NIC Chats Podcast with Dianne Munevar

Lisa McCracken (00:03):

Hi everyone. Welcome to the NIC Chats podcast. I am excited for our guest today, who is someone I’ve had the opportunity to work with a lot in the past year, Diane Munevar, Vice President of healthcare strategy at NORC at the University of Chicago. Diane, welcome. We've had a lot of conversations, but this is our first formal podcast.

Dianne Munevar (00:28):

I know. I’m excited. Thank you, Lisa. Hi everyone. It’s great to be here. It’s my first podcast, as I was telling Lisa, so I hope I get invited to more.

Lisa McCracken (00:40):

You and I have conversations all the time, but this is our way to share some of the enlightening conversations that you and I have with our audience. Before we jump into all the fun NIC NORC 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 a backup in terms of who we're speaking with. I would love to hear a little bit of your background. I'm always curious how people got to where they are professionally. What did you do before NORC? How long have you been with NORC? Just a little 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 into the journey a little bit and then quickly get to the more recent. I went to college seeking a degree in international relations and Latin American studies. I thought I would travel the globe and solve large diplomatic crises. I even thought of myself as maybe becoming a spy someday. I graduated from college and went to DC, and in those first two years, I pivoted and became very interested in US social policy, particularly issues that impact some of our most vulnerable members of society. I had, and continue to have, a passion for developing public policy that improves the lives of women, children, and older adults. I went back to school to study public policy and graduated from the Harvard Kennedy School with a Master's in Public Policy.

Dianne Munevar (02:21):

My focus was on welfare, labor, and education. Honestly, what I enjoyed most from my grad school studies was not necessarily any one content area, but a lot of the stats, econ, and econometrics classes. What I enjoyed was figuring out how to take big problems and solve them using data and research methods. I ended up with a toolbelt of research and data methods. After grad school, I began my career at RTI International, focusing on issues related to post-acute care. I spent three years learning about the Medicare payment systems for post-acute care providers, which included LTACs, SNFs, and home health. I became very familiar with the MedPAC May and June encyclopedia booklets about the payment systems, and I fell into the content area and loved it.

Dianne Munevar (03:21):

I ended up traveling the country doing a lot of primary research to support a CMS project called the Post-Acute Care Payment Reform Demonstration, or the PAC PRD. I became so interested, and I would say borderline obsessed, with PAC research that I thought, "This can't be all of healthcare; there must be more out there." So, I left RTI and went to Avalere Health to broaden my horizons. I spent seven years at Avalere learning more about how to take research and apply it to solve real-world problems for commercial clients who expect results in less than three to five years—more like three to five months—and how to be a consultant. To me, that means figuring out how to do the research effectively.

Dianne Munevar (04:17):

How do I connect the dots? How do I tell the story as quickly as possible? They probably need it for very timely advocacy reasons. Since 2010, for 14 years, that's what I've been doing. I really love keeping abreast of what's going on in the industry. I love working with clients, hearing what they are asking, and figuring out what they are not asking but what keeps them up at night. Then, I combine the data, the method, and the team to tell the story that helps them.

Lisa McCracken (04:55):

Yeah. Very cool. So that's good idea.

Lisa McCracken (04:57):

There's 100 percent of the work that comes from your team in the mostly post-acute senior space. You mentioned earlier women and children as a passion of yours. Do you dabble in that anymore?

Dianne Munevar (05:08):

Our team in healthcare strategy is about 20 individuals, and we have five verticals or hubs. Senior housing and healthy aging is one of them. We also have a Medicare space, Medicaid, where more of the maternal health and children's health work is located. Then we have prescription drugs and health systems. I sit as a VP over all of them, but I focus a lot of my time on senior housing and health.

Lisa McCracken (05:39):

That's fascinating because I want to come back to some of that. We don't function in silos and bubbles, and I think your exposure and your team's expertise in some of those areas has definitely helped us. As NIC has taken the research we've done with all of you, we try to connect the dots—what does this mean, and how do we move it forward? You talked about some of your passions, and I've observed your commitment to identifying solutions, alternative models, and answers to some of the challenges in our healthcare system. Can you tell me a little about your commitment on that front and maybe share some of your vision? I've noticed that when we've processed some of the findings, you often speak as if you have a vision of where we could go. So, just share 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 a tree right outside my window, and I spend so long looking at that tree and being like, but what's the ideal? What could we, what do we have the capability to do? What's our capacity? I think I talk a lot about what's the north star, which is the potential impact that we can make. I think that comes from earlier in my career, when I was really interested in research and applying the right methods and creating this toolbelt. A lot of health services researchers specialize in the data and the best research methods, and that's amazing. I want to leverage all of that, but I also want to ask, "Yeah, but what's the so what?" Why does this all matter?

