Humana CMO: Lack of Medicare Advantage Coverage a Barrier to Hospice

Patients covered by Medicare Advantage plans who are faced with the decision of whether to elect hospice may be discouraged by the need to transition off their health plan for most of their care. This practice that has the potential to change through the forthcoming value-based insurance design model demonstration, often called the Medicare Advantage hospice carve-in. 

Starting in 2021, payers and hospice providers will have the option to participate in a demonstration project testing the inclusion of hospice in VBID. The carve-in is designed to assess payer and provider performance within Medicare Advantage.

“I think one of the challenges previously had been that there was this sort of awkward benefit challenge around hospice and [Medicare Advantage] members’ admissions. They were getting care through our system, and then they had to make this decision: Am I going to continue to get curative care or am I going to switch to getting palliative care and to enter a hospice program?” said William Shrank, chief medical officer at Humana (NYSE: HUM), at the Better Medicare Alliance Medicare Advantage Summit. “That sort of dichotomous decision is a tremendous barrier to easing into a different paradigm of care. I think it caused patients and families an incredible amount of stress around making that decision. The new [Center for Medicare & Medicaid Innovation (CMMI)] model that allows MA plans to carve in hospice will fundamentally change that and allow a more progressive and more patient-centric, a more family-centric, a more just and compassionate way of having these conversations about advanced illness.”

Advertisement

Through Medicare Advantage, CMS contracts with private insurance companies to provide coverage for Medicare beneficiaries. The carve-in, according to CMS, is intended to increase access to hospice services and facilitate better coordination between patients’ hospice providers and their other clinicians. Reactions to the carve-in demo have been mixed, with many lauding the CMS action and others expressing concern.

Currently, when a Medicare Advantage beneficiary enters hospice, their coverage transitions out of the MA program to the Medicare Hospice Benefit. While the MA plan may continue to cover the patient, it would only apply to care or services that are unrelated to the terminal diagnosis.

Among Medicare Advantage plans, 53 will be covering hospice and palliative care in 2021 through the VBID model demonstration, according to the U.S. Centers for Medicare & Medicaid Services (CMS). Medicare Advantage is seeing record-high levels of participation for 2021 among beneficiaries, reaching about 42% for 2021, CMS reported.

The carve-in will begin at a time when Medicare Advantage premiums have dropped precipitously despite expanding benefits, even as the number of beneficiaries who opt into those plans swells nationwide. Premiums are down more than 30% for 2021.

“[Medicare Advantage] plans can be really thoughtful about how to create the right benefit structure, how to create the right network, how to create the right approach to make the most important care most affordable, to reduce premiums and out-of-pocket costs,” Shrank said.

Companies featured in this article:

,