Beyond I-SNPs: Exploring Other Ways Skilled Nursing Can Move into Medicare Advantage

Skilled nursing operators, increasingly fed up with demands for lower lengths of stay from their managed insurance partners — with little to no savings to show for it — have moved to seize control of the premium dollar by becoming insurance entities themselves.

The primary way they can do this, launching a certain subset of Medicare Advantage company known as an institutional special needs plan (I-SNP), involves a host of challenges, including network adequacy requirements, intensive capital thresholds, and individual state mandates for insurers. And those are just a few of the hurdles to clear.

Over and over again when talking about I-SNPs, experts in the skilled nursing space emphasize that it’s not the right fit for every provider.


“You need to look at all the health plans that were started by medical groups and hospitals that didn’t survive,” Rene Lerer, CEO of Longevity Health Plan, said in a recent episode of Skilled Nursing News’ Rethink podcast. “Because it’s not that easy.”

That’s why Jill Sumner, vice president of population health management at the American Health Care Association (AHCA) wants SNFs to know that they can move into Medicare Advantage without taking on all the requirements of an insurance plan.

Sumner sat down with SNN on the sidelines of AHCA’s first Population Health Management Summit in Washington, D.C., to talk about ongoing SNF interest in I-SNPs, why the Centers for Medicare & Medicaid Services’ direct contracting model is an opportunity for providers, and how long-term care can become part of the population health conversation.


When this event started, you gave an overview of the low-risk (networks and partnerships), moderate-risk (bundled payments, accountable care organizations, partial-risk partnerships) and high-risk tracks (I-SNPs, full-risk arrangements, direct contracting) for providers. Are providers starting with the lowest-risk options and moving up, or are you seeing different patterns?

It’s kind of all over the place. One of the reasons we wanted to cover all of them is to No. 1, bring awareness that if you don’t think being a health plan is for you, there are other ways to start moving down that volume-to-value continuum. One of the things that we’re trying to encourage people to do is not only build awareness around the different models, and how they can be a stepping stone, but to really sit and do some due diligence around all of them, and figure out what the skill sets and resources are for each one of them — where you fall, and then identify where the gaps are.

Part of that assessment … was also the market analysis, and understanding now — as more and more providers are moving into this space — what’s going on in your market? And how might you be able to build off of something that somebody else has already done?

So to answer your question, I’m not necessarily seeing: They start with value-based payments and partnerships with a health plan, and then they move to a bundled payment.

However, the folks who are doing health plans, they may have participated in bundled payments, and the folks who did bundled payments may now have a little more confidence: How do we take the next step?

Obviously there’s been a lot of interest in I-SNPs, but are you seeing interest in other options, like bundled payments? I know CMS and the Center for Medicare & Medicaid Innovation were talking a bit about a new post-acute bundled payment.

There’s definitely provider interest. There were a lot of providers who participated in Model 3 and were extremely disappointed that that went away. We have had discussions about what a new PAC bundle could look like, and are hoping that CMS will come out with something that is an opportunity for long-term care providers.

So not just a PAC bundle that is managed by a hospital or a physician practice, but a PAC bundle that can be managed by PAC. That would be great. And I think there would be a lot of interest in that.

Has there been any movement from CMS on that front?

They still have interest in the PAC bundle, but I don’t know that they’re doing anything on it.

Obviously there’s a lot of interest in I-SNPs, and one requirement for that is some kind of scale. Is this is something AHCA has considered moving into — essentially becoming an I-SNP with its members?

Some folks have asked that same question, and I don’t think it’s anything I’ve been involved in discussions around. I think our our focus is trying to provide as much education and opportunity for networking for our members.

We’ve seen more growth from a state-association standpoint, convening members to have discussions and explore opportunities around developing networks, integrated care networks, where they are focusing on improving quality and contracting with health plans are to take some risk.

Do you have any sense of the portion of providers that are interested in moving into I-SNPs or other special needs plans?

I couldn’t quantify it. We will know in January; CMS will release the the enrollment numbers towards the end of January, and that will give everyone a view as to what the growth is in I-SNPs — and be able to identify provider-owned- I-SNPs, and what the enrollment is. Until then, we have we have anecdotal information based on members that have talked to us about it and said, “We’re doing this.”

But we don’t have the full picture. There is increasing interest. If I look at the number of phone calls and e-mails, they have increased. It’s a lot of population health management stuff.

