Long-Term Optimism Boosting Skilled Bed Prices Despite Low Occupancy

Investment in skilled nursing facilities hasn’t slowed down despite persistent dark clouds surrounding the industry’s outlook.

One of the overarching themes this past conference season — including at the summits held by the American Health Care Association (AHCA) and the National Investment Center for Seniors Housing & Care (NIC) — is that there’s an ongoing influx of capital into the long-term health care space, as demographic trends and new payment models tantalize flush investors.

“The aging demographic discussion has been talked about for decades, and you have that expectation built in,” Bill Kauffman, senior principal at NIC, said during his firm’s annual expo in Chicago last month. “But you also have higher acuity — higher cash flow per bed if higher acuity is coming into these properties. I think there’s a lot there to think about, and it’s a multitude of factors for sure.”


But that trend is happening while Kauffman’s employer calculates quarter after quarter of record-low occupancy rates, which most recently fell to 81.7% in the second quarter of this year.

Despite the seeming discrepancy, several mergers-and-acquisitions experts say that there are perfectly valid reasons for why cash keeps flowing into an industry that, at least by the measure of heads in beds, appears to be struggling.

“You have a lot of new capital coming into the space that doesn’t fully appreciate — and therefore doesn’t fully underwrite the risks — in this industry,” Isaac Dole, founder and CEO of the Chicago-based investment firm Birchwood Healthcare Partners, told Skilled Nursing News. “So while census is declining, price per bed could be increasing.”

Another panelist at the NIC conference, Charles Bissell of JLL Valuation & Advisory Services, hinted at investors’ lack of intimate knowledge of the skilled nursing space as well, saying that the banks his firm works with don’t want to hear that per-bed prices are too high given the anticipated wave of baby boom demand.

“It’s our job as appraisers, as valuation consultants, to determine what a willing buyer would pay for the asset, and if the buyers are ignoring the fundamentals and pricing aggressively — if they’re effectively betting on the future cash flows, betting on cap rate compression — it’s our job to reflect that in a valuation,” Bissell said.

Bradley Schopp, managing director at appraisal firm Integra Realty Resources, agreed with that assessment.

“I do think in good areas, for good properties, people will overpay for those things just for what’s going to happen in the future,” Schopp told Skilled Nursing News. “They’re going to factor that in. I think we’ve seen some skilled nursing transactions, people paying prices that seem high, and I think it has a lot to do with just the availability of capital that’s out there.”

Schopp’s team typically tries to rely on firm data when pegging the price of a skilled nursing facility for its clients: banks that retain Integra to assign an impartial value on the properties they’re about to lend millions of dollars against.

Accessing available reimbursement information is crucial when determining the appropriate price for a building, he said, with the best appraisers realizing that in certain states, dollars could go up or down depending on census, political changes, and other factors; in other words, buyers can’t assume a favorable Medicaid rate will trend nicely upwards along with inflation.

“People will say it’s an art, and we’re just going to put a number on it, but no — it’s very scientific,” Schopp said.

In a state like Pennsylvania, for example, with a cost-based reimbursement system and cost reports available for the previous five to six years, buyers would be wise to analyze those historical trends for a fuller picture of what the future might look like.

“And that’s what you have to use — this is the information that’s going to say what the rate’s going to be for the next [several] years, and if you don’t use it, and if you don’t look at it, you’re really missing the boat on it,” Schopp said.

Those rates are just one of the many factors that can go into the eventual per-bed price that a buyer pays for a facility. At Birchwood, for instance, Dole’s team focuses on the distinction between licensed beds and functional beds, which could come into play as facilities remain licensed for certain capacities but phase out three- and four-person rooms.

“Historically, reporting was always price per licensed bed, but moving forward, I think buyers are referring to price per operational and price per licensed bed — even if there is a post-closing bed count compression in places like Kansas, where your bed tax liability falls significantly at 45 beds,” Dole said. “In this scenario, price per functional bed could be increasing compared to price per licensed bed.”

There’s another trend driving high prices: The major portfolio sell-offs that have dominated the space as Kindred exited the industry entirely, and major real estate investment trusts (REITs) restructured their portfolios by shedding assets. Mark Myers, executive managing director at Institutional Property Advisors in Chicago, said that big portfolio deals tend to carry a premium of 25% or more over one-off sales. In addition, Myers pointed to the trend of “merchant building,” or a developer buying a new property for sale to a skilled nursing investor.

