Study shows value of the Optum care model
UnitedHealthcare® ISNP members: 38% fewer admits than FFS
Harvard Medical School researchers study ISNP1
New study finds that on-site clinical model is associated with lower emergency department (ED) and inpatient utilization among nursing home residents
A new study by Harvard Medical School researchers found that members of UnitedHealthcare Medicare Advantage Institutional Special Needs Plans (ISNP) using the Optum care model had lower rates of ED, inpatient use and hospital readmissions compared with traditional Medicare fee-for-service (FFS) nursing home residents.
The American Journal of Managed Care, the leading peer-reviewed journal dedicated to managed care trends, published the study.
Comparing two groups
Two groups were compared to assess whether investing in clinical management in nursing home settings has the potential to enable residents to receive care onsite and avoid transfers to other, more costly settings. One group consisted of long-term nursing home residents who are members in a UnitedHealthcare ISNP plan. The other group was nursing home residents covered by fee-for-service Medicare. Both groups had spent one year in long-term care.
The researchers found significant differences in utilization between the two groups, even after adjusting for demographic differences. Compared with the FFS Medicare group, ISNP members had 38% fewer hospitalizations, 51% lower ED use and 45% fewer readmissions, while the rate of SNF use was 112% higher.
Potential $1 billion spending difference
According to the researchers, the results illustrate the potential relationship between clinical care investment in the nursing home and decreased institutional use outside the facility. The study results suggest that if traditional Medicare beneficiaries exhibited similar utilization patterns in inpatient, ED and SNF use to the ISNP beneficiaries, use of a care model such as the Optum model for UnitedHealthcare ISNP members could result in roughly $1.6 billion decrease in spending on these services annually (not including the costs of the care model).
The researchers examined data from UnitedHealthcare ISNPs, offered in multiple states. These plans partner with Optum, a leading health-services company, to include an added layer of clinical care to plan members residing long-term in a nursing home. Optum provides enhanced care through advanced practice clinicians (APCs) — nurse practitioners or physician assistants. APCs coordinate and deliver care in conjunction with the facility staff, primary care physicians and other providers.
Nursing home resources are stretched thin in the effort to keep up with the needs of their populations. The nursing shortage, for example, is a major challenge. According to new payroll-based data, nursing home staffing levels often fall below CMS expectations.2
Avoidable hospitalizations and readmissions are another concern. The rate of potentially avoidable readmissions dropped from 12.4% in 2011 to 10.8% in 2016, according to the Medicare Payment Advisory Commission.3 Although the trend is encouraging, industry observers believe that rate is still too high.
With the growth of ISNPs in recent years, nursing homes have more options to adopt on-site care models. This would potentially result in reduced transfers to high-cost settings. The researchers concluded that the UnitedHealthcare and Optum ISNP model is one potential approach to rebalance care away from the ED and hospital. It may also help inform value-based payment models in the skilled nursing facility population.
1. McGarry BE, Grabowski DC. 2019. Managed Care for Long-Stay Nursing Home Residents: An Evaluation of Institutional Special Needs Plans. American Journal of Managed Care 25(9): 400–405.
2. Geng F, Stevenson DG, Grabowski DC. Daily Nursing Home Staffing Levels Highly Variable, Often Below CMS Expectations. Health Affairs 2019; 38(7):1095–1100.
3. Kaiser Health News. Medicare Takes Aim at Boomerang Hospitalizations of Nursing Home Patients. khn.org/news/medicare-takes-aim-at-boomerang-hospitalizations-of-nursing-home-patients/. June 3, 2018. Accessed September 12, 2019.