ienjoyed most from my grad
(02:28):
school studies was notnecessarily any one content
area, but a lot of the stats,econ, and econometrics classes.
What I enjoyed was figuring outhow to take big problems and
solve them using data andresearch methods. I ended up
with a toolbelt of research anddata methods. After grad
school, I began my career atRTI International, focusing on
(02:49):
issues related to post-acutecare. I spent three years
learning about the Medicarepayment systems for post-acute
care providers, which includedLTACs, SNFs, and home health. I
became very familiar with theMedPAC May and June
encyclopedia booklets about thepayment systems, and I fell
into the content area and lovedit. I ended up traveling the
(03:23):
country doing a lot of primaryresearch to support a CMS
project called the Post-AcuteCare Payment Reform
Demonstration, or the PAC PRD.
I became so interested, and Iwould say borderline obsessed,
with PAC research that Ithought, "This can't be all of
healthcare; there must be moreout there." So, I left RTI and
went to Avalere Health tobroaden my horizons. I spent
(03:47):
seven years at Avalere learningmore about how to take research
and apply it to solvereal-world problems for
commercial clients who expectresults in less than three to
five years—more like three tofive months—and how to be a
consultant. To me, that meansfiguring out how to do the
(04:08):
research effectively. How do Iconnect the dots? How do I tell
the story as quickly aspossible? They probably need it
for very timely advocacyreasons. Since 2010, for 14
years, that's what I've beendoing. I really love keeping
(04:33):
abreast of what's going on inthe industry. I love working
with clients, hearing what theyare asking, and figuring out
what they are not asking butwhat keeps them up at night.
Then, I combine the data, themethod, and the team to tell
the story that helps them.
Lisa McCracken (04:55):
Yeah . Very cool . So that's a good idea .
There's 100 percent of the workthat comes from your team in
the mostly post-acute seniorspace. You mentioned earlier
women and children as a passionof yours. Do you dabble in that
anymore?
Dianne Munevar (05:08):
Our team in healthcare strategy is about 20
individuals, and we have fiveverticals or hubs. Senior
housing and healthy aging isone of them. We also have a
Medicare space, Medicaid, wheremore of the maternal health and
children's health work islocated. Then we have
prescription drugs and healthsystems. I sit as a VP over all
(05:31):
of them, but I focus a lot ofmy time on senior housing and
health.
Lisa McCracken (05:39):
That's fascinating because I want to
come back to some of that. Wedon't function in silos and
bubbles, and I think yourexposure and your team's
expertise in some of thoseareas has definitely helped us.
As NIC has taken the researchwe've done with all of you, we
try to connect the dots—whatdoes this mean, and how do we
move it forward? You talkedabout some of your passions,
and I've observed yourcommitment to identifying
(06:00):
solutions, alternative models,and answers to some of the
challenges in our healthcaresystem. Can you tell me a
little about your commitment onthat front and maybe share some
of your vision? I've noticedthat when we've processed some
of the findings, you oftenspeak as if you have a vision
of where we could go. So, justshare a little of that with us.
Dianne Munevar (06:38):
Thanks, Lisa.
That's so funny. It's spot on.
Even the looking out, there's atree right outside my window,
and I spend so long looking atthat tree and being like, but
what's the ideal? What couldwe, what do we have the
capability to do? What's ourcapacity? I think I talk a lot
about what's the north star,which is the potential impact
(07:00):
that we can make. I think thatcomes from earlier in my
career, when I was reallyinterested in research and
applying the right methods andcreating this toolbelt. A lot
of health services researchersspecialize in the data and the
best research methods, andthat's amazing. I want to
leverage all of that, but Ialso want to ask, "Yeah, but
what's the so what?" Why doesthis all matter?
Lisa McCracken (07:38):
People like us need the "so what." I mean, we
need to know your team's gotthe numbers, but the "so what"
is a big deal for us and ourconstituents.
Dianne Munevar (07:45):
Right. I absolutely need to know that
the research we produced is notjust sitting on a shelf like it
used to when people printedthings. I don't want it to sit
on a shelf, in somebody'semail, or only be posted to a
website and not get any clicks.
I want to know that apolicymaker has picked it up
out of their email or off theshelf, and they're considering
(08:06):
it, and that it's going all theway up to help people make
decisions. That could bepolicymakers, business
strategy, or even MA plans thatare really thinking about how
to take this research and makeit actionable.
Lisa McCracken (08:29):
Right.
Dianne Munevar (08:30):
Yeah.
