Improving Policy & Advancing SNP Care Capacity

SNP Alliance Policy Priorities

In 2024, the SNP Alliance will continue its historical focus on systemic complex care strategies for people with permanent chronic care needs of all abilities among all three types of SNPs.  The Alliance’s areas of focus this year home in on the unique composition of SNP enrollment, enhancing ties to Medicaid, supporting all duals, both full and partial, as well as ensuring SNPs have the maximum amount of flexibility feasible to meet the needs of this highly vulnerable population. To learn more about the SNP Alliance’s mission, vision, and core values, click here.

To view the 2024 policy goals, click here.

Quality Measurement and the Medicare Star-Rating System

The SNP Alliance believes that quality and quality measurement are critical elements of any Medicare-Medicaid system. To view the SNP Alliance’s principles, click here.

Social Determinants of Health & Condition Complexity

The complexity of conditions and social risk factors are part of what make special needs populations “special.” Complexities and risk factors have long been recognized by special needs health plans and the SNP Alliance as fundamentally important to care and support. Many SNPs have been working within and with their communities (prior to becoming a special needs health plan and after doing so)— focusing on low-income, elderly, and at-risk individuals.

The Special Needs Plan Alliance and its members have emphasized the importance of recognizing social determinant of health risk factors and continue to advocate for better policy, payment, and measurement to focus on SDOH, address underlying issues, and improve understanding of effective approaches.

Over the last five years, the Special Needs Plan Alliance and its members have emphasized the importance of recognizing social determinant of health risk factors. We have listened and learned, provided education,  participated in policy and research analysis, and conducted surveys, facilitated discussions, served on expert panels, and prepared reports to disseminate and share what we’ve found.

Plans have described in facilitated discussions, key informant interviews, and surveys how their health risk assessment, outreach, care models, tailored care management, calling centers, database systems, risk stratification models/processes, and quality measurement and improvement efforts have taken both SDOH and care complexity factors into account.

The SNP Alliance has surveyed these plans on SDOH risk identification, data sources, methods, aggregation, and challenges. We have collected information on health plan/provider/community partnerships. We have written Issue Briefs, Reports, and comment letters to ASPE, GAO, NASEM, and CMS. We have conducted key informant interviews on SDOH challenges and heard about successful case stories.

Health Outcomes Survey

The Medicare Health Outcomes Survey (HOS) is a self-report survey designed for the 65+ population to capture information on their health status, chronic conditions, functional abilities, and other characteristics.

The HOS is used by researchers to determine patterns, trends, and compare population characteristics and by data analysts and regulatory agencies. The HOS was created from a survey instrument developed in the late 1980’s and tested using a veteran population of primarily older white males. Items from this tool, the Veterans RAND 12-Item Health Survey, are used today in Medicare quality measurement.

The HOS is currently used by CMS as the data source for generating several measures in the Medicare quality measurement and reporting system for Medicare Advantage health plans, based on a random sample of plan members who voluntarily agree to participate. Measures collect data on specific questions and then ask that same person two years later the same questions. Responses from the later timeframe are compared to the earlier timeframe to determine if the person has improved, declined, or stayed the same.

HOS measures and the format of questions in HOS (e.g., wording, sequence, length, response scale) have not been validated in diverse populations, for example non-English/non-Spanish speaking individuals, those with low literacy, ethnically diverse, those with significant chronicity or frailty impacting endurance, those with serious and persistent mental health or cognitive issues, people with progressive physical or intellectual disabilities, and those with housing insecurity or other social determinant of health risk factors which complicate administration (e.g., no address, no phone).

The SNP Alliance strongly supports individuals self-reporting on their experiences of care, outcomes, and how well plans and providers have addressed their needs. This is critical information to guide evaluation and improvement.

Unfortunately, the HOS instrument does not provide the necessary information to do this–in its present form and given how measures from the HOS data have been crafted, the disconnect with the characteristics of the special populations that SNPs serve, and the long time delay from first data collection to being able to access the measurement results (3+ years). Because of these issues, the SNP Alliance supports refinement and retesting of HOS with changes to the instrument, case-mix and predictive model, methods of surveying, and analysis of results.

HOS Sample Measure Items

In general, would you say your health is: Excellent, Very Good, Good, Fair, Poor

Does your health now limit you in these activities? If so, how much? (Scale: limited a lot, limited a little, not limited at all) :

  • Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?
  • Climbing several flights of stairs?

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (Scale: none of the time, a little of the time, some of the time, most of the time, all of the time)

  • Accomplished less than you would like.
  • Were limited in the kind of work or other activities.

During the past 4 weeks, how much did pain interfere with your normal work (including work outside the home and housework)? (Scale: not at all, a little bit, moderately, quite a bit, extremely)

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (Scale: none of the time, a little of the time, some of the time, most of the time, all of the time)

  • Accomplished less than you would like
  • Didn’t do work or other activities as carefully as usual

How much of the time during the past 4 weeks: (Scale: all of the time, most of the time, a good bit of the time, some of the time, a little of the time, none of the time)

  • Have you felt calm and peaceful?
  • Did you have a lot of energy?
  • Have you felt downhearted and blue?

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)? (Scale: not at all, a little bit, moderately, quite a bit, extremely)

Model of Care

Special needs health plans have several requirements that general Medicare Advantage health plans do not have to meet.

One of these is that SNPS must submit a written Model of Care (MOC) to CMS for external independent review by the National Committee for Quality Assurance (NCQA) based on specific scoring criteria.  The plan’s MOC must address four domains (Population, Care Coordination, Provider Network, and Quality). Each domain has defined elements and factors. These factors have required components which are scored. The factor scores are combined to create an overall score for the Model of Care as a whole. Based on the overall score, the health plan is assigned a 1, 2, or 3-year cycle for the next review. The plan follows this Model of Care in their care management, coordination with providers, and quality improvement actions.

SNP Alliance Recommendations for Model of Care: Based on plan surveys, discussions and analyses, the SNP Alliance has offered several recommendations for modifications/edits in the Model of Care guidelines and processes—providing these recommendations to CMS and to NCQA:

  • Eliminate areas of duplication/redundancy and simplify the elements and factors listed
  • Substantially modify the Provider Network Training requirement under Model of Care to re-focus this toward ensuring providers can effectively and easily access the enhanced care coordination services and other beneficiary supports offered by SNPs.
  • Streamline annual submission to be required of C-SNPs on Model of Care by asking plans for redline/substantive changes only (CMS)
  • Improve training of Medicare Advantage auditors around Model of Care so that the audit review is in sync with the NCQA reviewer approach and uses consistent guidelines
  • Address issues with off-cycle review “window closed” timeframe which restricts necessary care management, operational improvement, and other infrastructure or process changes that need to be made by the health plan