At the most recent public hearings conducted last week by the Medicare Payment Advisory Commission (MedPAC), a staff report tackled a number of subjects tied to Institutional Special Needs Plans (I-SNPs) including whether the use of Medicare Advantage (MA) Five-Star ratings to assess bonuses for I-SNPs was a good fit, or not.

The staff report answered with an unequivocal “no.” Other experts in the space gave a more nuanced response to the question.

First off, an I-SNP is a type of MA plan that restricts enrollment to MA eligible individuals who, for 90 days or longer, have had or are expected to need the level of services provided in a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for individuals with intellectual disabilities, or an inpatient psychiatric facility.

MedPAC’s Take

The MedPAC staff report outlines how the ratings and bonuses work, and where the staff believe the system is flawed. From the report:

• I-SNP plans that receive a rating of 4+ stars get a quality bonus (a 5 percent increase in their benchmark)

• Ratings are based on 41 quality measures and use a variety of data sources

• Plans that are too new/small to calculate a rating get a 3.5 percent increase

• Ratings provide limited insight into I–SNP performance

• I–SNPs do not conduct the CAHPS survey (on patient experience) or the HOS (survey of changes in physical/mental functioning)

• Most HEDIS measures used in the ratings (9 of 14) exclude I–SNP enrollees over age 65.

MedPAC said despite these issues, most I-SNPs still receive a quality bonus.

• This year, 84 percent of I–SNP enrollees are in plans that received some type of quality bonus, which is higher than conventional plans (69 percent) and D–SNPs (58 percent)

• However, I–SNPs (particularly provider-sponsored I–SNPs) are much more likely to receive the automatic 3.5 percent bonus for new/small plans than other types of plans

• Overall, the star ratings do not appear to pose a major financial disadvantage for I–SNPs but are nonetheless a poor fit in terms of promoting better quality

Commentary from the commissioners stuck to a general theme of “we love I-SNPs” but “we don’t love the Five-Star ratings for I-SNPs.” One example of the problem is that commissioners said star ratings are not only not applicable but could be dangerous. A Quality Measure (QM) for instance on A1C control of diabetes does not consider the risk-benefit ratio of treating a person as they get more frail. A 95-year-old with dementia, for instance, is not what the QM was meant to measure for A1C control, they said.

Another Opinion

From her perspective, Anna Greditor, RN APNP BC, DNP, director of HEDIS and STARS and utilization management for Provider Partners, said she partially agrees with the MedPAC staff report’s statements on the ratings issue.

“From a clinical perspective, I do not believe the current Five-Star system fully captures the complexity and needs of the I-SNP population. However, from a business and operational standpoint, the Five-Star system is the existing foundation and provides a meaningful opportunity for I-SNP plans to demonstrate performance and access additional resources,” she said.

Greditor, also a family nurse practitioner with over 31 years of nursing experience, primarily in the post-acute space, along with extensive leadership experience across both I-SNP and community MA plans, said it is important to note that the I-SNP population is unique.

“The IE-SNP population, which is often grouped with I-SNPs, is actually more of a hybrid between frail community members and institutionalized individuals. So, the first question we should be asking is: which populations would these changes truly impact, and is it appropriate to equate their complexity?”

For reference, IE-SNPs are Institutional Equivalent Special Needs Plans, which are designed for people who require a skilled nursing level of care but live in community settings.

Greditor also explained that the current Five-Star system is deeply embedded in operations as a mechanism for accountability, consumer transparency, and value-based care. While it is not a perfect system, she said, it has created a consistent structure that plans rely on and has driven meaningful focus on quality and outcomes.

“If there is interest in revamping or innovating quality measurement, it can be individualized and grounded in reasonable, evidence-based expectations for each person,” Greditor said.

Possible QMs for I-SNP Plans

If looking to model QMs for the I-SNP population, she said quality measurement for this could reflect:

• Individual advance care plan goals

• Clinical needs and frailty

• Risk adjustment that goes beyond diagnoses to include psychosocial factors (economic status, demographics, support systems)

This approach is also consistent with the 4Ms Framework (What Matters, Medication, Mentation, and Mobility), which emphasizes aligning care with an individual’s goals, function, and overall well-being, Greditor said.

“For example, in our population, breast cancer screening is one of the most challenging measures to operationalize. Many of our female members are bedbound or have physical or cognitive limitations that make it extremely difficult—if not impossible—to access traditional screening, even when their stated goal is longevity. The same applies to colorectal screening. These are relatively easy measures to track, but they don’t always reflect appropriate or goal-concordant care,” she said.

Aligning Goals

Instead, care and measurement could align with a spectrum of goals:

• Longevity: pursue all appropriate interventions

• Maintenance: selective, non-aggressive interventions

• Comfort: prioritize quality of life and symptom management

“If we center care around individuals and their preferences, the right measures and outcomes can follow,” Greditor said. “That said, before proposing major changes, we need to be careful not to disrupt what is currently working. The Five-Star system is evolving and, while imperfect, it does provide plans with a pathway to access additional funding through strong performance.”

Creating entirely separate measurement systems for different populations may not be operationally feasible. However, enhancing risk adjustment—as discussed above—is a practical and achievable step, she added.

Provider Partners contracts with SNFs, assisted living facilities, and personal care homes to offer tech-enabled value-based care. The company also combines LTC expertise and real-time clinical intelligence in an ACO REACH model partnership.

Comments or questions? Email pconnole@parkplacelive.com.