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From the Front Row: Discussing the pandemic, aging population, and telehealth

Published on October 29, 2020

 

The following is a transcript of an episode of From the Front Row: Student Voices in Public Health, the University of Iowa College of Public Health’s student podcast. This episode features a conversation between CPH student host Steve Sonnier, CPH associate professor Brian Kaskie, and Anshul Dixit, an alumnus of the College of Public Health. They discuss telehealth, health care for the elderly, and how COVID-19 has affected care delivery and policy.

Stevland Sonnier:
Hello all, from all of us at From the Front Row. My name is Stevland Sonnier, and if this is your first time listening to us, welcome. We’re a student-led podcast that explores major issues across the field of public health. I’m tremendously excited today to introduce our two guests. First off, I’d like to introduce our College of Public Health alumnus, Dr. Anshul Dixit. He is a 2008 grad of the MPH and MHA programs. Currently, he serves as a medical director for a large commercial insurer on the West Coast. He will be joining us today in his personal capacity, and the views expressed on this podcast are his and ours alone, and not those of our employers.

Stevland Sonnier:
Second, I’d like to introduce Dr. Brian Kaskie, who is an associate professor in our Department of Health Management and Policy. Dr. Kaskie earned his master’s degree at Washington University in St. Louis, completed his doctoral training at the University of Southern California Leonard Davis School of Gerontology, and participated in a post-doctoral fellowship in health services research and policy at the University of California. His primary interests concern the intersection between public policies and older persons. Welcome to the both of you.

Brian Kaskie:
Thank you for having us.

Anshul Dixit:
Thank you for having me.

Stevland Sonnier:
Let’s start off by examining some of the prominent workforce issues among older adults that have been accelerated by the pandemic. For Dr. Kaskie, the focus of the recent Public Policy & Aging Report centers around age 50-plus employees navigating the changing workforce landscape. If you can briefly comment on some of the shifts that we’re seeing, and how employers can best address the challenges and opportunities presented by an aging workforce.

Brian Kaskie:
First off, Steve, thanks for having me and Anshul. This is really going to be fun today. Appreciate the opportunity. In regard to our aging population, the first point is there’s more. There’s more of persons over the age of 50 in the United States at any point in history. In fact, there are going to be more older persons in our country by 2030 than there are going to be children and people under the age of 18. That’s a huge trend that’s in front of us, and what we’re concerned about is how few employers have actually acknowledged how that will really transform the workplace. Employers are getting up to speed on handling issues concerning entry of women into the workforce, which really started to happen in mass in the 1980s. And they’re also developing great programs to acknowledge the diversity of the workforce, but those efforts seem to not be considering those who are over the age of 50, and that’s what our focus is on.

Brian Kaskie:
These folks, as an employer goes, need to be thought about in terms of not only conferring opportunities to continue working. Most persons who are older than age 50 are actually pretty healthy and productive, and you shouldn’t just think they’re going to retire, but at the same time, these individuals also do incur more health-related issues, so workplace wellness programs, health insurance, and other such benefits become even more important for these individuals.

Stevland Sonnier:
And Anshul, with regards to that, talking about transformation of workplace and age diversity concerns, with the substantial rates of unemployment across the country, we know that older adults face a tremendous burden of potential loss of health insurance benefits, especially now with the pandemic in full swing. What are some areas of concern here, and are there efforts to support these patient populations?

Anshul Dixit:
So, first off, Steve, let me say what a delight it is to be on your show. I’ve been a long-time listener, and as I was saying to my family, I’m an innovator and back bencher, so it’s great to be able to make it to the Front Row. I can say with conviction now that I’ve finally arrived after 12 years of grad school, so thank you for having me.

Anshul Dixit:
I guess valuable lessons we learned early on in the pandemic is that viruses do not respect the new graphic and territorial boundaries, and the pandemic has exposed gaps in our safety net. The argument in favor of strong public health and universal coverage has never been more persuasive. If you look at our workforce, more than 70% of the workforce cannot telework. Two in three adults within the ages of 50 and 64 cannot telework. And this proportion is even higher for individuals ages 65 and older, that three out of four individuals cannot telecommute.

Anshul Dixit:
So the gap is dark, and is even darker for ethnic minorities where the numbers are far lower for Black and Hispanic populations. So the need is certainly there to support these populations and the possibly of greater productivity even as they begin to struggle with health concerns, as Dr. Kaskie alluded to. Though the CARES Act did set aside about $2.2 billion for older workers to stay at home and to be able to collect unemployment insurance benefits, and hopefully some of that will continue in the coming months.

