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Regulatory moves toward greater transparency in Medicare Advantage could swing into the realm of palliative care payment.
The U.S. Centers for Medicare & Medicaid Services (CMS) recently released a Request for Information (RFI) on ways to improve data sharing and increasing transparency in Medicare Advantage.
Greater transparency within the Medicare Advantage arena could help shed light on palliative care utilization and reimbursement trends taking shape in value-based models, said Edo Banach, partner at Manatt, Phelps & Phillips LLP and strategic advisor of Edo Solutions LLC.
Having a wider lens into palliative care delivery and payment in MA could also help set the bar around more standardized services and quality standards, according to Banach.
“Transparency is something that’s going to allow us to know whether [payment] incentives work or don’t work,” Banach told Palliative Care News. “Palliative care is a perfect example of seeing what a supplemental, community-based benefit in Medicare Advantage looks like. The transparency comes in to zoom out and really understand how this flexibility has been used. Let’s use the data we gather to maybe set some benchmarks and baselines to make sure that, in the name of beneficiary protection, there’s a line under which you can’t go and use the words palliative care to describe it.”
CMS’ efforts to ramp up data insight come at a time when the Biden-Harris administration is focusing on ways to improve quality and access by reducing health care and prescription drug costs.
The White House aims to crack down on alleged health care price gouging to ensure equitable access and promote competition among providers. This includes preparation of a bill that would increase data transparency for supplemental benefits under Medicare Advantage.
If enacted, the bill, which contains proposed amendments to the Social Security Act, would require Medicare Advantage plans to report enrolled beneficiary data on supplemental benefits, such as palliative care, as well as patients aligned with the hospice component of the value-based insurance design (VBID) demonstration.
The proposed changes would take effect Jan. 1, 2027, stipulating that MA plans submit beneficiary data such as the types of services received, provider identification, utilization rates and payments – including costs on both the payer side and the out-of-pocket costs for beneficiaries.
Palliative care components are woven into some value-based models, including the hospice component of the value-based insurance design (VBID) model and Medicare Advantage’s supplemental benefits, as well as within Accountable Care Organization (ACO) arrangements. Some elements have been worked into models oriented around dementia, primary care, oncology, kidney care and other services. Hospice VBID is slated to end on Dec. 31.
Payers and providers alike need a greater level of insight into Medicare Advantage beneficiary data to better understand the scope of utilization and outcomes in palliative care, Banach stated.
“When we’re talking about Medicare Advantage, the story sometimes told is that MA plans have more flexibility to provide supplemental benefits and more flexibility to serve a more diverse pool of individuals,” Banach said. “But that’s only half the story. This flexibility doesn’t mean that they’re actually providing more care to those individuals in a way that is accessible. That’s something we’re only going to get through enhanced transparency. MA plans have flexibility even outside of VBID to pay for something that they call palliative care. They’re encouraged to provide the pay for palliative care and concurrent care. How is that defined? However it’s defined, how are we going to know whether someone gets that benefit or not? And what happens when they don’t get it? What recourse do they have?”
The nation’s patchwork of fragmented palliative payment systems represents a large barrier to improving access and awareness, according to Fred Bentley, managing director at ATI Advisory.
The myriad of palliative care services covered within the Medicare Advantage landscape has posed challenges around determining which types of services are covered in this reimbursement system and who is utilizing them, Bentley said.
“It’s going to be hard to measure palliative access and equity in the Medicare Advantage world,” Bentley said.
Palliative care is a somewhat “nebulous combination of services,” in MA plans, Bentley stated. While MA plans often recognize the value of palliative care services when it comes to reducing hospitalizations and emergency care costs among seriously ill populations, assessing utilization is a difficult feat given the degree of variation among those services, he explained.
Efforts to increase transparency could help strengthen understanding around ways to improve access to palliative care, Bently stated.
“It’s ensuring that there aren’t unnecessary hurdles or barriers to put up to the beneficiaries’ care,” Bentley told Palliative Care News. “This is coming at an interesting time in the VBID demo [in which] Medicare Advantage plans are making decisions around forming hospice and palliative care networks and starting to steer their members toward high value providers and away from those that plans perceive as low value providers. What we need to understand is the utilization management and authorization methodology that Medicare Advantage beneficiaries have.”
