Providers and I-SNPs are ready and demanding a greater role in value-based care

PHOENIX — The relentless push toward value-based care should force qualified care providers to take the reins themselves, even after years of regulators failing to involve them more in the process.

That was the message delivered last week during the eCap West Summit by a national healthcare executive, the head of a major insurance company, and the fastest-growing provider of Institutional-Special Needs Plans (I-SNPs) in the country.

The shift away from traditional Medicare is nothing new. Medicare Advantage penetration is now over 50% in 26 states and Puerto Rico. But as the Centers for Medicare & Medicaid Services continues to push to move all remaining Medicare beneficiaries into MA and other forms of value-based care arrangements by 2030, the pressure is growing.

More VBC arrangements could undermine financial stability at a time of great economic and labor market uncertainty in the long-term care sector, noted Ted Wahl, president and CEO of Healthcare Services Group and moderator of a panel discussion Tuesday. That’s a particular threat because so many VBC programs give acute and primary care providers the authority to make care coordination decisions that often minimize the role of skilled nursing, he noted.

COVID also slowed the shift of more qualified providers to I-SNP arrangements, which allow nursing homes to better target their spending and innovate on the clinical side with per capita payments and the ability to earn risk-based premiums.

This means that many healthcare organizations still have to figure out how to implement and benefit from value-based strategies over the next six years.

“It would be nice to say that every beneficiary is part of a value-based relationship by 2030, but is that really relevant and can be translated into a value-based care model or delivery system for post-acute care? I don’t know if that’s the case yet,” said Jess Dalton, vice president of strategic direction and innovation at Ensign Services.

“We’re certainly trying to get there. I would say we’re constantly communicating and having begging conversations with our managed care partners and leaders locally and nationally to help us develop value-based care concepts and reimbursement methods for the post-acute providers and patients,” Dalton added.

“It has deepened our relationships with our payers and providers. It has shown them that even though we are a small percentage of total Medicare spending, from a quality perspective we can have a significant impact on people’s lives if we just pivot and look at the quality, services and outcomes we can deliver. But that is not cheap and requires additional attention.”

Don’t sit and wait

Dalton said Ensign has sought to adopt several CMS models early, even if it doesn’t provide a direct benefit or cost advantage to nursing homes. The operator, which operates 312 health care facilities in 14 states, is currently drafting a plan to implement the new Transforming Episode Accountability Model (TEAM) that CMS proposed in April.

The company is doing this even before CMS announces which hospitals and markets it will focus on with the mandatory participation.

The alternative payment model puts hospitals in charge of coordinating 30 days of care for patients with traditional Medicare who need to undergo joint replacement, bypass or several other surgical procedures. That would mean connecting patients to primary health services for accountability purposes and paying for use of services such as nursing stays or follow-up visits.

“Holding individuals accountable for all treatment costs associated with an incident can promote care coordination, improve patient care transitions, and reduce the risk of preventable relapse,” said the CMS proposal, which still needs to be finalized before it can take effect in 2026.

“We could wait and start speculating which (areas) will be affected immediately, but instead we are training our teams. We are creating data and dashboards that track developments,” Dalton said.

This enables the company to present itself to hospitals.

“We may have been cut out of that care model, that value-based option, but we believe we can add value and we can increase your value proposition, and that’s how we do it,” Dalton said he would tell his hospital partners. “We’re willing to come to the table and say, ‘This facility is going to be a great partner for you.’ … There’s an element of proactivity. That’s extremely important. We’re all used to chasing the dollar. The dollar is now housed in value. So from an organizational perspective, we’re chasing value.”

I-SNPs accelerate growth

Insurers are also looking for value as they face pressure to eliminate duplicate or otherwise unnecessary benefits from the health care system. That’s one of the goals of Humana’s new plan, offered in partnership with Longevity Health, an independent I-SNP provider that covers 9,000 members at 300 facilities.

“When payers and providers are on the same page on incentives and we agree on quality and cost-effectiveness, we are always in a better position,” said Catherine Field, senior vice president and head of Medicare at Humana. “Ultimately, when we align incentives with providers, we can reduce costs and improve quality.”

Since the end of the public health emergency, the number of registrations at Longevity has increased fivefold, said CEO René Lerer.

“These facilities are really committed to caring for their patients,” Lerer said. “They are very conscious of the services provided to their members inside and outside of that facility.”

I-SNPs haven’t been a priority for most major insurers, Lerer noted. But with demographic shifts and Medicare Advantage becoming more widespread, that’s starting to change. And that means more opportunities for nursing homes to choose partners that can help them deliver better care and get premium payments for quality.

“The world of post-acute care is becoming much more important,” said Lerer.

“We know that nursing homes are under pressure in terms of short-term stays, prices and length of stay,” Lerer later added. “We believe that long-term stays are increasing. The government is pushing hard to move people into home care, but I think we all know that a significant portion of the population is simply not going to leave.”

These long-term residents, many of whom are both Medicare and Medicaid eligible, represent a great opportunity for skilled nursing staff from a value-based perspective. A plan that provides additional clinical support from nurse practitioners and technology can enable more proactive, holistic care for patients who may live in a building for multiple years.

“It’s making us think differently and really understand the nuances of (SNF) businesses that we may not always appreciate when we have 8,000 nursing homes in our network,” Field said. “When we partner on the inpatient, long-term side, we now have a foundation to build a deeper partnership, and I think that benefits both sides.”