SNFs Need to Stop Thinking of Themselves as Targets for Cuts — and Get Creative

In a health care world of payment evolution and alternative reimbursement models, skilled nursing facilities have been feeling the pinch.

There’s pressure to lower length of stay from both Medicare Advantage payers and accountable care organizations (ACOs). Multiple studies have found that ACOs and bundled payment models generate savings for the Centers for Medicare & Medicaid Services (CMS) by cutting skilled nursing spending.

But Brian Fuller, the CEO of the care coordination company Integrated Care Solutions (ICS), thinks that SNFs have to stop looking at themselves as the target of post-acute savings and get creative in their approach to other providers along the care continuum.


Integrated Care Solutions — which spun off from National Healthcare Associates, a skilled nursing provider that successfully participated in the Bundled Payments for Care Improvement (BPCI) Model 3 — serves as a convener under the new BPCI Advanced model, working directly with physician group practices and hospital systems to take risk on their behalf.

For the latest episode of our “Rethink” podcast, Skilled Nursing News sat down with Fuller on the sidelines of the Senior Care 360 conference in National Harbor, Md., to talk about how SNFs can thrive in the face of evolving payments — and why it’s a matter of when, not if, CMS will introduce a post-acute bundle.

Excerpts from the podcast — which can be found on iTunes, SoundCloud and Google Play — are below. If you like what you read, check out the podcast and subscribe to Rethink so you never miss an episode.


Responses have been edited for length and clarity.

What are some of the disconnects between acute and care and post-acute care, particularly when it comes to care transitions?

The two big gaps that we see are what I’ll call warm handoffs, where there’s a clinician-to-clinician engagement, information is shared that is pertinent and critical to the health status of the patient — the medical condition, but also all of the other socioeconomic, family, environment, things going on with the patient.

This is why we put nurses in the field, to be able to bridge some of those gaps between not just acute and post-acute, but also even when you get into post-acute, there are gaps between SNF and home health transitions, for example. I think that’s one big gap: A clinician who is the quarterback, if you will, or the navigator, a commonly used term, that is making sure all of the history, all of the perspective, all of the information is seamlessly transitioned from one clinical care team to the next. It’s a huge gap, and that transcends all settings.

The second really is technology. We’re becoming increasingly a tech-enabled industry, and the ability to be more efficient in what we do is no longer a “nice to have”; it’s an imperative. And the reality is none of our technology tools today transcend settings of care. All of the largest EMR systems really focus on that silo of care and really don’t go outside of the walls.

That’s the other thing I see us having to invest heavily in, is a technology system, a care management platform, that essentially works with all of those EMRs and takes in information, but also aggregates that into a workable system that our nurses can interact with and manage the patients actively — again, across that 90-day period of care.

How about disconnects on the post-acute side, in terms of what the industry doesn’t understand about acute care’s incentives and the need to generate savings?

In all fairness, particularly SNFs are in a situation of disadvantage; they’re highly targeted for savings, and understandably so. If you look at the data, lengths of stay are very long in some parts of the country still, and generally long across the country. But it’s really compounded in certain parts of the country. And then if you look at post-acute just broadly, it’s a large area of variation in the Medicare system, so it shouldn’t be a surprise to post-acute that they’re being targeted for savings.

I think the disconnect really comes in in a couple of different ways. I think from the perspective of post-acute, rather than sitting back and taking that target, or just viewing the acute-care hospital as an antagonist to those savings, try to figure out how to better work with acute-care hospitals in more of a partner-oriented way.

I’ll give you an example: Recently I had a SNF provider approach me and say, “We want to get more active in bundles. We want to move up the food chain, if you will, and not just serve as kind of a downstream source of savings. But we know that there are certain capabilities that we do not have and certain partners that we need to bring to the table.”

And so what this particular SNF provider did was [it] went to a large specialty physician practice in their market, with which they had close relationships around some clinical programs in their building, brought ICS to the table for our care management, data analytics, clinical assessment capability, and packaged that together in a solution and went to the hospital, the largest hospital system in their market, and presented that package to the hospital.

Post-acute thinks of themselves as the target of savings — they’ve got to get out of that mindset and say, “That is the reality. It is what it is. How do we then change our role, be more creative, and take more ownership for being a solution with our partners? Rather than just to some degree, idly sitting back and letting them target us for savings.”

There’s been some chatter that CMS will introduce a post-acute bundle — can you talk about what movement you’ve seen on that front?

There is chatter. There are actually active working groups designing options for what a post-acute bundle could look like. This group is being led by AHCA, along with the other major post-acute associations in the industry.

They’ve studied a number of different bundled structures, they’ve narrowed it down to two, and they’ve got working groups focused on those two program concepts so that they can go meet with CMS later this summer to actively discuss what the post-acute bundle could look like, from the post-acute industry’s perspective.

The other thing that CMS has done very vocally is they did have a listening session last spring where they brought into DC several successful Model 3 participants and asked about their experience. They — being CMS — also floated two concepts of their own for a post-acute bundle.

What were those?

Conceptual. It wasn’t a lot of detail, but it was things like mandatory versus voluntary — what is the reaction of the Model 3 to that kind of concept of mandatory versus voluntary. Another concept, which gets at some of the evaluation report criticism of Model 3, is a blended setting bundle, where you don’t have it just initiating in a SNF or initiating in a home health. But rather, a patient comes out of the hospital, and there’s a bundle for that patient regardless of what their first site of post-acute care is.

I can’t sit here and tell you what form a post-acute care bundle is going to take. What I can tell you is that there’s active interest and work going on on multiple fronts both at CMS and in the industry. And if you just look at some of the commentary from leaders like Adam Boehler, CMS has been very vocal that their ears are open.

So I don’t think it’s a matter of if we will have a post-acute care bundle, I think the question is: When will they — they being CMS — feel comfortable enough that they’ve got the right design, with all of the industry feedback that they desire in order to make a step towards announcement?

Moving from bundles to ACOs, CMS has been pushing ACOs into taking on downside risk. What is that going to do to how they interact with SNFs?

Most ACOs have been sitting in Track 1 for three or four or five or even six years now, and they’ve only had upside risk. And what that has caused is a large amount of variability into what is motivating the ACO. Are they motivated to really set about change? If they’re motivated to change, is it in the area of post-acute, or is post-acute kind of sitting off to the side? And if you ask most every ACO, “Do they have a SNF network?” almost all of them will say yes.

The devil is in the details of that, of how are they working with them differently — if they are. Is it all about length of stay, or is it about things that are broader than that? So I think that’s a little bit of the dynamic when you hear soundbites like: “ACOs have been a disaster for SNFs.” There’s certainly an acknowledged variation in how those relationships [are] happening today in markets.

What do I think will happen as CMS pushes more of them into downside risk? I think it will accelerate, certainly, the importance of post-acute care. I think whatever the ACO was doing prior, it will accelerate those efforts. So if they had a network prior and really weren’t working with them, I think you can see much more activity for them to be actively working with the SNF network.

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