In a zero-sum game of staffing, post-acute and senior care facilities face the worst workforce shortages and will be challenged to house all of the patients who need institutional-level care, pushing some of those patients to lower-acuity settings. This will leave many patients who are eligible for I-SNPs without access to the care benefits that those plans provide. However, those patients will still require the same care and attention they would receive in a long-term care facility.

This is where IE- (institutional-equivalent) SNPs will play a bigger role than they do now. IE-SNPs are meant for people living in the community who require an institutional level of care. If long-term care institutions will be challenged to accept as many patients as are necessary, there will likely be an increase in enrollment for IE-SNPs for those living in assisted living facilities and other lower-acuity senior residences.

There is still a question of workforce shortage to care for these people, however, because caring for a dispersed population in need of institutional-type care is much more difficult and costly than caring for them in one location, like a nursing home.

It’s difficult for C-, D-, and IE-SNPs to create structures that lead to better health outcomes since they can’t directly steer provider choice or directly shape SDOH inputs like food, transportation, and the physical structures of the places where enrollees live. An increase in geographical dispersion among SNP members leads to more challenges in creating better health outcomes (like managing SDOH inputs and engaging in provider steerage). For example, I-SNPs, with members in just one or a handful of long-term care facilities, can better manage care for their members than D-SNPs with enrollees spread across an entire state.

Care coordination is also easier when SNP members are close together. For example, a care coordinator can easily see all patient medical data when that patient is in a long-term care facility. But tracking care for a patient who lives in a private home or senior residence is much harder. In that case, the SNP operator must gather data streams from various third-party entities (transportation, providers, dietitians, local pharmacies, etc.).

Because the challenges of managing care for SNP members changes as they become more dispersed among the community, IE-, C-, and D-SNPs tend to experiment to meet the complex care management needs. D-SNP operators often have the advantage of access to preexisting state Medicaid rolls, which enables them to better aggregate the risks associated with this increased complexity of care. This is one reason D-SNPs are the only type of SNP plan that can be found around the country with any sort of regularity.

C- and IE-SNPs operators are challenged in both directions – the complexity of shaping outcomes is more complex compared to those in institutional settings (I-SNPs) because of geographical dispersion while the challenge of aggregating their risk is more complex than for D-SNP operators, who often have access to a known pool (Medicaid) of potential members.

Opportunities to overcome this challenge

• Food: SNP beneficiaries often have specific and restrictive dietary concerns. Meeting those concerns in urban food deserts or rural areas can be difficult, so transportation to grocery stores, food stipends, and food delivery services from a plan-curated catalog could help beneficiaries meet their needs.
• Transportation: MA plans can now cover cost of private transport to providers, which helps with steerage but doesn’t work well in lower-income rural areas without many clinical services close by. Some of this can be overcome through telemedicine, remote monitoring, and even telesurgery— but these services require technical knowledge and infrastructure that are often lacking in the areas where they are needed most.
• Internet access: Bringing virtual care into the home can help bridge distances. However, telehealth requires creating and maintaining a digital infrastructure in the home that may not exist in rural or remote areas. Few SNPs currently cover home internet upkeep or upgrades, but this will need to change as C- and D-SNP enrollment grows.

Case study example

How Zing Health serves the underserved by focusing on SDOH

Zing Health is a provider of MA plans in Illinois, Indiana, and Michigan. Its mission is to provide “managed care Medicare Advantage Plans that address social determinants of health that reduce health care disparities among historically underserved populations.”

Zing utilizes a data-driven choice model that identifies member situations and provides choice sets that match the member situation. The model incorporates the PCP as well as a care team that includes an RN, social worker, and behavioral health supports. Through the close contact with their members, Zing promotes prompt member decision cycles that drive recommendations that allow members to live independently and overcome hurdles.

For example, Zing provides benefits such as frozen meals when members are discharged from the hospital to help with food insecurity. Zing also partners with Papa, a caregiving companionship organization, and other external partners to provide care services to seniors that includes companion benefits like housekeeping, transportation, grocery shopping, and social companionship to help with access and isolation.

C- and D-SNPs almost always work with third-party entities, such as providers or pharmacies, that don’t necessarily share data with one another easily—or willingly. For an IE-, C-, or D-SNP to be successful, it must be able to bring data from all of a patient's different inputs (food, transportation, PCP visit, specialist visit, pharmacy, internet issues, etc.) together in front of the coordinator so they can paint an accurate picture for their PCP.

Opportunities to overcome this challenge

SNP operators must limit the number of voices their members hear from the care coordination team to one or two, in order to avoid confusion among their members. For patients who need a more hands-on approach, community care workers can go to older adults’ homes and help them manage their care, providing extra eyes and ears for the care coordination team.

• Outreach: SNP members can often be confused by the number of “touches” from different members of the care coordination team. SNPs will need to streamline their patient-facing interactions to just one or two coordinators.
• Data: Because IE-, C-, and D-SNPs almost always coordinate third-party resources instead of employing them directly (unlike I-SNPs), their ability to bring the various data streams together into a coherent picture of the member for the care coordination team is a challenge. So far SNPs have struggled to make this work.
• Polypharmacy: The biggest cause of rehospitalization among older adults is adverse drug events (ADE) caused by polypharmacy issues. But many IE-, C-, and D-SNPs don’t currently integrate pharmacists deeply into their care coordination team. Making pharmacists a central part of this team is essential for creating better member outcomes, especially for plans that have a telepharmacy capability.

