Medicare Advantage Challenges and Opportunities for Skilled Nursing Providers

Trilogy Health Services Chief Medical Officer Andrew McNamara, M.D., highlights the complexities and challenges that Medicare Advantage (MA) presents to skilled nursing facilities (SNFs). He identifies significant issues with unnecessary care delays and administrative burdens linked to high denial and appeal rates under Medicare Advantage. McNamara stresses the importance for SNF providers to gain a deeper understanding of Medicare Advantage policies and work collaboratively with payers to simplify care processes. Drawing from his experience at Aetna, McNamara emphasizes that appeals consume substantial resources for both payers and providers, suggesting that alignment and smarter practices are needed to reduce inefficiencies.

Trilogy operates over 130 senior living and care communities across five states, offering an integrated care model from independent living to skilled nursing. McNamara points out that providers must clarify their role and value in the Medicare Advantage ecosystem, ensuring oversight and intentionality in care delivery. He urges providers to recognize Medicare Advantage payers as potential partners rather than adversaries, given their significant market presence.

The discussion includes the importance of understanding Institutional Special Needs Plans (I-SNPs), a type of Medicare Advantage plan, cautioning providers to carefully assess third-party partnerships and alignments with organizational goals. Trilogy has launched its own I-SNP initiatives in Indiana and is exploring expansions in other states.

McNamara advocates for value-based care models that reward effective, evidence-based care rather than simple volume-based payment. He highlights prior efforts on the payer side to minimize repetitive appeals by improving initial authorization processes, noting that provider tiers or simplified credentialing could mitigate administrative burdens.

Reducing care delays and creating more streamlined processes are complex challenges that require incremental improvements. McNamara proposes considering a DRG-like payment system for short-term skilled nursing stays to incentivize appropriate lengths of care without compromising outcomes.

Overall, the interview underscores the need for greater education, collaboration, and regulatory clarity between Medicare Advantage plans and skilled nursing providers to enhance care quality and operational efficiency in a rapidly evolving healthcare market.