Post-acute and LTSS providers are beginning to form Medicare Advantage special needs plans (SNPs) to, in one provider’s words, “change their position in the funding hierarchy.” Here is how some LeadingAge members are disrupting traditional arrangements with SNPs and other approaches to value-based care.
Surviving and—they hope—thriving in a world of value-based care is a major concern of post-acute and long-term services and supports (LTSS) providers. As new managed care reimbursement models gain traction, many LeadingAge members are forced to find their place in the system as parts of preferred provider networks. As it stands, providers are participating, and managed care organizations (ACOs, health plans, bundled payment systems) and the enrolled older adults are benefiting, but in many ways the providers see themselves as, at best, valued passengers on the bus, but not drivers.
“Providers are doing all these great things but they are hamstrung,” says consultant Anne Tumlinson, CEO of Anne Tumlinson Innovations and founder of Daughterhood.org. “They can’t access all those dollars they are saving. Providers’ good work is going to the bottom line of some managed care organization (MCO), but the LeadingAge member is the one making the investment.”
The solution, many providers have concluded, is to take on risk—to control the premium dollar themselves. Some LeadingAge members already have experience in this area—operating Programs of All-Inclusive Care for the Elderly (PACE)—so there is precedent. But today’s growing interest in Institutional Special Needs Plans (I-SNPs), which allow a provider to enroll Medicare Advantage beneficiaries, reflects organizations’ desire to take a stronger position in the system.
The most recent CMS data (February 2019) on institutional special needs plans shows 57 Medicare contracts, 125 plans, and 84,317 people enrolled.
“Who would have ever thought any senior care organization would set [itself] up as an insurance company? [Organizations] are already managing this population, doing innovative things, and really struggling to have more control over the consumer’s use of health care,” says Tumlinson.
“The system was built on the backs of quality operators. It’s really time for us to take risk, move up the revenue stream, and capture the value from it,” says Terry Rogers, president & CEO of Christian Living Communities, based in Englewood, CO.
Rogers is one member that is partnering to take that leap.
A Consortium to Build a Multi-State Model
The Perennial Consortium, created by 3 aging-services providers and a managed services firm, is a brand-new entry into the Medicare Advantage universe.
The initiative is a partnership between Christian Living Communities; Columbus-based Ohio Living; Juniper Communities, based in Bloomfield, NJ; and AllyAlign Health, a firm that helps LTSS organizations create and operate provider-sponsored managed care plans.
The Perennial Consortium is jointly owned by the 4 founder organizations, and it will, in turn, own 51% of the operator-owned plans it establishes in the states it enters. The other 49% will be owned by the provider organizations that participate in those states. As of March 2019, the Consortium had plans to operate in Ohio and Colorado, with the possibility of a third state still to be determined.
“It will be a national network of operator-owned plans in states where we have quality organizations that want to have some equity and develop a Medicare Advantage plan,” says Rogers.
AllyAlign Health brings the insurance and plan-operations expertise. As Rogers notes, it is an equity partner but also a contractor. The company is involved with provider-sponsored Medicare Advantage special needs plans in 14 states. For instance, AllyAlign is a minority owner in Great Plains Medicare Advantage, founded by LeadingAge member Evangelical Lutheran Good Samaritan Society.
Regarding the origin of the Perennial Consortium, Larry Gumina, CEO of Ohio Living and a board member for both LeadingAge and LeadingAge Ohio, says his education in Medicare Advantage plans began a few years ago.
“We were having a discussion about the payment reform crisis we’re facing, and the headwinds coming at us,” Gumina says. “The incidence of Medicare Advantage is up to about 38% throughout [Ohio], and is expected to go up about 7-8 points more in the next couple of years. So we decided to embark on a journey of learning about [I-SNPs].”
Gumina spells out the 3 key elements of a successful Medicare Advantage plan: “First is compliance, which is the expertise that AllyAlign brings to the table; the second is a model of care platform that aligns all the participants together; and the third is enrollment.”