Lisa McCracken (08:30):
So, speaking of a hot topic that's very
important to us, we've reallytried to advance some
conversations to make theresearch translate into not
just actionable insights, butactual change in our sector. We
partnered with all of you in2019 and really led the
conversation around what waslabeled the forgotten
middle—the middle marketresearch. We know that research
(08:53):
has continued on our end andyour end, and we've learned so
much since 2019. That was justsome initial groundwork around
definitions and what we mean.
I've been with NIC for a year,so I wasn't around in 2019, but
I was a user of that report.
What we're most proud of is theconversation it has started;
awareness around the middlemarket and middle-income older
adults has skyrocketed. We'rein a much different place than
(09:14):
we were, but we still have aways to go on the vision, or at
least accomplishing some of thevision. When you look back on
that body of research and thattopic in general, what stands
out to you most? And where doyou hope we'll be in 10-15
years?
Dianne Munevar (09:51):
That whole research, which we've actually
continued, every year weproduce some type of
policy-relevant, timely updateto that work. And actually, I
think I mentioned this to youearlier. You and I were on the
NIC Fall conference stage thatMonday morning or Monday
afternoon, and probably 30minutes before we walked up, I
got an email from our team thatwe had just published three
(10:14):
more chart packs on the nearduals, which is a follow-up
study from the forgotten middlework. It's really exciting. We
just keep doing that work. Thething that has stood out to me
the most is, and thiscontinues—I just had a
conversation yesterday aboutthis topic—we often talk about
the middle market, theforgotten middle, and near
(10:36):
duals in these technical terms.
However many times, two toeight times the federal poverty
line. I honestly don't evenknow what that means. That
(10:56):
feels like it's at arm'slength. What stood out to me is
when you actually translatethis into real, normal person
terms, the forgotten middleactually ranges from $27,000 a
year to $103,000 a year. I thengo and translate that again. I
think, well, so what? The "sowhat" is that I think about
(11:17):
recent college graduates, andin that first year after
college, many of them areprobably making more than
$27,000 a year, and some makeover $103,000. Now we're
considering the 16 millionolder adults who make somewhere
between $27,000 and $103,000and the 11.5 million who, based
on their income and assetportfolio, are not able to pay
for senior housing if theysuffer even one debilitating
(11:42):
event. It's that translation towhat does that number actually
mean to a person that standsout to me and continues to
drive me to find solutions thatmeet their needs.
Lisa McCracken (12:03):
Well, I know when developers and operators
talk about developing a middlemarket community and product,
there's always thatconversation around whether to
advertise as middle market. Isthat a label we use, or does
the customer, the consumer,know they're middle income or
middle market? It varies somuch depending on where you
live. It's interesting becauseI think this middle-income
group has really gottenattention across a lot of
(12:25):
different age groups, andactually, the whole workforce
housing topic is really thatmiddle-income cohort. One of
the things we've been pushingat NIC is that the older adults
in workforce housing are justan older version of that same
cohort. We've been talking alot about affordability, and
you mentioned the near duals,and I want to talk a little bit
(12:46):
more about that. But it'sincreasingly clear that this
middle-income group is notmonolithic. We are increasingly
breaking it down into the nearduals, the middle-middle, and
(13:06):
the upper-middle. Now, how dowe define some of that? Some of
that gets a little trickier.
Talk a little bit more aboutthe near duals work. You've
done that, and the ScanFoundation has been a big
supporter of this research anda partner to all of you and to
us too. First of all, definethe near duals so we understand
what we're talking about. Anyinsights from that work?
(13:27):
Finally, I'll come back and askyou where people can access
this. I know it's a little morepublic now than what we
referenced with the hard copyreports sitting on the shelf
back in the day. So, nearduals—how do we define it, and
what insights do we have intothat group from the research?
Dianne Munevar (13:55):
If you think about the forgotten middle,
$27,000 to $103,000, the nearduals are the lowest income
strata of the forgotten middle.
They're at the lowest end ofincome and assets. We've
labeled them near duals becausethey look like dual eligibles
(14:16):
in terms of being eligible forMedicare and Medicaid, but they
also have similar health andfunctional needs as full duals.
Their income and assets areadjacent to full duals. To
define it more specifically,similar to what I said about
the forgotten middle, they haveincome ranging from $11,000 per
(14:36):
year to $28,000 per year andassets of up to $26,000. Assets
meaning the value of theirhouse is $26,000. I keep
thinking of a college graduate,and now I’m like, oh, this is
like a summer internship.
Lisa McCracken (15:06):
Right, right.
But now most of them arerenters, correct? I mean, home
equity is not a big portion ofthe near duals.