Lisa McCracken (07:38):

People like us need the "so what." I mean, we need to know your team's got the numbers, but the "so what" is a big deal for us and our constituents.

Dianne Munevar (07:45):

Right. I absolutely need to know that the research we produced is not just sitting on a shelf like it used to when people printed things. I don't want it to sit on a shelf, in somebody's email, or only be posted to a website and not get any clicks. I want to know that a policymaker has picked it up out of their email or off the shelf, and they're considering it, and that it's going all the way up to help people make decisions. That could be policymakers, business strategy, or even MA plans that are really thinking about how to take this research and make it 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 really tried to advance some conversations to make the research translate into not just actionable insights, but actual change in our sector. We partnered with all of you in 2019 and really led the conversation around what was labeled the forgotten middle—the middle market research. We know that research has continued on our end and your end, and we've learned so much since 2019. That was just some 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 the conversation it has started; awareness around the middle market and middle-income older adults has skyrocketed. We're in a much different place than we were, but we still have a ways to go on the vision, or at least accomplishing some of the vision. When you look back on that body of research and that topic in general, what stands out to you most? And where do you hope we'll be in 10-15 years?

Dianne Munevar (09:51):

That whole research, which we've actually continued, every year we produce some type of policy-relevant, timely update to that work. And actually, I think I mentioned this to you earlier. You and I were on the NIC Fall conference stage that Monday morning or Monday afternoon, and probably 30 minutes before we walked up, I got an email from our team that we had just published three more chart packs on the near duals, which is a follow-up study from the forgotten middle work. It's really exciting. We just keep doing that work. The thing that has stood out to me the most is, and this continues—I just had a conversation yesterday about this topic—we often talk about the middle market, the forgotten middle, and near duals in these technical terms.

Dianne Munevar (10:49):

However many times, two to eight times the federal poverty line. I honestly don't even know what that means. That feels like it's at arm's length. What stood out to me is when you actually translate this into real, normal person terms, the forgotten middle actually ranges from $27,000 a year to $103,000 a year. I then go and translate that again. I think, well, so what? The "so what" is that I think about recent college graduates, and in that first year after college, many of them are probably making more than $27,000 a year, and some make over $103,000. Now we're considering the 16 million older adults who make somewhere between $27,000 and $103,000 and the 11.5 million who, based on their income and asset portfolio, are not able to pay for senior housing if they suffer even one debilitating event. It's that translation to what does that number actually mean to a person that stands out to me and continues to drive me to find solutions that meet their needs.

Lisa McCracken (12:03):

Well, I know when developers and operators talk about developing a middle market community and product, there's always that conversation around whether to advertise as middle market. Is that a label we use, or does the customer, the consumer, know they're middle income or middle market? It varies so much depending on where you live. It's interesting because I think this middle-income group has really gotten attention across a lot of different age groups, and actually, the whole workforce housing topic is really that middle-income cohort. One of the things we've been pushing at NIC is that the older adults in workforce housing are just an older version of that same cohort. We've been talking a lot about affordability, and you mentioned the near duals, and I want to talk a little bit more about that.

Lisa McCracken (12:57):

But it's increasingly clear that this middle-income group is not monolithic. We are increasingly breaking it down into the near duals, the middle-middle, and the upper-middle. Now, how do we define some of that? Some of that gets a little trickier. Talk a little bit more about the near duals work. You've done that, and the Scan Foundation has been a big supporter of this research and a partner to all of you and to us too. First of all, define the near duals so we understand what we're talking about. Any insights from that work? Finally, I'll come back and ask you where people can access this. I know it's a little more public now than what we referenced with the hard copy reports sitting on the shelf back in the day. So, near duals—how do we define it, and what insights do we have into that group from the research?

Dianne Munevar (13:55):

If you think about the forgotten middle, $27,000 to $103,000, the near duals are the lowest income strata of the forgotten middle. They're at the lowest end of income and assets. We've labeled them near duals because they look like dual eligibles in terms of being eligible for Medicare and Medicaid, but they also have similar health and functional needs as full duals. Their income and assets are adjacent to full duals. To define it more specifically, similar to what I said about the forgotten middle, they have income ranging from $11,000 per year to $28,000 per year and assets of up to $26,000. Assets meaning the value of their house 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 are renters, correct? I mean, home equity is not a big portion of the near duals.

Dianne Munevar (15:13):

But they are still using that to cover food, to the extent that they need transportation, and healthcare services copays because they aren't eligible for the Medicaid safety net. That's the challenge they have—they are so similar to full duals, but they don't have access. They're not eligible for that Medicaid safety net, so they just keep bobbing at the surface, gasping for 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 talking about 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.

