In the years just prior to the arrival of a global pandemic that uniquely affects skilled nursing facilities, many providers were interested in expanding their role in the provision of care by moving into the insurance field.
And even though the toll of COVID-19 has sent costs spiraling for those operators who made the leap in 2018 and 2019, the institutional special needs plan (I-SNP) model proved its worth for many SNFs.
Nursing homes essentially become Medicare Advantage (MA) providers via the I-SNP, which covers beneficiaries who need in-home nursing care or are living in an institution.
Two new I-SNPs are moving ahead with plans for launch in Missouri and Minnesota, despite the cost concerns and challenges attendant with the pandemic, and both see paths to viability — albeit with longer timelines to hit projections than they faced when they were in the planning stages of the launch.
By nature, moving into the world of insurance takes time, sometimes almost a year from decision to going live with plan offerings. The providers who are launching or are about to form I-SNPs now started the process last year, before COVID-19 upended the world of health care across the continuum.
And while both Provider Partners Health Plans (PPHP) and UCare are optimistic about the worth and value of the plans in the long term, especially given their clinical emphasis, both are navigating major challenges — from new marketing methods to new timelines on expected enrollment — as a result of the upheaval.
Skilled Nursing News caught up with PPHP, UCare and UCare’s partner on its I-SNPs, the long-term-care-focused health care organization Genevive, in October to discuss how COVID-19 has changed the I-SNP game — and in some ways, made the model more attractive than ever.
Acquiring new members, adjusting timetables
PPHP launched its I-SNP in partnership with Health Systems Inc. (HSI) of Osage Beach, Mo.; residents of long-term care facilities serviced by HSI were able to sign up for PPHP’s MA services starting October 15, and membership will be effective January 1, 2021.
The agreement covers 59 long-term care facilities in 30 counties in Missouri, with more than 5,800 residents living in those facilities.
PPHP – which is based in Maryland and has partnerships with nursing home operators in Maryland, Pennsylvania, Ohio, Illinois and Texas – first submitted its notice of intent to apply for the Missouri I-SNP in November of last year, PPHP CEO Rick Grindrod told Skilled Nursing News on October 22. Securing an insurance license from the state typically takes three to four months — though some states can take longer, Grindrod noted — and then an application to the federal government is usually due mid-February the year before launching.
PPHP of Missouri followed this timeline, then started the process of building the out provider network, which “ultimately concludes with you having a certain number of specific counties in which CMS contracts with you to have an I-SNP Medicare Advantage plan,” he explained. That contract was signed in September of this year.
COVID-19 didn’t end up disrupting any of this setup work, since all of the documentation submission is electronic anyway, he said. Where it does create some unique hurdles is in acquiring members for the plan.
“From a marketing, from a marketing perspective — like any other business, this has been a very challenging time to acquire new members, because you can’t meet with people,” Grindrod told SNN. “So we’ve had to shift, like many other businesses, to other ways of communicating, whether it’s through zoom or GoToMeeting, or socially distanced meetings.”
This also proved to be a challenge for UCare and Genevive, which partnered to offer I-SNP plans for people with Medicare in senior living communities within a 14-county metro service area; the residents live in 160 Twin Cities-area long-term care and assisted living communities that are part of 22 participating organizations. Fifty-three of these facilities are SNFs.
There’s no way, for instance, to hold informational sessions for the family members of people living in the facilities in a world where mass gatherings cannot happen, said Ghita Worcester, senior vice president of public affairs and chief marketing officer at UCare, in an October 21 interview with SNN.
And because so many skilled facilities have restricted communal activities in light of the pandemic, word-of-mouth opportunities are also almost non-existent.
It also makes it much harder to chart a future course in terms of plan benefits and offerings, she noted.
“Usually, you have to start thinking in January and February, after the end of the annual election period, about what you’re going to do for the following year,” Worcester said. “And COVID, in my mind, means we’re not going to know a lot from this annual election period about: Did we put the right benefit packages together? Did we have the right price point?”
The timetable for I-SNP success can vary, as with any new business venture, but the pandemic has also made it much harder to determine when the new plans will hit key enrollment benchmarks, both plans said.
Grindrod said that projections around enrollment have been pushed back anywhere from three to eight months because of the pandemic.
UCare declined to provide specifics on enrollment projections prior to the October 21 interview, but Amanda Tufano, the CEO of Genevive, described the work to bring the I-SNP product to the Twin Cities-area communities as “a multi-year effort.” But COVID-19 makes it hard to assess how that will go.
“This is a long-term effort. This is a multi-year effort to to bring a product that community really needs,” she said. “It’s vague because it’s a weird time.”
Clinical upsides abound
The fiscal peril for any I-SNP during COVID-19 is the heightened risk of hospitalizations if there is an outbreak in the institutions covered by the plan.
Hospital admissions rose dramatically in many places during the start of the pandemic, Grindrod said, which led to costs far beyond what an insurance company would typically absorb. However, he has seen this declining in recent months, he told SNN.
And both PPHP and UCare argued that the significant clinical benefits of I-SNPs will become even more apparent during a major health crisis.
The plans offered by UCare and Genevive include a designated nurse to provide customized care coordination services, in addition to a range of other benefits, while PPHP makes use of a local provider clinical team with nurse practitioners from PPHP who visit members daily, according to the companies’ respective releases announcing the plans.
And Grindrod, Tufano, and Worcester all agreed on the clinical benefits I-SNPs can provide by their focus on caring in place for residents who might otherwise have been sent to the hospital — a destination that’s unpalatable for many reasons during the COVID-19 era.
“If the facility along with the health plan, nurse practitioner, and our care coordinator can do a better job of identifying potential health issues with the members earlier on, then those health issues can be treated earlier on in a less restrictive environment, and never require hospitalization,” Grindrod said.
As an example, a nursing home resident might have congestive heart failure, but the first emerging signs could be as small as a minor cough and slightly swollen ankles, he said. If that resident is part of an I-SNP, the nurse practitioner might see these signs as part of the daily rounds with members and issue a prescription before the symptoms become significantly worse and force a transfer to the emergency room.
For this to work, the facilities have to buy fully into the I-SNP model, and that makes educating them paramount, Worcester said, to ensure they are invested with UCare and Genevive.
COVID-19 has highlighted the challenges that frontline staff face daily even in normal times, and getting them onboard was crucial; the hope is that demonstrating that the I-SNP model can improve care coordination and integration will make them more comfortable going forward.
And the component of caring in place during the pandemic highlights the benefits of the I-SNP, Tufano argued.
“From a structural standpoint, as we were going through all of the changes that 2020 has brought, it really reiterated the necessity, for the I-SNP patient population and the residents who this is really focused on – our most vulnerable frail elderly — this high need for coordinated care,” she said.