Sam Trevino

Gaining network participation with a managed care organization can be difficult. In the ever-changing landscape of requirements to participate with an MCO, providers not only need to know what areas matter but also what matters in those areas.

Providers also need to be willing to take a critical look at these areas and potentially shake things up in their facilities.

While the lists of requirements each MCO may have are diverse, there are common areas to highlight. Providers will have to learn to navigate and manage these requirements and differences to gain network access to the roughly 19 million Medicare beneficiaries enrolled in Medicare Advantage plans as of 2017.  That number has increased steadily since 2004 and represents 33% of Medicare beneficiaries.1

One MCO might want an average length of stay (ALOS) at or below 14 days, while the next plan could want the ALOS at or below 21. This plan wants to see less than an 18% return to acute, while the next plan wants that metric at or below 13%.

Then there are clinical capabilities. Providers understand that one SNF is not the same as the next, but MCOs need to be shown the difference. Otherwise, they may say that their network is fine and doesn’t need to add any facilities.

These differences only scratch the surface of what can differentiate the desires of one MCO from another when contracting for a MA product. In general, however, all plans address these areas so it is important to know and understand them.

Average length of stay (ALOS)

When assessing how to best manage the ALOS in a facility, first step back, remove oneself from the position of chief executive, owner, operator, clinician or administrator of the SNF and take a serious critical look at the ALOS.

Is the traditional average 48 days, while the MA average is 24? A 2016 nationwide SNF performance review showed that the relationship between shorter LOS and increased risk of readmission “is not strong.”2

Medicare Advantage plans know this — they understand the correlations, their actuaries have done due diligence and they stand beside the lower lengths of stay. The plans have found that, by and large, shorter lengths of stay with transition to the next safest level of care provides quality outcomes.

Providers must reset their way of thinking, bring in new ideas, and shake things up to make changes. At some point, CMS will come knocking and asking providers why they were able to provide the same outcomes for MA patients as traditional Medicare patients in such a shorter amount of time (lower cost).  We have all heard of fraud, waste, and abuse.

Return to acute (RTA)

Managing a return to acute has many factors at play.  More than can be reviewed here, but a couple of items to consider: Post discharge, who is following up on patients in their home?  Follow-ups, whether real or automated, need to engage and probe the patient or caregiver for meaningful information. Information that will allow intervention to stop a return to acute.

Also, relationships with home health agencies are important. As noted by Adaeze Enekwechi, former Director for Health Programs at the White House OMB, MA networks tend to grow organically. A strong relationship developed with a home health agency, will serve the SNF and patient well, leading to potential readmissions to the SNF, rather than sending to the acute setting, and thereby positively affect the RTA and provide a strong partner in care. Further, this relationship can potentially be exhibited to the MCOs to highlight how an MA patient and plan can be well served and keep the RTA percentage down.

Quality data

What facilities can quantitatively show to MCOs matters. What are the reporting capabilities of the facilities’ software? A facility with a great wound program needs to be able to do more than state that it has a great wound program. What does “great” equal?

MCOs want to know that there are certified wound care nurses on staff, and they want to be able to see evidenced-based outcomes. Where did the wound start? How long did it take to heal? What was the process along the way?

The MCO may have a higher reimbursement rate for wounds, but the facility will need to show ability before the rate is considered. Likewise, the same would be for your therapy department.  All SNFs have therapy. What makes one therapy department better than the other? Is the facility able to highlight what that is?

A colleague recently attended the 15th annual World Health Care Congress in Washington, D.C.  A running theme noted throughout the entire four days was “Data.” She described it as the most-used word of the event — noting that any SNF not utilizing its data to manage care is significantly behind the proverbial curve.

As providers seeking to gain access in Medicare Advantage networks, you must know and be confident in your data. Know and be able to report ALOS, RTA and quality metrics in a quantitative and meaningful way.

MCOs not only want to know that one invests in their facility, or has the latest equipment and technology. They want to know, with data to back it up, what is being done with that equipment and technology. And what that will mean for MA beneficiaries and the MCO business.

How does it affect the ALOS, the RTA, the metrics?

Know your data. Shake things up.

References

1. ttps://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment-market-update/

2. http://us.milliman.com/uploadedFiles/insight/2016/2352HDP_Performance_20161212.pdf

Sam Trevino is a licensed nursing facility administrator and a senior consultant with Cypress Healthcare Consultants. He has a wide background of operational experience in nursing home administration, pharmacy and consulting and more than 16 years of healthcare experience in sales, marketing and healthcare operations. He recently worked with one of the largest skilled nursing facility management groups in Texas, where he was responsible for oversight of ancillary services for 23 SNFs, and was responsible for day-to-day management of the managed care portfolio for more than 40 SNFs.