“These are the more expensive properties, relative to older ones,” he said.

Over at Blueprint Healthcare Real Estate Advisors, a Chicago-based broker of senior housing and care assets, the key distinction is between stabilized and non-stabilized assets. Margins on buildings with solid operations and good cash flows may have decreased over the last three to four years due to wage increases and Medicare Advantage pressures, according to managing director Ryan Chase.

That has helped to drive interest in the non-stabilized side of the marketplace, where investors might be looking for some turnaround potential.

“Those that were, call it $45,000 per bed in 2015, are more like $50,000 per bed in 2018 — the same deal, with the same operations,” Chase said of properties tabbed as potential improvement projects.

Blueprint founding partner Ben Firestone also pointed to the overall optimism about the space as a reason why capital is increasingly chasing the market despite gloomier occupancy numbers. SNFs remain a lower-cost setting than hospitals and long-term acute cate hospitals (LTACs), he said, and some investors are even beginning to dig deeper into the financial math behind home health care — a setting that’s been increasingly championed by the government and insurance companies as a cheaper alternative to any kind of institutional care.

But the cost of receiving in-home care isn’t just a matter of paying an agency; that price doesn’t account for the other costs associated with holding onto real estate, such as property taxes and maintenance outlays.

“I think it’s really a perfect storm, and it’s why everyone out there really believes that occupancy and rate and mix are all going to go back toward a good healthy operating environment — even if labor and operating expenses continue to increase due to inflation,” Firestone said.

Written by Alex Spanko

The ABCs of Medicare Advantage STAR Ratings

“Why are payers still struggling with a lot of complicated tasks? What holds the key to solving their problems?”

Would you be surprised if the answer to the above question is patients themselves?

Although payers are fairly young in the US healthcare dynamics, they have become a substantial element in the transforming value-based healthcare. Considering the current pace with which we are evolving in terms of delivering quality care, it would become quite difficult to realize the dream of efficient healthcare if we leave payers behind.

Often the things that are missing end up making the most difference, and so is the case with providing patient-centric care. We may put in all our efforts into improving the patients’ health, but finding the missing piece of information for payers is the biggest challenge of it all. And then there are reviews, audits, HEDIS measures, and most of all, STAR Ratings.

Why are STAR Ratings such big shots for everyone?

CMS STAR Ratings directly impact the revenue for Medicare Advantage (MA) plans. Higher ratings bring better quality bonus payments (QBP) for payers, and on the other hand, lower ratings bring penalties and in the worst case, termination.

Going forward, the STAR Rating evaluation will be more crucial for not just the payer organizations but also for the providers. CMS is aiming for saving $2.2 billion over ten years for Medicare, something that would be in the line of advancing the goal of accountability, engagement, integrity, competition, and quality.

The complicated web of data for payers

About 60% of the US population suffers from at least one chronic disease, and many of them fail to adhere to their treatment regimes. A great number of patients are not able to follow-up on their physicians after an episode or a surgery effectively. There are many such cases and they account for higher admissions, readmission, ED visits, and many more.

The biggest challenge is that the data systems in healthcare do not communicate, and in turn, obstruct the connectivity between payers and providers. Be it patient charts, lab results, physician notes— all of these have crucial information to provide, but before that, they have to be brought together so that they could provide a clear picture of where the improvement is required.

The guide to capturing the fifth star with effective care management

Care management and payer performance go hand in hand. We cannot deliver true patient-centric care if payers are not able to get their hands on the most crucial data elements to act as an auditor. A while back, I came across a survey by McKinsey and Company which stated that only 21% of Medicare Advantage plan enrollees knew their plan’s STAR Rating.

