1. SNP Alliance 13th Annual Leadership Forum Washington, DC
The Role of Nursing Facilities in Serving Enrollees in Special Needs Plans
SNP Alliance 13th Annual Leadership Forum
Washington, DC
November 2, 2017
James M. Verdier
Senior Fellow
Mathematica Policy Research

2. Overview of Main Points
Medicare short-term skilled nursing facilities (SNFs) and Medicaid long-term nursing facilities (NFs) play major roles in providing care for Medicare and Medicaid beneficiaries
SNF and NF care in the fee-for-service (FFS) system is not well coordinated with other services or provided in the most cost-effective way
Medicare Special Needs Plans (SNPs) have opportunities to improve SNF and NF care and reduce costs
Dual Eligible Special Needs Plans (D-SNPs) have broader opportunities to improve nursing facility care than Institutional SNPs (I-SNPs), since D-SNPs also have varying degrees of responsibility for Medicaid long-term supports and services (LTSS)
I-SNPs can provide a greater focus on improving short-term Medicare SNF care and coordinating that care with hospital and physician care and other Medicare services
SNP tools to improve care and reduce costs include care coordinators, information exchange systems, selective contracting, and value-based purchasing (VBP)
Use of these tools should be informed and supported by quality and performance measurement
SNPs can build on measurement and improvement initiatives that already exist in the FFS system

3. Medicare and Medicaid Nursing Facility Spending and Utilization
Medicaid and Medicare paid for more than half of all nursing facility care in 2015
Medicaid – 32%
Medicare – 24%
Over 90 percent of all nursing facilities provide both Medicaid and Medicare services
NFs accounted for 50% of all FFS Medicaid spending on full benefit dually eligible beneficiaries in 2012, and SNFs accounted for 13% of Medicare FFS spending on full duals
10% of full-benefit dual eligibles used FFS Medicare SNF services in 2012 (vs. 4% of Medicare-only beneficiaries)
21% of full-benefit dual eligibles used FFS Medicaid NF services in 2012
SOURCE: ICRC Working with Medicare webinar, “Medicare and Medicaid Nursing Facility Benefits: The Basics and Opportunities for Integrated Care,” April 27, Available at: Slides%20WWM%20on%20SNF%20NF%20Benefits%20%20(Final)%20for%20508%20review.pdf

4. Enrollment in Medicare-Medicaid Plans, PACE, FIDE SNPs, Integrated D-SNP/MLTSS Plans, and I-SNPs

5. Current Aligned Enrollment in Integrated Plans*
Plan Type
2017 Aligned Enrollment
States
Medicare-Medicaid Plans (MMPs)
408,934
CA, IL, MA, MI, NY, OH, RI, SC, TX, and VA
PACE
40,379
31 states
FIDE SNPs
151,437
AZ, CA, MA, MN, ID, NJ, NY, and WI
Non-FIDE SNP Integrated D-SNP/MLTSS Plans
67,043
CA, MN, TN, and TX
*Aligned enrollment refers to the number of dually eligible enrollees who are obtaining both Medicare and Medicaid services from the same plan, or from companion plans operated by the same company in the same geographic area. Enrollment is for October, except for Non-FIDE SNP Integrated D-SNP/MLTSS Plans, which is for July.

6. I-SNP Enrollment by State, October 2017
Number of I-SNP Plans
Total I-SNP Enrollment
New York 11
18,525
Florida 8
5,190
Pennsylvania 7
4,797
Georgia 3
3,368
Connecticut 2
3,280
Colorado
3,181
North Carolina
3,007
Arizona 4
2,744
California
2,615
New Jersey
2,388
Wisconsin
2,230
Washington
1,783
Rhode Island
1,758
Virginia 5
1,680
Ohio
1,637
Indiana
1,422
Maryland
1,223
Oregon 6
Washington, D.C.
927
Delaware
Illinois
920
Nevada 1
646
SOURCE: CMS SNP Comprehensive Report, October Available at: Report html?DLPage=1&DLEntries=10&DLSort=1&DLSortDir=descending

7. I-SNP Enrollment by State, October 2017
Number of I-SNP Plans
Total I-SNP Enrollment
Texas 2
344
Oklahoma 1
197
Kentucky
193
Tennessee
177
Maine
149
New Hampshire
Massachusetts
121
South Carolina 43
Kansas 25
Michigan
TOTAL1
106
68,237
1 Ten plans spanned across multiple states. In this table, we divided the number of enrollees in those plans evenly across the states and added the plan to each state’s total number of D-SNP Plans. The total excludes 18 enrollees in plans with fewer than 11 enrollees