Dianne Munevar (15:13):
But they are still using that to cover food,
to the extent that they needtransportation, and healthcare
services copays because theyaren't eligible for the
Medicaid safety net. That's thechallenge they have—they are so
similar to full duals, but theydon't have access. They're not
(15:34):
eligible for that Medicaidsafety net, so they just keep
bobbing at the surface, gaspingfor air for services that they
just don't have access to.
Lisa McCracken (15:50):
Off the top of your head, do you have any
numbers in terms of magnitude?
How many seniors are we talkingabout here in the near duals
category?
Dianne Munevar (15:57):
Oh, gosh, I don't have the number in front
of me. I don't remember either. I don't have the number in
front of me, but one of thequestions you asked me when we
started talking about nearduals is where can people find
this information? Yes, and thisparticular number would be in
those. Our website has a spotfor all of the forgotten middle
research, and all of thesechart packs have been posted
(16:20):
there. I can follow up with youand send the link out so we can
put that in. We recentlytransitioned that work from
being about research to nowpolicy recommendations. Lisa,
you were on our advisorycommittee for that body of
research where we started toshift and pivot to think about,
okay, how do we find thesesolutions? They can't be
(16:43):
siloed; it can't be justhealthcare or housing. It has
to be a combination of both.
We've come up with five policysolutions that would support
the needs of the near duals.
That also came out last Monday,and all of that will be
showcased in a webinar later inOctober, which we can also post
when this podcast comes out.
Lisa McCracken (17:14):
Yeah. And we can work to get that
information back out to ourconstituents too. Okay, let's
pivot—the middle market stuffwe could talk about forever.
But we have also spent over ayear on a four-part body of
research that we have used theumbrella term "the value of
senior housing." Can youbriefly summarize what that was
(17:37):
for our listeners and what someof the key takeaways were from
that body of work?
Dianne Munevar (17:43):
Absolutely.
That body of work looked atpeople who had recently moved
into senior housing between2017 and 2019. We focused on
that period to avoid theimpacts of COVID, which took us
all for a loop. We looked at2017 through 2019 and the new
move-ins, and we studied whatfrailty looks like in the two
(18:03):
years following the move-in.
What we found is that frailtyactually increases in the first
three to six months aftermoving in, which makes a ton of
sense. It's a frail time for anolder adult and their families
to make that decision to movein, usually after some
debilitating events, so frailtyis high. W hat we also found
(18:42):
was that at about six months,frailty had peaked, and then
residents began to stabilize inthat new setting. They started
to see the physician moreoften, and their chronic
conditions were being activelymanaged. They had more access
to rehabilitative care. We callthis the "mountain effect,"
where frailty increases andthen comes down at the
six-month mark. We also lookedat access to primary care
(19:05):
services and found that accessincreased in the period after
moving in. Two things stood outto us about access to care:
more people were accessingprimary care after they moved
in. Prior to moving in, 70% ofthose individuals had seen a
primary care physician, butafter moving in, it was 90%.
Lisa McCracken (19:36):
Yeah.
Dianne Munevar (19:37):
The other thing that we found was that the
higher acuity property typethey moved into, the greater
the number of visits, whichmakes a ton of sense. But what
we liked to see was that thosevisits were more often
happening in the residents'homes.
Lisa McCracken (19:56):
Right.
Dianne Munevar (19:57):
But the doc was coming to them, giving them
more access to see the doc. Andso there was more active
management of chronicconditions.
Lisa McCracken (20:04):
Which we know is a big barrier for people
living in their own homes.
Getting to that, thatpractitioner.
Dianne Munevar (20:10):
Right. So we wrapped those up in 2023. And
then we came into 2024, lookingat longevity and health
outcomes. With longevity, westudied things like mortality
and more specifics related tolongevity—how long people lived
in that two-year period. Welooked at things like, assuming
(20:32):
you were living those twoyears, what percent of that
time were you spending at home,like in your own bed, versus in
a hospital or a skilledsetting. And what we found was
that senior housing residentswere spending more time in
their own bed as opposed to inthe hospital or in SNF.
Lisa McCracken (20:58):
Compared to
Dianne Munevar (20:58):
To the people living in the community. Right?
So, non-congregate individuals.
And then we also looked atthings like the number of days
on antipsychotic medication. Wefound favorable findings there,
showing that senior housingresidents were spending less
time on antipsychoticmedications.
Lisa McCracken (21:18):
Right. Right.
Dianne Munevar (21:20):
So all great. I think what we also found was
that they were receiving morepreventative and rehabilitative
care than people living in thecommunity, which picks up from
the access to care study, butthey were also seeing more PT
and OT and such.
