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.