Value-based care programs could be bridges closing gaps to accessing hospice care among underserved populations. Several hospices are honing in on expanding diversity, equity and inclusion efforts, as the pandemic further illuminates disparities in the U.S. health care system, often based on race or socio-economic factors.
In response, the Center for Medicare and Medicaid Innovation (CMMI) is currently reevaluating its 10-year vision around value-based care with the aim of reducing those disparities, according to a recent Health Affairs report penned by Chiquita Brooks-LaSure, the new administrator of the U.S. Centers for Medicare & Medicaid Services (CMS), Elizabeth Fowler, director of CMMI, and CMS officials Meena Seshamani and Daniel Tsai.
“We are considering whether and how current models meet the needs of underserved populations and where we could strengthen these approaches, and we are prioritizing potential new models based on their ability to achieve our refreshed vision,” the CMS leaders wrote. “Moreover, it will be important to ground innovations as part of a continuum of care delivery and payment, moving from fee-for-service to the most innovative approaches to drive higher quality, lower-cost care.”
Moving toward value-based care could effectively transform the hospice payment landscape, which historically has depended on the Medicare Hospice Benefit.
Beginning Jan. 1, the value-based insurance design demonstration, commonly called the Medicare Advantage carve-in, opened up hospice to a wider base of payer networks. Value-based payment models such as the carve-in and direct contracting options are designed to improve patient and family experiences of care, according to the CMS.
Diversity initiatives have been a growing focus in health care as providers nationwide seek to reach underserved communities of color. African American, Asian, Hispanic and Hispanic patients collectively comprised less than 20% of Medicare hospice patients in 2018, according to the National Hospice and Palliative Organization, while Caucasians were at 80%. Breaking down barriers preventing access to care has posed challenges for hospices that are working to better understand and connect with these groups.
Health care disparities affecting people of color have been pervasive for decades, but last year’s protests following the death of George Floyd brought renewed attention to the issue. Racial and ethnic disparities have been an impetus for hospices’ work to foster greater diversity within their organizations, according to a 2020 study published in the BMJ Supportive & Palliative Care Journal.
Integrating elements to foster diversity into value-based programs signals that CMS is seeking to ensure that every community has access to high quality care, according to Nicole McCann-Davis, chair of the NHPCO’s Diversity Advisory Council and associate vice president of health equity and access at Seasons Hospice & Palliative Care. Seasons is an AccentCare company.
“Providing hospice care to underserved communities and being intentional with meeting underserved patients where they are will potentially no longer be an option. This is essentially a call to action for all health care organizations to provide high quality and equitable care,” McCann-Davis told Hospice News. “Hospice organizations will have to dig deeper to understand patient needs and they may need to expand their traditional plans of care to address them.”
A key component of these efforts will be programs to address social determinants of health. Hospices have been exploring opportunities to provide nonmedical services to address these needs. In 2019 CMS announced that Medicare Advantage plans will begin covering supplemental nonmedical benefits to address social determinants.
Value-based programs should build in processes to address social determinants of health and unmet social needs, according to Altonia Garrett, vice president of public affairs and strategic partnerships at Capital Caring Health and executive director of the company’s Center for Equity, Inclusion, and Diversity. Measurement domains that value-based care programs should consider include social needs, care coordination, food insecurity, transportation, health literacy, and cultural competence, according to Garrett.
“Hospices care for the whole person, so addressing social determinants of health is in our very nature and can be addressed with the goal of eliminating disparities,” Garrett told Hospice News. “Knowing the care of the whole person is in our core, value-based programs should look to hospice providers as a key partner in ensuring this level of complete care to those that need it most. [Value-based care] allows us opportunities to increase and enhance access.”
Some organizations are using Medicare claims data and race, ethnicity, and language data as resources to measure disparities and create specialized programs that are culturally sensitive, according to Garrett.
Tracking demographic data may be a valuable tool for hospices in emerging payment models. A key part of understanding the impact of these programs is exploring the characteristics of beneficiaries. That will require utilizing patient-level demographic and standardized social needs data. Penetration data for CMMI models in underserved communities also would need to be tracked, according to the Health Affairs report.
Determining what data to track —and how to collect it — will be a challenge. Some providers have engaged with faith-based organizations and racial advocacy group leaders in the communities they serve.
CMMI will need to work with health systems and providers within minority communities to help them take on a more diverse range of patients. Many hospital systems have seen payments fall through decades of serving financially disadvantaged communities, the Coalition to Transform Advanced Care (C-TAC) indicated in a statement shared with Hospice News.
Developing community partnerships and tracking patient data will be key to a hospice’s value proposition as payment changes take shape in coming years, according to Acclivity Health’s Chief Operating Officer, John Dickey.
“Incentives, bonus criteria and reimbursement will tie to outcomes of the care quality and financial outcomes across these segments identified in the program as being underserved,” said Dickey. “Reaching more diverse patients will require developing relationships with community providers outside their existing networks and providing education to communities and groups who are less familiar with their services than the current make-up of their patient base.”