I-SNPs Keep Driving Skilled Nursing Value-Based Care, Despite Lagging Enrollment

Nursing home operators have for so long relied on Medicare fee-for-service (FFS) to get reimbursed, that it might take a rewiring of workplace culture to better receive value-based insurance models.

This is especially true after the beating such models took during the pandemic, Cheryl Phillips, president and CEO of the Special Needs Plan Alliance, said during a panel at the Post-Acute and Long-Term Care conference (PALTC22) earlier this month.

The institutional special needs plan (I-SNP) for one, a subtype of Medicare Advantage, was hit hard during Covid as a plan that serves a “very mortal” population – nursing home providers were also encouraging FFS payments during that time, Phillips said.

I-SNPs restrict enrollment to people eligible for MA who, for 90 days or more, need or are expected to need services of a SNF or other institution.

Between 2020 and 2021, I-SNP enrollment decreased by almost 11,000 enrollees, an 11% decrease in one year. From 2015 to 2021, however, enrollees grew from 53,073 to 90,000-plus, according to an analysis from health care consulting firm ATI Advisory.

There are 186 I-SNP plans in the country as of January this year, with about 95,000 members, Phillips said.

“There were a lot of things going on but the uptick is back,” added Phillips. “You’re starting to see a collaboration of both the nursing home providers, the clinical providers, and the health plans, and then tools and resources … pulling together data providers, you’re going to see growth in I-SNPs.”

Despite reduced uptake in the last year, industry leaders like American Health Care Association (AHCA) President and CEO Mark Parkinson believe a shift to more value-based care models is essential.

The skilled nursing industry faces a reimbursement reality: FFS is “dying,” Parkinson has said, but along with that death are “tremendous opportunities in the area of population health management.”

Dual eligible plans, or D-SNPs, fared better through the pandemic, dominating the SNP world at more than 3 million enrollees as of January. Medicare-Medicaid plans (MMPs) came in second with 401,513 enrollees followed by chronic condition special needs plans (C-SNPs) with 386,725.

I-SNP as a value-based pioneer

Another value-based care model, the next evolution of the Accountable Care Organization (ACO) with an emphasis on the high needs population typically found in a nursing home, builds upon many facets of the I-SNP.

The ACO Realizing Equity, Access, and Community Health (REACH) high needs model was first announced by the Centers for Medicare & Medicaid Services (CMS) in early March. It’s the new direct contracting entity (DCE) for Medicare patients with more complex needs.

“We think that high needs populations, for example the long-term care patients in nursing homes, are very appropriate for the high needs DCE population,” Kim Phan, founder and CEO of CareConnectMD, told Skilled Nursing News.

Primary care provider CareConnectMD focuses on partnering with nursing homes and working with physicians to grow its ACO offerings in California, along with other states; it was formerly called Gerinet Medical Associates.

Operators have until April 22 to apply to be part of the new DCE.

Alan Hoops, managing director for CareConnectMD, said high needs DCEs might elicit better results than an I-SNP from a financial perspective — while adhering to less regulatory requirements.

“When our patients are discharged from the facility and they go into a short-term, skilled bed, a major source of savings … whether it’s an MA plan, or a DCE or an ACO, is to manage that post-acute cost, and that’s where they enjoy the most profits,” Hoops explained.

ACOs are groups of doctors, hospitals and other health care providers that work together to provide coordinated care to Medicare patients, according to CMS. Initially a contentious payment model – some ACO programs eliminated SNFs as participants altogether – ACOs were found to generate savings by reducing length of stay.

A DCE also appeals to nursing homes looking to deepen their clinical capabilities – a motive behind I-SNPS and other value-based models of care.

Much like an I-SNP, for a DCE to work the plan has to generate enough savings and share enough of those savings with the nursing home in order for the facility to justify the move toward becoming a value-based provider, Hoops said, instead of sticking with an FFS model.

“I think that in many regards the I-SNP movement that has been taking place over the last four or five years by a variety of companies and getting nursing homes into the I-SNP business has in some ways heightened their knowledge and their interest in moving toward a value-based environment,” Hoops said.

CareConnect and its DCE offerings are enjoying the momentum that I-SNPs have created, Hoops added.

The ‘Five C’s’ of a successful I-SNP

Compliance, competence, capacity, culture and a person-centered approach to care delivery were among the “Five C’s” of a well-run I-SNP, but Phillips said culture especially was a big determinant of I-SNP success – especially upon initial introduction.

Phillips and Clare Hays, chief medical officer for Associated Care Ventures/Simpra Advantage, reviewed each “C” during the Society for Post-Acute and Long-Term Care Medicine (AMDA) hosted panel.

“There were a number of physicians who’s answering service said if it’s after [5 p.m.], go to the emergency room,” Phillips said of her time as a medical director in Sacramento. “Well, that’s a culture. How do you change that culture?”

The culture of the I-SNP, Phillips said, is how clinical staff will get the right care in the right setting for the right patient, at the right time.

I-SNP communities, or nursing homes with I-SNP contracts, are working to change that culture with its staff.

“If you throw in an I-SNP but you don’t deal with the culture, the I-SNP will not succeed because all of the things start to break apart right here,” added Phillips.

That change in culture, a shift to person-centered relationships for I-SNP members, has been “some of the best marketing” for the plan, she added.

Advance care plans and goal setting often times involves family members, along with the certified nursing assistants (CNAs), charge nurse, attending nurse practitioner (NP) and floor nurse.

“When the health plan is seen as a partner in the process, then you can start to build this person-centered approach to care delivery that goes way beyond filling out [cardiopulmonary resuscitation (CPR)] forms; [these forms are] all important, but that’s not where the relationship is,” Phillips said.

Compliance, competence and capacity

In a Medicare Advantage plan, compliance is “everything,” Hays said. It’s problematic when nursing home staff doesn’t understand health plan compliance, she added.

Simpra Advantage one-on-ones help explain plan compliance to staff, but turnover poses a challenge, Hays said.

A preference to review plan compliance in person among a staggering 103 nursing homes that use Simpra presents challenges as well.

“We have to do Simpra Advantage [compliance] one-on-ones constantly, which is really hard,” said Hays, with compliance measures covering chronic disease management, member experience, member complaints, customer service and available drug plans.

“All of this is more work that we sometimes have to ask the people to do,” Hays said of the compliance one-on-ones required within the I-SNP plan.

Capacity and competence are “twin sisters,” Phillips said of the last two “C’s.” A nursing home can have competent staff, but if there aren’t enough to serve the populace or they aren’t well versed in the types of comorbidities affecting residents, it’s difficult to see that competency shine.

“That’s where the partnerships become so critically important in a successful I-SNP,” Phillips said.

Partnerships that connect nursing homes with respiratory services, provide access to laboratory and diagnostic services – and connect nursing homes to the overall workforce – are a huge advantage for I-SNPs, she said.

Competency might not mean clinical competency either, Phillips added, but rather an ability to think critically.

“They have a list of to do’s … much of that is regulatory driven. But do we have the competency to do real critical thinking? If this, then this. I’m seeing this so I need to make that decision. The I-SNP brings a lot of partnership to that,” Phillips noted.