Payers need to collaborate with physicians to build a mechanism for them to support patient-health initiatives at every step. For scoring a higher STAR Rating, they need to ensure that their patients receive appropriate care and they are aware of what is happening to them. Here are the four key steps in developing a better patient-centric environment and ensuring higher returns on investment:

  • Not just plan your data but also your approach: It takes the collaboration of both providers and payers to improve the health of patients in their network and deliver better financial outcomes. Identify the quality measurements that are crucial for reporting purposes and target those with the most potential impact. Payers need to identify their ability and assess each measure corresponding to their ability and understand how it will affect their summary score. And to understand their performance, they need data not just from traditional EHRs or claims records, but from other sources such as practice management systems (PMS), financial systems, ADT feeds, pharmacy, and many more.
  • Engage your providers at each step: The providers can help in many ways to improve the overall quality scores. When their processes are streamlined, indirectly the processes of payers can be improved. Poor adherence to physician treatment plans and care plans result in reduced STAR Ratings and overall performance. With empowered and connected physicians and care teams, payers would be able to track the performance of each member on every reporting measure. Once they ensure a streamlined information management on-the-fly, they can help in reducing physician burnout, patient fall-rate, erroneous reimbursements, and a lot of other factors.
  • Pinpoint at the at-risk and high-risk patients: The most important step is to identify the patient population and segregate them based on their risk scores and other relevant factors to know which patients require the most care. Factors such as Length of Stay (LOS), hospital readmissions per 1,000, ED visits, patient satisfaction scores, among many contribute to the performance of providers and payers need to understand the actual number to these measures— and that too at the point of care.
  • Bring automation to enhance the quality of each step: The main culprit behind the sorrows of payers is the redundant task of acquiring member charts from providers— a process that demands hours of manual labor. Simply relying on such manually-intensive processes cannot enable payers to dive deep into the root of the care gaps to ensure coordinated care across the network. The best possible way to simplify the process is to enhance the connectivity among multiple health systems through automation. This would empower payers to map member activities along with network utilization to highlight the gaps in care and reduce the turnaround time to a matter of few minutes.

The road ahead

Risk adjustment programs are designed to financially reward payers with higher medical loss ratios (MLRs) to ensure that they enroll high-risk beneficiaries. Payers are an integral element in understanding different segments of healthcare as they direct the bulk of healthcare dollars. We need evolving partnerships. We, as members of changing healthcare, need payers and providers to work together, and we need payers, providers, and leaders to come together for a greater cause to delivering the care every patient deserves.

This blog has originally been authored by Abhinav Shashank.

Ohio to be one of 17 states with 100% of beneficiaries having access to both an HMO and PPO plan

Kaiser Family Foundation recently published their Medicare Advantage Spotlight for 2019 showing Ohio to be one of 17 states with 100% of beneficiaries having access to both an HMO and PPO plan. Medina, Summit, Trumbull and Mahoning Counties lead the way with over 30 available plan options! Also worth noting is the entrance of two new insurers; Mutual of Omaha and Valor. Let us know if you are an Ohio provider seeking more granular detail. We would be happy to forward you a copy of our Ohio penetration and payor report.

Aetna Announces Biggest Medicare Advantage Expansion in Its History

Oct 22 2018
Dateline City:

Aetna’s 2019 Medicare plans offer enhanced benefits and greater value

HARTFORD, Conn.–(BUSINESS WIRE)–Aetna (NYSE: AET) announced its 2019 Medicare plans, featuring expanded plan options with low or $0 monthly plan premiums in many areas, enhanced benefits and a more personalized member experience.

“We are proud to be a leader in $0 premium plan offerings, with approximately 72 percent of our 2018 Individual Medicare Advantage members enrolled in $0 premium plans,”* said Christopher Ciano, who was appointed head of Aetna Medicare earlier this year. “Our 2019 plan options will offer even more value to Medicare beneficiaries through a variety of expanded benefits, while still emphasizing affordability.”

Expanded plan options for greater access and choice

For 2019, Aetna is offering Medicare Advantage Prescription Drug (MAPD) plans in 45 states plus Washington, D.C. Aetna added 358 new counties and 6 new states — Idaho, Minnesota, New Hampshire, New Mexico, Oregon and Rhode Island. In Minnesota, Aetna and Allina Health will be launching a joint venture Medicare Advantage plan in the greater Minneapolis/St. Paul area. In total, Aetna will offer MAPD plans in 1,416 counties in 2019.**

This represents the biggest expansion of Medicare Advantage in Aetna’s history, providing about 7.4 million more Medicare beneficiaries (46 million in total**) access to an Aetna plan.

