NAHC’s Dombi: ‘Balance Business with Mission’

From Medicare advantage, a rapidly changing health care landscape, and burgeoning demand for care in a time of severe staffing shortages, William Dombi, president of the National Association for Home Care & Hospice has been a front-line advocate on the most pressing issues staring down hospice providers in today’s marketplace.

Prior to his keynote address at the Illinois Homecare & Hospice Council conference Dombi sat down with Hospice News to talk about the evolving state of hospice care in the United States and the Medicare Advantage hospice carve-in, which he called a “once in a generation policy issue.”

What does the 2021 Medicare Advantage carve-in mean for the hospice industry, and how should organizations prepare?


This is the biggest thing that could happen to hospice since it began as a Medicare benefit in 1983. This is a once-in-a-generation policy issue. For now, the carve-in is only a demo program that involves a limited number of Medicare Advantage Plans. CMS has yet to come out with any real details as to what it would look like.

The big questions are: Will the plans pay the providers a rate comparable to what they are getting through fee-for-service Medicare, or will they follow the path they have with every other sector and push for discounts?

Also, will they offer hospice as the unit of service it currently is—the bundled, integrated, flexible interdisciplinary service? Will they cover the therapies hospice currently offers, from nursing and pharmaceuticals to massage therapy or pet therapy? All of these bring comfort to individuals in hospice care. Will people still have access to those services?


Has the NAHC taken a position on the Medicare Advantage Carve-in?

We decided on a policy position at our board meeting last week. Our general position is that we oppose it.

The carve-in is perhaps a solution that is looking for a problem. We think the Medicare hospice benefit has proven itself to be an incredibly well-run, well-designed program that will not benefit from being integrated into Medicare Advantage.

We are not hostile to considering it. Given the lack of detail from [the U.S. Centers for Medicare & Medicaid Services], it’s hard to gauge what the precise impact will be. We will be at the table in discussions about trying a carve-in approach. If there are serious flaws in Medicare fee-for-service that need to be addressed, we also may be able to find alternatives to implementing a full carve-in.

Medicare Advantage insurance companies have asked CMS to reconsider the use of encounter data in their risk adjustment model. Can you comment on the use of encounter data for risk adjustment?

This is a very complex issue overall in terms of adjustments, whether it be encounter data, clinical data, functional capabilities, and other approaches CMS has taken over the years. In every sector when you adjust the rates according to certain data or certain measures, it has fallen short of accuracy. Any time we are looking at changing a rate model, be it through encounter data or otherwise, we really have to be very cautious. There can be consequences that are not repairable retroactively.

What do you see as the most significant opportunities for hospice providers in the current market?

There continues to be an increasing demand for hospice services. The culture of America has embraced the hospice concept. About 50 percent of Medicare decedents use the hospice benefit, which still leaves a significant number of people that could benefit from hospice care.

I think the way to bring more people in is to get patients and families the information about their choices for end-of-life care earlier. That is a growth opportunity from a business perspective, and also a value opportunity for Medicare beneficiaries who need access to good end-of-life care.

There is an increasing focus on the social determinants of health and involvement of community resources in home-based care, how will this affect hospice providers?

Hospice has always been a population health kind of model. This is one of the original great innovations from the very inception of the benefit. Hospices already look at social determinants. They look at the family factor, housing, nutrition, and how the overall environment affects patient care.

As the U.S. population ages, what are hospice leaders biggest priorities as they prepare for a potentially massive influx of patients?

You can’t fulfill your mission unless you have an effectively run business. There has to be value from a quality perspective while also keeping the business solvent. Whether you are talking in terms of regulatory compliance or ensuring appropriate staffing, the blend of mission and business has never been more crucial.

They need to ask themselves if they really are running an efficient business. Hospice today is not running in a value-based purchasing environment, but you are seeing referral sources who are increasingly looking at Hospice Compare, and they will be looking at the star ratings when those come out. That will influence their choices about which hospice providers they want to have a relationship with.

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