Inside an Anthem Subsidiary’s Attempt to Reward Skilled Nursing Facilities with Medicare Advantage Bonuses

Managed care and Medicare Advantage companies can be a sore spot in the skilled nursing world, but as the sector evolves, a subsidiary of a major insurer is looking at how to reward facilities for providing quality care — while keeping in mind the financial pressures that providers face.

CareMore Health, a subsidiary of Medicare Advantage giant Anthem, Inc. (NYSE: ANTM), has made a point of working with patients in the institutional and long-term care settings through its Touch program.

Touch currently serves at least 6,000 patients; about 5,500 of those 6,000 patients are institutional special needs plan (I-SNP) Medicare Advantage (MA) enrollees. The settings themselves include SNFs, assisted living facilities, and board and care homes in six different states: Arizona, California, Colorado, Nevada, Virginia and Texas.

Advertisement

In those states, the Touch program — directly operated by CareMore Health, which also contracts with other major insurers in addition to Anthem — works with roughly 200 dedicated SNFs, out of 1,000 different long-term care communities.

Touch partners with the facilities for both day-to-day management and support for custodial patients eligible for Medicare, as well as acting as skilled nursing and short-term care hubs for patients, James Lydiard, general manager of the CareMore Touch program, told Skilled Nursing News.

SNN caught up with Lydiard and with Dr. Sepideh Chegini, the senior medical officer of the CareMore Touch program, to talk about the plan’s model of care, how it partners with SNFs, and how the health plan is evolving with the changing skilled nursing landscape.

Can you explain the Touch program and how it fits into CareMore and Anthem?

Lydiard: This is a program where we employ the clinical staff that, day in and day out, are mobilized and actually go into the communities and manage these patients. They’re employees of CareMore Health.

The Touch program consists of a large book of Anthem’s I-SNP business, and then some complementary other members from Anthem’s [Medicare-Medicaid plan] or MA programs, and even some non-Anthem based health plans that have also have signed up with us — where, again, our Touch team of practitioners are going in and seeing these patients that live in these long-term care settings.

We’re not in every market that CareMore’s in, however.

What was the reasoning behind the decision to have clinical staff mobilized in the long-term care settings?

Chegini: We serve a population that is very complex medically and psychosocially. Also, they’re really vulnerable, so for them to go out for medical care to doctor’s offices, it would impose a huge burden on the patients and on their families and on the community staff.

It also causes fragmentation of care, because then they would have to go to multiple providers and multiple facilities, just to get the care they need. So the model of care that we bring to these patients who are living in the long-term community is that we bring all the care to them, and we really try to do that in a very coordinated fashion.

It’s a very team-based approach to care. It’s really common sense, and also a well-designed program that allows us to do that best. We’re basically experts in taking care of these complex, vulnerable patients who have very unique needs.

Was that part of CareMore from the beginning, or did you realize over time that this particular population needed this type of approach?

Chegini: I think this has always been CareMore’s approach. The goal, or the purpose, of CareMore was to deliver care that makes the most sense for each individual in a really holistic way, and also to really eradicate the fragmentation of care that existed and still does exist. The reason that CareMore Touch was founded or initiated was because for that particular population, a patient-centric approach really means delivering care to where the patient lives because it is really most difficult. This is not a very mobile population that can easily access care in a doctor’s office or care center.

When you’re working with the SNFs and the institutions themselves, what is that relationship like? Do you have particular arrangements, that you reach with specific facilities, or is it based on the patients and following them?

Chegini: It’s a little bit of all. The relationship is very much like a partnership; we actually partner with the communities where our patients live in. At times, our patients just move into a certain community, and we end up having to service that community. At other times, we’re already existing in that community, and then [patients] have to move in and [facilities] have residents who they may think our model of care will serve best.

It really does vary from whether it’s an assisted living facility (ALF), a board and care home, or a SNF. In our SNFs, we obviously have contracts with those, as opposed to ALFs and board and care homes that are not medical facilities. We don’t contract with them, so we don’t have a contractual agreement. But we do partner with them, to make sure that they are familiar and they know our model of care. They know our system.

We basically want to make sure that we’re welcome in our communities, because that’s the home, that’s where the residents live, and they have to welcome us as well.