Anshul Dixit:
In the early stages we saw the health insurance industry very costly for COVID testing, and that is set to continue as long as the public health emergency is in effect. Other effects was certainly having that conversation around paid sick days, we had a conversation about unemployment insurance. Some of the opportunities that we have to support older adults as they continue to be vibrant, productive members of our communities, next out of the billion of the protections of the ACA is absolutely vital. The Affordable Care Act does face a lot of legal challenges. The flight of these challenges will dictate efforts that support non-working older adults that are nearing retirement.

Anshul Dixit:
And finally, with the new administration in January, there are bound to be larger conversations around vulnerable populations, providing coverage to them, and these issues are likely to be deeper set in.

Brian Kaskie:
Just to add to that, Anshul, is another wrinkle in all this is not only are persons over 50 being displaced, they’re part of layoffs and other challenges that are going along with the continued spread of COVID, but these are the folks who are also primary care takers of those other older adults, their parents or their siblings, who actually are in need of support. They have contracted COVID or another healthcare crisis during the time, and now they’re split. They’re gone from working full-time to now in a caregiving role. So, another challenge here is for employers to consider how can they adjust to this new reality where it’s not just younger moms in the workplace who are going to be tied to raising younger children, and we need to develop strategies and cut the responses for that, but now we need to think about these aging workforce challenges that are fairly unique now.

Anshul Dixit:
Absolutely. That’s the double whammy that older adults are facing in terms of caregiving responsibilities. And certainly, they are in that vulnerable population where they are increased risk of coming down with the dividers and, indeed you have come up with a list that certainly point well taken. Employees do have an obligation to support whatever arrangements are feasible in terms of retraining, the right teleworking opportunities, and other sort of engagements. These will let us continue to be productive members of the workforce.

Stevland Sonnier:
Within those telework arrangements that you both are talking about too, one of the things we’ve seen come out of the pandemic really is the explosion of telehealth, where folks have been able to telework from home, interact with our patients as necessary, and really decrease the spread of COVID-19 while ensuring the continuing of care. We’re also faced with really big workforce shortage upcoming of older clinicians. So we’re starting to see this two areas intersect where we’re faced with a potential loss of medical knowledge, and a potential loss of really needed care, especially in rural communities where there’s a lot of trouble recruiting providers to those areas.

Stevland Sonnier:
In the uptick of telehealth has really posed a lot of questions about how are we going to reimagine the older workforce as well, as how do we deliver high-quality primary care and mental health care going forward throughout the pandemic. We are considering telehealth or other telework opportunities as a bridge, what opportunities or challenges do you both see for training or retraining older adults for virtual work environments?

Anshul Dixit:
I couldn’t be more excited about the opportunity that the pandemic has presented to reimagine high-quality primary care. I’ve been in my clinical career as a smart phone physician in Central Iowa, certainly access was certainly there. Someone said recently there are years when nothing happens and there are years when Dickens happen. We’ve seen a lot of progress in the past few months where the technology platforms have matured. Consumers and providers are more comfortable. They will overcome their initial hesitation of technology. Even the smart martyrs have caught up, and people are beginning to see the value of telehealth for non-acute services.

Anshul Dixit:
Certainly, telehealth allowed insurers to support family care practices when their volumes were down early on in the pandemic. As consumers get more and more savvy, they will begin to realize what the opportunities and the limitations of telehealth really are. These are new workflows for everybody, for clinicians, for staff, for patients. It does allow greater degree of automation that eventually will help the system harness more efficiencies, like gathering pre-visit information, like understanding which sort of visits are really geared toward telehealth, and what sort of visits are more geared towards in-person interactions.

Anshul Dixit:
Certainly, there’s opportunity to think more deeply about what constitutes a high-quality telehealth visit. Now, the [inaudible 00:10:32] is looking at putting together some sort of guidance and metrics around what a high-quality telehealth visit looks like, because we have seen HEDIS rates drop in the past few months, and certainly that’s a concern. Maybe there’s a way to incorporate some of those HEDIS metrics in our telehealth visits in these unprecedented times.

Anshul Dixit:
How do we better integrate telehealth visits with ancillary services, put in stents, labs, primitive care, immunizations, vaccine delivery, those sort of services. How do we think about integrating telehealth into social developments of health? Now that providers have a glimpse into the home environment, they’re able to identify social developments that might be easily addressed with interventions. How do you provide a more distinguished approach to care, how we bring in social workers, how did we bring in our mid-level practitioners into this vault for sharpest that has been making different communities around the country. How we begin to think of creative approaches that utilize the skillset of these very diverse teams in providing better care to the patient?

Anshul Dixit:
The other question I had was whether these meeting has been structures we have seen in the past few months, the zero cost chair, the regulatory dismantling. Will those be in place after the public health emergency ends? Will we be able to keep disparities from worsening knowing fully well that there are marginalized communities that won’t have access to our technology platforms, that will not be as health-literate or as savvy in terms of using these capabilities. And to our providers who sometimes struggle with burnout. Will these visits be as gratifying as in-person visits? Will patients and providers value the connection that they can know that our facilities provide. Will they each realize the value of these services while also recognizing then an in-person that might be of greater value.

Brian Kaskie:
Yeah, just to add to that, great quote. Decades can pass by in just a year. You know, up until now, we’ve been looking into telehealth for decades, actually it started in the mid-’90s. It’s not like it can’t happen. It’s been available in so many other industries… hello, education. We’ve completely transformed, not only secondary education, but here the higher education realm is going into a virtual format. There’s really very little reason behind the notion that you can at least do follow-up visits, check-in calls, all these sorts of supplemental supportive activities that could be construed as contributing to the social determinant of health.

Brian Kaskie:
The pain that is in there, it’s always been in there. It’s called cost savings. When you use telehealth, you have people who come back to the hospital for readmissions after discharge far less than those who don’t use it. You have people who maintain their medication regimens much better. The notion that we have to pay more for telehealth is just boggling to think, when it fact, it’s really an opportunity for health systems to become more cost effective.

Brian Kaskie:
And the other thing about it is, we do face, as one of our candidates have referred to, sort of a K economy happening, or an evolution in front of us. There are going to be a lot of health systems, and the patients therein, that are going to easily adapt to this. They already know how to connect with their patients electronically. They know how to transfer documents and medical records safely. And they know how to engage people effectively, if you will dose out in-person visits with the routine checkups that telehealth really do capitalize on. But there’s a large segment of the American population, especially in rural communities, that simply does not have access to any of this. They don’t have broadband. They don’t have the technology available to them to participate in this.

Brian Kaskie:
This is where it’s a really interesting conversation to have with healthcare administrators and public health officials is, “What are you waiting for? Why aren’t you in these communities building the infrastructure and collaboration with public health officials, in collaboration with telecom companies?” You know, we came together 50 years ago to build hospitals in communities. There was a huge infrastructure investment act that essentially made all these hospitals free to the people who now occupy them. Why is there not the same sort of effort being led by hospital administrators and public health officials to reach out to the people in their community and help set them up with this broadband capability and the technology needed to use this stuff? They’re paid for it. They have capital reserves. There’s no reason why we can’t do this.

Brian Kaskie:
I actually hope that this pandemic leads to that sort of consideration that healthcare systems really… They’re community-based systems. They’re not Wall Street-based. They need to participate more in developing their community, especially at a time like this.

Anshul Dixit:
I’m so glad you brought up the question of broadband. We have seen that in our schools in how broadband access, or lack thereof, has really widened disparities between communities.

Brian Kaskie:
I know. It harkens back to a day when we as a public decided that investing in the human capital of the citizens was important, and how did we do that? We built highways. We built roads. We built hospitals. We built schools. We used tax revenues to do that. 60 years later, it’s if some mystery why this is not being built and why it’s not reaching these communities. Folks, it’s no mystery. It’s just this sort of lack of community-based interest that we see from a number of healthcare systems and public health officials. They need to come together and work this out.

Brian Kaskie:
In any community, especially here across the Midwest, the single largest organization is the healthcare organization. They need to lead in this area.

Anshul Dixit:
Steve, you probably have some part-

Brian Kaskie:
Other questions.

Stevland Sonnier:
Yeah, I think these are fantastic conversations because you do have this concern, and the idea I keep on coming back to is the idea of you can’t have telehealth without this broadband infrastructure. You need a pipeline for this. Until we ramp up with either audio only, which is really still in its infancy, in terms of either regulatory or research efforts, there needs to be this investment. So is the investment going to be in advancing broadband initiatives? Is it going to be in retraining or rehiring your workforce who is getting ready to retire and should be working more in this virtual area so they have a bridge job while we try and recruit and retain younger workers? How does this work in both of your guys’ views. How does this work out so we can really meet the needs of our community, because we’re really facing a lot of issues, especially in the Midwest with mental health practitioner access. What can we do beyond building out these resources? It really seems like that’s where it needs to start.

