More nursing home residents than ever are enrolled in Institutional-Special Needs Plans, but their benefits remain out of reach to large swaths of Medicare beneficiaries, especially those living in the upper Midwest and Western states.
That’s the finding of a new study published this week in Health Affairs. The authors, including David Grabowski, PhD, of Harvard Medical School, say policymakers must do more to understand why plan providers enter or avoid certain markets and why long-stay nursing home residents choose to enroll if they have the opportunity.
Those insights could be especially important to seniors eligible for both Medicare and Medicaid — so-called dual eligibles who often face challenges in accessing and inefficiencies in paying for comprehensive care.
Research published earlier this year reported 80% of nursing home residents are dual-eligible, but few are using Dual-Special Needs Plans (D-SNPs) designed specifically for them.
“I-SNP benefits are tailored to the needs of long-term nursing home residents and provide an on-site nurse practitioner who works with nursing home staff to improve primary care, care planning, and care coordination,” researchers reported in the latest study. “As a result, I-SNPs may be better suited than D-SNPs to address the care needs of dual eligibles who are long-stay nursing home residents.”
The study, led by Harvard’s Amanda C. Chen and also co-authored by Joseph G. P. Hnath, was described as the first to provide a nationwide descriptive analysis of the I-SNP market. It compared enrollment and plan availability between 2006 and 2021 at both the county and nursing homes levels.
I-SNP enrollment peaked at 140,811 long-stay nursing home residents in 2019, which was a more than sixfold increase over 2006 enrollment.
The number of I-SNPs operating in the US grew from 35 in 2006 to 174 in 2021. Also during that span, the share of long-stay nursing home residents in I-SNPs jumped from 2.2% to 8.8% of all long-stay residents in the US.
Overall enrollment declined in 2020 and 2021, a factor plan providers previously told McKnight’s Long-Term Care News could be attributed to enrollment barriers during the early months of the pandemic.
I-SNP benefits
But plans have continued to forge new partnerships and move into additional counties in states in recent months. Some insurers see the plans as an alternative or supplement to more mass market Medicare Advantage plans for non-institutionalized seniors.
Still, the Harvard researchers found, nearly 70% of nursing homes did not have any residents enrolled in I-SNPs in 2021, and there were no I-SNPs available in more than 60% of counties. Six states had no I-SNPs available at all, and another 45 had counties with no I-SNPs available.
Many sector leaders view I-SNPs as beneficial because insurers provide additional clinical resources, most often nurse practitioners and telehealth services, to address residents’ needs. The research paper cites a 2013 Medicare Payment Advisory Commission analysis that found I-SNPs had lower-than-expected hospital readmission rates and higher rates of medication review than other special needs plans.
In addition to improving patient outcomes, I-SNPs can assist nursing homes unable to afford or coordinate such add-on benefits without a partnership.
The Health Affairs paper found that I-SNP enrollees did appear sicker as time passed, with the share with several chronic conditions — such as diabetes, depression, lung disease, and serious mental illness — growing by more than 10 percentage points in the study window.
“These findings suggest that I-SNPs increasingly may be serving nursing home residents with particularly high levels of medical complexity,” report authors wrote, noting the model may play an important role as policy makers look to align nursing home payment with quality of care and promote health equity.
“Addressing potential barriers to and variation in access to I-SNPs will be important,” they said. “Increased understanding of I-SNPs could inform policies to address long-standing concerns about the quality of care in nursing homes.”
