A Health Affairs study of 1.45 million hospital-to-nursing-home discharges finds Medicare Advantage enrollees are less likely to reach five-star facilities, largely because higher-quality buildings are more often left out of plan networks. Rehinged finds 3,011 five-star facilities among 14,690 scored SNFs, and 922 of them run below 80% occupancy. Separately, GLP-1 drugs are reaching nursing home residents faster than the payment rules built to cover them.
Why it matters for vendors: Quality alone is not filling beds. Vendors selling referral management, hospital discharge liaison tools, payer-contracting analytics or admissions marketing have a concrete target in the 922 five-star facilities with open capacity, led by Texas, California, Illinois and Pennsylvania. Pharmacy, nutrition-monitoring and assessment vendors should watch GLP-1 costs under Part A stays, where the operator pays.
Quality & RatingsReimbursement
Medicare Advantage Networks Limit Access to Five-Star Nursing Homes, Health Affairs Study Finds
What happened
A study in the November issue of Health Affairs examined more than 1.45 million Medicare hospital-to-SNF discharges in 2022, about 654,500 of them (45%) Medicare Advantage enrollees. Those enrollees could reach 61% of local SNFs on average. Compared with traditional Medicare beneficiaries, enrollees in narrow-network plans were 22% less likely to enter a five-star facility, and those in broader networks were 13% less likely. Higher-quality facilities, including those with stronger registered nurse staffing, were more likely to be left out of networks, even in plans with relatively broad ones. Black, Hispanic and Asian beneficiaries and dual-eligible enrollees were more likely to sit in narrower-network plans. The authors wrote that current network adequacy rules for SNFs “lack stringency.”
Why it matters
An operator with strong ratings cannot assume ratings alone will bring Medicare Advantage referrals. If network inclusion is the constraint, the value shifts to payer contracting, discharge-planner relationships and the data that makes a building’s case to a plan. The study uses 2022 discharges, so it describes a pattern, not today’s plan-by-plan networks.
Rehinged Intelligence analysis of 14,690 scored facilities finds 3,011 five-star nursing homes, or 20.5% of the scored base. They fit the study’s description of the buildings plans leave out: on average they report 0.97 registered nurse hours per resident per day, against 0.61 for every other scored facility. Rehinged does not hold plan network data, so we cannot say which of these buildings any plan has excluded. What the data does show is capacity. 922 of the five-star facilities, 30.6% of the group, have occupancy below 80%, averaging 63.0% filled across 94 beds each.
3,011
five-star facilities, 20.5% of scored SNFs
922
five-star facilities below 80% occupancy
94
average beds in those 922 facilities
Average occupancy (filled beds ratio)
Five-star, under 80% occupied
63.0%
All scored facilities
80.9%
Five-star facilities below 80% occupancy, by state
California has the most five-star facilities of any state, 270, but Texas leads the open-capacity group with 83 buildings, 59% of its 141 five-star facilities. California follows with 63, then Illinois with 53 and Pennsylvania with 52. These are operators with the quality credential plans say they value and beds that are not filled, which makes them the likeliest buyers of help getting into networks and in front of hospital discharge planners. Low occupancy has other causes, including local supply and staffing, so treat the list as a starting point for conversations, not a finding about any single facility. Vendors selling referral management, hospital liaison tools or payer-contracting analytics should start with these 922 buildings, beginning in Texas, California, Illinois and Pennsylvania.
Watch for: Whether CMS tightens Medicare Advantage network adequacy standards for skilled nursing, which the authors say are too lax, and whether plans respond by adding higher-rated facilities. The December 15 comment deadline on CMS’s proposed directory rule, covered below, is the nearest formal opening.
TechnologyReimbursement
GLP-1 Use Spreads Across Nursing Homes as the Cost Falls on Operators for Part A Residents
What happened
Skilled Nursing News reports that GLP-1 drugs have moved beyond diabetes and weight loss into nursing homes, with Venza Care saying 30% to 40% of its new admissions arrive on one. A Medicare Part D bridge program covers certain weight-loss GLP-1s for residents, with an added $50 monthly fee, and has been extended through 2027. The more permanent BALANCE program is delayed with no implementation date. For residents in a Part A stay, the nursing home bears the drug cost. Operators are asking Congress to extend consolidated billing so high-cost drugs can be billed to Part B, as chemotherapy and dialysis drugs can.
Why it matters
GLP-1 admissions bring an unfunded drug cost for Part A stays and new clinical work: weight, muscle mass and nutrition intake monitoring, side-effect watching, and medication reviews at admission. The article notes the $50 fee can also be hard for dual-eligible residents to pay. That favors pharmacy cost-management services, assessment and EHR documentation tools, nutrition monitoring and staff education.
Rehinged does not measure GLP-1 prescribing, so the useful question is where operators are already stretched on nutrition and medication management. Nutrition demand scores of 50 or higher are rare: 209 facilities, 1.4% of the scored base. Those buildings average 2.49 stars, report 52.1% nursing staff turnover against 45.9% across all reporting facilities, and average just 0.64 registered nurse hours per resident per day. 124 of them also score 90 or higher on medication safety need, averaging 2.60 stars and 91 beds.
209
facilities with a nutrition score of 50+
124
of those also at 90+ on medication safety
52.1%
average nursing staff turnover in the 209
Facilities with a nutrition score of 50+, by state
These are buildings where weight tracking, protein planning and medication review already fall on a thin and fast-changing staff, which is the same workload operators describe GLP-1 admissions adding. The group is small because the nutrition score is high for few facilities, so the wider market is large and this cohort is the most urgent slice of it. Pharmacy, nutrition-monitoring and EHR assessment vendors should lead with Part A cost control and weight and side-effect tracking, and start in Illinois, Ohio and Missouri, which hold 51 of the 209.
Watch for: Any CMS date for the BALANCE program, congressional movement on consolidated billing for high-cost drugs, and whether the Part D bridge fee is revisited before it runs through 2027.