Brian Kaskie:
Yeah, I would agree. We just did a travel across the United States. My family and I got on Highway 66, and then got off and took the Santa Fe Trail. It’s just amazing to see the communities as you go through Missouri, Kansas, New Mexico that just seem to be a decade or two behind in the sense that you go into those communities, and while I could still get my phone, my cell access, their healthcare systems don’t have that same sort of connectivity. It’s there. They could do it if they wanted to. They just haven’t marshaled up the wherewithal. Somewhere in these boards they’re deciding it’s more important to build another surgical theater, expand their emergency department, rather than use those capital funds to invest in connecting with their community in a modern way.

Brian Kaskie:
The more we can talk about this, the more I think you’re going to see, at least in some places, say, “Yeah, this is a good thing.” And Steve, to your point, I want to talk about opportunities for employment. Think about it, airline, banking industry, they’ve all gone virtual. Healthcare needs to get into the 21st century in this regard, and there’s a bunch of folks who would benefit, not only from the receiving end as patients, but also as the opportunities for employment.

Anshul Dixit:
As you alluded to in your brief, Steve, I believe the FCC is looking at some approaches to broadband access in our communities.

Stevland Sonnier:
Yeah. We’re seeing a revitalization in this area, and again, it’s the idea of the pandemic really is moving us forward. It’s really exposing these disparities that we’re seeing, and we are, I think, going to see federal investment, and we’ll also see private investment in both of these areas of where is this going with broadband access. The common phrase that everyone keeps saying is, “The genie is out of the bottle with telehealth.” Even though, as Dr. Kaskie said, “It’s been around since the ’90s,” but we’re coming around to it, we’re seeing… This is why we’ll need to make the big push in investment. I think ultimately it will be a community-led initiative. Like Dr. Kaskie was saying we need folks from all sides of the aisle coming together and saying, “This is a priority for us. We really need to invest in our communities because they won’t get healthcare either way.” It’ll be too far away, it’s always been, or there’ll be other things that crop up.

Stevland Sonnier:
We’re really at that point of we can secure access for folks. The payment side of things, we’re still figuring that out, but access and opportunities, we’re able to Zoom and Skype across the country. We can build this stuff out for folks. We just need to have the wherewithal and the focus from policy champions.

Brian Kaskie:
Actually, I’d just add to that, is this really comes down to hospital and health system leadership. The public wants this. Patients want it. Where the hurdle is, is internal to a health system or a hospital where there’s a small number of folks who see these things as threats. It’s like, “Wait a minute. I don’t want to invest in this because I’m a surgeon, and I don’t really use telehealth. And I need more surgical devices and machines and nurses. That’s where we need to put our recommends because that’s where we make our margins,” and things like that. There is that argument or those voices in these meetings. And those voices need to be balanced against everything Anshul said.

Brian Kaskie:
You know, telehealth really isn’t about having a back surgery. It doesn’t help you put in a spinal implant, but where it helps is on the discharge side when that person gets home and they don’t know how to take care of themselves, and they just need a video from a nurse to show them how to change their dressing, something like that. So until the bigger or more dominant voices come around and see the value of how it isn’t a threat to them, I think we’re going to be stuck on this for a while.

Stevland Sonnier:
Talking about that component of where telehealth can be geared towards, especially with discharge and everything along those lines, how do we ensure that this deployment matches the needs of older populations? Is it an idea of a well-designed user interface? Is this patient tutorials to guide folks through? Outreach campaigns? How does this look, because as you said, until the voices in the room start talking about this, this mostly probably will be a patient-led effort where it will be something to the effect of, “I saw this was an opportunity. I’d really like to pursue it. What do you mean X hospital doesn’t offer it?” How do we think that this area dices out in the future?

Anshul Dixit:
Well, Steve, you guys have had the past eight months to experiment with these technology, see what works, see what doesn’t work, and given that the comparable technologies are so easy to use, consumer expectations are already sky high in terms of what telehealth can do for them. Just in the past eight months, we’ve seen an evolution in how consumers are using these services. Initially there was this big spike as you saw, where everybody flooded into telehealth, and then gradual flattening of that curve when they realized there are services that are best accessed in person.

Anshul Dixit:
So, maybe the cohort that we have today in 2020 is a lot more tech-savvy than the cohort of 2010 when the first of the boomers turned 65. So we are already seeing those encouraging signs in that being an older adult does not equate with being not-tech-savvy. And you’ll see this transition deflected in the upcoming annual enrollment period. There will be Medicare Advantage plans that will complete on which [inaudible 00:24:01] health plans. They are cross-pay for virtual visits. And even the advertising of these plans, these Medicare Advantage plans will change.

