Structures like Medicare Advantage (MA) can help improve hospice program integrity and reduce the health care spend, according to Robin Heffernan, CEO of Empassion Health.
Empassion Health operates in 45 states. Its extensive network of hospice and palliative care providers combine technology with enhanced care coordination and clinical care, identifying eligible hospice patients earlier in their illness trajectory. The company serves patients within original Medicare, Medicare Advantage and Special Needs Plan (SNP) populations.
Hospice News sat down with Heffernan to discuss past program integrity issues within the home health benefit, how MA may have helped and what this means for hospices.
What did the home health industry go through in the past related to fraud and waste and abuse?
It probably started almost 30 years ago. My understanding is that it started in 1990 or 1991. There starts to be some rapid growth in home health, largely [private equity] driven, sort of similar to hospice, and between 1991 and like 1997, you go from I think 6,000 providers to more like 10,000 different providers, and the spend dramatically increases. It was something like $3.5 to $4 billion in 1991. It’s $16 billion by 1997.
The [U.S. Department of Health and Human Services Office of the Inspector General (OIG)] did some studies, and about 40% of those providers did not meet the thresholds for reimbursement. It wasn’t like these were all fraud, but almost half of the home health spend was not meeting the criteria that we developed for the home health benefit.
Very similar to hospice now, they put a six-month moratorium on any new home health providers. They went and did a bunch more audits, and then by 1999, they’ve tightened scrutiny.
How did Medicare Advantage factor in?
They put the benefit into MA. MA was allowed to create networks around home health and do utilization management. The spend goes back down from $16 billion to $7 billion. There were a lot of checks and balances to make sure that people were still getting choice on their home health and that they had enough access to home health.
All of those metrics seem to be good, but now there’s dramatically less utilization, less spend, and they found there were fewer hospitalizations during the home health episodes for members in MA versus fee for service.
There just seems like a ton of parallels for hospice. Putting something into MA is not the answer per se, but they did the gamut of putting more scrutiny on who’s going to get certified, do more audits, but also like mad MA plans financially accountable for this particular category, and allowed them to manage it. The outcome of that, from a system standpoint, has been objectively better.
Would you attribute those outcomes to the rise of Medicare Advantage?
“Maybe” is the right word. It would be very odd if you had an MA member, and every time they had a home health episode, you told an MA plan that they are not on the hook for that spend; that patient’s coming back to original Medicare for that period of time. That’s what we do for hospice. Putting the accountability with the MA plan, who already knows that patient, that has mechanisms in place to monitor their behavior.
How could this work for hospices?
It’s not great to have hospice carved out of MA right now, it creates a fragmented system. When [the U.S. Centers for Medicare and Medicaid Services (CMS)] did their hospice [value-based insurance design (VBID)] program, I think they had the right intention. We should give these plans accountability for this patient all the way through the end of their care journey, which includes hospice.
We actually do this inside [Accountable Care Organizations (ACOs). They are responsible for hospice. We just have this one anomaly, which is Medicare Advantage. When someone elects hospice, they go back to original Medicare. They don’t stay with the MA plan.
Have you been able to identify any kind of correlations between ACO participation and program integrity in the hospice world?
We were in a high-needs ACO, and we had 70% of our members die on hospice. Median length of stay was longer, but there were less crashes into hospice, and there were also fewer really long stays, because I think sometimes hospice can get abused.
When people use hospice, they more or less avoid the last one to two hospitalizations of their life, which they don’t want. The system doesn’t want that. Even the hospital doesn’t want that. It’s all good for program integrity, but you can’t do it if nobody’s managing it.
The flaw they had in hospice VBID is that they didn’t allow the plans to do utilization management. We do have verification on hospice elections, so you can just keep those rules, and you can create a network of high performing providers. In the hospice VBID first run, you couldn’t create a network. Patients could go anywhere.
What do you think hospices can learn from the home health experience?
I think it is inevitable that eventually MA plans will have accountability during hospice. If you are a hospice provider, you should prepare for that happening, whether it’s next year or in five years. You should try to forge good relationships with the MA plans, because probably half your volume is going to come from them, and the other half will come from original Medicare.
Many people say that hospice has no place in MA. There are fears of lower reimbursement, prior authorizations, limitations on patient choice and some other concerns. How would you respond to that?
These are very simple rules that you just establish up front. We’ve done this in other areas. We already have a mechanism today for hospice election where two physicians need to sign off. You have a terminal illness with six months or less to live. You just keep the same rule. You’re not going to further restrict people.
We do this in every other scenario where you mandate that the payer has a certain amount of network coverage. You must have at least two to three options in every county.
There’s no need to change the reimbursement. We can just pay hospices the per diem the exact same way we’re paying them today. There’s enough savings for the system without trying to take money out of the provider’s pocket.
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