Walking away from a Medicare Advantage plan may be disruptive, but some of the largest nursing home providers haven’t hesitated to cut ties with plans that fail to reimburse adequately. They say the risks can outweigh the rewards, particularly when promised increases in referral volume often don’t materialize.
At the opening session for Skilled Nursing News’ RETHINK conference taking place in Philadelphia this week, Saber Healthcare Group President and Founder Bill Weisberg, Majestic Care CEO Paul Pruitt and Creative Solutions in Healthcare CEO Gary Blake discussed, among other topics, the financial and operational challenges MA plans create for skilled nursing operators.
Saber has ended five to seven contracts over the past 24 months, Weisberg noted, including one just two weeks ago because they didn’t cover the cost of care. In his view, accepting lower reimbursement in exchange for the promise of more referrals often doesn’t work out because the MA plans cannot control where patients ultimately go.
“They don’t have control over the discharge planners or where families want to go, or the communities. So there’s no argument there that wins with me,” he said.
The solution to countering low reimbursing MA plans according to Weisberg: “I’d rather just cancel those contracts and put the pressure back on our leaders to go replace those with properly paying residents, and put it back to the residents to go fight with their insurance companies to make sure that they’re getting the best coverage that they should get.” he said.
At the same time, Weisberg said operators can strengthen their negotiating position by using data. Saber analyzes metrics including cost of care, length of stay, hospital readmissions and outcomes to demonstrate to MA plans that higher reimbursement can still result in more efficient care. In some cases, he said, plans have returned to the negotiating table after Saber presented comparative data and made the case for an additional $25 to $35 per day – and received the higher rate.
“We will walk away from those contracts, but we also go into them when we negotiate,” Weisberg said. “A lot of times, we find that they’ll come back to us, and we’ll be able to provide that data. So it’s kind of like you’re playing a game of chicken.”
At Creative Solutions, Blake said he and his team have tackled low reimbursement with MA plans by also walking away, but educating the residents.
“[We] have zero problem walking away from a contract. We also have zero problem educating the beneficiary, the recipient, of [their] benefit, in educating them because you can’t be a member of the plan one day and a victim the next,” Blake said. “We educate our families. Say there seems to be a lot of hospital visits … your MA plan may not be the best one for you. There are better ones out there, or there’s always traditional Medicare.”
Incentives offered by MA plans such as $25 grocery cards and other supplemental benefits overshadow the quality and adequacy of health care, but that has to be pointed out to the residents, Blake said.
Notwithstanding the original goal of using managed care to control health care costs, the system has become an increasingly difficult “game” for providers, Pruitt said. Operators are asked to meet quality and cost metrics with the expectation that improved performance will lead to better economics, but he said that promise often doesn’t pan out.
“I don’t oppose MA plan for what the purpose was supposed to be. On the other side, I wish they would all just go away,” said Pruitt. “You don’t get more referrals, you don’t get more patients, you don’t get any more profit. Now [MA plans] profit,” Pruitt said.
Advocacy for change
Operators also need to advocate for broader changes to the Medicare Advantage system. Creative Solutions is in ongoing discussions with lawmakers in Washington, and Blake argued that providers need to continue pushing for policies that better support seniors and the organizations caring for them.
“There has to be change, and it has to come from D.C. where nothing gets done. But you’ve got to have that conversation with them,” Blake said.
MA policies have created a tension between financial requirements and clinical judgment, he said, and can make it more difficult for nurses and therapists to focus on patient care. After all, providers can receive payment reductions or discharge pressures shortly after a patient enters a facility, even when clinicians believe the patient is not ready to return home.
“One of my biggest roles has been very heavily in Washington, meeting with the Ways and Means Committee, and sitting in rooms and really talking about the challenges, the struggles, advocating very strongly for a better outcome because it can’t continue. This cannot continue to be the solution where a patient comes in a building, they walk in the door and day two you’re getting a cut notice,” Pruitt said. “If I had my wish, I wish they would all just go away, but they’re not. So then, how do we advocate and fight for the right things for our seniors?”
The answer may lie in course correction through advocacy efforts when it comes to managed care plans.
Companies featured in this article:
Creative Solutions in Healthcare, Majestic Care, Saber Healthcare Group
