Medicare Advantage Hasn’t Always Prioritized Skilled Nursing — But That’s Changing

If skilled nursing facilities want to improve their relationship with managed care payers — particularly the ever-expanding Medicare Advantage plans — they have to ensure that they understand the payers’ pain points.

And they have to battle the reality that in the Medicare Advantage world, post-acute barely registers on insurers’ radar screens because it’s a small part of the premium dollar.

“There are not going to be a lot of people inside a Medicare Advantage plan who are spending time thinking about your business,” Michael Monson, senior vice president of long-term services and supports and dual-eligibles at managed care organization Centene Corporation (NYSE: CNC), said Wednesday at the Senior Care 360 conference in National Harbor, Md.


This is changing, Monson added, but the burden is still on post-acute providers to find out what the plans care about. Key factors, according to Monson, include the Healthcare Effectiveness Data and Information Set (HEDIS), quality measures, and star measures — all of which drive payment.

“Make sure you understand the drivers of our business,” he said. “And obviously we need to understand what drives your business, too.”

Mutual understanding

The current landscape is littered with barriers to partnerships between post-acute care and managed care organizations or health plans. If a provider comes to a managed care organization with “a great idea that impacts 200 members,” it’s hard to determine how much time and money should be devoted to that — compared with another strategy that might affect more members, Brad Smith, the COO of insurer Anthem’s (NYSE: ANTM) diversified business group, said.


While payers don’t always have an eagle eye on post-acute providers, they are starting to build more comprehensive post-acute strategies and could be open to partnership ideas that have a broader impact — making it even more essential to plant ideas in payers’ heads, Smith said

“[Try] to understand what your largest plans, your biggest payers are focused on, and how you can fit into that strategy,” he told the conference.

Managed Medicare plans have long been a thorn in the side of SNF providers, with lower reimbursements and intense length-of-stay pressures, but despite the challenges of managed care, many states see managed long-term supports and services (MLTSS) as the only way to manage their budgets as their populations age.

One key step for SNF providers to consider when navigating managed-care landscape is ensuring that post-acute providers and managed care plans are on the same page when it comes to data. When post-acute providers and managed care plans talk about various metrics, they aren’t always on the same page, leading to confusion and conflict. Sometimes that’s as simple as not having the same definitions for the term “care plans;” other times, the disconnect is much sharper.

“The problem is [post-acute providers] don’t have the downstream costs of what’s happening with members,” Nick Stupakis, vice president of commercial services at Highmark Health, said.

To illustrate his point, he described Highmark’s work to use scorecards for its roster of post-acute providers, which include 450 SNFs and 300 home care agencies.

“When we first had those conversations, we brought in every SNF, home health agency that we had contracts with,” Stupakis said. “And they all brought a presentation of how they had a 6% readmission rate for Highmark. And I would look at my claims and say, ‘That’s funny, because per my claims, you have a 42% readmission rate.'”

To avoid such gaps in communication, Stupakis said it’s imperative for post-acute providers to ask for specific data from their managed-care partners, since it’s not always a given that the plans will provide it.

Medicare v. Medicaid

When it comes to Medicaid and MLTSS, Centene is working on several value-based arrangements with post-acute providers — with a greater focus on SNFs than home care, though it is working on the latter.

A group of SNFs in Ohio receives bonuses for hitting certain quality measures, for instance, while many MLTSS health plans affiliated with Centene give SNFs a bonus for reaching certain levels on the Centers for Medicare & Medicaid Services (CMS) five-star rating system, Monson said.

For Medicare plans, the trajectory was a bit different, particularly since, as Stupakis noted, Medicaid has trailed in partnerships with post-acute care.

The two prevailing types of solutions that have emerged for managed Medicare plans were so-called “utilization management solutions” — which in the SNF setting translated to a focus on length of stay, Smith said. The other type was focused on specific, high-cost groups of individuals, with the plans taking “longitudinal risk,” he said.

“Where I believe the space is going is those two types of solutions starting to merge, and starting to build differentiated preferred provider networks, where they push value-based risk down to the preferred provider network,” Smith said. “I think we’re kind of in Version One of post-acute care risk in Medicare.”

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