AMY KASZAK: Thank you, Rhonda. I'm very happy to be part of the presentation today and appreciate the invitation.
RHONDA DEMENO: So happy to have you. So, we all know that data is telling us that the average age of residents admitting into senior living communities is around 85, and those residents may have three or more comorbidities. We know that the residents have an increased risk for poor health care outcomes because of those increased aging and comorbidities.
For today's conversation, I would like to better understand how special needs programs can successfully be integrated into the senior living operations plan. OK, so to get us started today, Amy would you mind giving us just a quick overview of the definition of an I-SNP?
AMY KASZAK: Happy to, Ronda. So, I hope that some of the listeners today have maybe listened into episode 1 of this podcast series where they can get a more in-depth overview of special needs plans. Just to make sure everybody listening today knows what we're talking about, special needs plans are Medicare Advantage plans. We have to cover Medicare Part A services, Part B services, and Part D-- so those drugs services.
There are three types of SNPs overall. Typically, with senior living organizations, we are talking about institutional or institutional equivalent special needs plans designed for seniors who meet that long-term level of care requirement or who live in an institutional setting.
And then also, the C-SNPs, Chronic Conditions Special Needs Plans, where to be eligible for the plan, you have to have one of the designated diagnoses for that plan. And a lot of times for assisted living memory care, for example, a dementia C-SNP snip could make sense for some of those residents.
So bottom line is SNPs are Medicare Advantage plans, and typically, I-SNPs, IE SNPs, and C-SNPs are most applicable to senior living.
RHONDA DEMENO: Thank you. Kenny, could you provide-- because of all the Medicare and your managed care experience, how do you see the special needs plans differing from a Medicare Advantage or traditional Medicare Advantage plan?
KENNETH WHITE: OK, certainly. So, Amy went over them in a definitional sense, but differently, the eligibility requirements for being a beneficiary of a special needs plan is more detailed than being Medicare-eligible. I mean, quite frankly, if you're disabled or you are 65 or older, you're eligible for Medicare.
To be eligible for a special needs plan, you have to meet the other criteria, which is be eligible for Medicare and meet one of the chronic conditions for a C-SNP, meet the requirements for an IE or assisted living specialties plan, be institutionalized, or have at-home care contemporaneous with a definitional meeting of-- you could be institutionalized, but you're being cared for at home, to meet the I-SNP criteria, or you're duly eligible, meaning Medicare/Medicaid. That's the primary difference.
There's a difference in reimbursement. The MRA, or Medicare Risk Adjustment, feature for CMS is a little bit different than it is for Medicare Advantage plans by themselves. There are also the quality measures that are used to determine the amount of reimbursement that a special needs plan is slightly different than a regular Medicare Advantage plan.
Another difference is that in Medicare Advantage, while many MA plans do provide Part D or drug benefits as part of the Medicare Advantage plan, that usually comes with an additional cost to the beneficiary. In special needs plans, that is required to be provided by the SNP, so it's treated differently there. There are also differences in enrollment.
So generally speaking, with MA plans, you have an open enrollment period where you can enroll. Unless something happens, you move out of a service area or you change level of services, et cetera, you become eligible for a special needs plan, or, in many cases, become ineligible because you've gotten better. That doesn't happen often in this demographic, but it does happen.
So, in that case, you would normally be limited to open enrollment with a special needs plan. There is more flow in and flow out of the special needs plan. They had to make adjustments for people moving locations, moving from assisted living to being in a nursing home, being in assisted living, and then coming out of it because of the reason they were in assisted living may have been more short-term, et cetera.
RHONDA DEMENO: Because SNPs have different roles or benefits, does that make the I-SNP more attractive for senior living operators?
AMY KASZAK: Yeah, I would say there, Rhonda, is that CMS, when they set up I-SNPs, they said their goal was for organizations to fashion and deliver services in a manner best-suited to the specialized population in that SNP's plan.