Lydiard: We are here to answer many of the misses and gaps in the health care system today. That doesn’t just mean for patients, it also does mean for these communities. And so I would hope that if one of our skilled nursing partners was on the line now, they would tell you that: “The CareMore team partners with us contractually,” meaning that we are the payer of record — if we’re having a patient be there for the short-term — and certainly the partner of record, if we’re serving a patient that’s there for the long term.

What does your relationship with the SNFs functionally look like?

Lydiard: They’ve really adopted our model. We have some buildings where we may only be serving 10% of their eligibles that are in the community, and they’re highly aligned, and it’s really because they adopt our model of care — they use our on-call, they look forward to the times our clinicians are on site and in the building.

And then we have buildings that are the opposite, where we might have 20% to 30% of the residents that call that building home, but maybe the other 70% or 80% of residents are with another provider group and [the building] really adopts that model. And so we kind of unfortunately are pushing a model out there that requires the staff to run in a slightly different direction, which can be tougher to adopt.

Chegini: To expand on that and explain what that means, it really is centered around communication, and it’s bidirectional communication. We really try keep not just patient and their families involved, but also the community staff well-informed and involved on any changes or concerns and have them be engaged and at the forefront of those discussions about concerns and suggestions.

And the reverse is true. We really expect those communities to reach out to us if they have any concerns, if there are any changes in conditions, because the success of our program really depends on developing those relationships and the communication.

What does CareMore specifically expect from SNFs in terms of communication, updates and metrics?

Chegini: We actually staff our communities our SNFs ourselves. What that allows us to do is to really collect the information we need because we have providers in those communities. So it really alleviates some of the burden of the nursing home staff, or the ALF staff, because our own providers gather most of the information that we need when they’re in the building.

In terms of data, we really do manage our own data.

Lydiard: The metrics we require from buildings, the communication we require from buildings, is actually minimized, because we do have our own team on the ground there that communicates back with our case management. That’s a perk in how we operate in the skilled nursing environment.

Because we’re the payer of record, and basically a capitated delegated entity of the health plans themselves, it also allows us to be the home for all the metrics. In fact, most often, we’re providing the SNF our metrics, so that they can report out accordingly, and they can also track and trend and we can analyze the data together on areas of improvement. In some of our agreements with buildings, they do actually provide us with those sort of things, and we try to align on some of the metrics that we’re asking of them and they’re asking of us. It’s a lot easier to align on goals when we care about the same thing.

Some of the things we’ll throw in that we expect [SNFs] to be able to report out on are things like: 30-day all-cause readmissions to acute, average length of stay, things like any fall-related issues, things like medication management.

Given all the changes in the SNF landscape, such as the coming Medicare overhaul and the shifts in patient acuity, is CareMore working on any initiatives or pilots on how it deals with SNFs?

Lydiard: Lots. As evolving as CMS and these facilities are, we’re trying to stay on top of that, too. We have certain initiatives that are clinically driven. By that I mean: Are there opportunities where we can do more direct admissions from one of our clinics, care centers, or emergency rooms straight to a SNF, avoiding a hospitalization, if that’s the right place for that patient to be?

We also have initiatives where we might complement post-SNF discharge patients with more robust on-site nursing after they’re discharged, in order to ensure that the patient doesn’t need to be a bounce-back to the hospital and help keep that SNF intact; it doesn’t attribute a readmission to them. There’s also a lot of digital health things that we’re trying out at CareMore, things where we can have telehealth capabilities in the building with our specialty leaders.

Outside the clinical initiatives, we’re also working to evolve our contract opportunities with these buildings. So are there quality incentives and bonuses along the way, outside of just our Part A/Part B arrangement, that can ensure that we start to reimburse the buildings when they’re in fact giving above-and-beyond care to the residents that call that building home and that enroll in our programs?

We figure that’s the right thing to do because … we realize that in many of these states and in many of these markets that we support patients, the Medicaid rate that is being reimbursed to these buildings is unfortunately not adequate. And we on the Medicare side of the dollar feel as though it’s not just a fiscal responsibility but an ethical responsibility to help retain those dollars with the care teams that are really delivering 24/7 care.

