Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure noted higher participation in value-based payment models like Institutional Special Needs Plans (I-SNPs) during a recent discussion with HealthAffairs, but also hinted that consolidation of such programs may be needed.
“Too many models in too many places that aren’t coordinated with each other,” is how Brooks-LaSure described the situation, adding that the agency will look to focus its attention on making sure such programs are working for their intended populations.
Avalere Health Managing Director Fred Bentley was not surprised I-SNPs were mentioned when discussing value-based care effectiveness, pointing to big payers seeing the model as an opportunity to expand their Medicare Advantage (MA) footprint, along with the skilled nursing industry.
SNF operators have either participated in or launched their own I-SNPs, a specific type of MA plan for nursing home residents; the plan provides more control over patients within the continuum of care. The model restricts enrollment to MA-eligible people who need or are expected to need SNF services.
Special needs plans, including institutional, chronic and dual-eligible offerings, have been increasing since 2016, according to Chicago, Ill.-based speciality investment bank Ziegler and the Kaiser Family Foundation, a nonprofit organization. Offered plans went from 578 to 975 between 2016 and 2021.
Value-based models were a product of the CMS Innovation Center, or the Center for Medicare and Medicaid Innovation (CMMI), which was founded as part of the 2010 Affordable Care Act.
Bentley also pointed to the model’s potential use with a wider population base.
“It fits into a much broader and deeper theme, an area focused around equity. There are lots of different types of vulnerable populations — when you think about beneficiaries who would qualify for the I-SNP plan,” said Bentley. “They are going to be almost by definition low income, most of them have many different comorbidities and so creating programs and models that promote better access, better care integration for low income vulnerable populations.”
Chris Utz, managing director of healthcare investment banking at Ziegler, anticipates special needs plans to evolve as Medicare and Medicaid evolves within the skilled nursing space, running parallel with Brooks-LaSure’s efforts to tackle health equity and better understand the social determinants of health.
“These plans and the programs associated are likely to start including more and more outside of primary care and care coordination,” said Utz.
“A number of [SNPs] are paying attention to some more of those social determinants of health and integrating some of those elements as benefits into the plan,” said Lisa McCracken, director of senior living research and development at Ziegler. “That would be more non-traditional, non clinical elements … fitness, meals … maybe transportation, some insulin support, things like that. Those are different things that I know are being watched carefully as these plans evolve.”
I-SNPs “very much align” with the administration’s broader equity agenda, Bentley said.
“There’s clearly a direct through line to the work that skilled nursing providers do, the populations that SNFs treat,” added Bentley. “There is a role for SNFs to play in terms of addressing equity.”
“Are we attracting providers, a diverse group of providers? Are we making sure that the underserved are in these groups?” posited Brooks-LaSure, adding that CMS under her care has turned a discerning eye toward health equity within these programs.
Aspects of value-based payment models that are working for patients will become a “core part” of the program, not just available to a small subset of beneficiaries.
“The point of doing models or demonstrations, same thing at the state level, is so that if things work, we can integrate it,” Brooks-LaSure said.
Special needs plans help integrate care specific subsets of people that find themselves in a SNF, according to Utz.
“You’re taking your care management or medication review, your functional status and your pain assessment, and you’re really trying to manage them all together at one time, instead of a historical model where someone just goes in for their quick knee replacement, their hip replacement and quick therapies, and then they’re in and out,” said Utz. “It kind of takes a skilled nursing facility and encourages them to take higher acuity patients.
Brooks-LaSure looked at I-SNPs within the context of a SNF population from a taxpayer perspective too during the HealthAffairs conversation, noting an attraction to the skilled nursing space by entities that would not normally get involved.
“There’s a lot of interest in managing this population because their costs are so high, probably because there’s a lot to do. We need to make sure it’s working for people’s care,” explained Brooks-LaSure.
While spending is not a “huge driver” for SNFs, Bentley said, CMS will continue to look for models to promote efficient use of skilled nursing resources.
Companies featured in this article:
