Special Needs Plans Are Special for Long-Term Care

In pursuit of elevating the quality of health care delivered, many care organizations and facilities have added a fourth aim—reducing caregiver burn out—to the classic Triple Aim in health care, which includes improving the health of populations, enhancing the experience of care for individuals, and reducing the per capita cost of health care.¹ In a fee-for-service (FFS) market, where the name of the game is volume and acute fragmented care, it is near impossible to hit any one of these aims. To even get close, a focus on coordinated, team-delivered, patient-centered care is essential. This type of care is not paid under FFS, but it is through value-based care arrangements and entities such as accountable care organizations (ACOs), bundled payments, and special needs plans (SNPs). 

While much has been talked about regarding ACOs and bundled payments, SNPs miss the attention of long-term care (LTC) stakeholders despite the fact that these are the most significant value-based offerings for LTC.

What Is an SNP?

An SNP, created by Congress in 2003, is an MA coordinated care plan (CCP) specifically designed to provide targeted care and limit enrollment to special needs individuals. There are three different types of SNPs²:

1. Dual Eligible SNP (D-SNP) for dual eligibles (2,157,682 enrollees)

2. Chronic Condition SNP (C-SNP), serving an individual with a severe or disabling chronic condition, as specified by the Centers for Medicare & Medicaid Services (CMS) (345,951 enrollees)

3. Institutional SNP (I-SNP) for an institutionalized individual (71,474 enrollees)

Obviously the I-SNP has direct application to LTC stakeholders, as it is specific to skilled nursing facilities (SNFs). But the other SNPs, C-SNP and D-SNP, also have LTC application, as those individuals will be served in the SNF subacute setting as well as after transitioning. A detail even more significant for LTC stakeholders is that, as LTC shifts from facility-based SNFs to the community, older individuals in need of LTC can be better served through these SNPs. Again, these models provide LTC providers opportunities to better coordinate care and provide services beyond those covered by Medicare or Medicaid, such as needs related to social determinants of health.

Types of SNPs

D-SNP

There are 11 million people dually eligible for Medicare and Medicaid in the United State; they are among the highest need populations in both programs. It is quite challenging for enrolled individuals, however, to navigate the current fragmented system due to poor coordination between the Medicare and Medicaid programs, which adds to the cost of both programs. D-SNPs enroll only individuals dual-eligible for Medicare and Medicaid. Starting in 2013, “all D-SNPs must have contracts with the applicable state Medicaid program that contains a description of how the plan will provide and coordinate Medicare and Medicaid-financed care.”³

Over the last few years, some states, health plans, and the federal government have increased efforts to overcome misalignments in Medicare and Medicaid to address some of the challenges that have hindered D-SNPs from more effectively coordinating care for dual-eligible beneficiaries.³ Care management tasks performed by D-SNPs include: (1) conducting assessments of new enrollees; (2) developing care plans; (3) arranging visits to care providers; (4) ensuring medication reconciliation; (5) connecting individuals to social and community supports; and (6) facilitating communication among an interdisciplinary care team. This care management can help improve health for the patients participating in this program.

C-SNP

C-SNPs may target a single chronic condition or more than one condition. These plans can serve beneficiaries with certain severe or disabling chronic conditions, such as cancer, chronic health failure, or HIV/AIDS. The list of specific chronic conditions that a C-SNP can serve are listed in Box 1. These are chronic conditions that are most often dealt with by LTC providers.⁴ CMS notes that they “may periodically re-evaluate the fifteen chronic conditions” upon new evidence of care coordination effectiveness through the SNP product and upon advancements in chronic condition management.⁴

I-SNP

I-SNPs are SNPs that restrict enrollment to MA eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in an LTC/SNF, an LTC nursing facility (NF), an SNF/NF, an intermediate care facility for individuals with intellectual disabilities, or an inpatient psychiatric facility. A complete list of acceptable types of institutions can be found online.⁵ 

An I-SNP that operates either single or multiple facilities, CMS may allow establishment of a county-based service area, as long as the I-SNP includes at least one LTC facility that can accept enrollment and is accessible to county residents. “As with all MA plans, CMS will monitor the plan’s marketing/enrollment practices and LTC facility contracts to confirm that there is no discriminatory impact.”⁵

The below conditions must be met for an I-SNP to enroll MA eligible individuals living in the community but requiring an institutional level of care (LOC)⁵:

1. “A determination of institutional LOC that is based on the use of a state assessment tool.  The assessment tool used for persons living in the community must be the same as that used for individuals residing in an institution. In states and territories without a specific tool, I-SNPs must use the same LOC determination methodology used in the respective state or territory in which the I-SNP is authorized to enroll eligible individuals.”

2. “The I-SNP must arrange to have the LOC assessment administered by an independent, impartial party (ie, an entity other than the respective I-SNP) with the requisite professional knowledge to identify accurately the institutional LOC needs.  Importantly, the I-SNP cannot own or control the entity.”

These “at-risk” models administered through an SNP, through investment in clinical management in the nursing home setting, have the potential to allow individuals to receive care on-site and avoid costly inpatient transfers.⁶

Practical Considerations

Given the high need for flexibility beyond FFS, successful SNPs should focus their attention on wellness, caregivers, coordination, prescription/medication management, end-of-life care, social determinants of health, and mental health. Of these, one of the most critical is medication management. Medication management is meant to assist individuals in taking their medications on time, at the proper time, and consistently, while helping prevent incorrect medication administration and the resulting negative effects. 

Medication management is one of the most important aspects of a SNPs. One of the stakeholders of medication management are LTC pharmacists who tailor care plans to a patient’s needs, educate patients and providers on medications, monitor therapy, make dosage adjustments, identify duplicate therapy, and manage drug interactions/polypharmacy and site formulary decisions. Pharmacists also have a role in transitions of care for LTC patients in case they have a fall or hospital admission as medications may be the cause. LTC pharmacists often write reports when there is a transition-of-care incident to determine if medications may be a culprit of a hospitalization and make recommendation to prescribers on changes to medications or discontinuation of a medication.

To improve clinical outcomes and lower costs, there must be consistent patient engagement with and easy access to a pharmacist expert with personalized medication counseling. Clinical pharmacists should be available to counsel and educate patients and plan members about their medications beyond the services provided in SNFs through drug regimen reviews. Most successful programs are founded on a process which includes motivational interviewing, relationship building, and solving the social determinants of noncompliance. These are the types of services not only possible but essential for SNPs to be clinically and financially successful so as to achieve the Quadruple Aim for LTC patients and providers. 

References

1. Feeley D. The triple aim or the quadruple aim? Four points to help set your strategy. Institute for Healthcare Improvement website. https://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy. Published November 28, 2017. Accessed February 19, 2020.

2. Kaiser Family Foundation. Medicare advantage: special needs plan (SNP) enrollment, by SNP type [2018 timeframe]. Kaiser Family Foundation website. https://www.kff.org/medicare/state-indicator/snp-enrollment-by-snp-type/. Accessed February 19, 2020.