So, for senior living operators and for senior living residents, what they get with an I-SNP may be a C-SNP if they get a plan that is really designed or should be designed for the way that they access health care services, for the way that they live in their senior living community, and for the intensity of health care services that they really need for their quality of life.
So, I think to put it in a nutshell, to me, the biggest difference is, is that as an I-SNP, we're able to really tailor a plan specifically for seniors who are living in a long-term care setting and need more advanced nursing and care services. So, I think it's really the ability to hone in and offer a personalized plan that works with the way you live today.
KENNETH WHITE: From an operator's perspective, I don't want to be crass, but, I mean, money is involved here. So, from an operator's perspective, is there a benefit to having the SNP versus Medicare Advantage? Well, I would assume that all operators, altruistic or not, want their residents to be well-cared for, to have a good quality of life for as long as they can, and to keep them out of an acute care facility if that is possible.
And in those cases, obviously the care model particularly, in the C-SNP arena where you have specialized care models for taking care of any of the beneficiaries that are in one of those 15 different conditions, is a great advantage to the member.
RHONDA DEMENO: No, I could really see the benefit of that even from a provider or operator standpoint. Occupancy, but not just talking about the numbers, really, the outcomes.
KENNETH WHITE: From the operator's perspective, it's a matter of cost. And it's going to be different if you are the plan, the plan owner, or if you're a JV partner with a plan owner, or you are a contracted part of a network that is part of the SNP.
Each of those has a different financial backing to it. There are certainly advantages to all of them. If you are able to provide the infrastructure necessary and can manage the downside risk associated with reimbursement in this level, then there are certain advantages we can go over those if you want.
AMY KASZAK: I want to back up. I think you mentioned this, Rhonda, length of stay, for example, letting your residents stay in their current living level for as long as possible, as safely as possible, those are some of the benefits of bringing in the right-- I would say the right Medicare Advantage partner, and that could be a SNP.
I think it often is a SNP, again, just because we are more focused on a very, very specific population and not trying to design plans for the masses, if you will, of senior beneficiaries.
And to that point, increasing your length of stay on campus, providing additional support for your residents, for your staff members, maybe being a differentiator in the marketplace by being able to offer more services on-site, that's, a lot of times, what we see first attract senior living organizations to MA, is they say, oh, you can help me have a podiatrist who comes on-site to see my residents.
I don't have to transfer or worry about transportation off-site for as many specialty visits because you're either able to bring those in through a primary care, you can add those in with telehealth services, and I see our job as the plan as being the-- we are the payer source to help make that happen. We're the funder.
And because putting even that network or those resources together, that's something that a lot of senior living organizations aren't staffed to do, they don't always have the expertise to do, and certainly today, don't have the time to try to put that together in a way that makes sense for all of their residents.
RHONDA DEMENO: I always go back to the story of my mother was in a senior living community for almost 10 years, and any time she needed to have an appointment or see a physician, I mean, it was-- and then later on in her disease process, because she had dementia, it was very traumatic for her to be transferred out to a physician's appointment. But if you can bring those services in.
And oftentimes, I know-- I'm hearing from some of our clients, since COVID, there's really long wait times to see specialists, or even not having the ability to get in touch with a dermatologist or a podiatrist or a dentist, sometimes those appointments take a long time.
So, this type of plan may help to bring those services to the resident in a more timely fashion and where it's managed a little bit more efficiently, just so the residents don't have the wait times and have to leave the community and have stress related to that.
One other thing I wanted to really ask is, does the organization have to its own IE-SNP or SNP plan in order to get the value for the residents or organization?
KENNETH WHITE: I'm going to pick this up because I want to pat Amy on the back so that she doesn't have to do it herself. So, in most of these cases, unless you are a full-fledged large-scale health system that extends well beyond acute care in your community, then having the infrastructure to do all of this on your own is probably outside of your reach. Having a partner like AllyAlign and other entities like that is all but an absolute necessity.
One, they take on all of the admin issues associated with the operation of a SNP, which is something that most senior living or long-term care providers don't have. Two, in many cases, they provide downside risk financing. So, you get to have the advantages without having to live through some of the disadvantages associated with downside risk contracting.
So, in that situation, the advantages come when you partner with a company like Amy's company that provides that level of sophisticated infrastructure and allows you as an operator to do what you do best, which is actually take care of the residents.
RHONDA DEMENO: So, to me, this sounds like a win-win situation. What would some of the barriers be-- or is it just the lack of education or knowledge from an operator standpoint of not me, why would we not want to participate-- or collaborate with a I-SNP?
AMY KASZAK: Yeah, well I'm happy to start with some of the questions that we get a lot of times or some of the concerns that we hear. I think maybe the first barrier sometimes for senior living organizations participating with Medicare Advantage is I routinely hear, well, all of my residents are private pay. So why am I worried by this?
And it took me a little while as a non-senior living owner to realize what that really meant. And I think what it means-- Kenny, jump in here, but I think what it means for most operators is that, hey, I am getting paid for all of my services directly from my residents. I'm not getting any Medicare dollars today and I'm sure not getting any Medicaid dollars today.
So as a Medicare Advantage plan, why do I even need to interact with you? That's not something I have ever had to do historically. I don't a reason to do it. Kenny, would you agree with--
KENNETH WHITE: Absolutely.
AMY KASZAK: --your partners? Yeah.
KENNETH WHITE: Well, let's ignore the dual-- the D-SNP thing for a second because Medicaid is different. But on the Medicare side, especially in an assisted living or even a nursing home deal, if the patients are private pay, then the facility charges are being paid for by the family or by the member themselves, they're probably eligible Medicare, and they probably have fee-for-service Medicare.
And their external care-- their primary care visits, if they go to the acute care facility or something like that, is all being paid for by Medicare, but the facility charges are being borne by the family or the member of the patient themselves.
So, in that situation, it's hard to get over the financial barrier of why do I don't want to get involved in this and expose myself to potential downside risk or an FCA claim or something else related to regulatory compliance when I don't have to? You can make that determination based upon--
If you are keeping your facility full and there's never an open bed, and you can charge basically whatever you want to charge and people are paying it, then the answer is probably, you probably don't want to be involved. But not everybody is that way.
AMY KASZAK: Right. And I think the other thing I would add there that is even for some of those owners who are doing extremely well, keeping their beds full, here's what CMS has told us because probably for most senior living organizations, 100% of your residents do have Medicare, some form of Medicare.
And CMS has told us that by 2030, 100% of Medicare beneficiaries will be engaged in some form of value-based payment. So that could mean that they are associated with a primary care doctor who's in an ACO. It could also mean that they are in a Medicare Advantage plan, or they might be in another one of Medicare's CMMI programs that they're working on, again, where they're paying-- Medicare is paying for outcomes.
And so, if you're a senior living operator and you are not thinking today about how you are a very important part of creating health outcomes for your residents and you are not thinking today about how, in the future, as other providers are paid for those outcomes that you're helping create--
If you're not thinking about how you stake your claim and say, wait I'm an important part of creating the value in value-based care and you're not entering into partnerships, collaborations, et cetera where you're being recognized and paid for that, there's a very good chance that in the future, you might not be able to go back and say, wait, wait, wait, let me in, I should be a part of this.
KENNETH WHITE: Yeah, you'll be out for everybody except the ultra-wealthy.
AMY KASZAK: Yeah. Who will be cared for at home anyway.
RHONDA DEMENO: To add to that, I think that that was an excellent point, Amy, and thank you so much for sharing that. So, it sounds like that's a big risk. By not being involved with an I-SNP, you may be left out by-- like you had mentioned 2030.
I want to go back to the beginning of our conversation. The average length of stay for a resident in an assisted living community is around 22 months. Do you have any data that can actually support that their length of stay, residents' length of stay is actually increasing by the impact of I-SNP?
