ACO Announcements Add to Existing Skilled Nursing Pressures

Value-based arrangements generate much of their savings by shifting spending away from the post-acute setting, according to recent government announcements. That ups the already-high pressure on skilled nursing facilities to lower patient length of stay while maintaining quality of care.

To cope, they’ll have to make themselves invaluable to both referral sources and payers who are part of accountable care organizations (ACOs). But SNFs will have to adjust to more than just the government changes.

“Overall, SNF behavior will be changing over the next couple of years, and it’s much broader than any changes in the ACO program,” Mike Cheek, senior vice president of reimbursement policy at the American Health Care Association (AHCA) told Skilled Nursing News. “As you know, Medicare Advantage penetration continues to increase, and that brings pressure to decrease length of stay. The Patient-Driven Payment Model (PDPM) also incentivizes shorter lengths of stay.


New ‘Pathways’ proposed

The Centers for Medicare & Medicaid Services (CMS) issued a proposal in late August to overhaul how groups of providers take on risk when they take responsibility for the total cost and quality of care of their patients. Currently under the Medicare Shared Savings Program (MSSP), ACOs have up to six years to avoid taking on risk under waivers from certain federal requirements. The “Pathways to Success” overhaul would cut the time an ACO can remain in the program without taking risk to two years.

That drive by CMS is the biggest issue for SNFs, according to Brian Ellsworth, vice president of public policy and payment transformation at the Minneapolis-based consulting firm Health Dimensions Group.


“I think over 80% of the ACOs in [the MSSP] don’t face downside risk,” he told SNN. “What we’ve seen out in the market when that’s the case is that the ACOs aren’t nearly as aggressive in terms of managing expenditures and driving change, particularly with respect to post-acute care.”

The Pioneer ACOs and the Next Generation ACOs both had to face downside risk, and many of them engaged with post-acute care to drive significant expenditure changes, Ellsworth noted. But the MSSP ACOs that faced no downside risk have not done the same, he said.

AHCA doesn’t have a count on how many SNFs are currently involved with ACOs, or how many would be involved with Pathways, Cheek said. But he agreed with Ellsworth that risk will be the most pertinent factor.

“I think it’s more of a question of how many existing ACOs, and how many potential ACOs, are willing to take on the downside risk,” Cheek said. “That’s a big jump for some of the existing ACOs to take on that sort of management of payments from CMS and … in effect, it’s functioning like a Medicare Advantage plan-lite. So I think it’s more a question of how the ACOs react, or the organizations that were considering becoming ACOs.”

How SNFs need to respond

Soon after CMS issued the Pathways proposal, it announced that the Next Generation ACO model had generated almost $62 million in savings for Medicare, in part by cutting spending in SNFs. Specifically, the ACOs reduce Medicare outlays in that setting by $16.61 million.

The Next Generation and Pioneer ACOs, as well as any in the risk tracks in the MSSP, are the most noticeable and the ones local SNFs tend to be most aware of, Ellsworth said.

“Those ACOs have done strategies like preferred networks and enhanced communication with providers, and in some cases, some attempts at clinically integrating care,” he said.

In light of both those factors and the overhaul proposal, SNFs will have to focus on how to cut lengths of stay. That’s an especially urgent task given the incentives of PDPM, the pressures from Medicare Advantage, and the various bundled payment programs from CMS, which pay for whole episodes of care and allow participating organizations to retain any savings.

“There are a number of elements that are placing pressure on shortening length of stay and so because of all those elements as well as Pathways, I think SNFs should be thinking about how to efficiently and in a manner that ensures quality, shorten length of stay overall,” Cheek stressed.

Ellsworth had similar words of advice.

“SNFs should be assessing what payers and referral sources in their market face downside risk and seek to engage those payers and providers in a discussion about their value proposition,” he said.

To do that, they’ll have to establish how they can provide high-quality, low-cost care, show good performance metrics, and engage with health systems and providers on initiatives like electronic medical records and clinical integration, he added.

Cheek also argued that SNFs should be examining clinical care to make it more efficient and more closely focused on patient characteristics. That would likely let them have a dialogue with ACOs on what the most appropriate length of stay should be.

“I’d also say thinking through how they can infuse care coordination functions into their buildings is important,” he added.

Written by Maggie Flynn

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