Managed care has reshaped our health care system, dramatically changing the landscape. Fee-for-service has, in most markets, been overtaken by Managed Care Organizations (MCOs) and the trend is expected to continue. With it come the hazards associated with managed care: rate reductions, collection challenges, and aggressive prior authorization processes.
Much advice has been given on how skilled nursing facilities (SNFs) can successfully attract and secure favorable contracts with key MCOs in their markets. But a contract alone does not ensure an equitable relationship for the SNF. Receiving a desirable volume and quality of referrals—and being paid fairly—under that contract is far from guaranteed.
To succeed SNFs should understand what drives their MCOs’ decision making and then position themselves accordingly. Most MCOs are charged with reducing Medicare or Medicaid program costs, better managing utilization of health services, and improving health care quality and outcomes. Some are given additional expectations to improve care for specific populations—often with chronic/complex conditions.
There are three key ways SNFs can increase visibility and enhance their partnership potential, and the right pharmacy provider can help them achieve a substantial edge against the competition.
Support MCO Expectations
These organizations are looking for ways to provide better care, improve clinical outcomes, and lower costs. Working closely with your pharmacy partner can ensure specific related benefits:
- Optimized medication review and reconciliation, which leads to
- Prevention of Adverse Drug Events (ADEs)
- Reduction in acute readmits (30 days post discharge)
- Identification of unnecessary/duplicative medications
- Continuity of medication regimens to optimize health outcomes through
- Rapid first-dose availability for new admissions
- Timely drug delivery when prescriptions change
- More optimal utilization of generic drugs
- Better management of chronic conditions/levels, including:
- Blood glucose
Join Post-Acute Networks (PANs)
Many forward-looking SNFs are proactively seeking membership in PANs. These networks select providers to form a continuum of post-acute care services (skilled nursing, home health, inpatient rehabilitation, hospice care). If selected into the network, SNFs gain access to MCOs and other value-based payment models they may otherwise miss. Selection criteria vary by network, but the bar is typically high and the competition fierce. Pharmacies can assist SNFs in PAN selection by supporting criteria popular among them, such as:
- Can the SNF admit patients 24/7?
- Are physician extenders on staff, with support from a consultant pharmacist?
- Which medications are onsite vs delivered?
- How long does it take for STAT delivery of medication?
- Can the pharmacy support ultra-short stays?
Can the pharmacy provide programs or services that ensure compliance, free up nursing time, and enhance outcomes?
Another strategy for succeeding with MCOs is to offer specialized clinical care for their populations who need it. Examples include respiratory, head trauma, bariatric, or behavioral challenges. To add new or ramp up existing services, SNFs must build clinical and operational competencies. It’s one thing to admit three residents with mental health conditions in a month, but quite another to admit three per week. Pharmacy can be key to specialization:
- Assure the appropriate medications are available in the SNF
- Refine processes to support medication fulfillment
- Assess the potential need for added consultant pharmacist support
Managed care has changed the game for skilled nursing providers. To succeed in the new ecosystem, SNFs must adapt and deploy new strategies. Having a solid pharmacy partner can help optimize those efforts…as well as the resulting clinical and operational outcomes.
Click here to download the tip sheet, 3 Ways Your Pharmacy Can Help You Strengthen MCO Relationships. More information on managed care is available here.