AMY KASZAK: So, as AllyAlign, our IE-SNP plans are still fairly new, meaning that we have about a year, a year and a half's worth of data on most of our members. So, we are still putting together that case, Rhonda. You really need at least three typically five years to really show what's happening.
However, I will tell you from some of my colleagues who have been doing this from a primary care perspective and putting in place primary care programs designed to provide that on-site preventive care, that you do see an increase. And there's information out there. CareMore had some good initial data.
My company, Curana, is putting together some data, again, mostly from our primary care first, but we're working on the I-SNPs. So, I have seen it. I do not have it within my company's data warehouse right now, but it will be coming out soon.
KENNETH WHITE: So, the commercial carriers that operate the vast majority of all MA plans have warehouses full of data. Now it's going to be better attributable to the C-SNP world, but they could map out for you and do map out for you the value associated with better care of adult lives.
So, they are the people if they are the payer. If they are the MA plan, then they are at risk for paying for the care for the member. So, if the member is at even a private pay Medicare institution and they fall, then they end up in an acute care facility.
Then they go from the acute care facility, they have an orthopedic, they have surgery, they have anesthesia, they have everything else. They then leave there and go to rehab. And they go from there-- it could be weeks or months before they get back to the institution that they came from. And all of that care is the responsibility of the MA plan. And financially.
So, if they partner with an institution that takes much better of their patients-- so their residents so that they don't trip and fall, then the MA plan, they have a better financial outcome. So, they would be much more willing to partner with a residence or a senior living operator that has very good metrics on the care and treatment of their residents because it's much better financially for them and they're willing to pay for that.
AMY KASZAK: Well, and I was just going to say, that is the data that I do have across the board where we can show that our plans were decreasing avoidable hospitalizations by about 39% typically from baseline when we go into a new senior living community.
We have very high member satisfaction scores. So, 95% or higher on our satisfaction rating, things that, I would say, would contribute to that longer length of stay like Kenny was saying, but right now, most of my data around AL and memory care is more anecdotal.
And again, I think where you're going to-- where we have better data is around primary care models there simply because, going back to the point of this whole podcast, senior living operators who have had historically private pay resident populations are really just now starting to work more with Medicare Advantage and special needs plans in particular.
So, I think you're going to see a lot more of these outcomes coming out over the next three to five years as we get more participation from those what I would call the middle layer in some ways or middle demographics of senior living residents.
RHONDA DEMENO: The middle market for sure. And because to Kenny's point, primarily assisted living, senior living is private pay, but there is a big need for middle market development, we're going to see more middle market communities being developed. And I think this really is a very good way to place-manage the residents and have improved satisfaction and improved length of stay, and it, to me, it's a care model.
Oftentimes I think people do get confused with senior living being a hospitality versus the care model, but we're seeing now through the evolution of the industry that it is definitely becoming more of a care model.
KENNETH WHITE: One more thing, Rhonda. So, remember, MA plans are contracted with CMS. They're geographically done, and it's usually done by county. So, it is a narrow network to start with and SNP plans or the narrowest of networks. You want to be able to keep the resident at the same facility for a longer period of time or else the revenue goes somewhere else.
You don't get to pick it up when the resident moves, and if you are in a situation where you have multiple levels of care in your organization so that you can go from assisted living to long-term care or memory care or particularly if you're connected with a large health system that's got acute care tied to it or rehab as well, then you can maintain the resident for a much longer period of time.
And I don't want to attribute it to like airlines, but, I mean, airlines want butts in the seats. They cost almost the same to fly the plane from one place to another whether it's full or whether it's empty. You want it to be full. And the best way to keep your facility full is to do a good job of taking care of the people who live there.
RHONDA DEMENO: That's correct, I love that. And I think that's a really good way to wrap up our conversation. Amy, is there anything else that you wanted to talk about?