Lisa McCracken (21:36):
So I know one of the things that did come out
of that research, in general,on average, and there's great
variability across thedifferent communities, but on
average, we also know that weare much more likely to send
residents to the emergencydepartment than their peers
(21:57):
living in the non-congregatesetting. That utilization was
much higher, and I don't thinkthat came as a surprise to
anyone, but it's something weneed to continuously have on
our radar and figure out what'sdriving it. How can we bring
that down? Some of that is riskaversion, some of it is
policy-related, and some of itis just not having full
insights. If you find someoneon the floor, did they really
(22:18):
fall, or did they laythemselves on the floor?
Nonetheless, that's one thatalways jumps out to me, and I
think there's more room topursue. Knowing all of the
research we've done and thequestions we're asking today,
because there's always moreresearch to be done, what is
the "so what" with that body ofresearch? Great, Diane, that's
interesting. People livelonger, generally with better
health outcomes, but tell uswhy we should care about that.
Dianne Munevar (22:53):
Yeah. This is such a good question. It's a
very big question. The reasonI'm pausing is that I think
it's really important to pausefor a moment and reflect on
this moment in time, becauseright now there's a multi-part
crisis happening in aging, inolder adults, and in healthcare
more broadly. First, we'reseeing many more older adults
(23:15):
who are aging and living waybeyond what we ever expected a
hundred years ago. While that'sfantastic and demonstrates
where we've come in terms ofmedicine over the past hundred
years, people are coming withmore chronic conditions, higher
rates of dementia, and allsorts of issues. There's a
(23:38):
shift in demographics. Second,healthcare costs are not
getting any less expensive;they just keep getting more
expensive.
Lisa McCracken (23:59):
Yeah.
Dianne Munevar (24:00):
And then the third is that, due in part to
shifting demographics, we justdon't have the workforce to
address all of the needs thatthis older population has. I
think this actually presents amoment for senior housing
because you are taking care ofhousing, providing nutrition,
and providing socialconnection, and all of that
(24:21):
relates to healthcare. The "sowhat" is that there's a moment
to really demonstrate the valueof living in senior housing
relative to maybe aging alonein your own home and risking
adverse events. I think the "sowhat" is that we need solutions
at both the federal level andat the state and local levels.
(24:45):
Solutions need to happen. Theyneed to be small ones that can
be tested and also big,innovative, barrier-breaking
solutions. I think this is thetime for senior housing to
propose some of thosesolutions.
Lisa McCracken (25:14):
Y eah. Well, and speaking of timing, I know
you were at our springconference in Dallas this past
March, and we had Dr. MinaSeshamani , who's the director
for the Center of Medicarethere. That was really the
first time that our sector hasever had CMS at our conference
(25:35):
and really focused on seniorhousing. The nursing sector
often has more of thatinterface. But for us, it was
the acknowledgment of, "Hey, weshould better understand senior
housing." And as you said, whatis the potential role that
senior housing can play inaddressing some of these crises
that we're either in now orthat are just around the corner
(25:56):
for us? Did you see that as asign of anything? We took it as
a different level of opennessand an opportunity for us to
build upon. What was yourobservation from that time?
Dianne Munevar (26:15):
Yeah, my observation from that time, and
you all were, we also workedwith you to respond to that
RFI, the request forinformation about MA data.
Correct. And then it soundslike there was interest
following from that letter. Ithink you're on the radar, and
(26:38):
I don't mean that in the way,you know, having two kids in
school, I don't mean that inthe way that you're on the
principal's radar. I mean thatyou're on the radar to be
invited to the table to discusshow senior housing could help
manage the healthcare needs ofolder adults. I think it's
really important to take thismoment and to remain in a
proactive position. Right? Youall are asking the right
(26:59):
questions, in my opinion,you're funding the right
research to demonstrate thatvalue. And I think what we need
to shift towards now is reallyunderstanding what's driving
those favorable outcomes andwhat's driving some of the
questions that we continue tohave, like on emergency
department visits, what'sdriving that, and are there
(27:19):
public solutions that couldhelp make that a little bit
better for residents and forthe senior housing communities?
