NAHC’s Bill Dombi: Quality Is Key For Hospices in VBID Era

The value-based insurance design demonstration (VBID) launched Jan. 1, promising to send waves of change throughout the industry. Often called the Medicare Advantage hospice carve-in, providers stepping into VBID are zeroing in on ways to differentiate themselves from their competitors. 

Quality will be a key element for providers to focus on when it comes to sustaining and surviving payment changes, according to William Dombi, president of the National Association for Home Care & Hospice (NAHC). Dombi sat down with Hospice News at NAHC’s Financial Management Conference in Chicago to discuss some of the most important prospects and pitfalls lying ahead as the demonstration unfolds.

The carve-in is opening “a whole new era” for hospices, Dombi stated following a conference session around value-based care.


What are the most important elements that hospices really need to pay attention to if they’re looking to participate in VBID?

Quality of care. We’ve had many conversations with the Center for Medicare & Medicaid Innovation (CMMI) that have raised the question whether we think quality should be one of the measures that they have in establishing the network formation of VBID. The answer was, absolutely a “yes.” The difficulty on the hospice side is that we’re still having a lot of development around saying what matters the most from a quality metric standpoint.

When CMMI comes up with a star rating, it’s going to be focused first on the family’s satisfaction and a hospice’s survey ratings. But what exactly is that? It’s hard to pinpoint exactly what should be there. [NAHC] thinks it’s got to be a robust analysis discussion of what fits and doesn’t fit into quality. Providers shouldn’t wait for the [U.S. Centers for Medicaid & Medicare Services (CMS)] to tell you how to do it right. They need to figure out how the process looks and what goes into the quality side of it.


What can be challenges in defining those quality outcome measures for hospice in value-based care?

Death is obviously an anticipated outcome in hospice, but the path to death is more important than anything else. There’s a lot of subjectivity not only from the individual receiving the care, but also from the person who is doing the assessment of a patient as they try to figure out how and where within that framework of care to follow the process and achieve good outcome measures.

VBID is about trying to develop things that are objective rather than subjective, and figure out where it all ends up best. This move towards value-based care is indicative of where we are in that evolution in analyzing on a going-forward basis on everything from network participation to even the future of public reporting for agencies.

When we’re looking at this value-based demo and quality measures, it’s an opportunity to learn what matters the most to the patient and provider. We start off with a structured analysis of outcome measures and process measures. Within these, you have measures that are objective and those that are subjective, meaning at risk of manipulation. A combination of outcome and process measures is the best way to go. Having those kinds of quality elements as part of the process tying into the patient outcomes is important, because of the risk of manipulation. The more objective the quality measures, the better.

What’s the biggest risk in value-based care for hospices?

The biggest thing that stands out for me at this point is all of those warning signs of having stepped up regulatory oversight. The [U.S. Department of Health and Human Services’ Office of Inspector General (OIG)] has increased audits in hospice, and there is still very high interest from CMS looking at the issue of relatedness. There may be a proceedingly growing interest from the hospice community saying, “Let’s get out of this relatedness issue, and just give us the money to do everything to give that quality of care.”

When we’re looking at hospice and at several different facets of it, the issue of value-based care as a whole is clearly important. Tied into VBID is the issue of quality of services, quality measures and public reporting for the traditional Medicare benefit. This is not just for those carved into the VBID approach. Quality becomes a focus everywhere, and some of the new standards coming out from Congress and otherwise are there for quality enforcement.

You are also seeing even more oversight actions stepping up against the claims side of hospice care too, so that’s another aspect to pay serious attention to.

What can they do to navigate potential pitfalls in a VBID world? What is going to be key for hospices to sink or swim as the demonstration makes waves in the industry?

Hospices should be redoubling their own internal auditing efforts, and likewise on the claims side as well, focusing on that quality of care. This can go a long way to preventing issues around quality.

Documentation is one of the biggest pieces of evidence that a hospice can have in saying why they provided this or that type of service or care at a certain cost. Hospices will need to go back to basics to strengthen their documentation and really look at how their processes really work.