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Managed Care Plans See Skilled Nursing as a Commodity, Not a Partner


Experts are increasingly calling on skilled nursing facilities to step up and tout their worth in the new value-based health care landscape.

But skilled nursing facilities may not have that much influence to wield, particularly when it comes to the growing force of managed care, one expert says.

“As an industry, SNFs have no leverage at all,” Anne Tumlinson told Skilled Nursing News. “They have almost no leverage on managed care plans, and the reason is because there are dozens and dozens of SNF providers in those markets.”

Tumlinson, the founder of consultancy Anne Tumlinson Innovations, previously led Medicaid oversight at the Office of Management and Budget (OMB), and founded Avalere Health’s post-acute and long-term care consulting practice.

In her experience, the culture of managed care can vary widely by region, and what one provider experiences in one part of the U.S. isn’t necessarily true in another.

Arnold Whitman, founder and chairman of Formation Capital, said SNFs need to leave “the kids’ table” and reach parity with other providers on the continuum an audience at an industry event in March; earlier this month, an executive at Consonus Healthcare said skilled nursing operators must tout their outcomes and use that data to negotiate rates.

The trouble, at least when it comes to managed care, is that most insurance is transactional and only transactional, Tumlinson told SNN. She has seen providers improve their quality, bolster clinical staff, and add new post-acute transitional care units, only to have conversations with health plans go nowhere.

“The managed care plans say, ‘That’s nice. It’s $350 a day. Do you want to contract with us or no?’” she said.

Part of the problem is that Nursing Home Compare, the Centers for Medicare & Medicaid Services’ (CMS) tool for assessing skilled nursing facilities, does not provide much insight into who is good and who is not, Tumlinson said. And while managed care plans do have quality measures, those measures are focused more on population health rather than on the services that post-acute operators provide.

“There’s certainly a lot of room for SNF providers to be more sophisticated,” she noted. “But my concern at the policy level and the payment level is that they’re going to invest all this time and and money energy and still not get rewarded.”

Tumlinson stressed the approach of adapting to episodic payments and bringing data to demonstrate value is the right one. But for it to work, health plans have to be willing participants in the process, which is far from guaranteed.

“Going to the managed care plan with your data and saying: ‘We’re a high-quality provider and you need us,’ is not in and of itself sufficient,” Tumlinson said. “You have to be willing to take on health care risk to some degree or other to even get close to the playing field.”

Written by Maggie Flynn

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Maggie Flynn on Linkedin
Maggie Flynn

When she’s not working, Maggie enjoys running, reading, writing and sports, in no particular order. Favorite things include murder mysteries, Lake Michigan and the Pittsburgh Penguins.

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