Enrollment Grows in Integrated Care Plans for Dual-Eligible Nursing Home Residents
Nursing home residents are among the most vulnerable people in the health care system, requiring continuous and complex care. Transitions between hospital and nursing home care occur frequently, and studies show that approximately 35-67% of hospitalizations among nursing home residents are preventable.
Nursing home residents who qualify for both Medicare and Medicaid have access to separate care because they go through two separate and incompatible programs. Medicaid provides long-term care, while Medicare provides acute medical care, including hospital stays. This division of responsibility often leads to poor cooperation, poor performance, and poor health outcomes. Recognizing these challenges, policymakers are experimenting with special managed care programs that provide financial incentives for coordinating care across Medicare and Medicaid, including for nursing home residents.
In a recent study, LDI Senior Member Eric T. Roberts, LDI Executive Director Rachel M. Werner, and colleagues conducted a first-of-its-kind survey of population enrollment. of two nursing homes that are eligible for special managed care plans. . They found that although many people choose such plans, the number of people in general is still low. The study also examined different types of enrollment in these programs across regions and nursing homes.
Managed Care Policy Types and Implications
Policymakers have proposed several specialty managed care plans to address the problems of separate care for dual-eligible individuals by creating financial incentives to combine Medicare and Medicaid services. These plans include Medicare-Medicaid Plans (MMPs), Fully Integrated Eligible Special Needs Plans (FIDE SNPs), and Institutional Special Needs Plans (I-SNPs). The first two are shared care plans that serve only dually eligible people in the community or in nursing homes. They have contracts with the federal Medicaid programs and set the risk for Medicare and Medicaid spending, which gives them an incentive to coordinate medical and long-term care.
The third type, I-SNPs, serves only Medicare beneficiaries who need nursing home care, many of whom are dually eligible. I-SNPs put insurers and nursing homes at risk for residents’ medical spending. Because Medicaid covers long-term nursing home costs while Medicare funds most medical care, I-SNP can provide a unique way for nursing homes to use these funding sources together to coordinate care. I-SNPs have the potential to promote more efficient care delivery, such as improving on-site medical services and reducing unnecessary hospitalizations. However, unlike MMPs and FIDE SNPs, I-SNPs do not have contracts with Medicaid programs.
While much is still unknown about how these different types of managed care plans improve care coordination for dually eligible beneficiaries, understanding current enrollment patterns is the first step to important.
Enrollment Procedures in Managed Care Plans
This study examined enrollment trends in MMPs, FIDE SNPs, and I-SNPs using Medicare and Medicaid data related to dual nursing home residents from 2013 to 2020. and to analyze the geographic distribution and characteristics of nursing homes associated with high enrollment. They also compared enrollment in these managed care plans with traditional fee-for-service Medicare and non-compliant Medicare Advantage plans.
Results revealed that enrollment in MMPs, FIDE SNPs, and I-SNPs increased significantly from 6.5% in 2013 to approximately 17% in 2020. Nursing homes with residents enrolled in these programs often they were larger buildings and in metropolitan areas with higher Medicare Advantage. to break through. However, the study found few differences in population or health conditions in nursing homes with different levels of managed care residents. Enrollment is also geographically concentrated, with 76% of enrollment occurring in only 16% of counties.
Notably, I-SNPs have driven the majority of enrollment growth across these types of managed care plans, with the share increasing from about 5% of the population in 2013 to about 12% in 2020.
Managing Shared Care Will Require a Future Focus on Quality
Most dual-eligible nursing home residents remain on fee-for-service Medicare, which provides no financial incentive to coordinate care with Medicaid. As enrollment in managed care plans continues to grow among eligible individuals, it is important for policymakers to understand the factors affecting enrollment in plans that have financial incentives to integrate care and assess the quality of care. care provided.
Several legislative initiatives, including the 2024 Unified Access to Emergency Services (DUALS) Act, aim to further unify care for dually eligible beneficiaries. Although the DUALS Act does not provide a direct mandate for I-SNP compatibility with Medicaid, it supports the broader goal of integrating financial incentives and care delivery across Medicare and Medicaid. This would create a single plan to manage all types of care, simplifying services for residents of two qualified nursing homes.
Integrated care models have the potential to provide higher quality care at lower costs by coordinating financial incentives. However, as the registration of these votes increases, researchers and policy makers will need to ensure that they achieve their goal of reducing the split in the dual system and promoting comprehensive, coordinated care to improve outcomes for this vulnerable population.
The study, “Eligible Nursing Home Residents: Enrollment Increases in Managed Care Integrated Care Plans, 2013-20,” was published on September 3, 2024 in Health Issues. Authors include Eric T. Roberts, Xinwei Chen, Eliza Macneal, and Rachel M. Werner.
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