Dianne Munevar (16:02):

I don't have the number in front of me, but one of the questions you asked me when we started talking about near duals is where can people find this information? Yes, and this particular number would be in those. Our website has a spot for all of the forgotten middle research, and all of these chart packs have been posted there. I can follow up with you and send the link out so we can put that in. We recently transitioned that work from being about research to now policy recommendations. Lisa, you were on our advisory committee for that body of research where we started to shift and pivot to think about, okay, how do we find these solutions? They can't be siloed; it can't be just healthcare or housing. It has to be a combination of both. We've come up with five policy solutions 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 in October, 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 our constituents too. Okay, let's pivot—the middle market stuff we could talk about forever. But we have also spent over a year on a four-part body of research that we have used the umbrella term "the value of senior housing." Can you briefly summarize what that was for our listeners and what some of the key takeaways were from that body of work?

Dianne Munevar (17:43):

Absolutely. That body of work looked at people who had recently moved into senior housing between 2017 and 2019. We focused on that period to avoid the impacts of COVID, which took us all for a loop. We looked at 2017 through 2019 and the new move-ins, and we studied what frailty looks like in the two years following the move-in. What we found is that frailty actually increases in the first three to six months after moving in, which makes a ton of sense. It's a frail time for an older adult and their families to make that decision to move in, usually after some debilitating events, so frailty is high.

Dianne Munevar (18:36):

What we also found was that at about six months, frailty had peaked, and then residents began to stabilize in that new setting. They started to see the physician more often, and their chronic conditions were being actively managed. They had more access to rehabilitative care. We call this the "mountain effect," where frailty increases and then comes down at the six-month mark. We also looked at access to primary care services and found that access increased in the period after moving in. Two things stood out to us about access to care: more people were accessing primary care after they moved in. Prior to moving in, 70% of those individuals had seen a primary care physician, but after 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 type they moved into, the greater the number of visits, which makes a ton of sense. But what we liked to see was that those visits 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. And so there was more active management of chronic conditions.

Lisa McCracken (20:04):

Which we know is a big barrier for people living in their own homes. Getting to that, that practitioner.

Dianne Munevar (20:10):

Right. So we wrapped those up in 2023. And then we came into 2024, looking at longevity and health outcomes. With longevity, we studied things like mortality and more specifics related to longevity—how long people lived in that two-year period. We looked at things like, assuming you were living those two years, what percent of that time were you spending at home, like in your own bed, versus in a hospital or a skilled setting. And what we found was that senior housing residents were spending more time in their own bed as opposed to in the 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 at things like the number of days on antipsychotic medication. We found favorable findings there, showing that senior housing residents were spending less time on antipsychotic medications.

Lisa McCracken (21:18):

Right. Right.

Dianne Munevar (21:20):

Um, so all great. I think what we also found was that they were receiving more preventative and rehabilitative care than people living in the community, which is the picks up from the access to care study, but they 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 the different communities, but on average, we also know that we are much more likely to send residents to the emergency department than their peers living in the non-congregate setting. That utilization was much higher, and I don't think that came as a surprise to anyone, but it's something we need to continuously have on our radar and figure out what's driving it. How can we bring that down? Some of that is risk aversion, some of it is policy-related, and some of it is just not having full insights. If you find someone on the floor, did they really fall, or did they lay themselves on the floor? Nonetheless, that's one that always jumps out to me, and I think there's more room to pursue. Knowing all of the research we've done and the questions we're asking today, because there's always more research to be done, what is the "so what" with that body of research? Great, Diane, that's interesting. People live longer, generally with better health outcomes, but tell us why we should care about that.

Dianne Munevar (22:53):

Yeah. This is such a good question. It's a very big question. The reason I'm pausing is that I think it's really important to pause for a moment and reflect on this moment in time, because right now there's a multi-part crisis happening in aging, in older adults, and in healthcare more broadly. First, we're seeing many more older adults who are aging and living way beyond what we ever expected a hundred years ago. While that's fantastic and demonstrates where we've come in terms of medicine over the past hundred years, people are coming with more chronic conditions, higher rates of dementia, and all sorts of issues. There's a 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 just don't have the workforce to address all of the needs that this older population has. I think this actually presents a moment for senior housing because you are taking care of housing, providing nutrition, and providing social connection, and all of that relates to healthcare. The "so what" is that there's a moment to really demonstrate the value of living in senior housing relative to maybe aging alone in your own home and risking adverse events. I think the "so what" is that we need solutions at both the federal level and at the state and local levels. Solutions need to happen. They need to be small ones that can be tested and also big, innovative, barrier-breaking solutions. I think this is the time for senior housing to propose some of those solutions.

Lisa McCracken (25:14):

Yeah. Well, and speaking of timing, I know you were at our spring conference in Dallas this past March, and we had Dr. Mina Sima, who's the director for the Center of Medicare there. That was really the first time that our sector has ever had CMS at our conference and really focused on senior housing. The nursing sector often has more of that interface. But for us, it was the acknowledgment of, "Hey, we should better understand senior housing." And as you said, what is the potential role that senior housing can play in addressing some of these crises that we're either in now or that are just around the corner for us? Did you see that as a sign of anything? We took it as a different level of openness and an opportunity for us to build upon. What was your observation from that time?

