Evolving network adequacy requirements within the value-based insurance design (VBID) model demonstration have some hospices concerned that Medicare Advantage payers may have narrowed views on reimbursement and access.
This year the U.S. Centers for Medicare & Medicaid Services (CMS) introduced changes to the VBID model that included modifications to network adequacy requirements for Medicare Advantage Organizations (MAOs) participating in the demonstration.
Commonly called the hospice carve-in, MAOs that have participated since the program’s launch in 2021 can now offer beneficiaries incentives to use their plans’ in-network providers. New entrants to the VBID program, however, are still under its first-phase requirements, which required MA plans to pay 100% of the fee-for-service per diem regardless of whether the patient chooses an in-network or out-of-network provider.
Concern has mounted that these network adequacy changes could have Medicare beneficiaries facing limited choices in hospice providers as well as create an imbalance of cost control for these services, according to Theresa Forster, vice president for hospice policy at the National Association for Home Care & Hospice (NAHC).
“As part of that [VBID] model CMS announced big changes that relate to network adequacy, and this is very important,” Forster said during NAHC’s Financial Management Conference in New Orleans. “This is sort of the other shoe dropping, because this is one of the biggest concerns that we have around this model. We are moving more toward a traditional approach under Medicare Advantage, and the Medicare Advantage plans being able to control who those patients utilize for these services. And that’s a big concern when it comes to hospice care.”
Using in-network providers to gauge the value of hospice reimbursement can limit how cost is viewed by Medicare Advantage payers. This could leave them with an incomplete understanding of the hospice benefit and what it encompasses, according to Jordan Holland, vice president of value-based contracting at Compassus.
This could cause some Medicare Advantage organizations to set the bar too low on reimbursement rates due to a lack of insight around how length of stay and care utilization play into payment and quality of care, he said
“It’s important to understand the highest level of risks and opportunities of VBID from the provider side,” Holland said during the conference. “On the risk side, [it’s] worrying about the commoditization of hospice care. These managed care organizations pay us significantly less than the traditional Medicare application. So there’s going to be some understandable rate pressure. There’s opportunities here to have increased collaboration with health plans and the goal would be to increase access to hospice care in a variety of different ways.”
Compassus provides hospice, palliative care, home health and infusion services in 29 states nationwide. The home-based service provider has navigated value-based care contracts within Medicare Advantage utilizing an “interactive” approach to educating payers about the nature and nuances of hospice care, Holland indicated.
Hospices navigate a “teeter-totter landscape” of risks and opportunities within VBID, Jordan said. Medicare Advantage payers in VBID set reimbursement rates based on many variables of hospice services, such as average length of stay and utilization costs around each level of care.
But these averages can tell a much different story than actual, individualized care needs and goals of care that drive services delivered and health costs, Jordan stated. For instance, medication and caregiving needs can change drastically during the last seven days of life, with more expensive care costs that a monthly lump sum in VBID may not cover fully.
A key for hospices to succeed in value-based reimbursement environments is the ability to have direct communication and interaction with payers within the VBID model, Jordan stated. These interactions allow hospice providers to build deeper relationships with payers and better educate them about the value proposition of their services, he said.
“Largely, [it’s stating the] earlier identification and earlier engagement of these patient populations, and [seeing] how the Medicare Advantage organization can be a huge partner,” Jordan said. “They have case managers that are interacting with patients all the time.”
This interactive approach with payers can foster more opportunities for providers to negotiate improved reimbursement rates, as well as increase access and utilization of hospice care in Medicare Advantage patient populations, he said.
“What are you doing to educate them about the hospice benefits and how they talk to their constituents, their beneficiaries and potentially collaborate with the hospice provider to get those patients?” Jordan stated during the conference. “That’s a really solid opportunity to increase access to hospice care, transitional concurrent care. Hospices provide a unique expertise in how that care can be delivered. There’s a really good opportunity for hospice providers to take a more front-footed approach on their recommendations to create care models with Medicaid and Medicare Advantage organizations.”
Companies featured in this article:
