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The American Journal of Managed Care September 2019
VA Geriatric Scholars Program’s Impact on Prescribing Potentially Inappropriate Medications
Zachary Burningham, PhD; Wei Chen, PhD; Brian C. Sauer, PhD; Regina Richter Lagha, PhD; Jared Hansen, MStat; Tina Huynh, MPH, MHA; Shardool Patel, PharmD; Jianwei Leng, MStat; Ahmad Halwani, MD; and B. Josea Kramer, PhD
The Sociobehavioral Phenotype: Applying a Precision Medicine Framework to Social Determinants of Health
Ravi B. Parikh, MD, MPP; Sachin H. Jain, MD, MBA; and Amol S. Navathe, MD, PhD
From the Editorial Board: Jan E. Berger, MD, MJ
Jan E. Berger, MD, MJ
Medicaid Managed Care: Issues for Enrollees With Serious Mental Illness
Jean P. Hall, PhD; Tracey A. LaPierre, PhD; and Noelle K. Kurth, MS
Multi-Payer Advanced Primary Care Practice Demonstration on Quality of Care
Musetta Leung, PhD; Christopher Beadles, MD, PhD; Melissa Romaire, PhD; and Monika Gulledge, MPH; for the MAPCP Evaluation Team
Physician-Initiated Payment Reform: A New Path Toward Value
Suhas Gondi, BA; Timothy G. Ferris, MD, MPH; Kavita K. Patel, MD, MSHS; and Zirui Song, MD, PhD
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Managed Care for Long-Stay Nursing Home Residents: An Evaluation of Institutional Special Needs Plans
Brian E. McGarry, PT, PhD; and David C. Grabowski, PhD
Did Medicare Advantage Payment Cuts Affect Beneficiary Access and Affordability?
Laura Skopec, MS; Joshua Aarons, BA; and Stephen Zuckerman, PhD
Medicare Shared Savings Program ACO Network Comprehensiveness and Patient Panel Stability
Cassandra Leighton, MPH; Evan Cole, PhD; A. Everette James, JD, MBA; and Julia Driessen, PhD
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Evelyn T. Chang, MD, MSHS; Rebecca Piegari, MS; Edwin S. Wong, PhD; Ann-Marie Rosland, MD, MS; Stephan D. Fihn, MD, MPH; Sandeep Vijan, MD; and Jean Yoon, PhD, MHS
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Kevin N. Griffith, MPA; Donglin Li, MPH; Michael L. Davies, MD; Steven D. Pizer, PhD; and Julia C. Prentice, PhD

Managed Care for Long-Stay Nursing Home Residents: An Evaluation of Institutional Special Needs Plans

Brian E. McGarry, PT, PhD; and David C. Grabowski, PhD
This study examines UnitedHealthcare’s Institutional Special Needs Plans and their association with hospital and skilled nursing facility use.

Objectives: To evaluate the patterns of clinical service use for long-term nursing home residents enrolled in UnitedHealthcare’s Medicare Advantage Institutional Special Needs Plans (I-SNPs), which provide on-site direct coordinated care for beneficiaries through the use of advanced practice clinicians.

Study Design: Observational analysis of 8052 I-SNP members and 12,982 Medicare fee-for-service (FFS) long-term nursing home residents across 13 states.

Methods: Multivariate analyses were performed to compare rates of emergency department (ED), inpatient, and skilled nursing facility (SNF) use between I-SNP members and Medicare FFS long-term nursing home residents.

Results: In comparison with FFS institutionalized Medicare beneficiaries, I-SNP members had 51% lower ED use, 38% fewer hospitalizations, and 45% fewer readmissions, whereas their SNF use was 112% higher.

Conclusions: “At-risk” models, administered through specialized Medicare Advantage plans, that invest in clinical management in the nursing home setting have the potential to allow individuals to receive care on-site and avoid costly inpatient transfers.

Am J Manag Care. 2019;25(9):438-443
Takeaway Points

In comparison with traditional Medicare fee-for-service nursing home residents, Institutional Special Needs Plan beneficiaries had lower rates of emergency department and inpatient use and higher rates of skilled nursing facility use. Managed care models that use advanced on-site clinicians to care for nursing home residents, in conjunction with a health plan being financially responsible for nursing home and medical care, may help prevent costly transfers to hospital settings.
Many nursing home residents experience poor access to clinical care, which often leads to unnecessary healthcare utilization and poor health outcomes.1-3 For long-term nursing home residents who will likely spend the remainder of their life in a facility, their care is typically either financed by Medicaid or paid out of pocket. However, all of their healthcare, including physician, hospital, postacute, and hospice care, as well as prescription drugs, is covered by Medicare. Thus, nursing homes typically have minimal incentive to invest in on-site clinical models because the payers of long-term nursing home care will not cover it and any savings from decreased hospital or emergency department (ED) utilization go to the Medicare program.4

