As the U.S. Centers for Medicare & Medicaid Services (CMS) extends the Medicare Advantage hospice carve-in through 2030, providers are concerned about preserving patient choice and the nature of concurrent care.
Originally slated to complete in 2024, CMS recently extended the hospice component of the value-based insurance design model (VBID). The agency further announced that patients will be able to receive curative treatments in tandem with hospice care and that it would permit health plans to further restrict the utilization of out-of-network providers.
Networks could close
The possibility of plans closing their networks raises questions about patients’ ability to choose who provides their hospice care, according to Mike Smith, CEO of Hospice of Iredell County.
“As it currently stands a patient can choose whichever hospice they want when they elect hospice care. Narrowing that choice by creating a network could potentially reduce the pool of high-quality options for the patient depending on what criteria are used for inclusion,” Smith told Hospice News. “Another issue is the monopolistic concept of ‘pay-viders’, where the payer is also the provider. The concern is that the only providers in the network will be those owned by payers. This, by default, reduces patient choice.”
One potential example is size criteria, the possibility that plans will prefer to contract with large-scale providers rather than smaller, community-based organizations, according to Smith.
Providers would benefit from greater clarity around the potential terms of contracts with MA payers, he said.
Among the concerns is whether CMS will require plans to continue paying for hospice at the same rate they currently receive through the traditional benefit. If not, some of the ancillary and complementary services that hospices offer could be in jeopardy. CMS has yet to release details on how payment may or may not change during the extension years.
“Many community-based hospices really work hard to understand and fulfill the needs of their community and oftentimes that’s above and beyond what’s outlined in the Medicare Conditions of Participation. Some rely on philanthropic donations to support these service lines, but many reinvest the already small margins from their hospice operations back into the community,” Smith said. “These are value-added services that are potentially at-risk if they lose a large portion of funding. This could create significant gaps of care in the community.”
The challenge of defining ‘concurrent care’
Thus far, details are scarce as to how the agency will define “concurrent care,” and how it will differ from provisions currently baked into the program.
From day one, CMS has allowed some degree of concurrent care within hospice VBID, with few specific parameters. The agency describes this care as “transitional,” designed to foster greater utilization among patients who may be wary of ending their other treatments.
“For example, a transitional continuation or phasing out of treatments such as chemotherapy services, blood transfusions, or dialysis may permit an enrollee to conclude or phase out over time a course of therapy while concurrently receiving hospice care and services,” CMS indicated in a request for applications. “The provision of transitional concurrent care under the Model does not change the necessary criteria for hospice benefit eligibility or the requirement that the designated hospice provider provides all services and levels of care available under the hospice benefit.”
Currently, defining the scope of concurrent care is largely left up to the plans themselves. CMS advises Medicare Advantage Organizations (MAOs) to work with hospice providers to define and provide a set of time-bound services ”that are related to the patient’s terminal condition and appropriate to continue on a transitional basis.”
The agency did indicate that its intent was to make concurrent care within VBID more consistent with what is available in other model demonstrations. CMS did not name those other models, but one is likely the Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) demo, which launched in January.
Under the Global risk-sharing track of that model, ACOs can offer concurrent curative care to beneficiaries who have elected hospice. All expenditures would be included as part of the total cost of care of the ACO for the relevant performance year, according to CMS.
“We use that phrase [concurrent care] pretty loosely when we’re thinking about some of the things that are outlined in the rule. There are a number of treatments that have a palliative intent, but are probably too expensive to cover under the benefit dialysis,” Mollie Gurian, vice president of home-based and home- and community-based services policy at LeadingAge, told Hospice News. “It’ll be interesting whether they define ‘concurrent care’ as those things or are they defining it as like getting that fourth-line chemotherapy that actually might cure your cancer, but you have access to hospice at the same time.”
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