Dianne Munevar (26:15):

Yeah, my observation from that time, and you all were, we also worked with you to respond to that RFI, the request for information about MA data. Correct. And then it sounds like there was interest following from that letter. I think you're on the radar, and I don't mean that in the way, you know, having two kids in school, I don't mean that in the way that you're on the principal's radar. I mean that you're on the radar to be invited to the table to discuss how senior housing could help manage the healthcare needs of older adults. I think it's really important to take this moment and to remain in a proactive position. Right? You all are asking the right questions, in my opinion, you're funding the right research to demonstrate that value. And I think what we need to shift towards now is really understanding what's driving those favorable outcomes and what's driving some of the questions that we continue to have, like on emergency department visits, what's driving that, and are there public solutions that could help make that a little bit better for residents and for the senior housing communities?

Lisa McCracken (27:34):

Right. We definitely need to get a little more granular and answer some of these questions that, I think, came out of the research. Clearly, it's a good thing if people are living longer, they're getting access to care where they call home, things of that nature. But again, for those that are in the 75th percentile and really off the charts in terms of some of those things, what can we learn? I think we've gotta unbundle that a little bit more, 'cause I think it's naive to think, I mean, the reality is it's not gonna come out of this and say, "Oh, great, CMS is seeing that senior housing people are living longer, they're less likely to be hospitalized, things of that nature, so we're just gonna pay them more."

Lisa McCracken (28:19):

That's not the reality of it. Right? So, it's not that simple, but we do need to unbundle. Are there certain models, or are there certain— I know we talked about primary care, and there are a number of operators that are really developing some robust frameworks around that. And we haven't really talked about any of the healthcare costs, but that's gotta be part of the conversation too. What is the lens that CMS and payers are looking through right now? I mean, honestly, you mentioned, we mentioned Medicare Advantage plans. A lot of them are hurting, quite frankly. So, there's— and this probably goes to the "so what," but I think us identifying the value proposition of what senior housing brings to the table for the payers is huge. So, what would you say is top of mind for payers right now, whether it's a Medicare Advantage plan or CMS?

Dianne Munevar (29:18):

I mean, it has to be reducing costs. Boom, it has to be reducing costs through better outcomes. It's reducing some costs on the Part B side, but it's really about reducing those high-cost events—hospitalizations, ED visits, stays. How can you make that stuff go away through better outcomes? How do you make better outcomes happen through more access to primary care, good integrated primary care, and also through more rehabilitative care? Helping people with their functional status, reducing falls, is really huge. But I also think it's about ensuring that people have the internal motivation to care for their own health. Something we learned from our interviews and conversations with some of the Vanguard senior housing communities and Payviders is that they are really thinking about what internally motivates people and asking them, "Where do you see yourself as a resident? Where do you see yourself, what do you want to be doing in a year?" 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 of those organizations that are really doing that type of thing say it pays dividends. Not only do they feel like, "Hey, this is the right structure and model," but it increases satisfaction, improves occupancy, and all of those measures that we often define success by. All right. I want to ask one final question here before we wrap up. All of this research that we're doing is at the big national level, the macro level, and we could release another five reports in the next year that's showing this and that, telling the story for senior housing, and setting the sector up for success. But at the end of the day, this is very local. It can be very local and very regional. So, what's the call to action for the boots-on-the-ground operators? What can they be doing to position themselves to be stronger with all of this and use this information to their advantage?

Dianne Munevar (31:47):

Yeah. Um, I think it's three things. Um, I think it's, number one, you need to do research, or they need to do research that informs their value proposition. Um, which means like, get to know your data. Um, what are you doing well? Where, what do you still need to work on? Honestly, you know, not trying to, um, cover it up, but really understand yourself, right? Um, or your organization. Two, develop partnerships with the risk-bearing entities in your market area so that you can then align that value proposition with what is keeping them up at night. Like what, where are their gaps, right? Um, and then I would say the third thing is don't take your eye off of CMS, you know, um, continue to stay informed of where they're going, um, you know, where the winds are pointing. Um, and then try to continue to keep that dialogue open, which I know you all are doing. Um, right. So I would say those three things.

Lisa McCracken (32:47):

Lisa McCracken: (32:47)
Awesome, well we've got it all figured out. At least a really good foundation! So this was great and I appreciate your time. We could continue the conversation but this was a nice 30 minute overview and primer for folks who want to learn about the work we've been doing with you and want to learn more, and it was a good priming the pump for what comes next. And we know there's plenty more to come next and more research to follow. Thank you all for listening to the NIC Chats podcast. 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.