Not too long ago, Special Needs Plans (SNPs) seemed destined for the dust heap. SNPs were literally on life support in the mid to late 2000s, with last-minute congressional authorizations extending their life on a number of occasions. SNPs at the time were seen by both the Centers for Medicare and Medicaid Services (CMS) and congressional policymakers as little more than year-round marketing tools for Medicare Advantage (MA) plans. They were membership and profit machines. There was little commitment to the original purpose of the program or to improving quality for the institutional, chronic, and dual eligible members they served.
But CMS deserves credit for recognizing the potential that SNPs have for reducing overall costs and improving quality in both the Medicare and Medicaid worlds. It has spent the better part of the last five to seven years rethinking SNPs and building a robust value proposition around them.
The problem for CMS was clear: we know it as the 80-20 rule in health care. In general, 20% of the population is going to use 80% of resources. In the case of dual eligibles in the Medicaid and Medicare worlds, the numbers may be slightly different but the principle remains the same. The problem faced is how to reduce cost and improve quality on the subset of the population of elderly and disabled who consume a disproportionate share of resources and who have significant co-morbidities and health literacy and other socio-economic barriers to receiving appropriate health care.
The critical reforms brought to the program should mean success on both the cost and the quality front moving into the future. CMS and Congress finally reauthorized SNPs in the Affordable Care Act (ACA) but with a major overhaul, including a series of accountability reforms.
- First, there have been a series of changes within the MA SNP world proper:
- Requiring each SNP to have an initial Model of Care (MOC) certified by the National Committee for Quality Assurance (NCQA) and attainment is necessary for ongoing recertification. The MOC certification and recertification process is a robust one and plans can no longer skate by with minimal programmatic and clinical investments.
- Limiting the disease states to be served in Chronic Care SNPs to those with the greatest potential to improve quality and reduce costs.
- Forcing dual eligible SNPs to sign agreements with Medicaid agencies to better coordinate funding streams and access in both insurance worlds. This has led to fully integrated MA SNPs with Medicaid funding streams in some cases and, at the very least, better coordination of the systems when duals remain with Medicaid fee-for-service (FFS) for secondary coverage.
- Enhancing reports and monitoring processes for the Model of Care and other SNP activities.
- An enhanced audit focus and approach to ensure consistency with the Model of Care and SNP-specific regulations/policies.
- Second, CMS created a parallel Medicare-Medicaid Plan (MMP) program through the ACA, which is outside the MA program proper. In this “dual demonstration” program, CMS and state Medicaid agencies contract directly with plans willing to serve Medicaid and Medicare dual eligibles. This incubator approach ensures the greatest integration and coordination between Medicaid and Medicare funding. CMS and some Medicaid agencies are experimenting with a number of models, including one in which the responsibility for all Medicare and Medicaid acute care funding as well as chronic institutional spending (and alternatives to institutionalization such as home care and assisted living) is delegated to plans. As Medicaid is the predominant funder of long-term care services for the poor and middle-income earners later in life, these types of fully integrated programs offer the greatest hope in reining in costs in America’s two biggest healthcare programs, which now account for over $1 trillion in spending annually.
The reforms are not without challenges. MMP funding challenges and rate adequacy have been identified in some states. Plans also complain that both the MA Star program and the Hierarchical Condition Category (HCC) funding system implicitly discriminates against SNPs or plans that serve a disproportionate share of dual eligible members. To its credit, with Star success under its belt and an HCC system with a decade of near smooth sailing, CMS is now looking at reforms in both these areas to ensure plans are rewarded fairly for taking on such risky populations. It recently announced it is moving forward with an MMP Star program, which could form the basis for a separate program for MA SNP Star as well.
Plans for their part have begun to recognize the seriousness with which CMS is approaching SNPs. Audit scrutiny will be severe and plans need to constantly adjust to the ever-increasing demands CMS will put on plans in the future. As with the greater MA program, CMS is still concerned that poor players need to be rooted out, and that only those with a true commitment to quality remain in the SNP business.
