Cornerstone CEO: Leverage Hospice Skillsets to Spur Growth

Chuck Lee took the helm of Florida-based Cornerstone Hospice & Palliative Care, Inc. in 2013 after spending more than a decade as a hospice executive working to develop strategic plans, develop new leaders, grow census and expand service areas into new markets.

He has also served as board chair for the Florida Hospice & Palliative Care Association, working to advance the interests of providers and patients in Cornerstone’s home state.

Lee sat down with Hospice News recently at the Senior Care 360 conference in Maryland to talk about key policy issues including the Medicare Advantage hospice carve-in, value-based payment models, the 2020 final rule and calls for stepped up regulatory enforcement following the recent U.S. Department of Health and Human Services Office of the Inspector General (OIG) reports.

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As he sat down, Lee remarked about the extensive change he sees throughout the hospice space.

“We come into this world of hospice because we want to take care of people, and many of the factors that impact that provision of care is changing,” Lee said. “I think during the next few years we will have to take a fundamental look at what we do and how we do it and make sure that we can retain the heart and soul of hospice care amid this changing landscape.”

You mentioned that you saw the hospice industry changing. Can you expound on the kinds of changes you are seeing?

We are seeing many changes in the world of hospice, just about every aspect of our work and how we serve people. We are seeing changes in how patients are referred to us. We see changes in how families want us to communicate with them, and they need more interaction.

We are seeing changes in how our health care partners work with us, whether that be referring hospitals or physician practices, in the level of control and timeliness they expect, and we are seeing changes in how we get paid and with who is going to pay us [in light of the Medicare Advantage hospice carve-in set for 2021].

You’ve said during the conference that hospice care may not be confined to patients with a six-month terminal prognosis under the Medicare Advantage carve-in. How likely do you think that is?

I think it would be an exciting development if that happened. We already know that we say six months, but then we have patients whose median length of stay is two weeks. And there is nothing that says you can’t stay longer. We have the face-to-face recertification process, so the patient doesn’t have to be discharged on day 181.

I think a more exciting change in a Medicare Advantage environment is leveraging the skillsets of our interdisciplinary teams to engage patients and payers further upstream in the care continuum.

If the managed care companies, those intermediaries between the hospice and the insurance companies, are really looking at the value of hospice care and how our interdisciplinary teams can really help address the most fundamental problems that many families are facing, then we have the opportunity to have an engaged seat at the table for dialogue about how we can get into that process sooner and bring families into our care. We hear over and over from families that they wish they had begun receiving services sooner.

Many providers are worried about potential payment reductions due to negotiations with Medicare Advantage plans, do you share those concerns?

It’s a fair and valid concern. Anytime you have a project that goes out to bid, for example, you are probably going to get a lower price than if you just call one person and tell them how much a service is going to cost. If we have to have a competitive bidding process as a part of a Medicare Advantage environment, then most likely our reimbursement will go down.

But the carve-in does give us the opportunity for a couple of things. One is if we can have patients for longer, then we are going to receive some compensation for that duration of care.

Also, it gives us the opportunity to show payers our skillsets, which we have defined as hospice but really can support patients and families through a range of conditions and circumstances. Some of the monikers for these services include palliative care, chronic care management or advanced illness management.

I think we would have an opportunity to serve these folks for a year or longer, probably not for the same per diem that we get how for hospice, but if you look at the opportunity to serve more patients for a period of time then organizations can still fulfill their mission, meet their needs and remain fiscally sound at the same time.

Do you see other movements towards value-based models payments in hospice beyond the carve-in?

A few years ago you had the [U.S. Centers for Medicare & Medicaid Services (CMS)] Choices Model that allowed for some degree of concurrent care, but that didn’t go very well in germs of the number of people who enrolled in it.

In that instance I think the requirements and enrollment criteria for the program set us up to not make the maximum impact.

