‘All the Stars Aligned’: Operators Boast 30% Readmission Reductions, Market Gains with I-SNPs

As skilled nursing facilities work to establish their position in an increasingly value-based health landscape, many are looking at the world of Medicare Advantage as more than a pressure point for billing.

They see it as an opportunity to take control of the premium dollar, moving into the business of providing insurance for their patients.

And though warnings about SNFs moving into the institutional special needs plan (I-SNP) model abound, launching the Great Plains Medicare Advantage I-SNP has been the right move for the Evangelical Lutheran Good Samaritan Society, Mark Scharnberg, executive director at Great Plains, said in a media briefing at the American Health Care Association’s (AHCA) Population Health Management Summit last month.


In fact, Scharnberg described this model as “really the only population health model available to SNFs.”

J. Mark Traylor, a member of the board of directors of the I-SNP Simpra Advantage in Alabama, was similarly effusive.

“I wish I could go and tell every [patient]: You need to be on this model,” he said at the briefing. “Because I’m a strong believer that it’s the right thing to do. It truly is a structure of all the stars aligned.”


Clinical improvements abound

The non-profit Good Samaritan Society, which was acquired by health system Sanford Health at the start of 2019, has seen significant clinical improvements with its I-SNP, Scharnberg said.

Specifically, the rehospitalization rate for the Good Samaritan’s I-SNP beneficiaries is 30% below that of “an unmanaged population,” he said. And it allows Good Samaritan to offer benefits that the I-SNP members and residents wouldn’t have in the original Medicare program.

The numbers build on what then-executive director Kevin Potas told SNN in April 2018: a focus on preventing hospitalizations and improving care management.

“This has really been an investment in bringing providers into our facilities, to really ensure that we are meeting the clinical needs of our residents,” Scharnberg said at the AHCA summit. “That investment is worth it from a clinical standpoint.”

The Great Plains Medicare Advantage plan has been in operation for about two years, with more than 1,200 members expected by this month across 60 contracted facilities, he noted.

The Sioux Falls, S.D.-based Good Samaritan is primarily focused in the Midwest, with most of its locations in the Dakotas, Kansas, Iowa, and Minnesota. The non-profit found that many of the large insurers were unwilling to come to that region — the Dakotas particularly — because of the economic disincentives to offer Medicare Advantage plans in rural areas, Scharnberg said.

In fact, where the plan operates in the Dakotas and Nebraska, there’s less than 20% Medicare Advantage penetration.

Simpra Advantage, the I-SNP arm of SeniorSelect Partners, LLC, is also a Medicare Advantage plan that was able to build up strength in a rural market that otherwise might have been overlooked. Simpra has 23 SNF owners in its network, which touches every county in the state of Alabama, Traylor said during the briefing.

He also echoed the clinical benefits, and argued they are part of the reason that SNFs can succeed in the Medicare Advantage model in the first place.

“What I believe nursing homes do probably better than anybody in the continuum of health care is we manage the comorbidities better than anybody,” Traylor said.

For Simpra, getting started involved getting over the hurdle of a capital raise; its leadership started considering the insurance move in 2011, but it didn’t go live until 2018, Traylor said.

Now that the plan is live, the biggest challenge is wearing two different hats: the nursing home hat and the insurance hat. Simpra’s CEO, Ron Chaffin, has an insurance background and little SNF experience, while the nursing home owners had the reverse in terms of resume.

“The unique dynamic that I thought worked out pretty well for us is we’ve been able to pull Ron — who is a traditional insurance guy, understanding how they think — and let him realize: If you allow us to care for these people and do certain things, you’ll be amazed at the good financial results your insurance company will have,” Traylor said. “But more importantly for us, the good clinical results that we’re going to get out of the SNFs — that was the yin of the yangs.”

By becoming an I-SNP, the SNFs in the network are thinking differently from an acuity level, Traylor said: In terms of clinical practice, Simpra hires nurse practitioners to help educate staff and place a more advanced set of eyes on the patients.

And as most providers in the space have seen, the acuity of the SNF population is increasing.

“With this model, [we’re] doing a lot of what rural hospitals used to do, right?” Traylor noted. “The rural hospitals used to take care of people who had pneumonia, flu, whatever. We’re now taking care of them in our building.”

This idea has echoes of an argument made by an anonymous post-acute operator, who argued that SNFs need to take the fight directly to hospitals. But another benefit that Traylor sees is the sense of pride the I-SNP model gives the nurses, and the need for them to be more intensive clinically.

For Great Plains Medicare Advantage, the partnership with Sanford adds the resources of the health system, both clinically and in terms of the health plan. For now, it’s not looking to add ancillary services less directly related to health care, as some MA plans are considering. But those offerings are the plan’s radar, according to Scharnberg — with the focus likely to be on companionship, and how to bring non-health care benefits to members as a supplemental benefit.

The path of the future?

Both Scharnberg and Traylor are overwhelmingly positive about the benefits of I-SNPs; Scharnberg related how members who were on Medicaid and had to travel long distances for dental services could go to the local provider for care as a result of the clout the Great Plains I-SNP provided.

“Our goal is that the Great Plains Medicare Advantage model of care is the standard in the facility,” Scharnberg said. “If we have five members enrolled of 100, that’s not the standard.”

And given how much Good Samaritan has invested in the plan, it wants to be able to leverage the investments it’s made for improvements in care management over the past five or so years.

Still, many experts have warned that the I-SNP model isn’t for every provider, and AHCA vice president of population health Jill Sumner stressed to SNN that there are other options for SNFs to move into population health than just I-SNPs.

“One of the things that we’ve tried to do is sort of reframe it in the sense that I-SNP is one option,” she told SNN.

But for providers with the scale and the right market, the move could lead to significant dividends both clinically and financially in a health care world that’s moving toward outcomes and value.

“This has been, without a doubt, the right investment for us to make,” Scharnberg said.

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