Innovation and disruption
SNPs Create Unique Opportunities for Post-Acute Providers
The recently passed Bipartisan Budget Act of 2018 (BBA 2018) included several provisions impacting health care, including the Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act (CHRONIC Care Act). Of the many provisions, one in particular appears to be getting attention from certain post-acute providers. That provision relates to Special Needs Plans or “SNPs” that fall under Medicare Advantage. SNPs create a unique opportunity for post-acute providers, and although they may not be appropriate for all, some are taking a closer look to determine if participation could be a viable strategy.
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) created a new type of coordinated care plan within Medicare Advantage. These coordinated care plans focus on individuals with special needs for specific diseases or conditions, and are tailored to meet those needs. In general, there are three types of special needs populations that SNPs are allowed to target for enrollment:
- Chronic conditions or “C-SNP”: Individuals that have one or more severe or disabling chronic conditions such as cardiovascular disorders, end stage renal disease (ESRD), dementia, HIV/AIDS, or neurological disorders.
- Institutional or “I-SNP”: Individuals who live in an institutional setting, such as a nursing home, or require nursing care at home.
- Dual eligible or “D-SNP”: Individuals who have both Medicare and Medicaid coverage.
SNPs provide coordination of care, identify providers, and in some cases provide care coordinators to assist with a variety of different activities aimed at keeping members healthy. While enrollment remains a small part of total Medicare beneficiaries at just over 4 percent, enrollment has grown from 670,000 in 2007 to about 2.36 million in 2017. SNPs were set to expire on December 31, 2018, but with the passage of BBA 2018 and the provisions of the CHRONIC Care Act, they have been made permanent, and therefore we can expect enrollment to continue to grow in the coming years.
Key strategy considerations
While SNPs are coordinated care plans under Medicare Advantage, certain post-acute providers are considering participation in them either by establishing their own Medicare Advantage plan or as a contracted provider. CMS requires SNPs to have specific Models of Care (MOCs) that will provide critical guidelines on how care will be provided to enrollees. These MOCs are often designed to reduce avoidable hospital admissions and readmissions, provide care in the nursing facility when clinically feasible, and ensure residents are achieving optimal living functions. Success in implementing the MOCs, in most cases, will require elevating the clinical capabilities at the nursing facility.
Improving clinical practices
While not directly related to SNPs, a study released by The Centers for Medicare and Medicaid Innovation (CMMI) in September 2017 provides some insights into the processes and challenges associated with improving clinical capabilities in post-acute facilities. The report titled CMS’s Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents provides a detailed analysis of how participating facilities were able to change their clinical practices and directly impact hospitalization of nursing facility residents. CMS partnered with seven Enhanced Care and Coordination Provider (ECCP) Organizations in different states who in turn partnered with 143 different nursing facilities. The ECCPs were required to employ registered nurses (RNs) or advanced practice registered nurses (APRNs). The key variables that were monitored as part of the study were:
- All-cause hospitalizations
- Potentially avoidable hospitalizations
- All-cause emergency room visits
- Potentially avoidable emergency room visits
- Medicare expenditures associated with each of the above
One ECCP operating in Missouri (MO ECCP) was able to claim statistically significant positive effects on all measurements. The goal of the MO ECCP was to work with nursing facilities that had high populations of Medicare and Medicaid residents and high hospitalization rates and to help them:
- Reduce rates of avoidable hospitalizations
- Improve health outcomes
- Improve transitions between hospitals and nursing homes
- Reduce health care costs
The table below shows that the MO ECCP successfully reduced hospitalizations and emergency department (ED) visits during the demonstration period. The table also highlights the effect on Medicare expenditures for the same measures and time period. The change in each measure for both utilization and Medicare expenditures was considered statistically significant, and the MO ECCP was the only ECCP of the seven in the study to achieve this type of result across all measures monitored.
The key to the MO ECCP’s success was employing APRNs who delivered clinical care to residents, along with training, mentoring, and education to existing staff. The APRNs also provided support to the nursing facility staff on how to effectively use key tools to monitor and document changes in resident health, medication management, quality improvement initiatives, advanced directives, and end of life care.
Opportunities in payment transformation
As payment transformation continues to evolve, providers across the full continuum are evaluating which opportunities might provide their specific organizations the greatest potential for success. For some post-acute providers, participation in a SNP presents a new and unique strategy. For others, it may not be a viable approach. Whatever direction is chosen, post-acute providers have an opportunity to position themselves as attractive options for insurers, other providers, and patients by developing capabilities to deliver higher quality care through effective and efficient care pathways.
Demonstration projects like the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents conducted by CMS provide insights and a potential framework to guide post-acute providers along this path of change. The framework may not work for all providers, as each organization has its own unique set of challenges, so variation and modification will be necessary. But if you’ve been standing on the edge debating about dipping your toe into the water, these insights may be the springboard you’ve been waiting for to immerse yourself in the pool of change.
How we can help
Transforming organizational culture and capabilities is no small or easy task. We understand the challenges associated with these changes and will come alongside you and key stakeholders in your organization to develop tailored strategies for improvement. Our professionals are as passionate about the future of health care as we are about positioning you for success. If you are not sure where to start, or are uncertain about how to face these challenges in the future, we’d love to hear your thoughts, and we want to help you.