The Perennial Consortium will adopt the Connect4Life model developed by Juniper Communities as its care platform. It integrates chronic care management into service-enriched housing—co-locating therapy, primary care, pharmacy, and other supportive services in an assisted living or memory care community. A human navigator or concierge coordinates services.
Editor’s note: For more on the Connect4Life model, scroll down to hear a 2018 LeadingAge magazine podcast featuring Lynne Katzmann, founder and CEO of Juniper Communities, and Anne Tumlinson.
Gumina and Rogers say the Consortium is now seeking commitments from interested providers in the 2 states; HMO applications must be submitted to the states later this year. The steps after that will include building a provider network and applying to CMS, including confirmed details of the network and model of care, by February 2020.
The client enrollment period should begin in October 2020, and the planned launch date will be New Year’s Day, 2021.
Asked how many people the Perennial Consortium could enroll, Rogers says, “We don’t know what our capacities will be. Our goal in each plan is to be at 1,000 enrollees after year 1, and 2,500 after year 3. And I think we’ll have the opportunity to be well above those minimum requirements.”
Gumina says it’s too early to spell out the plan benefit package in great detail, but adds that, “The package will need to be more attractive to residents and family members compared to the plans that exist today. We’re excited about not doing this in a vacuum, but doing it with other providers. The sum of all perspectives will be a great help.”
Primary Care Plus Medicare Advantage
One way that Presbyterian Homes & Services (PHS), St. Paul, MN, is moving into value-based care is by taking an ownership stake in Genevive, a geriatric medical practice and care management organization that serves more than 5,500 older adults.
Genevive, formerly Geriatric Services of Minnesota, was founded 16 years ago by North Clinic, a multi-specialty health care clinic, and is half-owned by Allina Health, a nonprofit system with 12 hospitals, more than 90 clinics, and many other health services. In January 2019, North Clinic sold its 50% ownership in Genevive to PHS.
“Genevive is a primary care physicians group, and a big chunk of what they do is care coordination for dual-eligible individuals,” says Mike Bingham, vice president of Optage & health care initiatives for PHS. (Optage is the home and community services division of PHS.) Ownership of Genevive is part of PHS’ strategy to invest in primary care and Medicare Advantage as a way to, in Bingham’s words, “change our position in the funding hierarchy and influence or control care delivery.”
“Care for dual-eligible seniors under MSHO [Minnesota Senior Health Option] contracts is Genevive’s primary focus, but as part of that they also pick up people who are private pay,” Bingham says. “The idea is to expand the focus not just in the care centers, but on an entire campus. Our campuses have assisted living, memory care, and skilled nursing. We want to be able to care for a resident regardless of where they are, in a holistic way, as they move through the continuum.”
“Interlude represented an innovative care delivery model, but it wasn’t a funding innovation,” Bingham notes. “But the partnership with Allina, the common care pathways, the access to a common medical record, and the common training of the care teams has yielded good results.”
The long-standing partnership makes Genevive a logical next step.
“We’re very much aligned in major aspects of the vision for Genevive, including the campus care model,” Bingham says, and both organizations want to develop both I-SNP and D-SNP (Dual-Eligible SNP) capabilities.
“Genevive gives us the benefits of scale and scope benefits, as we partner with payers. We have a much better position when talking to payers, and it also gives us a footprint outside of our own campuses. We bring care and wellness capabilities and Allina brings its deep experience in managing chronic disease in an acute care setting. It’s a powerful combination of skill sets and experiences.”
Bingham says that people moving through the LTSS continuum too often must change care teams, medical records, and protocols: “From the resident or family perspective that’s not ideal. And our staff have to manage through the complexity of [these changes] as well.”
Drivers Rather Than Passengers: What’s the Advantage?
