Hospice Regulatory Landscape Could Change in the Election’s Wake

The outcome of the 2020 presidential election creates some uncertainties for hospice providers. As President-elect Joe Biden takes office in the coming year, his administration could have a transformative impact on the way hospices do business in a shifting regulatory and payment climate.

A Biden presidency could reverse course on programs already in place, including payment model demonstrations, or develop new policies or initiatives that could impact hospice and palliative care providers, Edo Banach, president and CEO of the National Hospice and Palliative Care Organization (NHPCO), said at the Hospice News Elevate conference

Biden has pledged to enhance the existing structure of the Affordable Care Act and has also laid out plans to expand access to Medicare by proposing to lower the age of eligibility from 65 to 60, giving rise to questions in the hospice space and beyond around an evolving payment landscape in the wake of the election.


Change was already set in motion for 2021 as the hospice industry begins to explore value-based payment models, including the Primary Cares initiative. The direct contracting options under the initiative include three voluntary payment models that are designed to help the U.S. Centers for Medicare & Medicaid Services (CMS) and health care providers reduce the cost of care and improve quality within Medicare fee-for-service programs. The models adapt and integrate concepts from other programs such as Accountable Care Organizations, Medicare Advantage and the Medicare Shared Savings Program, along with strategies used in the private sector as well.

CMS will also test the inclusion of hospice with the implementation of the value-based insurance design (VBID) model demonstration project, commonly called the Medicare Advantage hospice carve-in, currently set to take effect January 2021. Hospice industry groups and some members of Congress have urged CMS to push back the carve-in’s start by two years until 2023, contending that providers need additional time and information to prepare for a value-based payment arena.

“There may be no [hospice] carve-in if the Biden administration decides to delay or do away with this or other demonstrations,” Banach told Hospice News during the conference. “One thing on people’s minds is the effect on some of the demonstrations that have happened under the Trump administration, if for no other reason than that they weren’t the idea of the incoming administration. They happened at the end of the Obama [administration] and the beginning of the Trump administration, and will happen with this administration. We have some demos slated to start in January of 2021, and those may well be delayed — not because of any difference of opinion on the policy, but just to allow the new administration to get their arms around the policy and probably put their stamp on it.”


As the implementation dates for these programs approach, hospices are looking to identify and demonstrate their value proposition and revenue potential to Medicare and other participating payers.

Hospice coverage through value-based insurance models will be available in 13 states and in Puerto Rico. With a total of 53 Medicare Advantage plans participating, representing 8% of the overall market, the hospice carve-in is set to start small in its first year. The program’s growth over the course of the four-year demonstration will be a determinant of whether CMS decides to make it permanent.

“The risks are mitigated because there may be no carve-in if the Biden administration comes in and decides to delay or do away with this or other demos,” said Banach. “There are only a handful of plans that are participating, and so the risk is mitigated because it’s not going on everywhere and not going on in every region. If this were an all across the board MA carve-in everywhere, that would be a risk and also a real problem. The demo is currently slated to be small, however, there are risks here. It’s almost a certainty that providers who contract with these plans are going to be paid less than fee-for-service. That’s a problem, and that’s a risk.”

According to Banach, a bigger risk for providers lies in potential obstacles that the demonstrations may pose to access of hospice and palliative care without more time to develop and flesh out the defined parameters of the specific benefits that are included. Improved access to care is among the goals of the direct contracting and Serious Illness Population models. The programs are designed to help CMS and health care providers reduce the cost of care and improve quality and access to care for patients and their families.

The continued spread of COVID-19 is anticipated to be a primary focus in the early days as Biden takes office in 2021. Regulatory policies could affect a number of temporary flexibilities allowing for expanded telehealth during the national public health emergency, and which of those could be made permanent.

The CARES Act, enacted on March 27, also played a pivotal role in stretching community-based care, allowing for the current face-to-face hospice recertification requirement to be fulfilled via telehealth. The possibility for expanded telehealth under new administration would allow hospice providers to do more for patients with fewer staff under strains of a shrinking workforce, according to Banach.

“A lot of the changes we’ve seen will continue,” said Banach. “Telehealth is probably the biggest thing to come out of this [pandemic], and we can think about it as a silver lining. I think it will likely stay with us because we have fewer people caring for more people. If it turns out that eyes could be put on the patient virtually and fraud abuse isn’t going up, then that might be a very telling thing about whether or not we can continue to use telehealth for this purpose and also for other purposes. That is significant. We do need to leverage technology. At the same time, we don’t want to go too far. People still need a touch. People still need individual contact. People are still lonely, they’re isolated, they’re depressed and we’re not going to solve that solely through telehealth.”

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