If federal regulators truly want to ensure better care coordination for long-term care patients, they must adopt changes that make Accountable Care Organizations more accessible and more financially rewarding for skilled nursing providers.

That’s the message of a new white paper on ACO participation published Wednesday by the  American Health Care Association/ National Center for Assisted Living and the National Association of ACOs and shared with the Centers for Medicare & Medicaid Services. The recommendations call for “attributing” patient lives to nursing homes, which can then share in an organization’s savings when they hit certain goals.

The organizations said their recommendations would increase the participation of long-term and post-acute care providers in ACOs, which are groups of doctors, hospitals and other providers who band together to better coordinate care and create financial efficiencies while serving Medicare patients.

ACOs have remained largely physician-oriented since 2012. In a press release Wednesday, AHCA said fewer than 2,000 skilled nursing facilities participate in ACOs and nearly 70% of ACOs have no SNF participation. 

“Current program policies in ACO models do not align well with LTPAC providers, including those that determine which patients ACOs are accountable for, setting financial benchmarks, and quality measures,” AHCA reported. “But as one of the highest-cost and most complex patient populations, LTPAC presents a significant opportunity for improved resident outcomes and reduced costs to the Medicare program.”

Typically, ACOs contract with physician groups, who are paid a set amount to coordinate care for given patients. They can be rewarded for hitting certain healthcare outcome targets set by individual organizations.

The white paper calls on CMS to make it easier for skilled nursing facilities to earn those incentives, in part by decoupling long-term residents from their community based physician providers. AHCA and NAACOS want nursing homes to move from being “preferred providers,” basically unpaid partners, to “participant providers” who can receive payments for the patients attributed to them. 

In current contract arrangements, AHCA and NAACOs wrote, “LTPAC providers are expected to provide better and more efficient management of patients but may not share in savings or other means of recouping the investments required to provide improved care delivery. In certain cases, providers may also experience added pressure from a reduction in fee-for-service payments for specific ACOs, such as those currently in the ACO REACH model.”

How to improve

The paper provides specific and in some cases technical guidance on improving participation options; establishing an appropriate financial model for SNF participants; developing long-term care specific quality measures to rate performance; and data collection parameters. It also outlines needed elements for a future voluntary model for SNF episode-based payments “that could be nested within an ACO.”

One of the largest ACOs serving skilled nursing patients is LTC ACO, which contracts with more than 2,000 physicians and nurse practitioners who care for about 15,000 beneficiaries. LTC ACO is one of the few groups in the Medicare Shared Savings Plan to target long-term care patients and has about 2,000 SNFs in its national network.

President and CEO Jason Feuerman told McKnight’s Long-Term Care News Wednesday that he had participated in a steering committee that helped the advocacy groups develop their recommendations. He called the recommendations good, even though if adopted, they could increase competition for his brand.

“We’ve been in this business since 2016 with very little competition,” for long-term care patients, Feuerman acknowledged. “But to get CMS to think differently about things, I think it’s just going to have to evolve over a period of years, not something that will happen next year or the year after.”

Need to split hairs

He said the sector would have room for more long-term care and post-acute focused ACOs, but CMS and its Center for Medicare and Medicaid Innovation would “have a challenge in trying to align things the way they were presented to them.” 

For nursing homes to coordinate care on behalf of patients, they need to have patients’ lives “attributed” to them. That gives the nursing homes a stake in the financial risk and reward associated with care. In effect, Feuerman explained, the facility becomes the “member” instead of a community-based doctor that may only see a patient occasionally during a stay, or not at all anymore.

“The recommendation that was made was that when physicians are seeing patients in a nursing home, that nursing home becomes the point from which attributions of beneficiaries exist, and not solely from the physician side,” he said. “We’re really splitting hairs there but that’s a big deal. I think nursing homes in general have felt left out of the value proposition in value-based care.”

AHCA/NCAL Vice President of Population Health Management Nisha Hammel called the recommendations “a tremendous opportunity for long-term and post-acute care providers to lead the way” on value-based care.

There is future work to do, as well. The paper acknowledged that CMS would have to study more in-depth how skilled nursing could be incentivized to provide certain care to cut costs across the continuum of care.

“SNF providers play an integral role in managing costs and care for the Medicare population that live in their communities,” AHCA and NAACOS wrote. “There may be cost-saving strategies that could be deployed, such as treating in place with an add-on payment for more intensive care or directly admitting to their SNF in lieu of hospitalizations, or utilizing hospice and/or palliative care for end-of-life care.”

More inclusion needed

A NAACOS spokeswoman said she hoped the recommendations sparked new attention for ways skilled nursing patients, providers and the entire Medicare system could benefit from broader ACO participation.

“If CMS is to achieve its goal of having all Medicare beneficiaries in an accountable care relationship by 2030, then it must take steps to better include provider types less represented in ACOs, including SNFs,” said NAACOS Senior Vice President of Government Affairs Aisha Pittman.

Providers also deserve to be rewarded for work they’re already doing, experts said. In many existing value-based care models, many LTPAC providers argue the barriers to entry are too challenging, such as when it comes to recruiting each individual patient to receive benefits associated with Institutional-Special Needs Plans. From the provider perspective, the ACO model requires one sign-up for the facility to become the “member,” though patient tracking and data collection are keys to success. 

In 2023, LTC ACO was able to split $10 million in savings among its members. Imagine, Feuerman said, the level of cash infusion possible for the long-term care sector if more providers are able to play a role in coordinating care within an ACO.

“It’s good that the nursing home industry is recognizing the opportunity to put themselves out or in line for the value proposition because today, unless someone is willing to share savings with them, such as us, they’re cut out totally,” he said. “Because of COVID, quite frankly, these providers, they’ve been decimated with costs, they’ve been decimated with their staffing, and because of all that, it has not allowed them to focus on this part of the value stream. So it really is somewhat evolutionary.”