Participation in the value-based insurance design (VBID) demonstration, known as the Medicare Advantage hospice carve-in, will double next year. The demo got off to a small start in 2021, but its influence on the industry will likely prove more substantial as the four-year test progresses.
The U.S. Centers for Medicare & Medicaid Services (CMS) has announced that 13 Medicare Advantage organizations will participate in the program next year, up from nine in year one. This raises the number of actual MA plans to 115, up from 53 in 2021. Geographically, the program will be available in 461 counties nationwide, compared to 206 in 2021.
“CMS is grateful for the broad engagement, support, and perspectives we have received from stakeholders and will continue to work with palliative and hospice care providers, [Medicare Advantage organizations], and all others in extending current relationships and building new ones,” the agency indicated in a statement.
The carve-in is designed to assess payer and provider performance related to hospice within Medicare Advantage. Participation in the demonstration is voluntary for both payers and providers.
Historically, Medicare Advantage beneficiaries have transitioned to the traditional hospice benefit when they elected those services. Their Medicare Advantage plan would continue to cover any claims that are deemed unrelated to their terminal diagnosis. Switching to the Medicare Hospice Benefit also usually meant transitioning to a new care team.
The largest player in year one of the program was Humana (NYSE: HUM), which operated more participating plans than any other payer.
The carve-in represents the most significant step to date in moving hospice towards value-based payment models. While the carve-in could give providers access to more patients who wish to elect hospice but prefer not to leave their MA plans, it also comes with greater financial risk.
VBID requires plans to pay rates comparable to the per diems providers receive through the traditional Medicare benefit during the first year, but allows plans to negotiate for lower rates in subsequent periods.
“In the short term, this growth represents primarily an opportunity for hospice providers in the markets where these plans are operating. The plans must pay Medicare rates and accept any hospice provider for a limited time,” Anne Tumlinson, CEO of ATI Advisory, told Hospice News. “The key opportunity/potential longer term threat is that the plans may move forward and establish special ‘value-based’ arrangements with a subset of the hospice market.”
In these arrangements, MA plans will seek rate concessions in exchange for higher patient volume. Plans will also likely offer to pay for other services such as palliative care and incentive payments tied to quality or cost savings, according to Tumlinson.
Palliative care is also a key component of VBID. Each participating payer to date is including palliative care consults, comprehensive care assessments, an interdisciplinary care team model, goals of care discussions and advance care planning. They are also offering caregiver support and access to services to address social determinants of health.
The plans also allow for a period of concurrent transitional care through in-network providers as the patient readies for hospice. However, many of the plans during 2021 were not engaging their contracted hospices to provide those palliative care services.
The phrase “in-network” is key. While the program is open to virtually any hospice during 2021, plans will have the option to limit or close their networks in subsequent years.
The anticipated expansion has furrowed the brows of stakeholders who have opposed the carve-in, such as the National Home Care & Hospice Association (NAHC).
“NAHC continues to have concerns about the appropriateness of the Medicare Advantage program for coverage of hospice care and the impact it will have on beneficiary choice and the scope and integrity of the hospice benefit,” Theresa Forster, NAHC’s vice president for hospice policy, told Hospice News. “CY2022 is the first year in which there will be plans competing in the same states and in some of the same counties, so that will also provide some additional perspective as to how a universal carve-in could impact hospice and the patients they serve.”
The National Hospice & Palliative Care Organization (NHPCO) voiced concerns about VBID’s transitional concurrent care component, which the advocacy group says does not represent “comprehensive palliative care.” NHPCO contends that this could create a barrier to patients’ access to palliative care.
Last year, NHPCO called on CMS to delay the demonstration’s Jan. 1, 2021 start date, citing the COVID-19 pandemic and a lack of beneficiary protection.
“Nearly a year into the demonstration, CMS has not shared data or explained how this demonstration improves access to hospice care. We see no evidence to support a second implementation year,” said NHPCO President and CEO Edo Banach. “Furthermore, providers and consumer advocates are disheartened by CMS’s decision to continue with this experiment while many states are experiencing their highest COVID-19 positivity rates, hospitalizations, and worst workforce shortages since the beginning of the pandemic.”