Lisa McCracken (27:34):
Right. We definitely need to get a little
more granular and answer someof these questions that, I
think, came out of theresearch. Clearly, it's a good
thing if people are livinglonger, they're getting access
to care where they call home,things of that nature. But
again, for those that are inthe 75th percentile and really
off the charts in terms of someof those things, what can we
(27:57):
learn? I think we've gottaunbundle that a little bit
more, 'cause I think it's naiveto think, I mean, the reality
is it's not gonna come out ofthis and say, "Oh, great, CMS
is seeing that senior housingpeople are living longer,
they're less likely to behospitalized, things of that
nature, so we're just gonna paythem more." That's not the
(28:20):
reality of it. Right? So, it'snot that simple, but we do need
to unbundle. Are there certainmodels, or are there certain— I
know we talked about primarycare, and there are a number of
operators that are reallydeveloping some robust
frameworks around that. And wehaven't really talked about any
of the healthcare costs, butthat's gotta be part of the
conversation too. What is thelens that CMS and payers are
looking through right now? Imean, honestly, you mentioned,
(28:43):
we mentioned Medicare Advantageplans. A lot of them are
hurting, quite frankly. So,there's— and this probably goes
to the "so what," but I thinkus identifying the value
proposition of what seniorhousing brings to the table for
the payers is huge. So, whatwould you say is top of mind
for payers right now, whetherit's a Medicare Advantage plan
(29:06):
or CMS?
Dianne Munevar (29:18):
I mean, it has to be reducing costs. Boom, it
has to be reducing coststhrough better outcomes. It's
reducing some costs on the PartB side, but it's really about
reducing those high-costevents—hospitalizations, ED
visits, stays. How can you makethat stuff go away through
better outcomes? How do youmake better outcomes happen
(29:42):
through more access to primarycare, good integrated primary
care, and also through morerehabilitative care? Helping
people with their functionalstatus, reducing falls, is
really huge. But I also thinkit's about ensuring that people
have the internal motivation tocare for their own health.
(30:03):
Something we learned from ourinterviews and conversations
with some of the Vanguardsenior housing communities and
Payviders is that they arereally thinking about what
internally motivates people andasking them, "Where do you see
yourself as a resident? Wheredo you see yourself, what do
(30:23):
you want to be doing in ayear?" And then creating a
custom plan for that.
Lisa McCracken (30:46):
And that's not easy work. That takes time and
commitment, but I think most ofthose organizations that are
really doing that type of thingsay it pays dividends. Not only
do they feel like, "Hey, thisis the right structure and
model," but it increasessatisfaction, improves
occupancy, and all of thosemeasures that we often define
success by. All right. I wantto ask one final question here
(31:08):
before we wrap up. All of thisresearch that we're doing is at
the big national level, themacro level, and we could
release another five reports inthe next year that's showing
this and that, telling thestory for senior housing, and
setting the sector up forsuccess. But at the end of the
day, this is very local. It canbe very local and very
regional. So, what's the callto action for the
(31:29):
boots-on-the-ground operators?
What can they be doing toposition themselves to be
stronger with all of this anduse this information to their
advantage?
Dianne Munevar (31:47):
Yeah. I think it's three things. I think
it's, number one, you need todo research, or they need to do
research that informs theirvalue proposition. Um, which
means like, get to know yourdata. Um, what are you doing
well? Where , what do you stillneed to work on? Honestly, you
know, not trying to , um, coverit up, but really understand
(32:10):
yourself, right? Um, or yourorganization. Two, develop
partnerships with therisk-bearing entities in your
market area so that you canthen align that value
proposition with what iskeeping them up at night. Like
what , where are their gaps,right ? Um, and then I would
say the third thing is don'ttake your eye off of CMS, you
know , um, continue to stayinformed of where they're going
(32:33):
, um, you know, where the windsare pointing. Um, and then try
to continue to keep thatdialogue open, which I know you
all are doing. So I would saythose three things.
Lisa McCracken (32:47):
Awesome, well we've got it all figured out.
At least a really goodfoundation! So this was great
and I appreciate your time. Wecould continue the conversation
but this was a nice 30 minuteoverview and primer for folks
who want to learn about thework we've been doing with you
and want to learn more, and itwas a good priming the pump for
what comes next. And we knowthere's plenty more to come
next and more research tofollow. Thank you all for
listening to the NIC Chatspodcast. This is Lisa McCracken
with NIC and thanks again,Dianne, for being our guest
today.
Speaker 4 (33:25):
Absolutely. Thank you so much, Lisa. Thanks
everyone for listening.
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If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
Las Culturistas with Matt Rogers and Bowen Yang
Ding dong! Join your culture consultants, Matt Rogers and Bowen Yang, on an unforgettable journey into the beating heart of CULTURE. Alongside sizzling special guests, they GET INTO the hottest pop-culture moments of the day and the formative cultural experiences that turned them into Culturistas. Produced by the Big Money Players Network and iHeartRadio.