Our Work

An Idea That’s Growing

Long-Term Care Providers Taking Charge in Managed Care

THE ISSUE

While traditional insurance companies sponsor most Medicare Advantage (MA) plans, a growing number of hospitals, health systems, and physician groups also offer this coverage. Provider-led plans in long-term care facilities represent an important innovation with potential to improve resident care and quality of life, reduce unnecessary medical utilization and total Medicare spending, and strengthen the financial sustainability of long-term care facilities providing critical community services. As provider-led plans gain visibility, state and federal policymakers will look to understand the the benefits and challenges of these plans to inform industry standards.

OUR WORK

ATI Advisory analyzed Medicare Advantage data on provider-led plans. We found that I-SNPs led by LTC providers now comprise 33 percent of all I-SNPs. Most LTC provider-led I-SNPs are smaller than traditional Medicare Advantage plans, but enrollment is growing.

We also studied three long-term care provider-led I-SNPs, with average membership varying from 269 to 3,086 and time in market varying from 16 years to fewer than 5 years. Our interviews with plan leadership focused on their perceptions and lessons and results to date.

Case study participants emphasized that to be successful, provider-led I-SNPs must achieve two core goals: enroll residents and reduce unnecessary inpatient hospitalizations among the enrolled population. The information collected through these interviews revealed competencies necessary to achieve the core goals. We organized these factors into a six-component framework for successful operation of an LTC provider-led I-SNP.

OUR VIEW

LTC provider-led SNPs are one of the most promising risk models to emerge from the federal push to delegate risk to providers. At their best, they combine enhanced primary care with residential long-term care 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.

As with any innovation in healthcare, federal policymakers have an obligation, as this trend continues to grow, to protect against potential plan abuses and failures. But they also have an opportunity to enhance scale and expansion among providers who execute well against our six-component framework for success. With time, this degree of support and engagement will foster a broader scaling of care models that improve outcomes among the complex care population, regardless of where they live.

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