Anshul Dixit:
A few years ago, we used to see ads for any plans that featured horses scampering on the beach or vineyards in all their glory. Now we are more likely to see a couple holding an iPad and presumably engaging in a telehealth visit. So that evolution and consumers becoming more tech-savvy, and especially older consumers is being reflected in plan offerings and outreach, and even their branding advertise.

Brian Kaskie:
Just to add to that, this is already happening. Older adults are using Fitbits. They’re getting health watches. They’re getting online to fill out their Medicare forms. They’re getting online to Zoom and chat with their kids. The only place where it’s not happening is healthcare. They’re onlines with their banks, they’re onlines with their lawyers, yet healthcare magically, mysteriously can’t make this happen. I think two things need to happen is patients need to continue to demand this. You know, walk into your doctor’s office and say, “Why do I need to come back in two weeks after surgery to have you check on my colostomy bag? Why do I need to sit in the waiting room for two hours so you can finally get to me, spend five minutes looking at it and say I’m okay, and then I can go back home.”

Brian Kaskie:
That represents a five-hour chunk out of my day, when all you really needed to do was just schedule a time that an email sends me in the morning that says, “Dr. Jones will be able to see you at 2:15.” And then I flip on a switch, and then they can do a visual and audio check-in on me. I mean, the fact that consumers aren’t demanding this is just mind-boggling. So, that’s step one.

Brian Kaskie:
Second thing is more and more homes that are being built for seniors are actually incorporating an IT structure into the home itself. So another sort of… how should we say, lazy man dismissal of why they’re not doing this is people say, “Well, we don’t have the infrastructure in persons’ homes in place.” That’s not true anymore. Homes are being built with WiFi capabilities, connectivity. We’re just waiting for the plugs to come from the health system. That’s where it is right now.

Brian Kaskie:
So, how do you get the health system to change? Patient education is routine. They’re supposed to spend time with you when mission in the hospital talking about your end-of-life choices. That gets blown off. They’re also supposed to talk to you about your discharge plans. Who’s going to take care of you when you need the hospital? That gets blown off. Well, not surprisingly, they’re also blowing off this opportunity to say to their patients, “Hey, do you have connectivity issues? What can we do about this?” So, I think, again, back to the health systems, they just have to assume more responsibility other than bringing people in for a treatment and then sending them back home. It’s not hard. They’re community organizations. They should start acting like they’re supporting the community.

Stevland Sonnier:
Yeah, you have a really good point there, and it’s something I’ve mentioned a couple times as well is the idea of broadband access really becoming a social determinant of health. We’re seeing this tremendously happening now with the pandemic, with access to telehealth rather initiatives, and it needs to be something that hospitals and health systems are accounting for and asking. It can be simple to add it on to one of the checklists for intake, and say, “Is this going to be an issue for you when you’re finished up here?”

Stevland Sonnier:
With delivery of the checklist or something to this effect, Anshul, how do you think this could be incorporated from a health insurer perspective? When we’re thinking about the evolution of telehealth and pushing this further down the way, how do we account for connectivity as an issue?

Anshul Dixit:
Certainly, there are challenges to connectivity as both of you mentioned. Some of them may be relating to the infrastructure and others, of course relating to the country and healthcare and how much emphasis we place on connectivity as a social determinant of health. We have seen in education, and we are seeing in healthcare that lack of connectivity, lack of access to social interactions can have devastating impact on outcomes, especially scenarios when such isolation can worsen their sense of isolation, can lead to a spike in mental health concerns, anxiety, depression, and of course not being able to see their loved ones.

Anshul Dixit:
I totally agree with Dr. Kaskie that it is past time to pull everybody together to have all our hands on deck in terms of ensuring that broadband access is available to the extremes of our population.

Stevland Sonnier:
Within that idea of connectivity, especially with the senior population, one of the big things that we’ve seen recently with telehealth was a big fraud insurance scheme. We were looking at this surge of the pandemic. It’s redefined telehealth. We can clearly see that even though you can have connectivity, you can have people coming to the table with these ideas, program integrity approaches are critical. They do need to be refined. And from an insurer perspective, Anshul, where do you see health systems or insurers headed with response to fraud, waste, and abuses with telehealth as it becomes more commonplace and demanded by the consumer?

Anshul Dixit:
As you already stated, there’s a potential for abuse, potential for bad actors to jump into the fray. Fraud, waste, and abuse has a real impact in terms of cost of care and in terms of the premiums that members and employees pay for their healthcare. Not only that, it does impact healthcare of communities. Not too long ago, there was online opioid pill mills that were freely prescribing these controlled substances to individuals resulting in poor outcomes in our communities. There’s, of course, the cost side of it, but there’s also a quantity side of it as well.