We’re coming in periodically and proactively as we can, but it’s the on-site med-techs and charge nurses and night nurses and leadership of each of these buildings that really is being short-changed by the way the states reimburse.

In which states are you working on that kind of contract initiative?

Lydiard: We have enacted contracts in Nevada, Virginia, California, and Arizona that all have those — we’ll call them amendments or addendums — in their contracts such as: If residents in these selected enroll in our Anthem or Amerigroup plan, and then of course get the care delivery by Dr. Chegini’s team, as long as certain key quality metrics are met or exceeded, then they get bonus payments thereafter.

We’re not looking to overpay or in fact make up a certain gap. It’s just a starting point, and it’s a way in which I think us on the Medicare payment side start to show these buildings that there’s really great things that they’re doing, day in and day out, that we want to reimburse them for — that sometimes don’t involve in a short-term skilled stay.

I think that’s where a little bit of where the industry has gone, and the tail is chasing the dog at times — and it may be why the government and Medicare are trying to reinvent some of the payment, just because they’re seeing some ways in which skilled is not as fruitful as it once was.

At the Senior Care 360 conference in National Harbor, Md., one of the panels was on the managed care view of post-acute care, and managed care has been something of a challenge for SNFs. From your perspective, what do you want SNFs to know to work better with managed care?

Chegini: What we’re looking for in a sub-acute or SNF is really three things. One is having great communication, and it’s bidirectional communication regarding patient status — especially on skilled patients.

The second one is really availability. Having bed availability is very key; oftentimes there is an urgency when we are asking for a skilled bed to become available.

Then the third thing is really reliability of delivering the services and making sure that the patient receives the care they need, when they need, so that there is no delay in the care.

All that goes back to quality of care, making sure that the quality of care that patients receive is really up to the standard.

Also, expertise of the staff — because sometimes we have a very unique population mix, so at times we do need SNFs better able to handle maybe more behavioral issues. At times we have patients who come from the acute hospital, and they may need isolation beds or they may need more complex medical care. We do really have a wide range of patients with different needs, and having really different facilities that are experts in different things is really helpful, because then we don’t run into a delay in getting the patients placed.

Lydiard: One of the reasons I think CareMore Health continues to excel in our partnerships with SNFs is that we employ the field-based nurse practitioners and physicians going into the buildings. I think where many managed care companies have maybe built that unfortunate reputation you called out — on not being the easiest to do business with at times — is that if you’re a managed care organization (MCO), and you’re asking a facility-based medical director, who maybe supports five or six payers in one building, to abide by your [utilization management] protocols, your last covered day protocols, your admissions protocols, and it’s slightly different than what the other five payers of that medical director [want], it just leaves a lot to be desired.

So we have decided that’s why we’re going to expect our clinical teams to be in the weeds, and actually helping the partner facilities manage our UM processes, and it’s provided ease in doing business with us.

And conversely, what can MCOs learn about working with SNFs?

Lydiard: Don’t judge a book by its star rating. I think that unfortunately, the way that state surveyors and auditors and the comparison websites display facility star ratings is a bit unfortunate, and MCOs and other companies that sort of rate and rank SNFs might do themselves a discredit in overlooking a really quality building because of a survey that was conducted three years ago, and found one citation — and maybe not even a citation in care delivery but in dining.

I think it’s a very interesting time for SNFs, and I hope that as a health care space that’s so vital to the care needs for some of the toughest-to-care-for patients, that we don’t fall victim to what has been happening in the past year or two, which is: so many buildings straying away from custodial care and going towards short-term skilled nursing care.

Those [custodial] patients still have to go somewhere. They have to live somewhere, and they’re not being maintained in these nursing homes that for so long have truly been like community-based custodial nursing homes. Now, because of these buildings trying to fill a niche and go more post-acute/sub-acute, we’re seeing less and less custodial beds in every nursing home and more and more short-term beds. It’s a bit of an unfortunate thing, given that the aging population so needs nursing homes for residents going forward.

Editor’s Notes: This interview has been condensed and edited. In addition, this story was updated on August 20, 2019 to more clearly describe the relationship between Anthem and CareMore.