AMY KASZAK: I think I would be remiss if I didn't circle back around to Kenny's previous point, which is that as Medicare Advantage special needs plans specializing in senior living residents, what's the difference for senior living operators and working with us versus run-of-the-mill MA?
We are willing to pay senior living operators to help create successful outcomes-- i.e., lower hospitalizations, longer length of stay and facilities, lower number of falls, all of those quality indicators, we're willing to pay you and we can pay you under current Medicare Advantage. We can do quality payments out to you; we can pay for care coordination services.
When you are helping create healthy outcomes for your residents, that is payable under Medicare Advantage plans. You just need to find a partner who's willing to pay you in the right way for services that you can provide and to give you transparent data and metrics, so you actually know if you're helping make a difference in the lives for your residents.
RHONDA DEMENO: That's an excellent point, and one other question to that, Amy. Is how do senior living operators, where do they go? Where should they go to find out what the best fit for them is, where they can find a provider to really sit down and have this discussion-- planning discussion and work through these payment issues? Work through the coordination of care piece. Where should communities or operators look to find a good partner?
AMY KASZAK: Well, first of all, I think you all are doing a great job, Rhonda, at making some of this information available.
RHONDA DEMENO: Thank you.
AMY KASZAK: --that people listening to this podcast can follow up on the website to get some more information. But I also always recommend, first of all, as a senior living organization, if you've got a strong primary care partner on-site, I would talk to your docs and say, hey, are you participating in value-based care? If so, who is it? Let's talk to them together.
I would do some homework, see what plans you have in your area. And then, by the way, you can always come to companies like Curana. There's several of us out there who work specifically with senior living providers to offer existing plan participation. In some cases, to develop new plans often with a network or a number of senior living providers in a particular state.
And I-SNP plans, C-SNP plans are continuing to grow. So, if it's not available in your county, in your state today, it very well could be there in the near future.
RHONDA DEMENO: Very good information. Very good information. Well, we really appreciate that, and Amy, I'm so happy that you were able to spend some time with us and to share your knowledge with our clients. And Kenny, Kenny is our WTW superstar, Managed Care Practice Leader, and we were so happy to have you as well.
Kenny, thank you very much for helping out our senior living clients to better clarify the processes and steering your knowledge on how Medicare payment works and how I-SNP can be an effective care provider for senior living residents.
KENNETH WHITE: Thank you for inviting me.
RHONDA DEMENO: Yes. Thank you so much, Kenny and Amy. Thank you again today for joining this conversation. We really appreciate it.
AMY KASZAK: Great. Thank you, Rhonda, and Kenny, always a pleasure.
RHONDA DEMENO: And I want to thank all of those who attended our podcast today. We hope you found the information helpful. If you would like additional information on the I-SNP plans, please feel free to reach out to me at rhonda.demeno@wtwco.com, or you can find out our identify or find contact information from our panelists on our podcast page. Their bios will be there, and their contact information will be there So you can easily reach out to those individuals who participated.
Keep in mind that this is a three-part series. We just completed episode number 2, and hope to have you join future Senior Advisor Podcast. Keep in mind that WTW Senior Living Health Care Practice Mission is to help our clients provide residents with quality of care, foster rewarding and engagement atmospheres for employees and residents, and ensure a safe environment for all. This concludes today's podcast. Thank you all very much for attending.
SPEAKER: Thank you for joining us for this WTW podcast featuring the latest perspectives on the intersection of people, capital, and risk. For more information, visit the Insight section of wtwco.com. WTW hopes you found the general information provided in this podcast informative and helpful.
The information contained herein is not intended to constitute legal or other professional advice and should not be relied upon in lieu of consultation with your own legal advisors. In the event you would like more information regarding your insurance coverage, please do not hesitate to reach out to us. In North America, WTW offers insurance products through licensed entities, including Willis Towers Watson Northeast Incorporated in the United States and Willis Canada Incorporated in Canada.