8. United and Other I-SNP Enrollment, October 2017
Note: United HealthCare I-SNP enrollment includes Care Improvement Plus, Oxford Health Plans, and Sierra Health and Life.
SOURCE: CMS SNP Comprehensive Report, October Available at:

9. Special Needs Plan Opportunities to Improve Care and Reduce Costs in Nursing Facilities

10. ICRC TA Briefs
Reducing Avoidable Hospitalizations for Medicare-Medicaid Enrollees in Nursing Facilities: Issues and Options for States (April 2015)
Available at: ospitalizations%20508%20complete.pdf
Value-Based Payment in Nursing Facilities: Options and Lessons for States and Managed Care Plans (October 2017)
Will be posted shortly on ICRC web site:
MACPAC identified 23 states that were using VBP programs to improve quality in nursing facilities in 2014
ICRC interviewed state officials and managed care plans in 6 of those states for the TA brief
Arizona, Indiana, Minnesota, Ohio, Tennessee, and Texas
Appendices provide detailed information on VBP program structure and quality/performance measures used in the 6 states

11. Strategies to Reduce Avoidable Hospitalizations in NFs: Findings from a CMS Initiative
CMS demonstration selected organizations in seven states (AL, IN, MO, NE, NV, NY, and PA) to work with nursing facilities to reduce avoidable hospitalizations of long-stay residents in FFS
Results from evaluation covering
Decline in all-cause hospitalizations (all 7 states)
Decline in Medicare expenditures (6 states)
Strategies of most successful models (IN, MO, and PA):
Strong role of Initiative-funded nurses
Consistent, hands-on clinical care led to changes in facility culture, support for reducing avoidable hospitalizations, and buy-in from facility staff
Importance of building relationships
Strong relationships between nurses and staff, and between nurses and primary care providers
Most sustainable initiative components
INTERACT tools, medication review focused on reducing antipsychotic medications, quality improvement efforts to reduce avoidable admissions, and use of advance care planning/advance directives
Potential challenges to implementation
Staff turnover, consistent buy-in among physicians, pressure from family for hospitalizations, difficulty with new technology, facility leadership support, time of initiative implementation
For health plans: limited resident count could impact NF willingness to participate
Next phase of the initiative will begin using payment as an additional tool
SOURCE: ICRC e-alert. “Spotlight: Latest Evaluation Results from the CMS Initiative to Reduce Avoidable Nursing Facility Hospitalizations.” March 29, Available at:

12. Medicare SNF FFS Payments: Recent Trends
High and sustained Medicare SNF margins (difference between Medicare payments and provider costs)
Over 10% for 16 years in a row
12.6% in 2015
In 2015, 9% of facilities (1,007) with relatively low-cost and high-quality care had median Medicare margins of 19.4%
Costs varied widely among facilities
Variation in costs based on ownership and coding practices
Variation not attributable to case mix
Medicare Advantage pays considerably less than FFS
Medicare FFS daily payments received in 2016 by four large nursing home companies averaged 23% higher than Medicare Advantage rates
May be due to lower payment rates and/or stricter rules than FFS for SNF admissions, lengths of stay, therapies, etc.
SOURCE: Medicare Payment Advisory Commission (MedPAC). “Report to the Congress on Medicare Payment Policy.” Chapter 8: Skilled Nursing Facility Services. March 2017:

13. Transitions From Hospitals to SNFs
In FFS, Medicare beneficiaries who are discharged from a hospital with a need for post-acute SNF care receive little or no assistance in choosing a SNF
Some hospitals have sought to establish preferred networks of SNFs to reduce future readmissions, with limited success
See John P. McHugh, et al. “Reducing Hospital Readmissions Through Preferred Networks of Skilled Nursing Facilities,” Health Affairs, September 2017, vol. 36, no. 9, pp
Health plans that are at risk for both hospital and SNF costs have greater incentives to use such preferred SNF networks, and may have greater leverage with SNFs

14. Measuring Nursing Facility Quality and Performance

15. Available Quality/Performance Measures
Nursing Home Compare
Basic source of CMS measures for Medicaid and Medicare nursing facilities
Includes measures for both short-stay and long-stay residents
For more information, see:
SNF Quality Reporting Program (QRP)
Starting in FY 2018, payment penalties for failure to report specified measures
SNF Value-Based Purchasing Program (VBP)
Begins in FY 2019
Payment penalties and incentives based on SNF all-cause 30-day readmission measure
For more information on QRP and VBP, see:
MLN/MLNProducts/downloads/snfprospaymtfctsht.pdf
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16. Mathematica Policy Research E-Mail: jverdier@mathematica-mpr.com
Contact Information
James M. Verdier
Senior Fellow
Mathematica Policy Research
1100 1st Street, NE, 12th Floor
Washington, DC
Phone: (202)