After a year dominated by a global pandemic that proved especially deadly for the elderly, skilled nursing operators are navigating recovery thanks to the rollout of vaccines against COVID-19.
But many operators are looking at not just how to return to normal, but how to build a foundation for the future after the pandemic. And the institutional special needs plan (I-SNP) is one of the options at their disposal.
The I-SNP is a type of Medicare Advantage (MA) plan that restricts enrollment to people eligible for MA who, for 90 days or more, need or are expected to need the services of a SNF or another institution, according to the Centers for Medicare & Medicaid Services (CMS).
It’s an option that comes with challenges for operators who decide to launch their own plans, but it also allows them more control — both over the continuum of care for patients and of their destinies more broadly.
And moving into I-SNPs could be one of the only ways SNFs survive in a health care landscape shifting to focus on outcomes and value.
“If we want to see skilled nursing facilities move towards value-based payment and taking risks, this is really the only model out there for them,” Jill Sumner, vice president of population health management at the American Health Care Association (AHCA) told Skilled Nursing News. “Losing the bundled payments took away an option. ACOs [accountable care organizations] are great, but the facility doesn’t hold a contract. It’s the physician that’s really leading it. So I-SNPs are an important solution – and the only solution that we see at this point for providers to be able to take this leap.”
A model for ‘when things are challenging’
The COVID-19 pandemic struck health systems across the world with considerable force, and the U.S. care continuum was no different. The residents and workers in SNFs were uniquely vulnerable; the results were devastating losses of life.
For providers who moved into the I-SNP model pre-pandemic, the clinical benefits to residents covered by the MA plan were significant. As such, they present one of the strongest arguments for the model going forward, despite some of the financial and operational struggles that came with COVID-19, multiple I-SNP operators told SNN.
“When you think about the value proposition – and this rang really, really true during the pandemic – … each of our members has a nurse practitioner who’s really dedicated to their personal care goals,” Marc Hudak, chief growth officer at Longevity Health Plan, told SNN. “And when a member enrolls, we spend a lot of time with that member, with their loved ones, with their [primary care provider], with the SNF staff, and we ask them questions about … their goals. And we decide a personalized care plan that we manage and implement with that broader team.”
This close involvement, especially the connection with family members, was critical during COVID-19, Hudak said.
Longevity uses a provider-sponsored model wherein the legal entity for the I-SNP is created by Longevity with ownership split evenly between investors at the parent company and the local operators. It has affiliated I-SNPs in Colorado, Florida, Illinois, Michigan, New Jersey, New York, North Carolina and Oklahoma.
“We were hit very hard in April in both New York and New Jersey, and in New York, we at one point lost 30% of our members in a month, just because that’s how bad COVID was at that point in time,” Hudak said.
During COVID-19, Longevity’s nurse practitioners would check in with family members to give them updates on SNF residents, which was both a benefit to Longevity plan members and a help to SNFs who were understaffed, Hudak noted.
“That was clearly one of the benefits of our model for families and their loved ones during the pandemic,” he said.
For Simpra Advantage, an I-SNP partnered with 99 facilities in Alabama, the staffing strains of COVID-19 meant having its nurse practitioners care for all patients in a given facility, whether or not they were Simpra members, J. Mark Traylor, president at Traylor Porter Healthcare and a member of Simpra Advantage’s board of directors, told SNN.
“As an operator, it was a lifesaver,” he said. “We had one of the worst homes in the state as far as outbreaks go. It’s a very large home. They wound up with just shy of 50 patients at one given time in the building with COVID, and then we had about 60-plus employees who contracted COVID.”
Simpra’s I-SNP is backed by mostly independent owners, or people who own 10 or fewer nursing homes, Traylor noted. Given the limited resources many SNFs faced during COVID, having Simpra nurse practitioners serve as “clinical eyes on every patient” was critical, creating additional opportunities to catch any changes in breathing or behavior as part of the effort to best detect and treat COVID-19, he said.
“It kept us afloat,” Traylor said.
The pandemic era ushered in unique collaboration among medical professionals working in the SNF setting, and for Simpra Advantage, that meant overcoming some of the traditional hurdles of care coordination that typically come when an I-SNP is first introduced in a SNF, Traylor said. It’s something that reinforces the I-SNP’s clinical advantages, and he believes it has carried over to operations even as COVID’s hold on SNFs loosens.
Hank Watson, chief development officer at American Health Partners, also emphasized the importance of care coordination within the I-SNP model. He said the pandemic only confirmed care coordination’s importance to the success of the I-SNP.
American Health Partners has seven divisions, with the I-SNP division, American Health Plans, currently operating in nine states, with the work for 2023 expansion ongoing.
“When we look back on 2020, it confirmed [the I-SNP] model for us, and highlighted the components that we think are critical, including integrated care management, being connected with the plan and with the plan operations and with the facility, and not being a fragmented, outsourced delivery system,” Watson told SNN.
This also includes a facility relationship between the I-SNP operator and the facility with “true commitment,” he said, an especially important consideration given the pounding facilities took on census throughout the pandemic.
“The reason you do the work on the front-end to structure the joint ventures, and shared ownership and capitation and shared savings economics with the facility, is to put everybody on the same page when things are challenging,” Watson said. “That’s what proved out through the pandemic.”
Still the path of the future
The financial stresses caused by COVID-19 for I-SNPs were considerable. When CMS approves an I-SNP for a given market, it receives a premium to manage its members each month based on historical utilization patterns and costs – all of which went out the window when COVID struck.
“For example, inpatient utilization at different points was a multiple of what it is historically for a well-managed population, and that was 100% driven by the pandemic,” Hudak explained. “When we set this rate with CMS, it was based on historical utilization, and COVID never occurred before. We never experienced that as an industry. So we had much higher inpatient utilization — and when you think about the major cost that any I-SNP plan incurs, the primary costs are inpatient.”
With more people utilizing it “than ever before,” and the increasing acuity that led to the utilization of more costly services such as ventilators, in addition to large parts of Longevity’s population getting test for COVID, its I-SNPs were facing costs that had not been calculated in any way when the premium was set, Hudak said.
But even with these realities, Sumner told SNN that AHCA’s members are still very interested in pursuing the I-SNP model, especially given the value of having the clinical model in facilities and the stories of nurse practitioners stepping up to fill clinical needs.
“We’ve still seen new plans emerging,” Sumner noted. “There’s been an increase for 2021, and there’s still a pipeline. It might be a smaller pipeline than would have occurred if we didn’t have COVID, but there’s still an uptick in the emergence of these provider-led and provider-owned models.”
The provider-owned aspect is important; as Traylor observed, most SNFs think of managed care as the entity that denies payments when it can and audits what it pays. But providers who are in the managed care space have a window on both the clinical and payment sides that integrates the two – and COVID-19 showed that I-SNPs “are going to be and should be an integral part of how we care for patients going forward,” Traylor said.
Watson agreed.
“Our partners and American Health, we were able to navigate COVID because we structured those relationships in a way where everybody was in it … for the long term, and setting these plans up and executing the clinical model,” he told SNN. “If you do that, and you have that integrated operating model with field operations, with clinical care, and with the facility, you’re well-positioned to succeed with the I-SNP. That didn’t change during COVID, and that didn’t change post-COVID vaccinations.”
