Annie Acs, director of policy and innovation for National Hospice & Palliative Care Organization (NHPCO) recently spoke with Hospice News about the opportunities and challenges for hospice providers and health plans working within the value-based insurance design model (VBID), often called the Medicare Advantage hospice carve-in.
With a background in health policy, Acs spent more than eight years at the U.S. Centers for Medicare & Medicaid Services (CMS) working on the Affordable Care Act and health reform provisions, including exchange, eligibility and enrollment. Joining NHPCO in2019, she serves as the organization’s lead for work related to the Center for Medicare & Medicaid Innovation (CMMI) models.
Acs recently met with a contingent of Medicare Advantage plans, hospice providers and CMMI staff to discuss lessons learned since the program’s Jan. 1 implementation date.
You were involved in some meetings recently with VBID stakeholders. Can you share some of the issues that you discussed?
We have been trying to get all of the key stakeholders together to better understand the lessons learned from the first seven months of implementation of the VBID model, specifically the hospice component kicked off in January of this year. We convened (virtually) a group of participating providers and health plans.
We had representation from CMMI on the call to discuss those lessons learned and kind of four key topic areas: network adequacy, quality measures, the innovative payment arrangements between plans and providers, and seamless transitions of care from palliative care into hospice.
Can you add some color around the network adequacy issue? Is that regarding the plans’ ability to limit or close their networks in subsequent years of the program?
CMS is implementing a phased approach for network adequacy standards over the first two years of the demonstration. MA plans that are currently participating in 2021 are in Phase 1 and will be in Phase 2 in 2022. MA plans that are newly participating in 2022 will enter phase one, so your phase depends on how many years you’ve been participating in the model.
Earlier phases of the model involve more open networks, meaning that beneficiaries are not subject to any sort of prior authorization process. If they choose an out-of-network provider, plans need to pay that provider 100% of the fee-for-service rate for hospice.
In-network providers may end up actually being paid less than out-of-network providers, because we know that a lot of those contract arrangements between in-network providers and plans involve payments that are below the fee-for-service rate. We had a long discussion about how to build out the network adequacy standards.
There was a pretty clear consensus among plans and providers that prior authorization should not be included in this model. It’s a very sensitive time for beneficiaries trying to access care when they’re seriously ill or at the end of life. We definitely don’t want to inhibit anyone from being able to access the services they need.
Time and distance standards that are typically used within Medicare Advantage don’t seem to make a lot of sense for this model, again, because of the sensitivity of how quickly folks need to be able to access services. We need to really focus on where the beneficiary lives and make sure that they have access to an adequate network in future phases of the model.
What were some of the issues surrounding quality measures that you discussed?
There was some discussion about waiting long periods of time and not having intermittent data points is critical. This is often a concern with a lot of the programs or models that are being tested and implemented. When you have a lag or delay in receiving that data back, it’s hard to truly measure the quality.
Most participants felt like it was too soon to answer the question of whether there was a significant difference in the hospice enrollment link for those in VBID. compared to those in fee-for-service. There’s also a large consensus that the [visits during the last seven days of life] measure should be broadened, and access to palliative care should be brought in to get a better sense for utilization.
What seemed to be working or not working in regards to seamless transitions of care?
One of the main pillars of the model is that there’s a seamless transition between palliative and hospice care. Many of the plans that are currently participating have their own palliative care provider that they’re using. They are not using those in-network hospices in VBID for palliative care. That is resulting in few referrals for palliative care for those hospices that are participating. That is concerning in terms of making sure that there is that seamless continuum for beneficiaries that are enrolled.
That’s really important from a consumer aspect and to make any sort of value headway within this model. That’s a really critical component. Better understanding, defining and tracking that is really important. We can’t have a hands-off approach on seeing whether that works.
There is also a lack of defined core services included in the VBID palliative care benefit. We’re seeing the quality and type of services being received by beneficiaries vary greatly. We think there should be a standard definition for core services that are included in community-based palliative care. That’s one of the reasons why we’ve been pushing for a dedicated Medicare palliative care model demonstration.
Can you give a few examples of the innovative payment arrangements that you’re seeing?
That’s the terminology that CMMI has been using. They’re encouraging innovative payment models, and I think they’re trying to stay out of those contractual agreements between plans and providers, which definitely makes sense.
The issue there is that right now we’re mainly seeing that providers are paid less than 100% of fee-for-service, when you could make the argument that referring to hospice and having a contract with a provider within MA should be providing some cost savings to that plan.
We’ve been encouraging hospices to demonstrate their value to these plans. Bring the data that shows that you’re helping to keep beneficiaries out of the emergency department and those acute hospitalizations. We hope that this can be something that is improved upon going forward.
We have seen that there are some successful components of the arrangements. Concurrent care is something that can be utilized in this model for a certain amount of time. It doesn’t seem like that’s taken off greatly, but in the cases where it has it seems to be very beneficial to beneficiaries, plans and providers. Some of the supplemental benefits like to support social determinants of health have been a really valuable point within the model.
What are some of the most significant opportunities that the stakeholders are seeing in VBID eight months into the program?
One of the main opportunities is new partnerships, providers and plans working with organizations that they haven’t worked with in the past. I think there’s a real opportunity there to be innovative, and that’s one of the main pillars of why CMMI tests these models.
We’ve been just trying to really encourage hospices and other organizations to demonstrate their value, collect the right key data sets to demonstrate that value and show what a great benefit they bring to the table.
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