Steven Littlehale

It’s a curious day when I lift a lyric from the Spice Girls to title an article. The Spice Girls’ first single, “Wannabe,” was released in 1996 and rocketed to the top of the British singles chart. “Wannabe” went on to hit number one in some 30 countries. 

But this lyric is so perfect and reflects the key messages that the sensational Heidi Wold, chief clinical officer of Longevity Health Plan, and I presented this August at Zimmet Healthcare Services Group’s annual conference. Do you “wannabe” in a preferred network, have high occupancy, and most importantly, have excellent resident outcomes?

Heidi and I spoke to an audience of approximately 1,200 skilled nursing facility providers, owners and operators concerning the challenges and opportunities of working with a diverse variety of payors. In our healthcare ecosystem, Medicaid remains the predominant payor for long-term residents, but through the years, the field has become crowded with alternatives such as Managed Medicaid, Managed Medicare, I-SNP, APMs (ACOs, bundles), and, of course, traditional fee-for-service (FFS) Medicare and private pay, to name just a few. 

These payors are external customers of the SNF and are buying the SNF’s services for their “member,” “covered life” or “beneficiary,” otherwise known as the resident. The SNF must be accountable to all these external customers and attempt to garner favor with them to ensure a steady flow of referrals to their nursing home and (potentially) equitable payment for services rendered. 

Regardless of which external customers are buying services, the SNF must meet federal and state requirements and also be responsible to the resident and family. The resident is at the center of this complex relationship — and retaining this fact is a daily struggle for SNF providers. The external payor is attempting to direct care, but that direction may be based upon little or no insight into the resident’s condition, such as in the classic request to shorten a resident’s length of stay. But again, the buck stops with the SNF provider, who is ultimately the resident/patient advocate during their stay in the nursing home. 

What metrics matter to get into and stay in a preferred network

Five-Star: Heidi shared that, “Typically, a managed care plan will evaluate a SNF, and if they’re less than three stars, they will likely not be included in [the plan’s] preferred network. The exception would be if there’s a network adequacy issue or [the plan needs] to engage another nursing home provider. Five-Star rating is a gating factor to get into contracting.” 

Heidi is currently working with a couple of SNFs that are both less than three stars. A national health plan recently told us they don’t want to include them in the plan’s preferred network. 

“We are presenting to the managed care plan the root cause of the star rating issue and the risk mitigation strategy. This proactive approach has been successful in the past. But if they have a choice, the health plan will likely contract with the three-star and above nursing home.”

Quality measures: Even though the short-stay quality measures only include traditional Medicare FFS residents, alternative payors still contemplate these outcomes. Heidi recounted that, “Managed care companies view your outcome measures. They look at both short- and long-stay measures and staffing to see how you’ve performed.” 

The myriad of hospital utilization metrics (rehospitalization, hospitalization, ED use, etc.) all come into play and matter greatly to the payor.  

“Rehospitalization and hospitalization are very important to managed care plans; managed care is also heavily evaluated on their 30-day readmission rates for their star ratings,” Heidi observed. “We want to make sure that if the person needs to go to the hospital, they should go. But if there are things that should be done and treated or things that should be avoided, there must be a system and process in place in the SNF to improve this.” 

Payors scrutinize the hospital utilization outcomes, but also the QMs that are leading indicators of hospital utilization. Payors will examine falls, infections and medication reconciliation when evaluating a facility’s membership in a preferred network. They will also look at resident satisfaction. What the resident shares back with the payor matters. 

Length of stay: “Managed care plans do look at both short-stay and long-stay members in your buildings and their average length of stay. They do look at SNFs with similar levels of acuity, demographics, diagnoses, et cetera. If you are an outlier, maybe there’s something missing in your ‘data story,’ and your residents are not being properly reflected,” shared Heidi. 

This can become a conversation point in your managed care negotiations. Who are the kinds of people that you serve, and how are they unique?

Keep in mind, it’s not just the payors saying, “I’ll tell you what I want, what I really, really want.” In your role of advocate, you must also tell the payors what you “really, really want” for your residents’ success. 

How to advocate for your resident with an external payor

Remember that everyone is on the same side regarding length of stay. Most SNF operators will cite tension around length of stay or discharge date. Their perception is that the external payor, which isn’t in the SNF, is directing care in a way that often clashes with what is best for the resident. 

Recast this assertion that SNFs and payors are not on the same side; in fact, everyone is playing for the same team. If the resident returns home and then is readmitted, everyone loses. The managed care plan, the SNF, and, most importantly, the resident are all hurt by a premature or badly planned discharge. It’s essential to be very specific and articulate the needs of the resident. In your continued-stay review, list why the resident still requires skilled care in the SNF. Think of it as an SBAR. What is the situation, background, assessment and recommendation supporting the resident’s continued stay? 

Use SNF documentation and coding on the MDS for managed care’s continued stay reviews. I really appreciated this statement by Heidi: “What often happens is that we don’t get very good data from the SNF to tell us really what’s going on with a resident. But if you’re doing MDS reviews, you know what’s going on, you know what the goals that are in place, and you also have time frames to meet these goals. That’s really useful information for the managed care plan.” The RAI is an important vehicle to aid in communication with external payors.

Engage the doctor. Physicians can have a peer-to-peer discussion with the health plan’s medical team. Sometimes, to potentiate a safe discharge to home, it takes the facility medical director intervening and stating what the resident requires, the progress they’ve made, their future goals, and the time frame needed to get everything done. 

“Yo, I’ll tell you what I want, what I really, really want”: safe resident-centered care that delivers positive outcomes, as defined by the resident, in the most efficient way possible.

Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.