Despite the turmoil caused by the COVID-19 pandemic, long term and post-acute care providers are continuing to increase their presence in the Medicare Advantage (MA) marketplace by forming on their own or in collaborative arrangements, so-called Special Needs Plans (SNPs), which allow providers more control of the care management of residents who benefit from an increased clinical presence allowed for under such health plans.

This trend is documented in a new report commissioned by the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) and written by ATI Advisory.

Findings in the report include that long term care provider-led SNPs are one of the most promising risk models to emerge from the federal push to delegate risk to providers. The report said at their best, “they combine enhanced primary care with residential long term care [LTC] to reverse the revolving door between nursing homes and assisted living and emergency rooms and inpatient hospitalizations. This is better for residents, families, and the Medicare program.”

Anne Tumlinson, founder and chief executive officer of ATI Advisory, tells Provider the market seems to be embracing these provider-led I-SNPs, which is shorthand for Institutional-Special Needs Plans. In fact, the report said LTC provider-led I-SNPs grew from 9 percent of all I-SNPs offered in 2015 to 33 percent in 2020. Follow-up analysis shows the share growing further to almost 37 percent in 2021.
To delve into the trend, ATI studied three LTC provider-led I-SNP plans, with average membership varying from 269 to 3,086 and time-in-market varying from fewer than five years to 16 years. The plans are offered by PruittHealth, Elmbrook Home, and Senior Select Partners.

Tumlinson said at their core, the three plans worked well because the I-SNP has taken on the full financial risk for the resident members. “This creates a degree of financial alignment with delivery of care that works with families and the members,” she says.

This alignment of care is vital and includes the need for a skilled nurse practitioner (NP) to carry out the health plan’s goals of keeping residents as healthy as possible in a proactive manner.

“Being at risk for the total cost of care gives the nursing home providers the ability to invest in all of the things that they truly need to do,” Tumlinson says.

Even though the pandemic has tested this model, given the higher costs of care necessary, Jill Sumner, AHCA/NCAL vice president of population health management, says interest among LTC providers has not waned.

“There is still a lot of interest and growth. Financially, it has been very hard on plans that were hit hard by COVID, because hospitalization costs can be quite expensive and were not budgeted for,” she explains. “But we also have heard loud and clear that without this model providers would not have been able to weather this storm as well as they have from a clinical perspective.”

Among the key highlights in the report are outlines of what providers need to do to have the best chance at being successful in the I-SNP universe. These requirements, the report said, include hiring onsite health plan staff, or member advocates, to help navigate member issues with SNP benefit coverage, services, and provideSecondly, the I-SNP needs a culturally competent NP to spearhead the clinical care aspects of the health plan.

“Care management and the Model of Care are not well executed without an engaged NP who takes the time to connect with their patients to not only recognize change in status in a timely manner, but also gain trust to skill in place [take skilled care in the facility]. This means going above and beyond traditional medicine by getting to know the resident and family and understanding culturally specific attitudes and values,” the report said.

Among the critical decisions and challenges to starting and operating an I-SNP are in recruiting NPs to serve in rural areas and finding experienced member advocates, the report said.

Find the report here.