Joining payor networks is key to hospice success in Medicare Advantage


The path to value-based care remains uncertain, but has an impact for palliative care. Providers and payers from all walks of life are taking a closer look at palliative care as the Value-Based Insurance Design Demonstration (VBID) project nears its second year. Hospices need a seat at the negotiating table in order to stay in control of their financial destiny, according to industry stakeholders.

Commonly referred to as the Medicare Advantage hospice carve-in, the demonstration project went into effect on January 1. The intention of the program is to increase access to hospice palliative care services and facilitate better coordination of care, according to the United States Centers for Medicare & Medicaid Services (CMS). . The carve-in is designed to assess the performance of payers and providers related to palliative care within Medicare Advantage. Participation in the demonstration is voluntary for both payers and providers.

Carve-in changes the way participating hospices receive payment for their services. In the VBID arena, palliative care providers accept greater financial risk in exchange for incentives to improve quality or reduce costs.

The importance of value-based care networks will be a game-changer in palliative care, according to Jeremy Powell, CEO of technology company Acclivity Health. Joining a network will be key to understanding the incentives and penalties as the demonstration develops, according to Powell. In the coming years, MA plans are expected to create consulting firms. Hospices will likely need to work with these companies to understand how payments and products will work in the future.

“The biggest change from the first year is that you are now paid by one of these network plans. Being out of the network is going to penalize your agency and potentially reduce the number of patients you serve each year, ”said Powell, speaking at the National Hospice & Palliative Care Organization Interdisciplinary Conference. “There are different consulting opportunities that will allow you to become a provider and network partner for this Medicare Advantage organization. This allows a hospice to help create what payment triggers, milestones, incentives, and penalties are based on how they define their product.

The sooner a hospice can get involved in these value-based payor networks, the more leverage they will have to build relationships with payers, Powell said.

The aging of the country’s population is expected to result in the need for end-of-life care and serious illness. In the United States, the number of people aged 65 and over will reach 95 million by 2060, or nearly 25% of the total population, up from 15% in 2016, according to projections by the US Census Bureau.

These demographic trends are driving a growing demand for palliative care. Palliative care use among people who died from Medicare hit a new high in 2019 at 51.6%, up from 50.6% in 2018, according to the Medicare Payment Advisory Commission (MEDPAC).

VBID got off to a relatively small start in its first year. A total of 53 health plans offer palliative care through VBID in 2021, covering 8% of the market, according to CMS. Palliative care coverage via VBID is available in a limited geographic area, 13 states nationwide and Puerto Rico. The plans are managed by nine insurance companies, only two of which are larger companies: Humana (NYSE: HUM) and the Kaiser Foundation Health Plan.

The program is expected to expand to a number of additional states next year, according to Powell. This could have a trickle-down effect that could hold great promise for palliative care, including extending time limits.

“The hospice itself is the target of innovation around improving what could be concurrent care capabilities and improving the payment and reimbursement range,” said Powell. “It could also improve hospice benefits over time and perhaps provide an opportunity to relax the definition of six-month benefits that exists in the CMS definition of hospice. get involved if they happen in your market, and you are not today, part of these particular organizations, encountered the carbon benefit for hospice care. Our recommendation is to contact us, we can make presentations, people who are part of these organizations in your market.


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