The launch of the value-based insurance design demonstration (VBID) on Jan. 1 has opened up a new payment world to hospices. In addition to the opportunities they present, evolving payment models have brought a plethora of billing and operational challenges. In preparation, hospices have diversified their services, ramped up recruitment and retention efforts, and adapted to new billing processes.
Often called the Medicare Advantage hospice carve-in, the value-based insurance design (VBID) demonstration is one of the most disruptive things to happen to hospice since the establishment of the Medicare Hospice Benefit, according to Susan Ponder-Stansel, president and CEO of Florida-based Alivia Care. Ponder-Stansel recently sat down with Hospice News at the National Association for Home Care & Hospice (NAHC) Financial Management Conference to discuss strategies for navigating the shifting tides.
Alivia Care is among a growing pool of hospice providers that have diversified their services to capitalize on value-based care. The organization in 2019 launched pediatric and palliative care services through its CommunityPedsCare program. The community-based hospice also began addressing social determinants of health last year, opening a Program for All-Inclusive Care of the Elderly (PACE) center. The Jacksonville, Fla., PACE location is a joint venture with Aging True Community Senior Services.
Alivia’s approach is oriented around a “buy, build or partner” strategy when it comes to operational and financial decision-making, Ponder-Stansel told Hospice News.
How are you seeing value-based care shape the hospice industry, and what can providers be doing now to prepare?
Many providers feel like Medicare Advantage is something they tolerate, because their job is to figure out how many pennies they can keep. Oftentimes, this squeezes providers financially and pushes cost to the consumer. Hospice can’t afford to ignore the impact of the carve-in.
Going forward in Medicare Advantage, we’re going to see a lot of pressure for discounts on the services that we provide. There’s a lot of pressure right now for hospice to add a lot of bells and whistles, but there’s risks in expanding those services. As providers, we need to ask ourselves what’s really worth investing in, and how we can avoid stretching ourselves or our patients and their families too thin. This comes from asking ourselves what really matters to them, to our staff and to our referral sources.
Before we invest in anything at Alivia Care, we ask ourselves if this is something that we should buy, build or partner with other organizations to provide, including the services we provide and our staffing resources as well.
How does your hospice determine whether to buy, build or partner with other organizations?
That’s really a two-part question around building up both staffing and a more diversified enterprise. It’s the rising high demand for hospice care and expanding services coming back to the staffing shortage issues, leading to complex organizational challenges to work through.
A main challenge is that many are reaching retirement and leaving the workforce, and we don’t necessarily have people coming up behind us that are willing to work some of these crazy long hours. What we are asking of this younger generation is too much to sustain in the value-based world in hospice’s future. Retention is going to be just as much about money and staff pay as it is creating an environment where we really have some boundaries and healthy balances in place. This approach will especially be a challenge for employers who expect their staff at executive and leadership levels to give up their lives. Finding leadership is going to be an ongoing challenge, especially as fewer clinicians are in those roles.
What has your hospice seen as a successful strategy in terms of boasting its staffing volumes as your grow your service lines?
It can be hard simply because there’s a small pool of hospice-specific professionals out there and resources are scarce, but that doesn’t mean other skill sets and backgrounds can’t be applied and trained for end-of-life and serious illness care.
Alivia Care has turned to recruiters, because we started looking at our ability to really cast a wide enough net and to have enough eyes on the right areas where staffing support might exist. Our staff recruiters were able to source a lot of excellent candidates very quickly. This was also a great learning opportunity around our own internal hiring processes and things we were seeing that we could improve upon. For example, staff orientation and onboarding had to be stronger in introducing and acclimating employees to our culture. The staffing recruiters really learned our niche in hospice and what we were looking for, which reduced a lot of stress and time in hiring.
As providers swell their service lines, what are the biggest opportunities that lie among the challenges with the hospice carve-in?
The government is giving a lot of signals that are continuing to sweeten the Medicare Advantage plans’ pot, giving them more opportunity for more benefits and to collect more money. With the hospice carve-in, what many of us in the industry are worried about is that health plans don’t really do scoring on health outcomes around serious illness and end-of-life care right now, so it’s almost a black box of unknowns when it comes to measuring quality and understanding how to get to a better and different patient outcome.
One opportunity is to expand the choice requirement for patients when it comes to hospice. In value-based care, they wouldn’t necessarily be asked to make that terrible choice in a program designed to coordinate and transition care. A symptom of a larger problem in hospice is patients who could have received care but didn’t, because that choice can be difficult for anyone to make. For a long period of time we’ve been working in a fragmented system with patients and providers alike going into debt.
However, with this opportunity is also a challenge in drawing increased regulatory scrutiny as the [U.S. Department of Health and Human Services’ Office of Inspector General (OIG)] focuses hard on things such as patient length of stay. There’s danger. It’ll change the hospice benefit, because the plans will start to do what they do — argue about how many visits and where people are. That changes the face of hospice.
On the other hand, if payers focus too much on the money, they may not get the good outcomes they want in terms of quality patient care and satisfaction. Hospices with poor quality or low resources, those will be the ones that are going to get weeded out against others who can really deliver the full continuum of care — that’s our bread.
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