Anshul Dixit:
The good news is that advanced analytics tools that identify fraud, waste, and abuse are equally applicable to telehealth services. That just where it takes an expert to see a heightened focus on quality and value of telehealth services, technology matures, as consumers and providers become more savvy about using it. And as these visits, the sheer volume of these visits begin to pop up on our screens, these analytics tools that are used to identify fraud, waste, and abuse.

Anshul Dixit:
That brings me to another point in that we will need robust patient identification as patients begin to access these services. And there are technologies available that allow a robust of patient identification during their health encounters, and hopefully the technology will move towards that standard so that the provider and the member are sure of their identities and where they’re accessing these services from.

Brian Kaskie:
I would suspect the fraud most likely occurs in fee-for-service Medicare arrangements, obviously. And this is a function, again, I may be overplaying this particular point, but again, it gets back to health administration. If health administrators simply farm out these functions to third parties, and these third parties invoice for services, either separately to Medicare, because they were approved by the medically qualified physician says, “Yes, I approve of this,” that physician really has no stake in whether or not the company bills fraudulently. Just like they have no stake in monitoring and prescribing practices.

Brian Kaskie:
So, what do you do here? Well, first off, you look at where managed care operations are, because they see this as a cost savings. So if they are in charge of their own aggregate budget, they’re probably going to be a little bit more circumspect about A) the development and deployment of telehealth, and then B) they’re going to watch for excessive or inappropriate use. Again, this is not hard to figure out. The fraud occurs when leadership takes these positions that essentially are agnostic from the practice of third parties that come in and bill excessively for this stuff.

Brian Kaskie:
How do you stop that? Again, you can either go to a capitated arrangements, or as Anshul says, you just need to ratchet up. The oversight of these billables, i.e. trap patient IDs and whatnot. Medicare fraud’s a longstanding issue, and this is just a new wrinkle. Again, it largely comes down to this notion of fee-for-service and the lack of administrative oversight.

Stevland Sonnier:
When we’re talking about the issues we’ve discussed today, whether it’s telehealth or it’s older adults in the workforce, within your respective fields, what do you think is the most pressing situation that you want to handle with your career that the general public should be aware of?

Anshul Dixit:
Well, Steve, from my standpoint, it is improving value for members and employer. As biz transition from the traditional review of claims processes to becoming more health-centric, not healthcare-centric, but health-centric, because you must centric organizations. They will get there by exploring new partnerships, by continuing to invest in social claims as well. And by testing invited programs in the populations that we just talked about, Medicare Advantage and the Medicaid populations.

Anshul Dixit:
The goals of overall superior member experience and meeting those members where they are, where their capabilities are, and ensuring that we do not lasso where the needs of underserved communities that are not as health-literate and health-savvy. I would say my focus in the next few years will be affordability.

Brian Kaskie:
I’ll add to that, maybe a little higher level point of view is how we as a society need to embrace this whole phenomenon called population aging. Our generation, and folks right now who are 20 years old, have been given an extra 30 years of life. Since 1950, the longevity of any individual born has far surpassed that in any point in history. So most of us, when we designed Social Security and Medicare and all this healthcare, the notion was people would maybe make it to 70 or 75. If you’re born today, you can expect to live to see 100. How are we going to make sure that those last 25 years of life are healthy and exciting and engaging? Because they can be. I’ve seen it.

Brian Kaskie:
There are a number of older Americans out there who you’ll see them on the ski slopes and they’re 85 years old. You’ll see them at lectures, and they’re asking questions. There’s this stereotype that aging is nothing but some sort of inevitable decline. It’s just not true. So with that in mind, how can we in healthcare, which is the primary variable that shapes the aging trajectory, how can we assure that we’re facilitating successful aging for our population of aging Americans? You know, the ones who made America great because they served in World War II. Let’s start there. They’re the ones who defended us. What are we doing for them other than what we’re currently doing?

Brian Kaskie:
That’s the question I’d put out there. So my goal is to say, “Yeah, we need to move away from just seeing them as revenue opportunities.” We need to stop thinking of them as, “Oh, okay, well they have insurance coverage. Let’s try to give them all these medical procedures we can.” I mean, many hospitals across the country rely primarily on Medicare patients for revenue stream. That’s just odd to me that they see it as such. Why aren’t they thinking about these people as resources in their community? Why aren’t they doing more to support them, to get engaged in, let’s say, community partnerships with schools, to be tutoring for the kids in their areas that might need some help with reading, because both of their parents are working. That’s health. That’s public health.

