Institutional Special Needs Plans could be the tool nursing homes need to find better clinical and financial success and help the government achieve its goals of reducing costs and improving quality, a trio of researchers and policy advisors argues in the New England Journal of Medicine.
But more data is needed to determine whether the plans are generating the kinds of outcomes that the Centers for Medicare & Medicaid Services is pushing for in its other value-based care payment models.
I-SNPs have grown both in the number of plans and in resident enrollment, surpassing 100,000 beneficiaries in 2023. Nursing home participation is often seen as a defensive maneuver, given that the plans can be an alternative to other, lower paying Medicare Advantage plans.
Despite the clinical add-ons provided by plans — most notably nurse practitioners, specialist support and supplemental benefits — it’s currently hard to measure their impact because of misaligned ratings information, the researchers wrote in an Aug. 31 perspective.
“We believe I-SNPs warrant further investigation as a value-based model for financing care provided to nursing home residents. The financial risk taken on by these plans creates incentives for on-the-ground investments in clinical care,” wrote Harvard’s David Grabowski, PhD, and Amanda Chen, PhD candidate; and Scott Sarran, MD, of Harmonic Health and Triple Aim Geriatrics.
Sarran is a member of the Medicare Payment Advisory Commission; Grabowski is a former commissioner.
“Moving forward, we believe there is a need to further assess how the I-SNP model affects operations in nursing homes, especially with respect to the increased expectations for clinical management within the nursing home (as opposed to transfer of residents to the hospital) that is core to the model’s success,” they added.
“It will also be necessary to evaluate the performance of these plans to understand the effects of receiving care under an I-SNP for long-stay nursing home residents. Such evaluations could use metrics that directly capture the quality of the care provided to I-SNP beneficiaries, such as measures of acute-care admissions or resident satisfaction. … Stronger evidence is needed regarding the outcomes that I-SNPs could improve, the mechanisms by which they might do so, and whether and how to increase incentives supporting the adoption of these plans.”
Medicare Advantage plan ratings include data on community-dwelling and institutionalized beneficiaries, while nursing home ratings include both short- and long-stay residents covered by various insurers. It’s not possible to discern the quality or results of specific I-SNPs in specific nursing home populations.
Pace of adoption, effectiveness questioned
The authors also recommended CMS gather more information on the still relatively “slow uptake” of plans by nursing homes, which could include resistance to risk sharing among nursing home owner-operators and challenges around marketing plan participation to individual beneficiaries.
“This type of evidence is important for understanding how I-SNPs fit into the broader context of the Medicare Advantage program, including whether they face issues related to patient selection, coding, and overpayments that are similar to those associated with other types of Medicare Advantage plans as well as challenges related to Medicare Advantage plan sales and marketing processes in these facilities and populations,” the trio wrote.
Their article noted that many previous CMS value-based care models “misalign” the financial interests of CMS, acting as a payer, and nursing homes aiming to deliver quality care services. Medicare Advantage plans have been accused of reducing the cost of SNF care by pressuring facilities into accepting low contractual rates and shortening lengths of stay for skilled care.
I-SNPs instead provide capitation payment to cover Medicare-eligible costs, with the risk that they could be on the hook for any potential difference in actual costs.
“These plans have increased in popularity as a mechanism for nursing homes to potentially share in the savings that can be generated under capitated-payment models if most care can be provided in the nursing home, instead of in a costlier, acute-care setting,” the authors wrote.