Here are some of the biggest recent and anticipated future focuses of CMS as it continues to hone its SNP approach to save money in both Medicaid and Medicare and improve quality outcomes:
- As with MA generally, plans will need to ensure that they integrate IT systems to coordinate all care. With speedy turnaround of audit universes and audit scheduling post notification, having all documentation in one system is an absolute must.
- CMS is telling plans that nothing short of a 100% Health Risk Assessment (HRA) rate, whether initially on enrollment or annually thereafter, is acceptable. Given the serious issues affecting many dual eligibles and SNP enrollees, the idea that a plan can reach literally 100% of enrollees is a bit far-fetched. But CMS is putting this marker out there for plans to achieve. It is telling plans that multiple documented outreach attempts are just not good enough anymore. If a member can enroll, plans must find creative ways to reach the individual for assessment, including coordinating closely with providers.
- Again, as with other regulatory standards in the MA realm, timeliness of initial and annual assessments is being stressed and plans will face penalties for not consistently assessing members within prescribed timeframes. Indeed, failure on this front goes to the ultimate survivability of the SNP plan in the future.
- CMS is also moving beyond a focus just on initial and annual assessments and looking to ensure assessments are done as often as the health of the member demands. It is looking at a number of areas on this issue. First plans must ensure immediate care transition assessments and processes. Second, it is asking plans to look at other ways to constantly identify risks and restratify populations for new or renewed interventions. For example, plans must move beyond intervening when hospitalizations occur and look to chronic emergency room usage, lack of Primary Care Physician (PCP) and specialist engagement, non-adherence to prescribed medication regimes, among many others. This not only improves Model of Care compliance but boosts Star performance and revenue.
- With assessments, CMS is asking plans to move beyond the sheer identification of clinical problems and look to the socio-economic and health literacy barriers to quality of care. Whether the plan type is Dual Eligible SNP (D-SNP), Chronic Condition/Care SNP (C-SNP) or Institutional SNP (I-SNP), dual eligibles are the predominant enrollees in each and intervention on the socio-economic barriers can pay as many dividends as focus on clinical ones.
- CMS has already telegraphed to a number of plans that pro-active stratification of risk and intervention— even before the initial HRA—may become a dictate in the future. CMS’ rationale here is that early engagement of the member is critical. While plans may or may not have claims and other data with which to intervene, they do have other resources at their disposal (e.g., an understanding of socio-economic barriers faced by members, general characteristics of members served in the plan, and input from providers) that can form the basis for an interim care plan and interventions to drive certain positive outcomes even as the formal initial assessment is pending.
- As much as assessment is important, CMS is very concerned that plans still do a bad job of creating individualized care plans (ICPs) and having an interdisciplinary care team (ICT) approach for each member. So CMS will not only scrutinize assessment of members, but demand that plans show how they have actually engaged the member, PCP and overall ICT to address problems, barriers, goals, and interventions. It wants to see constant communication in these areas to address the inevitable changing risk and needs of the member.
- And related to the above, CMS also is telling plans that it is a bit frustrated that care plans are not actionable and achieving results is not prioritized. While all identified problems should be addressed, CMS more and more would rather see a clear list of defined, priority issues or problems with an emphasis on goal achievement (well-documented). No longer will plans get away with a laundry list of problems identified without follow-through and achievement. Results are what count.
- CMS is also expected to push plans to have a much stronger methodology, including data and reports, to evaluate their MOC’s and SNP’s performance.
There will be a good bit of give and take as the more robust approach to SNPs and Models of Care are worked out. But the approach is sound and in line with CMS’ established priorities of value, cost-containment, and quality. As we said last week and we will say again now, bold reforms are needed in an American healthcare system in desperate need of change. Half measures should be resisted by everyone as they will not fundamentally shift the paradigm.