Medicare Advantage beneficiaries in the last year of life transition to fee-for-service coverage at least twice as often as those who are expected to live longer. Health care costs associated with those patients were an estimated $422 million higher in 2016 than they would have been if they had stayed with their Medicare Advantage plans, according to a new report from the Government Accountability Office (GAO). In 2017, the added costs exceeded $490 million.
GAO analyzed Medicare disenrollment and mortality data for 2015 through 2018 and used claims data to estimate the relative costs between MA and fee-for-service. The agency excluded hospice payments from its comparison. Because payment for hospices almost always goes through the dedicated Medicare benefit, disenrollment wouldn’t shift dollars away from MA and into fee-for-service.
“MA plans are prohibited from limiting coverage based on beneficiary health status, and disproportionate disenrollment by MA beneficiaries in the last year of life may indicate potential issues with their care,” the GAO indicated in its report. “Stakeholders told GAO that, among other reasons, beneficiaries in the last year of life may disenroll because of potential limitations accessing specialized care under MA.”
Through Medicare Advantage, CMS contracts with private insurance companies to provide coverage for Medicare beneficiaries. Hospice is one of the forms of specialized care that historically has not been available through Medicare Advantage. Patients who enroll in the Medicare Hospice Benefit have the option of leaving their Medicare Advantage plans altogether or maintaining that coverage to pay for services outside the scope of their terminal diagnosis.
However, only a portion of the MA benficiaries who disenrolled during the study period entered hospice. According to GAO, nearly 421,000 MA beneficiaries disenrolled to enter fee-for-service programs during 2016. Of those, slightly more than 199,000 elected hospice.
Results in 2017 were similar, of the 454,000 patients who disenrolled about 217,000 entered hospice.
These data were gathered prior to the Jan. 1 launch of the value-based insurance design (VBID) demonstration from the Center for Medicare & Medicaid Innovation, often called the Medicare Advantage hospice carve-in. The program is designed to test coverage of hospice care through Medicare Advantage.
All told, 53 health plans will offer hospice through the VBID demonstration in its first year. These plans cover 8% the market and a limited geographic footprint, according to data from the U.S. Centers for Medicare & Medicaid Services (CMS). The program is expected to grow in subsequent years, with more plans and providers set to sign on.
The carve-in is designed to assess payer and provider performance related to hospice within Medicare Advantage. Participation in the demonstration is voluntary for both payers and providers. Based on the geographic availability of the 53 participating plans, the program will be available to beneficiaries in 13 states and Puerto Rico during 2021.
GAO recommended in its report the CMS begin to pay closer attention to the MA beneficiaries at the end of life, including the reasons that so many disenroll.
| “The administrator of CMS should review disenrollments by MA beneficiaries in the last year of life as part of the agency’s broader efforts to review disenrollments by MA beneficiaries in poorer health,” GAO said in the report. |
