Questions abound about the potential long-term impacts of the value-based insurance design (VBID) demonstration, known as the Medicare Advantage (MA) hospice carve-in. As the program approaches its second year, hospice and palliative care providers are asking questions about the delivery, setting and future outlook for their industries.
The carve-in started small in 2021, but this is just the beginning of a four-year demonstration with parameters that will change over time, with the potential to reshape the hospice payment landscape, which has historically depended on the Medicare Hospice Benefit.
Hospices have honed services, expanded patient and referral outreach efforts, and revamped their approaches to payer partnership in preparation for the gradual shift to these risk- or performance-based models that also include the direct contracting program and Primary Care First, among others. As hospices rushed to prepare for these changes, they made substantial investments in diversified services, staff training, marketing tools, and technologies such as predictive analytics and machine learning, even among a global pandemic.
Misaligned payment is at the core of issues providers face, according to Susan Ponder-Stansel, president and CEO of Florida-based Alivia Care.
“We’ve made all these investments and physical plants in capacity business models, and when you start to make some of those changes, it’s hugely disruptive,” said Ponder-Stansel at the Hospice News Elevate conference. “Instead of running off and looking for new models of care, I would recommend that we make the change incrementally by giving consumers a real option and resourcing them well, so that capacity is there. Maybe that will create a tipping point where people have options, versus trying to butt heads right away and say you have to change your business model and align it with what people want.”
Value-based payment models are designed to improve patient and family experiences of care, according to the U.S. Centers for Medicaid & Medicare Services (CMS). The program’s components include programs to address social determinants of health, with CMS in 2019 announcing that Medicare Advantage plans will begin covering supplemental nonmedical benefits.
Payment models in the United States are currently misaligned for providers to deliver more choices and options in care delivery and settings, Ponder-Stansel told Hospice News. Misalignment stems in large part from requiring patients to forgo curative care in order to enter hospice, as well as insufficient support for family caregivers.
Existing systems in health care are poorly designed when it comes to home- and community-based services, with patients often driven into institutional care settings, according to Ponder-Stansel, with impacts of growing demand for end-of-life care and rising health care costs putting financial pressures on a strained health care system.
“We under invest terribly,” said Ponder-Stansel. “We’re going to see alternative living situations and care situations continue to rise, a real avoidance of institutional care, and a demand for better options where the care not only focuses on some of the acute things that happen, but also just providing those supports that are part of allowing successful aging and avoiding those more expensive, high-acuity interventions. Unfortunately, that is really where our system pushes people right now, and that just won’t work for the future — not financially and not from a consumer standpoint.”
An aging Baby Boomer generation has swelled health care costs as it moves across the care continuum. Since 2011, roughly 10,000 people become Medicare eligible each day, a rate that’s projected to remain a steady climb of continuation until around 2030, according to a Medicare Payment Advisory Commission (MedPAC) report.
Demographic trends of a swelling aging population, a growing prevalence of serious and chronic illnesses and a favorable regulatory landscape could be making the time ripe for value-based care to expand in hospice. Demonstrating that their services represent cost savings from reduced hospitalizations, emergency department visits and nursing home admissions is a large key for hospices to bring to the table of value-based care.
The Center for Medicare & Medicaid Innovation (CMMI) recently launched a new strategy designed to foster equitable patient outcomes through “high-quality, affordable, person-centered care.” Their demonstration models will be reoriented around caring for patient needs, generating cost savings, and enhancing diversity, equity and inclusion.
Care preferences of a swelling aging population and a strained financial health care system structure may be driving forces pushing value-based care models deeper into hospice, according to Joshua Proffitt, president of LHC Group (NASDAQ: LHCG).
“Value-based care is here to stay,” said Proffitt at the conference. “Payment models are at the forefront and tend to drive, then the care pathways follow. At the heart of everything we’re seeing from a policy perspective, it is intended to drive down the total cost of care. I envision a health care system some 40 years from now where you can truly age in your desired place, comfortably and independently in place at home. That’s even far beyond and prior to hospice, supportive and palliative care, and just providing a health care infrastructure for our aging population.”
Hospices will need to offer a longitudinal suite of services across their markets, breaking down a siloed health care system, according to Proffitt. Providers will need to take a step back from hospice services and view other touch points impacting the total cost of care that patients experience across their health journey and into the end of life.
Growth in value-based care is expected ahead. Last month the CMS projected that participation in the carve-in would double next year with a rise of up to 13 Medicare Advantage organizations by 2022, up from nine in year one. This brings the total number of actual MA plans to 115, a jump from 53 in 2021. The program is also expanding geographically, becoming available across 461 counties nationwide, compared to 206 this year.
As VBID tips into another year, hospice stakeholders and advocates are also baulking at the impact of the carve-in during a continued state of national public health emergency as COVID-19 continues its spread. The National Hospice and Palliative Care Organization (NHPCO) in collaboration with Families USA, and Medicare Rights Center recently expressed concerns in a letter to CMS Administrator Chiquita Brooks-LaSure and to CMMI Deputy Director Elizabeth Fowler. NHPCO called for a delay of the second year of the model, citing concerns about the pandemic’s effects, the lack of a standardized definition of palliative care and their belief that this could interfere with patients’ access to care.
“It’s not to look in a silo and figure out how we can convert the hospice benefit to a value-based benefit and reduce costs out of the hospice benefit,” Proffitt told Hospice News. “How about you step back from a 30,000- or 50,000-foot view and say, ‘Where are the touch points of the total cost of care that patients experience toward their end of life journey?’ [It’s] that hospice, palliative and supportive care services that can then be interjected to reduce [emergency department (ED)] admissions or reduced institutional stays. If we can look at payment reform in that kind of a holistic way to penetrate total cost of care, that’s where I think we’ll have success and build the care models around them.”
Companies featured in this article:
Alivia Care, Families USA, LHC Group, Medicare Rights Center, National Hospice and Palliative Care Organization
