Despite the legitimate anxieties of many hospice providers about the Medicare Advantage carve-in demonstration in 2021, some have expressed cautious optimism.
“The success of Medicare Advantage in achieving better health outcomes for American seniors and people with disabilities highlights the importance of an integrated system,” Allyson Schwartz, president and CEO of the Better Medicare Alliance said. “We are keenly interested in examining options and opportunities to enhance integration across the continuum of care for those who are terminally ill, including palliative care, hospice and end-of-life care.”
Medicare Advantage plans are offered by private insurance companies approved by the U.S. Centers for Medicare & Medicaid Services (CMS), and include HMO, PPO, and fee-for-service plans among other options. The program represents an integrated care model that promotes coordination of services and provides incentives for quality and patient satisfaction. Beginning in 2020, the program will be available in all 50 states as well as U.S. territories.
Also in 2020, Medicare Advantage plans will be able to offer expanded telehealth capabilities as well as services not primarily related to health care, including those that address social determinants of health. These include meals, transportation, and other factors that impact a patient’s quality of life. Though these types of services have long been covered under the Medicare hospice benefit, it’s encouraging that Medicare Advantage patients wouldn’t necessarily lose those particular benefits.
Promotion of advanced care planning, including planning for palliative care and end-of-life care, is also an important component.
“If a demo can let people know about hospice and bring people into hospice sooner, for longer than a couple of weeks, then that would be a good thing,” said Edo Banach, president of the National Hospice and Palliative Care Organization, in a podcast. “People would have earlier access to spiritual care and emotional support and all kinds of therapies that they don’t have access to in the rest of Medicare. That would be a good result.”
The plans could also support improved access to palliative care. Though this prospect remains a possibility rather than a certainty, it would be a positive development. CMS recently announced that beginning in 2020 Medicare Advantage plans could begin covering home-based palliative care, which the agency describes as services to diminish symptoms of terminally ill beneficiaries who have a life expectancy of greater than six months, not covered by Medicare Part A.
Though palliative care can be delivered at any point in the course of the patient’s illness, Medicare treats it as a precursor to hospice. Medicare’s hospice benefit becomes available after physicians indicate that the patient will likely expire within six months. Increasing patient awareness of palliative care, and giving them earlier access, could help facilitate a smoother transition to hospice when the time comes.
“Most community-based palliative care is provided by hospices.The question is how do we make this so people get access to a palliative care benefit that you can wrap your arms around, how you can transition to hospice care when [patients] really need that, ideally from the same provider so folks aren’t jumping around.” Banach said. “That will be key for us to understand in the roll out of any carve in: Where does palliative care come in and what is the intersection between palliative care and hospice care?”
Stakeholders are also encouraged that the development of policies that would govern the carve in are not occurring in a vacuum. Hospice industry organizations have been meeting regularly with CMS to represent hospice providers’ interests, including the National Association for Home Care and Hospice and the NHPCO.
NHPCO recently formed a partnership with the Better Medicare Alliance to conduct research and advocate for hospice organizations, patients, and caregivers.The partnership is gathering input from hospice and palliative care leaders, clinicians, health plan leaders, policy experts, and other stakeholders to help shape policy direction and payment model design, according the NHPCO.
The fact that CMS is beginning Medicare Advantage hospice coverage with an optional demonstration is also seen as a positive by some stakeholders.
“One of the things about a demo is that it gives the opportunity for only the ones who feel ready and who want to take that risk [to participate],” Schwartz said. “I think that is an advantage of doing a demo versus actually mandating it.”
Medicare Advantage plans have been increasingly popular with consumers. During 2018, more than 20 million beneficiaries (34 percent) were enrolled in such plans. Medicare Advantage enrollment has doubled during the past decade, according to the Henry J. Kaiser Family Foundation. Leading U.S. insurance companies have seen enrollment in their Medicare Advantage programs grow substantially during the 2019 enrollment period.
As with any change, the devil is in the details. Ultimately, the success or failure of the carve-in will depend on its specific policies and processes and on how the program is implemented.
“Hospice providers manage the whole [patient] and the family and work with them to make sure they get everything they need,” Banach said. “Whether that dynamic is going to change or not is going to impact whether hospice providers jump up and down or whether they will have a real hard time with this.”