Brian Kaskie:
Why aren’t they engaging more seniors in nutrition service programs to help people who when they come home from the hospital might need a little help? Why aren’t we thinking about this? Well, my goal… I pretty much recognize that it’s not the people who are senior to me that are going to change the system. When you meet folks my age, they’re like, “Well, I’m only five years away from retirement. I don’t want to take on this kind of battle. I’m just going to ride out the system as it is.” That’s your problem, Steve.

Brian Kaskie:
Well, that’s my goal is to give you all who follow us enough of an internal drive to basically say, “We need to transform the system, because I’m going to…” me, Steve, and my kids are going to be around a lot longer. And the way the system’s currently designed, if we look at the numbers, it’s going to be bankrupt in a few years. And then what we’re going to see, again, is this play where a large number of Americans who are already healthy and well and educated and have access to retirement pensions and supplemental Medicare, they’re going to be fine. It’s all the others, and it’s more than half of the current population of aging Americans that simply just don’t have the same access and opportunities that the other aging Americans do.

Brian Kaskie:
It’s not like they did it because they were lazy or they didn’t work hard, or they didn’t serve America or believe in our values, it’s just how it works. There’s a diversity in our aging population and we need to reconcile that. So, my goal is to get people thinking more comprehensively about this. It’s great that we focus on the importance of elective surgical procedures, but you know what, I’m not really all that interested in that relative to making sure that older adults get discharged back to their home, and they know who their caregiver is, and they’re connected with their providers, so they don’t have to get out of bed and drive in for a follow-up appointment. That’s my goal.

Anshul Dixit:
You’ve talked in the past, Dr. Kaskie, about adequate funding for geriatrics and gerontology, graduate critical education, and there are certainly the resources and the manpower to care for an aging society. Do you see any movement in terms of the system beginning to support the holistic care of older adults that geriatrics and gerontology [inaudible 00:39:41].

Brian Kaskie:
I think you see it in small doses. I think you see it in certain healthcare systems that have moved in to a fully capitated arrangement where they take on the risk, because those systems get how much costs there are for them to save by moving into this arena. The amount of excess spending in many healthcare systems, especially in a fee-for-service world… Gosh, if you gave me an opportunity to reduce costs by 20% and improve outcomes at the same time, I’m doing that. If I’m a billion dollar system, that’s $200 million, right? So I think there are systems that are starting to figure that out.

Brian Kaskie:
I also think there are communities of older adults that are starting to figure that out. When I worked out East, there was a series of retirement communities. The guy had a business plan where they essentially figured out if they could bill the community that had about 4 or 5,000 residents, it was a big enough market or population if you will, that they could go to their local health system and make demands and say, “Look, we’re here at Sunny Oak Village. We have 5,000 Medicare beneficiaries, and if you guys start setting up arrangements with our village after surgical care, like teleports, we’re going to drive all our residents into your health system.” So I see that, and that’s pretty cool.

Brian Kaskie:
But, by and large, geriatrics, gerontology still is not a profession a lot of people move into. It’s not a profession that people move into because it’s a hands-on profession. It’s not a procedure-based profession. As long as you have a for-profit interest in healthcare, which has emerged over the last 20 years, considerably, as long as you have administrators who play this agnostic role of they have no commitment here to do anything other than make their margin ahead of their mission, I don’t know what we’re going to do. So I think we really want to address this notion of mission of community hospitals.

Brian Kaskie:
Why were they founded in the first place? They weren’t there to be banks or money changers between Medicare and providers. But that’s what they seem to have become in a lot of places, and I think that’s the conversation you want to have.

Stevland Sonnier:
These are all excellent insights. I’ve had such a wonderful time today getting to chat with both of you about your respective fields of interest, and the intersection of my own, so I really do appreciate getting to take the time out of today to chat with you all. I know that Anshul said he had a special question for me as well too he’d love to ask.

Anshul Dixit:
Thank you, Steve. I do have a question for you. Sorry if it was mentoring if you will. You run a very successful podcast and you’ve had lots of interesting guests over the past several months. I’m just curious, what does it take to get a podcast like this off the ground. Of course, it takes commitment and all those other things, but how do you get something like this off the ground in case there are some listeners who are toying with the idea and want to winch it out into the podcast world.

