The challenges of Covid-19 and its aftermath have made it difficult for some skilled nursing facilities to increase their engagement in value-based care — but they are at risk of falling behind as the health care system continues to evolve, and they are also potentially leaving money on the table.
That’s according to Jason Feuerman, president and CEO of LTC ACO, which was the first Accountable Care Organization (ACO) specifically designed to serve Medicare beneficiaries residing in long-term care facilities.
The value-based care world is complex and SNFs are still finding it difficult to find their niche, Feuerman said. But the Centers for Medicare & Medicaid Services (CMS) is pushing ahead with its goal to have all beneficiaries in a value-based care framework such as an ACO by 2030.
The ACO is an alternative payment model under which a variety of providers are encouraged to work together along the care continuum to improve care and reduce costs for each beneficiary under their control. And, within that space, LTC ACO is a Medicare Shared Savings Program (MSSP) for Medicare Beneficiaries in specifically long-term care (LTC) facilities.
LTC’s model is based on creating an alignment between physicians and SNFs. And while the model is evolving, it differs from other models of care such as an Institutional Special Needs Plan (I-SNP), in that LTC is more dependent on physicians, while the I-SNP is more nurse practitioner-centric.
Feuerman said LTC’s unique access to data can enhance quality and savings.
“We want SNFs to know on an almost real-time basis what’s happening, what’s the cost structure with the care delivery of their patients. There’s data that we have, that they don’t necessarily have. They’ve got certain data points, but we can see almost everything happening to the patient throughout the continuum,” Feuerman said.
And last but not least, there’s financial upside and downside to consider. Feuerman believes too many ACOs still make money “off the back of SNFs,” and differentiates LTC ACO on that score.
Feuerman told Skilled Nursing News that his organization shares 25% of its profits with SNFs, with no downside risks for the SNFs.
“We were the first ones out there, and our model has always been to share 25% of the savings with SNFs, 25% with physicians and nurse practitioners and the balance remains with the ACO because of all the infrastructure that we take on and because we’re taking all the downside risk,” Feuerman said.
The following transcript has been edited for length and clarity.
What’s the future of SNF involvement with ACOs as new ACO models are being proposed?
There are around 500 ACOs in the country. There are only three that focus on the long-term care population, LTC being one of them. ACOs are not going away. They are a permanent part of the Affordable Care Act. It’s an important model in CMS’ goal of having 100% of the population in a value based program by 2030. And so, SNFs are going to have to lean in and collaborate with health care systems better, more effectively and more efficiently … This presents similar challenges to what Medicare Advantage is doing right now.
Now that value-based care is gaining traction more broadly, how does that or will that impact ACOs?
An ACO is a value-based care program, and ACOs are a key tool that CMS is using. So whether it’s the Medicare Shared Savings or ACO Reach, these are all programs designed to [encourage] primary care providers to participate in a program that moves their population into value-based care at some level along the continuum. So it is gaining traction.
CMS has stated that the goal is to have 100% of the Medicare-Medicaid population in a value based care program, and so obviously, you’ve got almost 50% in managed care today, which eats up half the population … We’ve got 20%-25% of the total population in ACOs. So, there’s still a long way to go and CMS continues to work to find ways to incentivize providers to enter these models that create value in the care delivery system.
Are there plans for growth or change for LTC or changes to its model since you last spoke to SNN?
In terms of our growth, it’s been material growth. You know, we serve approximately 20,000 long-term care residents and so throughout the country, we’re in 34 states, and we’re able to operate in all 50 states. We’re in approximately 2,000 skilled nursing facilities throughout the country, and we partner with groups that represent approximately 2,500 physicians and nurse practitioners throughout the country.
I think the biggest change since we originally developed this model, we thought the main distribution channel would be skilled nursing facilities when in fact some of our learnings indicated that the physicians are really where the growth comes from. Many facilities aren’t completely aligned or knowledgeable about physicians that serve their residents and their patients. So we have targeted the physician community that serves long-term care residents to join the ACO in order to grow it.
That said, our whole goal of providing incentives to all three parties – meaning the ACO, the physician and the skilled nursing facility – is still in place. We believe it’s a three legged stool and we need everybody and we want everybody rowing in the same direction.
What has impacted growth of ACOs and value-based care?
With Covid, the pressure in these facilities has just been overwhelming and very distracting from both a care delivery perspective and from a staffing perspective, and their ability to really move forward with value-based care. That said, whether they’re on board or not doesn’t affect our growth. It affects our underlying thesis, however, of having everybody aligned to deliver the best quality care possible. So we have many facilities that just don’t have the bandwidth, and it’s not that they don’t want to participate. But they are missing out on substantial shared savings by not participating.
What are some of the hurdles to expansion of ACOs?
It’s a confusing environment. You have groups like us out there and you’ve had I-SNPs out there [and others]. And so people get confused about the populations being served. Sometimes, [industry players] don’t understand how our program and the I-SNP program can really work together. And, on top of that with Covid, they’ve just been overwhelmed. It’ll take hopefully not a few more years, but a year or two longer before they’re able to lift their heads up, and really engage in a different discussion.
Are there any financial upsides for SNFs that are participating with the ACOs?
In our ACO, the answer is yes. They can share in up to 25% of the savings that are generated. We take on their downside risks. So there is significant upside for SNFs, and there’s no downside. There’s no downside risk at all. In a typical ACO they typically wouldn’t share savings.
What are the biggest pain points for SNFs? Is it harder or easier now for SNFs to have a seat at the ACO table?
I think for us, it’s as easy as it’s ever been. As I said, we serve about 20,000 residents in more than 2,000 facilities, and we want SNFs to have a seat at the table. We want them to participate … I think for the typical ACO, it’s all a matter of geography and the willingness of the ACO to invite SNFs to be at the table. That said, I think that many ACOs make their money off the SNFs’ back.
SNFs can make up some of the loss with additional volume that could be shifted from other providers that aren’t at the table. So I think there’s a very welcoming environment out there. I just don’t think that SNFs have yet found — in many markets — their niche to get to the table.
Our desire is that by having SNFs participate with us, and having them aligned with the physicians that are serving their residents, they can collectively work to decrease unnecessary hospitalizations. You can also work on polypharmacy issues that go on in this environment. Physicians and SNFs can work together, and up until this point there hasn’t really been financial incentive for them to do so. And under our model, they can create better quality with more efficiencies.
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