Bingham ties the practical value of these changes to mission: “Kaiser Health data shows that, long-term, only about 10% of your overall health is driven by the health system,” he says. “Most of health is driven by where you live, your genetics, and your behaviors. We think we’re called, as part of our mission, to help residents and families live their best years with us. How do you move up Maslow’s hierarchy [of needs]? One way is to reduce the use of the acute care, rescue-oriented health system, and reinvest those dollars into life enrichment and purposeful living.”
As for where these value-based changes will leave most providers, Tumlinson believes that organizations not bearing risk can nevertheless benefit.
“Smaller providers will be an important part of the overall enrollment tool for these plans,” she says, “as long as you’ve got 1 anchor member in a state. It already is happening in New York, where a prominent provider is running an I-SNP in its nursing home, and enrolling the residents of smaller providers.
“I’m not saying there won’t be friction between the provider side of the business and the plan side of the business, because there always will be,” Tumlinson adds. “But it’s different to be negotiating that with someone who is a colleague and a friend, and someone in your professional community, rather than [a big insurance company]. I think a thousand flowers will bloom out there, and there could be a lot of interesting arrangements.”
“This is a mission sustainability initiative,” Gumina says. “These payment reform pressures are beating us up now, and will get more intense as managed care penetration continues in states. We continue to get less in terms of reimbursement for the care we’re providing, and if you look ahead, we’re not seeing increases in Medicaid reimbursement.
“In the absence of doing something, we’ll stay in that back seat and our missions will be challenged,” Gumina continues. “This time in our field demands innovation. The risk of not doing this is even more daunting.”
Rogers thinks it will open further opportunities for collaboration and partnerships: “It will be possible to tie into larger organizations even if you’re a small provider. But you will have to invest in care models and partnerships. We think this will be a disruptive solution to the big issues around health care finance. We see it as the next insurance model for older adults.
“This hits a home run so for the older adults [we] serve,” Rogers adds. “It provides better outcomes for them, and for families we’re adding a seamless coordinative care model that makes their lives easier. For [provider organizations] we’re trying to slow the erosion and in fact replace the Medicare revenue that’s been lost over the past few years.”
Bingham agrees: “The investment into making lives more purposeful will lead to a self-fulfilling, self-funding strategy of lowering health costs and using acute care less, and allow investing more in life enrichment that will attract more residents. In this case, the right thing to do is also the economic thing to do.”
In 2018, Tumlinson helped survey and interview LeadingAge members about payment and service delivery reforms and the activities they were participating in. This PowerPoint (link downloads a file) offers a useful summary of what was learned.
“I think it has less to do with the size of the organization and more with the mindset of the leadership,” Tumlinson says. “When we did that project, we asked ‘Why do you do what you do?’ Across the board, they never said ‘So we can find a way to be financially sustainable, to protect ourselves against managed care plans.’ Almost to a person they thought it was a strange question. They said, ‘This is who we are, we’re here to find better ways to deliver care to vulnerable populations.’
“If that’s your mindset, there are going to be opportunities regardless of how big you are.”
Care Integration and Managed Care for LTSS Providers
In this LeadingAge podcast, consultant Anne Tumlinson and Juniper Communities’ Lynne Katzmann talk about why aging services providers must embrace integrated care and managed care. Katzmann also introduces us to her organization’s Connect4Life program.
This podcast originally appeared with an article in the July/August 2018 issue of LeadingAge magazine. We are linking it here because of Katzmann’s involvement with the Perennial Consortium, which will use the Connect4Life model.
0105: What pressures are payers feeling?
0215: What does this mean for LeadingAge members?
0323: Why aren’t long-term services and supports providers sharing in the savings they produce?
0445: Why aging services providers must begin to integrate with the health care system, and why our field needs to begin to take on risk.
7:04 Description of Connect4Life program: importance of care transitions; electronic operating platform; creation of care transitions program; integrating service-enriched housing and clinical services for those with chronic illness and functional impairments.
9:50 How Juniper Communities makes integration of care work.
12:35 "Measurement of success" and cost savings.
15:40 How can we build on this? What’s next for our field?