From managed care burdens and “punitive, vindictive surveys,” to threats posed by the potential federal staffing mandate and issues stemming from the “radically broken” Five Star rating system, Ignite Medical Resorts CEO Tim Fields is well aware of the many challenges facing skilled nursing providers.
But as Ignite celebrates its fifth year as a company and expands into its seventh state, he is trying to push for solutions to the sector’s thorny problems.
His perspective on the staffing mandate provides one example. Fields is optimistic that the mandate will not take effect as currently written, given the huge groundswell of advocacy and the sheer impossibility of meeting the proposed requirements. But he emphasized that providers should not just fight against the mandate but push for better policies.
“Let’s talk solutions,” he told Skilled Nursing News, during an interview at the recent National Investment Center for Seniors Housing & Care (NIC) Fall Conference in Chicago.
Those potential solutions include policies that would increase the pipeline of immigrant caregivers and clinicians to U.S. facilities, Fields said. He also cited the need for more resources and support to enable providers to run CNA and nursing schools to elevate their own pool of workers.
“Some states are super easy, some are horrible,” he said. “We just went through something in Illinois, where it took us almost two years to do a CNA school. That’s ridiculous.”
He also floated the notion that incentives – perhaps tax breaks – should be created to motivate people to become caregivers.
While advocating for these policy changes, Fields said that he and other Ignite leaders continue to bring “a ton of energy” to hiring and retaining the right people for the company’s demanding but rewarding model. That model revolves around caring for complex patient populations, with consistency of outcomes but flexibility in operations to meet the needs of hospital systems and payers across different markets.
Ignite’s 5-year journey: PDPM, Covid-19 and beyond
Ignite has weathered five tumultuous years since the company’s founding, from the dawn of the Patient Driven Payment Model (PDPM) through Covid-19 and the pandemic’s economic and regulatory aftershocks.
But while the road has not been easy, Ignite’s model – rooted in being able to care for high-acuity patients – has stood up well to the particular challenges of the last few years. In fact, because of Ignite’s clinical capabilities and the fact that the company did not have a long-term care population to protect, the pandemic created opportunities for Ignite to demonstrate its strengths.
“Probably the best thing we ever did was, we were one of the first in the country raising our hands … opening Covid units,” Fields said.
Ignite’s leadership made that decision in April 2020, driven by the intense needs they observed in their markets. For instance, an Ignite facility was right across the street from a Kansas hospital trying to cope with a large number of Covid patients.
“We’re going to care for them, and here’s how we’re going to do it,” Fields said, explaining the company’s message to concerned state officials.
This approach of identifying and trying to meet the needs and pain points of hospitals and health systems has extended beyond Covid-19. As a result, Ignite has had to be a “chameleon,” changing its colors from one market to the next, specializing in a range of services – be that respiratory, bariatric, cardiac, mental health or other types of care.
Often, the health systems are seeking assistance with populations that have complex needs and are difficult to manage within the context of value-based frameworks such as bundled payments or accountable care organizations (ACOs), which place a premium on reduced rehospitalizations and delivering population health solutions.
In these situations, Ignite seeks to become a “center of excellence,” Fields said. To explain the concept, he drew on the example of patients with end-stage renal disease (ESRD) or renal cystic disease (RCD).
“They’re sick – they’re not just on dialysis, they have hypertension, diabetes, there are a lot of issues,” Fields said. “So if … we’re going to be a center of excellence for that, we’re not only going to do dialysis, we’re going to to peritoneal dialysis, we’re going to do a CKD [chronic kidney disease] program, we’re going to work with your nephrology group and really develop this care program.”
This approach not only helps drive referral volume but supports the bottom line, given that PDPM scales up reimbursement based on acuity.
“PDPM has been really good to us,” Fields said.
Still, he believes that the skilled nursing reimbursement system is broken, because payments are not tied to quality. And he thinks that the way that quality is measured and reported via Five Star also is “radically broken.”
One major problem lies in how closely tied star ratings are to surveys.
“If you have one harm tag, you’re automatically a one- or two-star building,” he said. “So if you take care of 2,000 patients in a year, and you have one issue with one patient that is arbitrarily tagged by a surveyor who doesn’t know what they’re doing, now our star rating is automatically broken.”
Adding to this issue, some states are more punitive than others in their approach to surveys. At the moment, this is an area of major concern for Fields, who said that in the last six months, he has seen more “punitive, vindictive” surveys than ever before.
“We just have some of the weirdest stuff I could ever imagine, where states are not accepting IDRs [informal dispute resolutions] that we win,” he said. “We have a surveyor come out and say that a complaint is unsubstantiated, and then we get a 2567 with a tag – it just doesn’t make any sense.”
