‘It Changed Everything’: Skilled Nursing Provider Cantex Leverages I-SNP to Drive NOI, Transform Care

Skilled nursing providers are looking for ways to get ahead as the long-term care industry increasingly moves toward a value-based payment world.

Operators who have taken the leap to create their own in-house insurance plans are starting to see the move pay off in a big way, both on the clinical and financial side of the business.

Institutional special needs plans (I-SNPs) in particular are seen as the future for skilled nursing facilities that have been previously pummeled by ongoing changes to reimbursement – especially when recovery from the pandemic remains slow.


Between 2020 and 2021, I-SNP enrollment decreased by 11%. 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.

In October, the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI), unveiled its updated 10-year strategic plan which highlighted its goal to shift all Medicare and the majority of Medicaid beneficiaries out of fee-for-service (FFS) and into value-based payment and alternative methods.

American Health Care Association President Mark Parkinson has gone so far as to say back in December that fee-for-service is “dying.”


For many years, Carrollton, Texas-based Cantex Continuing Care Network looked for ways to bring advanced practitioners into its buildings, preferably ones employed by the operator, but there was no path to reimbursement.

Cantex leadership decided to take matters into their own hands by starting an I-SNP and it’s proven beneficial in more ways than one, according to Cantex Principal and Managing Partner Peter Longo.

“Institutionalized Special Needs plans … were the funding source to enable us to bring nurse practitioners, or physician’s assistants and primary care providers of other types, into our buildings and have that paid for, and that has really changed everything in terms of the way we provide care,” Longo said during a panel at the National Investment Center for Seniors Housing & Care Spring Conference in Dallas.

Cantex has skilled nursing, hospice and home health facilities throughout the states of Texas, Louisiana and New Mexico.

When Cantex was in the beginning stages of developing its I-SNP, those operating other established plans told Longo and his colleagues that financial upside should not be the “primary driver” to get into the insurance business.

Instead, Longo said, the goal is to “amp up” a facility’s clinical acumen with a nurse practitioner who can closely oversee patients and residents to assure quality outcomes.

“At the end of the day that will result in increased profitability,” he said.

The impact on cost and care

Having one nurse practitioner for every 60 members of the I-SNP plan has been a “game changer” in that the NP can really get to know and interact with the patients under their care, Longo said.

The nurse practitioner role in an I-SNP has also been shown to reduce rehospitalization rates, which can have both financial and care outcome implications.

Longo said some data has suggested members of I-SNPs are seeing rehospitalization rates that are roughly one-third lower compared to the average nursing home resident.

“What we know already is it’s a demonstrable and material reduction in rehospitalization rates for members of institutionalized special needs plans, and it shouldn’t come as any surprise when you have a primary care provider who is doing nothing but caring for a small group of patients and constantly interacting with them,” Longo said during the panel.

SNFs can be penalized by CMS if rehospitalization rates are too high.

The relationship between hospital systems and nursing homes has been ever evolving throughout the COVID-19 pandemic, but that dynamic is seemingly more collaborative as of late. Still, hospitals are more cognizant than in the past about skilled nursing quality and are determining referral relationships accordingly.

Kevin Mulhearn, chief financial officer at Hillcrest Health System, told Skilled Nursing News that he believes hospitals are finally starting to understand where post-acute fits within their business model.

“We’ve experienced a new level of respect saying, ‘OK, I need you as a partner.’ As more and more get into any type of risk arrangement, which hospitals are more aggressive about, they’re realizing that all providers are not the same,” Mulhearn said.

Longo said when Cantex’s I-SNP was first getting off the ground, he was initially concerned about how a director of nursing (DON) or other medical staff member would respond to a nurse practitioner coming into the facility.

The DON’s have overwhelmingly embraced the nurse practitioner, Longo said, because “this is someone new who has advanced diagnostic and assessment skills and can do things that help them.”

That proved itself in more ways than one for Cantex during the COVID-19 pandemic.

“The contribution of our nurse practitioners in terms of testing and vaccinations and other Covid-related procedures that we were undertaking, as well as infection control and just bringing a calmness to the building, in terms of having high level practitioners on-site constantly, was tremendous for us,” he said.

And Cantex wasn’t the only post-acute provider who was able to lean on its nurse practitioners during the pandemic.

Simpra Advantage, an I-SNP partnered with facilities in Alabama, had nurse practitioners caring for every patient in a facility, whether or not they were members of the plan, due to the staffing challenges Covid presented, according to J. Mark Traylor, president at Traylor-Porter Healthcare and a member of Simpra Advantage’s board of directors.

“As an operator, it was a lifesaver,” Traylor told SNN back in June 2021. “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.”

Expanding the I-SNP’s reach

Now that Cantex’s I-SNP plan has developed into what Longo calls a “mature” Medicare Advantage plan, the operator is looking for ways to expand its reach by working with health care providers across the care continuum.

This means having nurse practitioners interface with new home health or hospice patients in their own facilities, but also reaching out to assisted living facilities in communities where Cantex operates to gain new members.

“Now … our businesses are straying into each other, because now we look over the bow of the ship and say, ‘Well, why are our members only our patients in our buildings, we’re surrounded … by assisted living facilities all around us who would benefit from having plans like this in their buildings as well, but maybe they don’t have the financial wherewithal to do it,’” Longo said during the panel.

That can be done through an IE-SNP, or institutional equivalent special needs plan.

“There are future levels of this potential new tool to enhance your NOI that could be even more beneficial to the bottom line in terms of bringing new revenue streams to your company that are profitable,” he said.

As the skilled nursing industry continues to rapidly change and evolve both through reimbursement and regulatory overhaul, Longo remains confident that having an I-SNP, and continuing to find ways to innovate, keeps Cantex ahead of the curve.

“We’re all trying to have traction in our markets, to our populations that we serve, by providing the most cutting edge services, and I think you’re always in a good place when you’re trying to be ahead of the eight ball,” he said.

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