Hospice News recently sat down with Kirk Allen, senior vice president of the home care segment at Humana Inc. (NYSE: HUM) to discuss the payer’s perspective on the first year of the hospice component of the value-based insurance design (VBID) demonstration.
Some hospices have reported seen gaps between the Medicare Advantage carve-in’s design and its results. Humana told Hospice News that the company is encouraged by the demonstration’s progress to date, and that “a great deal of opportunity” exists in evolving hospice provider and payer relationships.
The carve-in began with a small start of 53 Medicare Advantage plans participating in 2021. The U.S. Centers for Medicare & Medicaid Services (CMS) indicated that participation will double next year to a total of 115 MA plans and expand its reach geographically to become available across 461 counties nationwide, compared to 206 this year.
For 2022, the overall VBID Model has 34 participating Medicare Advantage Organizations (MAOs), up from 14 in 2020 and 19 in 2021. These are the companies that operate the various health plans. Of these MAOs, 13 are participating in the hospice component.
Humana operates the most MA plans offering hospice and also participates in VBID as a provider, through its Humana at Home subsidiary. In year one of the carve-in Humana covered 145,000 eligible members in 10 plans and across five markets: Atlanta, Cleveland, Denver, the Louisville, Ky., metro area (including southern Indiana), and the Richmond-Tidewater region of Virginia.
The company’s role as both a payer and a provider has given Humana a unique perspective in the value-based payment space, according to Allen.
What has Humana’s experience been like to date within the value-based demonstration, both as a payer and a provider?
We’ve watched the hospice carve-in from the very beginning, and think it’s a really well thought-out plan that CMS and [the Center for Medicare & Medicaid Innovation (CMMI)] have put in place for the VBID demonstration. Our experience has been that it’s delivering just about exactly what we thought it would deliver in the first year.
From Humana’s perspective, we’re one of the largest providers, [and] because of our size and being one of the first and largest entities in VBID, we’ve really had a good experience. Each market is a little bit different in the dynamics of how health care is delivered. We chose to not only put a variety of markets in, but also to test some specific things in each market.
From the standpoint of provider participation, we’ve actually had a lot of providers who have reached out with interests in the plan, and we’ve had a lot of providers who signed on and became in-network providers.
We’ve also had a lot of providers who have decided that they want to cooperate, but they’re going to wait until a later year to participate. We’ve really good interest in the program and ending year one is right where we would have expected it to be.
What are the most important elements that hospices really need to pay attention to if they plan to participate in VBID?
We’re also a hospice provider, and we had to we had to evaluate the carve-in demonstration from that perspective as well. We began with developing an understanding of the overall goals of the demonstration. Among those goals, CMMI wanted to test the ability of a Medicare Advantage organization to really be financially responsible and accountable from beginning to end of the full continuum of care for their members. This includes hospice, and that’s certainly one of the things that they were looking at.
They’re also looking at the ability to create a seamless care continuum in an MA program, particularly coordination of services between Part A and Part B. What stood out to me is the need to have comprehensive palliative care services outside the hospice benefit available as part of the plan. When somebody makes the hospice election, it’s clear that we need to be caring for them under hospice plans, but there also is a requirement that we make palliative care available upstream of the patient’s decision to elect hospice.
Also in understanding the overall goals of the CMMI VBID demonstration, you really want to develop a relationship with MA plans that have a large market share in your area. If you’re interested in being a provider, you want to get in early and provide input into the way that benefits are developed. This is still a demonstration project, and it’s still under development, so it’s about being able to have input into the scope of the care that can be delivered and how the payment models are structured and being a partner to the MA plans.
As those plans are finalized or as they become more baked, take full advantage of the added and supplemental benefits for your patients that are likely going to be available through a MA-provided hospice plan.
Can you elaborate on what those benefits would be for hospice providers to focus on as VBID continues to roll out?
One opportunity is to provide transitional concurrent care in conjunction with a Medicare Advantage plan. You can start hospice services while a person is still receiving transitional concurrent care, and that’s something that would have under normal circumstances made someone ineligible for hospice.
For example, in our model, we have benefits such as in-home respite in addition to the inpatient respite. We offer a benefit where a member can add a member or a patient can access in-home respite care services, and we’ve seen that play out in a couple of different ways. We’ve seen patients able to stay in their home or give their caregiver a break in circumstances that might otherwise have turned into someone revoking the hospice benefit.
Another benefit that Humana offers in addition to the traditional payment is a health care assistance allowance for hospice members. We have a supplemental benefit of $500 a year that is used to support our member’s quality and comfort of life. We can use that for home modifications, meals, transportation, caregiver support and a lot of other things as well, but it is to really smooth out any social determinant of health needs that a patient might have that can help make their hospice episode more enjoyable.
A common concern among providers is that MA plans will pay less than the current per diem through the Medicare Hospice Benefit. How do you address that concern? Are there factors that mitigate that financial risk?
We’ve really approached this demonstration as an opportunity to learn. We’re particularly interested in reducing barriers that patients have to electing hospice and making it easier for them to remain under the hospice benefit when medical challenges arise, and then assisting with social determinants that really may negatively influence their experience during hospice. In addition to the standard hospice payment, our approach has been to provide payment for those services that are either not covered by traditional Medicare or through those supplemental benefits to reduce barriers to providing services through the supplemental benefits.
What I would say to a provider is that as you’re learning more about the MA plans, evaluate all that’s available in the payment model, the base payment and those supplemental benefits and how that might influence the ability to keep patients on your service who might otherwise revoke or to discontinue services. You want to leave them on the hospice benefit in value-based care and ensure there’s no interruption to service or care and no the challenges that you would have had if they were under the traditional benefit. Look at the model in totality would be my advice.
Providers have voiced concern that MA plans are not using their in-network hospices to provide palliative care. How would you respond to that concern?
We really liked the fact that CMMI is requiring the provision of palliative care services as part of the VBID demonstration, because we’re big believers in identifying patients who are nearing the end of life and making sure that they have access to all the services they need in that really vulnerable time. We went into the demonstration with the intent to test different things, and we actually have been really intentional at that.
We actually have markets where hospice agencies are the palliative care provider, and as part of the demonstration we are testing different scenarios where it might be a dedicated palliative provider that is not a hospice agency.
In short, we have a mixture of dedicated palliative providers and hospice agencies providing care, and that’s one of the things we were specifically testing during the demonstration is to really share results that we have.
What do you foresee happening in the long term when it comes to value-based care in the hospice space? Where is this ultimately going?
Humana has had a really good experience in providing value-based care. What we’ve learned is that there is a path to value that will come over time, but it requires learning in partnership with the hospice providers.
We really think that there’s a great deal of opportunity to evolve the hospice provider payer relationships, and to be able to test these end-of-life, value-based care models. The hospice demonstration is an opportunity to test models aimed at better integrating the end-of-life care experience for our MA members and for hospice patients. It’s going to be a data-driven approach to really learning what’s working well over time and it’s going to take time, but I think we’ll get there. We have to learn it together.
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