As we start talking about value-based care with hospice, there are opportunities with chronic illness management programs because you have patients with congestive heart failure, chronic obstructive pulmonary disease or cancer who repeatedly go back to the hospital. The skillset that traditional hospice providers bring to bear would be perfect for helping to address a lot of those needs, whether its medical, psychosocial, or whether some of the social determinants come into play. So as we look at things like home-based primary care and other access points further upstream, again the skillset that hospice interdisciplinary teams have can benefit those patients.

Will it mean the full interdisciplinary team as it is defined in hospice? Probably not. Is it going to require the same level of intervention or the degree of acuity? Certainly not if you factor in general inpatient care or continuous home care, so we are going to have to look at ways that portions of our interdisciplinary teams can serve those patients and look at payment streams that would allow us to bring in more elements of the traditional hospice model.

What is your reaction to the 2.7% payment rebasing in the 2020 final rule?

I think that the rebasing is a first step in the right direction. A lot of folks may not agree, because for most agencies most of the days of care are routine home care, and there is going to be a reduction in those payments, but I think there are a lot of providers out there who seek intentionally not to provide continuous home care, who choose not to provide general inpatient care, or who aren’t able to.

From my individual perspective, if an organization can’t provide all the levels of care, you have a fundamental question as to whether that agency ought to be in the business of providing hospice care.

If we are aligning some of the payments to support much more expensive levels of care for those agencies that are actually providing that care, then I think it’s an appropriate adjustment.

Even with those adjustments, the value that a hospice provides through a day of general inpatient care is still a fraction of the cost than if the person were to receive full-blown hospital care, so we still represent a tremendous value.

So for some programs, it’s going to be a headache to get the 2.7% cut in your reimbursement. That is never a fun thing to deal with. But if you look at the [Medicare Payment Advisory Commission] reports, they say every year that they see programs that are not providing all levels of care. Well if you can’t do that, then you can’t be a licensed hospice.

If the remedy is for CMS to look at hospice cost reports and see that providers are losing money on those kinds of care, and seeing the value in that kind of care versus the hospital, then I think it’s appropriate to adjust that payment. Hopefully it will provide an opportunity for those who don’t provide those levels of care to see if it is something they can fit into their economic model and figure out a way to do it, whether through their own unit or via contract with a hospital or skilled nursing facility.

That said, this rebasing is a haircut, and we have to make sure we don’t take too much of a haircut so we can ensure that all the services that we provide through routine home care remain sustainable.

How do you feel about the new requirement for an addendum to the hospice election statement?

Sometimes people get a surprise in terms of what they have to pay for. The more information that we can provide to a patient or a family, the better, especially as they come into what is probably foreign territory for them. I think it’s a fair thing to let people know what we cover and what we don’t.

And much of this is a reaction to what MEDPAC and CMS are seeing, that programs are not always doing that. If all of us were doing that and being very clear, then I think we would have a better understanding from patients and families.

I think it is going to force some organizations to look at things like what medications they offer, because you have hospices operating within an economic model that is dependent on reducing costs or not paying for certain drugs that some could argue we should be covering. Maybe we should be paying for a certain medication that we haven’t been, or for certain equipment, or if that’s not the case we need to be clear about that right from the beginning. That’s the “informed” part of informed consent.

If my mother needed hospice care,for example, then before we sign that notice of election we need to understand what the hospice is going to provide to my mother and to my family, and that may help us decide whether or not we go with that particular program or another depending on what they choose to cover.

What is your reaction to calls for stepped up regulatory enforcement following the recent OIG reports?

Where we have bad actors in the hospice space, I think there should be a substantial increase in enforcement, whether that is more surveys or if CMS and other fiscal intermediaries are empowered to take more punitive action. Because right now all they can do is a retrospective review and they may ask for some money back.

For example, we talked about the four levels of care. If you are serving a normal distribution of patients you are going to find some that require general inpatient care, who require respite care, who require continuous home care. That’s just our normal world, and if you have providers that are not ever providing those levels of service, they are not providing the full benefit.

And when I look at the benefit, those rules are called the Conditions of Participation. There’s a part of me that says that if you are not providing all the levels of care, then you should not be participating.

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