Stevland Sonnier:
That’s a great question, Anshul. You know, I inherited this podcast from someone else who also had inherited the podcast and so, while I’m not the original founder of From the Front Row, when I look at how a podcast is successful, I think that it is the diversity of ideas that come into it. We just recruited a couple new folks who will be joining on, and they’ve been able to help identify areas that I hadn’t considered going into. But when someone else says it, I think, “Oh, my gosh, why didn’t I think of that? That’s such a great idea.” And when I look at how our podcast is branching out and reaching other folks and the accomplishments we’ve been able to make as a team, everybody reflected on that, it is a team effort of founding this because as much as I’d like to take credit and say, “Gosh, I pushed this all together, and I did everything,” it’s been founded by other folks and it really has been a student-led podcast.

Stevland Sonnier:
I think that really is one of the founding things that I’ve seen in effective podcasts is you’ve got someone else along for the ride. It’s not just you talking and another person. I really have found that when you have a dialogue of other folks coming on who are part of your team, or who bring those different insights, I think that’s really the most effective way that you can lead a podcast because you’ve got that conversational style of things. It’s not just an interview. It’s what we’ve got going on here where it’s we can go off on segments or tangents or anything along those lines. I think that really helps engage folks as listeners.

Anshul Dixit:
Wonderful. You and your colleagues have done an amazing job, and I come here to gather lots of good insights. So thank you for doing it. It’s been fun during these pandemic months to see how the public health student community is engaging, and would also in all of that.

Brian Kaskie:
Just before we sign off, actually, Anshul, I want to give you a shout out too. Remember when Steve… gosh, it was sometime this summer, and I said, “You know, we have a lot of alums in our college who aren’t in Iowa City anymore, and they’re out there in the world doing really cool things.” I came up with a list, and you were definitely at the top of the list. I think for the listeners here, maybe you could spend the last minute or two telling us a little bit more about what you’ve done, because you have carved out a career in which you are blending these values we’ve talked about. I’ve been harping on this notion of community and Pareto function, or however you want to call it, and blending that in to the actual operations of healthcare.

Brian Kaskie:
So to be clear, I think we do a lot of tremendous things here in our college. The people who graduate from our college go off and do great things for their organizations, and they really do advance patient care. But you’re the kind of alum who’s taken that extra step or two and pushed into this sector that I think is really critical for us to start considering. So, maybe, just let the other students who are listening, or other professionals know, who’s Anshul, what do you do now. Give us that idea how you married public health values with medical care.

Anshul Dixit:
It started off during my career as a [inaudible 00:46:23] physician back in Central Iowa where I realized that there was more to health than healthcare itself. As is art, I got intrigued, but drawn into the sway of public health and healthcare management. And I still consider myself very much a student more than anything else. I played that swim card as long as I could, and I would encourage the listeners to do the same. Go for those informational interviews, dive into as many dreams and opportunities as you can. Make the most of those office hours that you have when you’re in school, although those are probably virtual now. And continue to be curious about what’s happening in the larger world around you. What are the socioeconomic protocol and healthcare issues of the day that affect your work, and how you can begin to get engaged, get on board, and delve into insight from others, as Steve said.

Anshul Dixit:
Just start tapping into that brains trust of the network that you will help build over your journey as a student and during the first steps in the world ways. And so for me, it was really Dr. Kaskie, it’s been an evolution. It’s been a series of learning experiences that were arranged over the course of public health, and subsequently, and just continue to benefit from the wisdom of many others who were fortunate to give me their time. Too many to name, but again, I’m grateful to all of them, yourself included.

Brian Kaskie:
Steve, any last moment acknowledging points, thoughts for the future?

Stevland Sonnier:
Yeah, no, I think this has been a wonderful conversation about the integration of public health into higher spheres today. I think we’ve all touched on aspirational, but achievable, areas, whether it’s reforming the approach to healthcare delivery, whether it’s reforming the approach of how we think about population aging, and even in the context of the podcast. How do you approach listeners and in engaging populations as a whole? Ultimately, I want to thank both of you for your time today, and for these valuable insights into the pertinent issues across the bill of public health, and to wish you well in the upcoming year and hoping that 2021 goes on smoothly for both of you.

Brian Kaskie:
Thanks for having me.

Anshul Dixit:
Thank you, Steve. Thank you for having me.

Stevland Sonnier:
That’s it for this week’s episode of From the Front Row. Our guests were Dr. Brian Kaskie and Dr. Anshul Dixit. This week’s episode was hosted, edited, and produced by Stevland Sonnier. You can find our team on iTunes, Spotify, and SoundCloud as the University of Iowa College of Public Health. Our podcast is brought to you by the University of Iowa College of Public Health. If you enjoyed this episode, please share it with your colleagues. You can reach our team at cph-gradambassador@uiowa.edu. Stay safe and keep on keeping on out there.