Case study example

How Cureatr is reducing ADEs from polypharmacy

Cureatr is a digital medication management firm that provides patient medication history and telepharmacy services to payers and providers. Their remote clinical pharmacists use real-time data to maintain up-to-date medication lists and to ensure patients take the right medications appropriately and consistently to avoid ADEs. In randomized clinical trials, Cureatr has seen a 15% decrease in hospital readmission rates due to medication management issues among their users.

Given the volatile nature of the senior care labor market and the growing population of chronically ill older adults, it is in the health care industry’s best interest to ensure there are enough qualified workers to care for facility-based older adults to avoid unnecessary hospitalizations and other avoidable costs. However, many SNP operators, even provider-operators, do not seem concerned about workforce supply and demand.

Most SNPs use RNs or advanced practice providers (APPs) to coordinate care, but I-SNPs and IE-SNPs also rely on certified nursing assistants (CNAs) and other direct care workers to care for their patients. These are traditionally the roles with the highest turnover and are the most difficult to recruit and retain.

Nationwide, nursing homes are down more than 240,000 employees since the start of the pandemic, and no state is able to meet the minimum staffing requirements. This leads to closed beds, wings, or entire facilities, forcing more work onto family caregivers and leaving many older adults without the care they need—ultimately leading to delayed care and unnecessary hospitalizations.

Additionally, with fewer nursing home beds or facilities available, fewer older adults will be eligible to enroll in I-SNPs—which right now are growing quickly— and may not qualify for C- or D-SNPs if they do not meet the eligibility criteria. And having fewer post-acute beds available makes operations more difficult for those same facilities, since they have to turn away patients, which lowers revenues further.

This also has a ripple effect of pushing patients who should be in nursing homes into lower-acuity settings like assisted living or retirement communities (which, of course, makes them ineligible for I-SNPs). While IE- and C-SNPs could be effective alternatives, there may not be enough workforce to sustain those models, particularly given the travel involved to care for individuals in their homes and increase in home care workers necessary to support those models. This leads more older adults to age in place without the care or support they need, adding financial strain to the health care system when these patients are hospitalized for delayed care.

Opportunities to overcome this challenge

Workforce shortages will affect the growth of I-SNPs more than the other three types due to the labor required in nursing homes. Though I-SNPs are the second smallest SNP product by enrollment (only ahead of IE-SNPs), they have an established model of success in managing care for their patients in a cost-efficient way and are the fastest growing segment of the SNP market.

This is because I-SNP plans tend to employ their own clinical labor staff, as opposed to C- and D-SNPs that typically rely on third-party providers. This also allows I-SNP operators to shepherd their internal workforce into risk arrangements with less resistance than SNPs that rely on 3rd party providers.

And because an increasing number of I-SNPs are run by providers, there is an opportunity to invest in workplace culture to help retain and attract staff. While that is difficult to do in this climate, providers feel more confident about creating these cultures than plans do.

Plans and providers should work together to create a positive culture and work environment for these clinical and non-clinical workforces to help retain the workforce to encourage I-SNP growth over time.

D-SNP regulation

MA penetration is increasing overall, and D-SNPs are a large part of that shift away from FFS Medicare. D-SNP enrollment increased 22% from 2021 to 2022. And more older adults will continue to qualify for SNPs as they age into Medicare eligibility.

D-SNPs take all patients for as long as they have both Medicare and Medicaid. That population is growing—there was a 543% increase in total debt for Americans over age 70 from 1999 to 2019.

D-SNPs are already the largest and most difficult to manage of the SNP products due to their sheer size—D-SNP enrollees made up 88% of the total SNP population in 2021. The D-SNP population includes the most transient and underserved senior population, and D-SNP operators must navigate different state Medicaid regulations. D-SNP enrollees are also the most expensive of the Medicare population to care for, which is why CMS provides D-SNPs higher reimbursements than other SNPs.

As the complexity of older adults’ care rises and the dual-eligible population grows, the reimbursement rates currently seen for D-SNPs may not continue to grow at its current pace. There is also increased worry that the rapid growth in D-SNPs could lead to financial misconduct, which would engender much closer state and federal oversight and slow the growth of D-SNPs available in each state.

I-SNP regulation

The number of I-SNPs has grown rapidly over the past five years, and the fastest growing sector of I-SNPs has been provider-led I-SNPs. Providers and facility owners have begun creating their own SNPs in an effort to get a greater percentage of the premium dollar and limit the number of payers operating inside their facilities.

Although most providers and facility owners have found financial success with their SNPs, their value-based care model can disincentivize providers who know their patient population well but don’t have the enrollment numbers to appropriately manage the risk. The need for I-SNP operators to aggregate risk has limited the ability of smaller, more rural or remote organizations to succeed in this market.

Many of these smaller providers who do create an I-SNP plan have enrollments that are small enough to fall beneath the CMS reporting threshold, and thus don’t receive a star rating. Given the rapid growth of I-SNPs run by small providers and facilities, the growing percentage of patients in non-reporting SNPs will likely force CMS to more closely regulate these smaller operators.