Other 2019 plan options include:

  • Explorer Plan Portable PPO: Medicare eligibles who like to travel will have increased access to our expanded Explorer Plan Portable PPO offering with a multi-state network. This plan is now available in 17 new states for a total of 28 states.
  • Dual Eligible Special Needs Plan (DSNP): For those who qualify for both Medicare and Medicaid benefits, we expanded our DSNP offering to a total of 9 states: Existing DSNP markets include Florida, Pennsylvania and Virginia, with new DSNP markets in Georgia, Kansas, Louisiana, Missouri, Ohio and Texas.
  • Prescription Drug Plan (PDP): All three plans in our PDP portfolio are now available in all 50 states and DC. This includes the Aetna Medicare Rx® Select (PDP) plan, which has an average monthly premium of $17; no deductible on Tier 1 and Tier 2 prescription drugs; $0 copay for Tier 1 prescription drugs at preferred pharmacies; and enhanced coverage in the doughnut hole.
  • Medicare Supplement: We offer standard Medicare Supplement plans in 49 states and ancillary products in all 50 states. This includes a combined dental, vision and hearing product launched earlier this year.
  • Group Medicare: Our Group Medicare business offers a suite of products for employers and retirees in all 50 states. This includes a new fall prevention program (also available for Individual Medicare Advantage members) and community-based support services.

Enhanced benefits for added convenience and improved overall wellness

To make it more convenient for our members to get the care they need, we expanded and enriched the following Medicare Advantage benefits for 2019:

  • Meal delivery after a hospital discharge is now available with 73 percent of our plans, up from 5 percent.
  • Over-the-counter (OTC) health and wellness products*** are available with 67 percent of our plans, up from 29 percent.
  • Transportation to plan-approved locations is available with 21 percent of our plans, up from 7 percent.

In addition, we’ll continue to offer Medicare Advantage members access to the following benefits and services at no additional cost:

  • Fitness memberships
  • Routine vision, dental and hearing coverage****
  • Resources For Living® service, which connects members to community-based providers that offer social, wellness and behavioral services

“We recognize that good health goes beyond just physical care,“ added Ciano. “That’s why our Medicare Advantage plans take a total approach to health and wellness, so our members can age more actively.”

Need help choosing a Medicare plan?

We’re here for you. Our plans are designed to help meet your health, lifestyle and financial goals. For more information, visit aetnamedicare.com. Or call us at 1-855-335-1407 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m. The Medicare Annual Enrollment Period runs from October 15 through December 7, 2018.

*Data as of September 2018.
**This number includes Aetna’s Joint Ventures in Minnesota (with Allina Health) and in Northern Virginia (with Innovation Health).
***For example, vitamins, dental, eye, ear care products, first aid items, cough, cold, allergy OTC medicines.
****Level and type of coverage vary by plan.

About Aetna 
Aetna is one of the nation’s leading diversified health care benefits companies, serving an estimated 38.8 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental and behavioral health plans, and medical management capabilities, Medicaid health care management services, workers’ compensation administrative services and health information technology products and services. Aetna’s customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups and expatriates. For more information, see http://www.aetna.com and learn about how Aetna is helping to build a healthier world. @AetnaNews

Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal. This information is not a complete description of benefits. Call 1-855-335-1407 (TTY: 711) for more information. Members who get “Extra Help” are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays. The pharmacy network may change at any time. You will receive notice when necessary. Aetna Medicare’s pharmacy network offers limited access to pharmacies with preferred cost sharing in: rural Missouri, urban Alabama and urban Tennessee. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including pharmacies with preferred cost sharing, members please call the number on your ID card, non-members please call 1-855-338-7027 (TTY: 711) or consult the online pharmacy directory at http://www.aetnamedicare.com/pharmacyhelp. See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

©2018 Aetna Inc.
Y0001_4002_14502_M Accepted 10/2018

New Payer Announcement: FrontPath

Access Advantage is excited to announce a new addition to our roster of Payers, FrontPath.
FrontPath Health Coalition, based in Perrysburg, Ohio, is a Self-Insured Plan covering individuals and their families in NW Ohio, NE Indiana and SE Michigan. The Coalition was founded in 1988 by eight Fortune 500 employers to provide a competitive alternative to traditional health insurance plans and HMOs.

For our Access Advantage Member’s outside the immediate FrontPath geographic areas, payer participation provides access to FrontPath enrollees traveling outside their immediate service area, and assures payer participation if the Plan expands to cover additional territory.

For more information feel free to connect with Renee Cummings at reneec@accesselite.com.