Medicare Advantage (MA), which replaces traditional Medicare fee-for-service (FFS) coverage with a managed care model, has incentives and tools to promote high-value healthcare services.5-7 Because MA plans are “at risk” for any healthcare spending, they have an increased incentive to invest in clinical care at the nursing home.8 The basic financial model is that the MA plan is paid on a capitated basis by CMS, and contracted providers submit claims that would otherwise be submitted to CMS to the plan for payment. Long-term nursing home costs are covered by Medicaid or paid privately, but the MA plan is financially responsible for all Medicare-eligible costs, regardless of setting. Institutional Special Needs Plans (I-SNPs) are a specialized form of MA that is limited to Medicare beneficiaries who are long-term (ie, ≥90 days) nursing home residents or are certified as needing nursing home–level care. In 2017, 61,694 beneficiaries nationally were enrolled in these plans, which is a relatively small share of the almost 1 million long-term nursing home residents.9 However, these plans were created, in part, to help align the financial incentives of the nursing home and Medicare and to improve care delivery across various healthcare settings.10

UnitedHealthcare offers a number of I-SNPs in numerous states. All of these plans include a model of care—formerly known as the Evercare model—that provides enhanced care in the nursing home through the use of advanced practice clinicians (ie, nurse practitioners and physician assistants). These on-site clinicians coordinate and deliver care in conjunction with I-SNP members’ primary care physicians, facility staff, and other providers at no additional cost to the facility or the patient. They are responsible for establishing a comprehensive plan of care for each I-SNP member, which is shared with all members of the care team. They provide primary, acute, and preventive care for I-SNP members, including biannual visits for comprehensive assessments and monthly visits for routine assessments. If the member develops an acute illness, the visits occur daily until the member has stabilized. Additionally, the advanced practice clinician facilitates family care conferences to help address medical, behavioral, and social needs; establish goals of care; coordinate care with specialists; and manage various therapies.

Under UnitedHealthcare’s I-SNP model, the 3-day qualifying hospital stay requirement for Medicare Part A benefits in a skilled nursing facility (SNF) is waived. This waiver allows for skilled services within a SNF to be covered without a qualifying hospitalization. By identifying and treating a patient’s change in condition early via appropriate medical management overseen by the I-SNP’s advanced practice clinicians, combined with the coverage of SNF services not otherwise available under traditional Medicare absent a prior hospitalization, unnecessary and avoidable ED visits and hospitalizations can potentially be reduced.

Three bodies of literature help motivate our research question. First, evidence generally suggests that nursing homes with a nurse practitioner or physician assistant on staff have fewer avoidable hospitalizations among long-term residents.11 In a systematic review of nurse practitioners in nursing homes, all 7 articles that were identified suggested a decrease in hospitalization rates when nurse practitioners were used as part of the team, and 5 of the studies found a decrease in ED transfers.12 Second, MA plans that eliminated the 3-day rule over the span of 2006 to 2010 did not experience an increase in hospitalizations or SNF admissions.13 Finally, a line of research has examined managed care models generally for long-term care recipients.14 With regard to research focused on the nursing home population, MA and FFS beneficiaries exhibited little difference in the quality measures reported on the federal Nursing Home Compare website.15 For residents with advanced dementia, a study of Boston-area nursing homes suggested better quality among MA recipients.8

The I-SNP model combines all of these elements: nurse practitioner staffing, elimination of the 3-day rule, and the capitated financing of managed care. An early CMS-sponsored evaluation of the I-SNP model obtained positive results.16,17 The incidence of hospitalizations was twice as high among the comparison residents as the model participants. On average, each advanced practice clinician was estimated to save about $103,000 a year in hospital costs. These early results were promising, but limited in 2 regards. First, the data are more than 15 years old and, thus, they do not account for a number of changes in payment and delivery of services in nursing home settings. Second, the data focused on only a limited number of nursing homes in 5 markets. We estimate that in 2015, 40,733 long-term nursing home residents were enrolled in UnitedHealthcare I-SNPs from 1308 nursing homes in 270 counties in 26 states.

The objective of this research is to analyze whether an at-risk MA plan utilizing advanced practice clinicians on-site in the nursing home setting is associated with different healthcare utilization relative to nursing home residents in FFS Medicare.

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