In the era before COVID-19, specialty in-house Medicare Advantage plans had emerged as one of the hottest topics in long-term care — control the payer source, the thinking went, and an operator could eliminate the financial uncertainty and pressure that comes when working with managed care plans.
But with a global pandemic running rampant through skilled nursing facilities, the clinical benefits of Institutional Special Needs Plans (I-SNPs) are also shining through, and a major operator in the space credits its existing partnership with specialty managed care company Optum for giving it a head start on coronavirus preparations.
“It’s not that we had to build a collaboration to face this,” Saber Healthcare Group chief medical officer Nancy Istenes told SNN in late April. “It’s the strong collaboration that we had leading up to this that allowed us to be so successful together.”
Optum embeds its advanced practitioners in more than 50 of Saber’s 100-plus nursing facilities across the Southeast and Midwest, according to Optum chief medical officer Ronald Shumacher.
Through Optum’s sister company, UnitedHealthcare, about 70,000 skilled nursing facility residents are covered under its I-SNP nationwide — about 1,300 of which live in Saber facilities.
Optum’s model relies on a more intensive care plan, with nurse practitioners from the insurer working alongside skilled nursing staffers to enhance clinical capabilities.
“We’ve had to shift some of our focus to being able to provide care for patients remotely,” Shumacher said of the current COVID-19 situation. “We probably focus more attention on advanced care planning and goals of care. But a lot of these things are what we were already doing with Saber.”
The directive, from both a clinical and financial standpoint, is to treat residents in place whenever possible — a factor that became increasingly vital given the danger of sending vulnerable nursing home residents into the acute-care setting amid COVID-19.
“They’re seeing residents very frequently. Their goal is to keep people medically stable and treat in place in the facility,” Istenes said. “So that allowed us to know that we’d already maximized the care for those residents, so that our residents are in the best medical condition that they possibly can be coming into a potential epidemic.”
I-SNPs operate as dedicated Medicare Advantage plans only for long-term residents of nursing homes or other institutional sites of care. Operators can either create their own, or partner with companies such as Optum to provide back-end and clinical support.
The process of launching an I-SNP isn’t easy; insuring nursing home residents and caring for them are two completely different businesses, even though the goals and challenges often intertwine.
Because each state has different capital and other operational requirements, providers face startup costs in the multiple millions of dollars before the first member even signs up. In addition, patient-choice rules mean that operators can’t just expect to capture every one of their residents — and plans typically need a clear path to at least 1,000 beneficiaries to have any real shot at long-term success.
But for the operators with the capital, patience, and forward-looking vision, the upsides can be tantalizing. Financially, being an insurer gives providers more control over costs and reimbursements. That’s a major consideration given that Medicare Advantage plans, on average, pay around $100 less per day than regular fee-for-service Medicare — according to the most recent data from the National Investment Center for Seniors Housing & Care (NIC) — and exert more pressure to reduce lengths of stay.
That imperative to reduce costs, while maintaining quality patient care, frequently revolves around strategies to reduce hospitalizations, which represent a significant episodic cost for insurers — and place frail, elderly residents at risk of infection and other complications.
For Optum, that means placing nurse practitioners and other clinicians directly into facilities to provide a higher level of expertise not often found in the long-term care setting, where shortages of registered nurses have persisted for years. That also means investing in telehealth programs, a factor that presented a serious advantage for Saber once the federal government rolled out restrictions on visitations in March to help stem the COVID-19 tide.
The operator was able to lean on Optum to implement remote interventions, Istenes said, both from a technological and practical standpoint.
“Not only is it their willingness to do that, and for us to get those providers in there, but the willingness to pilot my software and my devices and my instructions, and give me some feedback on — this works, this isn’t working, that perspective from a provider who’s utilizing it in a building,” Istenes said.
Like the rest of the industry, Optum and Saber’s path hasn’t been without challenges. As of SNN’s conversation with Istenes and Shumacher on April 24, access to testing remained an issue — at the time, according to Istenes, health departments and private testing companies weren’t always able to fully accommodate the company’s request for kits, a common problem for operators across the country.
“It might be that we would like to test 40 people, and we can only get testing supplies for 20,” she said. “So then we have to pick which 20 make the most sense.”
Securing a sufficient supply of personal protective equipment (PPE) has also represented a major hurdle for the companies, though their partnership helped to augment a collection drive of homemade masks inspired by Istenes’s crafting hobby.
Saber thus far has received donations of more than 10,000 homemade masks from staffers, religious and community groups, and families, according to Istenes — with Optum kicking in more than 1,000.
“Our presence in the facility, and the relationship that we have, really allows us to step up in a big way in the setting of a crisis,” Shumacher said.