Medicare Payment Policy

tABLe
14–4 Readmission rates by type of snp
plan type
total
admissions
for SNPs. The average rates of advance care planning,
medication review, functional status assessment, and
pain screening are higher than the rates for all SNPs
for the same measures. The I–SNP rate for medication
reconciliation within 30 days of a hospital discharge (not
an element of the star ratings) is about the same as the
overall SNP average (31 percent).
Compared with other MA plans, I–SNPs also perform
well on a number of process measures. Specifically, they
have comparatively higher rates for monitoring of a group
of persistently used medications and glaucoma screening
in older adults. Although I–SNPs also have higher rates
than regular MA plans for the use of potentially harmful
drugs among the elderly and the use of drug combinations
with potentially harmful interactions, their higher rates of
monitoring of persistently used drugs suggest that drugs
with potential interactions or adverse effects are also being
closely monitored.
322 Medicare Advantage special needs plans
observed rates of
readmission
Risk-adjusted expected
rates of readmission
Ratio of observed to
expected rates
HMOs* 1,032,428 14.3% 15.7% 0.91
Local PPOs* 186,490 13.2 14.8 0.90
Regional PPOs* 126,151 14.8 15.3 0.97
snp-specific results
I–SNPs
HMOs 5,749 15.0 20.9 0.72
Local PPOs 1,623 9.9 19.2 0.52
D–SNPs
HMOs 103,353 16.6 17.2 0.97
Local PPOs 3,141 14.5 16.9 0.86
Regional PPOs 3,803 19.3 16.6 1.17
C–SNPs
HMOs 10,253 16.3 19.8 0.83
Regional PPOs 14,950 20.7 16.6 1.25
All SNPs
Regional PPOs 18,758 20.4 16.6 1.23
Note: SNP (special needs plan), PPO (preferred provider organization), I–SNP (institutional special needs plan), D–SNP (dual-eligible special needs plan), C–SNP (chronic or
disabling condition special needs plan).
*Overall categories include SNP results for contracts that include both SNP and non-SNP enrollees because data cannot be disaggregated. Results exclude Puerto Rico.
Source: MedPAC analysis of CMS Healthcare Effectiveness Data and Information Set ® public use files.
I–SNPs also perform well on risk-adjusted rates of
hospital readmissions relative to other SNPs and other
MA plans (Table 14-4). HMO I–SNPs have observed-toexpected
readmission ratios of 0.72 and preferred provider
organization (PPO) I–SNPs have observed-to-expected
readmission ratios of 0.52. These ratios show that I–SNPs
have fewer hospital readmissions than would be expected
given the clinical severity of their enrollees.
I–SNPs’ performance in hospital readmission rates is
an important measure of whether they provide a more
integrated delivery system. I–SNPs attempt to reduce
hospital and emergency department utilization through
care management and by emphasizing the provision of
primary care. For example, some I–SNPs employ nurse
practitioners to work with nursing home staff to provide
primary care, care planning, and coordination of medical
services. Achieving readmission rates that are lower than
expected demonstrates that I–SNPs are meeting their goal