Other providers also have expressed concern over how surveys are being conducted presently, and they have explained that the trend is driven in part by the large number of recently hired – and therefore eager but inexperienced – surveyors. But Fields is not sure what is behind the difficult survey environment, except that he sees it as a “top down” issue; that is, as the latest outgrowth of the Biden administration’s generally antagonistic stance toward the sector.
Once again turning to solutions, Fields proposed that quality measures – such as fall rate, rehospitalization rate and the like – should be weighted more heavily and utilized in a reformed reimbursement model, because these data points are less subjective than surveys and therefore can drive greater alignment and consistency across states.
Such a system could form the basis of reimbursement reforms and also would be more helpful to consumers and hospitals, Fields argued. Consumers today all too often are stymied by the Five Star system, because the ratings do not reflect variations in the acuity of patient populations cared for by SNFs. A patient being discharged might want to go to a facility rated five stars, only to be told that they will not be accepted there due to the complexity of their needs.
For similar reasons, star ratings are not reliable indicators to hospitals as to which SNFs in their markets that are likely to be the most effective partners. And Fields said he has to expend needless energy explaining to hospitals why, despite low star ratings, some Ignite facilities still are strong partners, as reflected in metrics such as rehospitalizations and in the level of clinical care they can deliver.
Managed care burdens
While PDPM has benefited Ignite, the rise of Medicare Advantage has created pressures for the company, as for many others across the sector. Managed care payments now account for about 40% of Ignite’s business, Fields said, and a particular concern relates to variation across states. That is, even large insurers such as UnitedHealthcare and Humana are working with Ignite at a state level rather than a national one, and these managed care organizations “talk differently” and offer different terms across states.
“Why am I being paid differently in San Antonio, Texas, than Chicago if I have the same cost structure? … Managed care is arbitrary,” Fields said.
Ignite is trying to shift the conversation with the large payers by drawing their attention to the large volume of beneficiaries that Ignite serves, despite operating a relatively small number of facilities in total.
“We’re number one in Kansas City, we’re number one in Chicago, we’re number one in all the major markets in Texas – we’ve got a lot of admission volume, so we’re taking care of their members, it’s just they don’t have the ability to tie it all together,” Fields said. “So, that’s an administrative burden.”
Ignite also is focused on justifying its value in order to win more favorable payment rates from Medicare Advantage insurers. This involves demonstrating through data that Ignite can take complex patients and provide high-quality care with strong outcomes – including low rehospitalization rates and favorable length-of-stay numbers – at lower costs than other settings.
And Ignite touts its case management team of 11 dedicated employees, to keep billing and other important administrative and regulatory processes timely and accurate.
“It’s the bigger plans … that I don’t think see a value in our industry; they see it as a necessary evil that they have to send patients to us,” Fields said. “So, we’re trying to create that value-add.”
Growth strategy, strategic initiatives
Ignite’s recent entry into Indiana is an example of the type of growth that the company is pursuing, Fields said – that is, “smart growth that makes sense, that fits our model, that [means] we can continue to grow our mission and vision.”
More specifically, the two newly acquired facilities are located in the Northwestern Indiana markets of Dyer and Crown Point, which are close to Illinois markets where Ignite already has a stronghold. Furthermore, Fields is familiar with these buildings, as he opened them when he was with Symphony in 2015. They are eight years old with private rooms and able to run on Ignite’s operational model.
“They’re great buildings, have great people,” Fields said.
The “people” part of the equation is particularly important and has been the focus of several initiatives – including a daycare discount program and a pet insurance discount program – meant to further Ignite’s culture.
Professional development is another key priority, and involves some initiatives by Ignite’s clinical leaders to redevelop certain programs.
“We educate our facilities so that we can continue to strengthen our disease management in cardiac and pulmonary and renal and stroke, et cetera, where you can really fine-tune those programs, and then go integrate them [with] the hospitals and show value, again,” he said.
He is keenly aware that working in a SNF is a demanding job that can be draining, and he is striving to strike the right balance of accountability and appreciation to further Ignite’s culture while driving quality.
“We want to have fun in our buildings, we want to be celebrating, we want you to go home and tell your spouse, I had a great time at work today,” he said.
And even through the harder challenges that come with working in a SNF, the rewards should compensate for the difficulties.
“It’s exciting when you get to see these high-acuity patients that we’ve taken that are going home, and their family [says], ‘I didn’t think my dad would walk again,’ or, ‘We didn’t think we’d ever take mom home.’ Those are great stories, and that keeps leading us into why we’re doing this,” Fields said.