Fully integrated D-SNP plans aren't improving the member experience, study finds

A comparison between two different types of dual-eligible special needs plans (D-SNPs) as well as non-dual-eligible special needs Medicare Advantage (MA) plans in a recent research letter in JAMA Health Forum contends they perform at about the same level in terms of the services they provide and patient satisfaction.

That’s not the way it should be, though, according to the researchers. D-SNPs are a type of MA plan that coordinates care for beneficiaries eligible for both Medicare and Medicaid coverage, but the coverage packages remain separate, often to the detriment of patients and providers.

Enter fully integrated D-SNPs (FIDE-SNPs), meant to seamlessly coordinate Medicare and Medicaid benefits. However, the researchers found these plans are not having a major effect on the patient experience.

David J. Meyers, Ph.D., a professor at the Brown University School of Public Health and the research letter’s corresponding author, told Fierce Healthcare that “what we found, at least in terms of beneficiary care experiences—there are no substantial differences depending on which type plan people enroll in.”

David Meyers
David J. Meyers, Ph.D. (Brown University)

He said this surprised the researchers.

“There are pretty strict requirements about what makes a fully integrated special needs plan in terms of the integration that exists, and we thought that we’d especially see a difference in care coordination and patient ratings but didn’t,” said Meyers. “But on the other hand, it’s still a relatively new program.”

In the JAMA Health Forum piece, researchers with Brown University and the University of Pittsburgh noted that “FIDE-SNPs performed better than non–D-SNP MA plans in some domains but worse on domains including care coordination. Furthermore, FIDE-SNPs generally did not perform better than coordination-only D-SNP plans. The findings highlight some benefits in patient experience associated with enrollment in FIDE-SNPs and an opportunity to improve patient experience in these plans.”

Individuals dually eligible for Medicare and Medicaid are among those with the greatest care needs and have enrolled in MA plans at faster pace than non-dual-eligible individuals, according to the research letter.

“To improve care for this population, the Centers for Medicare & Medicaid Services [CMS] has encouraged development of dual-eligible special needs plans (D-SNPs)—MA plans that exclusively serve dual-eligible beneficiaries, coordinate Medicare and Medicaid benefits, and, in some cases, manage Medicaid spending.”

D-SNPs were created in 2003 as part of the Medicare Prescription Drug, Improvement, and Modernization Act and began operating in 2006. According to CMS, as of February 2022, D-SNPs function in 45 states and Washington, D.C., and serve about 3.8 million dually eligible beneficiaries.

FIDE-SNPs were part of the Affordable Care Act and provide fully integrated care for dual eligibles in a single Medicaid health plan that contracts with a state. Both D-SNPs and FIDE-SNPs were permanently authorized in the Bipartisan Budget Act of 2018.

Meyers and co-authors use mined data from the MA Consumer Assessment of Healthcare Providers and Systems surveys from 2015 to 2018 to make their comparisons. They reviewed data from over 180,000 individuals: 30.05% were in coordination-only D-SNPS; 5.81% in FIDE-SNPs; and 64.14%, in non–D-SNP MA plans. The research letter adheres to STROBE reporting guidelines, and the Brown University Institutional Review Board proffered a letter of consent because the research uses secondary data.

Compared with non–D-SNP MA plans, respondents in FIDE-SNP plans reported significantly lower ratings for care coordination and getting needed prescription drugs but higher satisfaction with their prescription drug coverage, getting appointments and care quickly, customer service and care quality. Respondents in FIDE-SNPs reported significantly higher ratings than those in coordination-only D-SNPs for plan rating and healthcare quality rating. Differences between FIDE-SNPs and coordination-only D-SNPs in other outcomes—such as having physicians who communicated well—were not statistically significant.

“These D-SNPs vary in the extent to which they manage Medicaid spending,” the research letter said. “Coordination-only D-SNPs (60.6% of D-SNPs in 2023) provide limited care coordination (eg, notifying Medicaid when enrollees are hospitalized) but do not manage Medicaid spending. Fully integrated D-SNPs (FIDE-SNPs) (8% of D-SNPs) have capitation contracts to manage Medicaid long-term care and behavioral health care spending.”

Meyers said that “there were some improvements compared to other Medicare Advantage plans. But really, the differences were quite small, and probably not that meaningful in terms of patient care. There’s probably more that needs to be done to ensure that any D-SNP meets the needs of this complex population.”