One of the things that we’ve tried to do is sort of reframe it in the sense that I-SNP is one option. An I-SNP is one choice under an umbrella of Medicare Advantage. And all these things are just tools to provide the financial and the regulatory flexibility that allows providers to take care of their residents the way they know makes sense, but they can’t do under the fee-for-service system.

I-SNPs do tend to take up a lot of the oxygen in this conversation; what are some other options providers should be looking at that maybe aren’t getting the attention they deserve?

If somebody has an I-SNP, they are a Medicare Advantage plan. An I-SNP is just a product. And other product options are out there.

A traditional Medicare Advantage plan, typically you need a larger number of enrollees. But we see our provider profiles shifting in terms of interests. So I-SNP was really mostly SNFs in the beginning, but we are seeing assisted living embracing it, senior housing embracing it.

As you look at those other types of providers, and you start to drill down on what their populations are, the point is matching up the population with the right product, so that you can offer the right benefits and the right model of care. So for example, one of our members, Sunrise Assisted Living has a chronic condition special needs plan (C-SNP), which is another one of those selections under the Medicare Advantage umbrella.

It’s focused on dementia, because they knew that not everybody was going to meet a nursing facility level of care, but they may have dementia. So starting with a population and then looking at what could fit their needs most closely.

The other thing that I think is really interesting is the direct-contracting model, which is very new, something that CMS is introducing. There’s been a cycle already where you had to have applied, but it’s almost like an ACO model that’s for more than just primary care physicians. You know, specialists can apply. PCPs can still apply, but other providers — I mean, our providers — could apply. It’s much more open.

It has three different risk tracks that you can choose from. You still need scale because you’re looking at being able to pull together about 5,000 enrollees, or attributed members, but one of the speakers that we had here yesterday — Bluestone Physician Services — they have focused solely on the assisted living space, and bringing in geriatric care models and geriatric nurse practitioners into the assisted living space.

They’ve been doing this in three different states now. They did apply to be a Medicare Shared Savings Program ACO, and they also applied for the direct contracting. Some of our conversations have been around: How can we — especially if there’s a state association that’s interested — how they can educate their members on opportunities in direct contracting?

Well, if that happens to be somewhere where Bluestone has applied, then here may be a natural fit for them to be able to take that model to our members in assisted living. So I think that’s really interesting.

Is direct contracting something that could be a fit for skilled nursing AHCA members, do you think?

It could be, but Bluestone has been particularly focused on assisted living. They’ve left the SNF side to other geriatric practices, and they’ve focused on assisted living. There was an application timeframe that went with direct contracting, and so since that’s passed, you need to find somebody who’s already applied. So I think that’s a really interesting one to watch.

The last question I have is related to the fact that population health tends to focus on hospitals and their work. Where do you see skilled nursing and long-term care providers fitting in, and how do they become a bigger part of this conversation, especially as the population ages?

That’s exactly why we did this conference. Since I started a year ago, and we started talking about population health, I’ve gotten people e-mailing and saying, “Look, there’s this conference coming up around population health, and it says learn about long-term care.”

All of those, every single one of them, the target audience are hospitals, health systems, and physicians. And it’s all about how you manage post-acute, and there is nothing that was about how post-acute can move into this space and take accountability and manage. That’s why we did this.

And as you can see, there’s a lot of interest, and there’s a lot of opportunity. There’s opportunities that we’ve talked about, whether it be through low-risk, moderate-risk, or high-risk options. There are ways that post-acute care providers can work with other types of post-acute care providers — home health providers, hospice providers — and start to take ownership of these models. They just need the platforms. They’re there to a degree; we want to see those grow.

We’re working with CMS and folks on the Hill to provide additional opportunities, but there’s interest, there’s opportunity, and they have the skills. [And] if they don’t have them now, they are acquiring them.

Making decisions at the bedside is much better than making them 3,000 miles away. The further you are from the people that you serve, the easier it is to make bad decisions. That’s what we see happening with large health plans, who have realized that they can’t manage these vulnerable populations and start outsourcing them.

And that’s after those plans have consolidated.

Right, and they outsource the management, and it’s still a distance relationship. Everyone in the facility is involved in the care of a resident, and you get the best communication when you’re educating and you’re working closely with your housekeeping — and your dietary and your nurse practitioner is part of the family.

This interview has been condensed and edited.

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