NAHC Comments on Senate Finance Committee’s Chronic Care Policy Options: Hospice Comments (Article 2 of 2)
January 30, 2016 11:59 AM
This article summarizes NAHC’s comments on the Senate Finance Committee’s Chronic Care policy options pertaining to hospice. The policies under consideration by the Committee affect hospice, home health, palliative care and other providers.A previous article (available here) summarized NAHC’s comments on the policies pertaining to home care.
The National Association for Home Care & Hospice (NAHC), along with its affiliate the Hospice Association of America (HAA), submitted comments to the U.S. Senate Finance Committee regarding the Chronic Care Working Group’s policy options pertaining to hospice. As reported in the December 29, 2015, edition of NAHC Report (available here), the Senate Finance Committee released the “Bipartisan Chronic Care Working Group Policy Options Document” in December 2015 after announcing the creation of the Working Group in June 2015. NAHC has been actively engaged in discussions with the Committee on this important issue; for previous coverage of some of NAHC’s activities in this area, please go here, here, and here. Releasing the options document was intended to generate additional comments, feedback, and input from Finance Committee members and stakeholder groups as the Committee works on a more finite list of policy ideas to improve care coordination in the Medicare program.
“We appreciate the opportunity to comment on elements of the Chronic Care Working Group’s Policy Options document that address issues that relate to effective management of advanced illness and palliative and hospice care,” NAHC and HAA stated in the comments. “We look forward to continuing discussions with you and other members of the committee as the deliberative process continues on these very important issues.”
Following is a summary of the comments submitted by NAHC and HAA based on the policies under consideration in the document.
Inclusion of Hospice Under the MA Benefit Package
Under the Policy Options Document category of Advancing Team Based Care, the Bipartisan Chronic Care Working Group indicated it is considering requiring Medicare Advantage (MA) plans to offer the hospice benefit provided under traditional Medicare as part of the MA benefit package. The Policy Options document indicates that this change is under consideration because “current coverage options lead to either a disruption in care or fragmented care delivery.”
“We do not advocate a move toward inclusion of hospice services under the MA benefit package,” NAHC and HAA wrote in the comments. “With the existing comprehensive approach to care required under hospice, it is not clear that such an action would advance team-based care; instead, we believe that the value of the services provided by the hospice team could be greatly diminished. Further, while some complexities related to current coverage changes would be eliminated, a great many more would ensue.”
NAHC and HAA highlighted the following issues as justification for why the Committee should table the concept.
MA/Structural Issues: NAHC said the vast majority of MA plans “have no experience with the complexities of end-of‐life care for the Medicare population,” and highlighted several issues of concern for bringing hospice under the MA benefit package.For example, most MA plans “do not offer home health benefits on an episodic basis – rather, they contract with providers on a per‐visit basis and permit only a small number of pre‐approved visits at a time.” This has caused issues for home health agencies that should be of concern with regards to hospice as well, such as the home health agency waiting for approval and facing increased administrative costs. “Some of these ‘hurdles’ create fragmentation of services and beneficiary confusion as providers wait for approval of additional visits or of a change in the plan of care,” NAHC said.
NAHC further noted that the hospice benefit is “much more complex than the home health benefit in terms of what is contained in the bundle of services, and certain services must be provided under explicit rules.” NAHC cited specific requirements, saying it is unclear how MA plans would handle them.
NAHC also highlighted the lack of a “single, reliable publicly-available means for comparing the quality of or satisfaction with an individual hospice provider’s care… This gives MA plans little to go on when judging which hospice provider(s) to contract with for services other than low bids by hospice providers.” Those agencies best positioned to offer low bids are those that admit patients for longer lengths of stay—an area of particular concern to policymakers.
Beneficiary Issues: NAHC and HAA acknowledged that the coverage rules that are applicable when a MA enrollee elects hospice care are somewhat more complex than would otherwise be the case if hospice were provided as part of the MA benefit package. However, the benefits that would be gained by streamlining the process are more than negated by the additional challenges that would be faced by beneficiaries in the final stages of life and their informal caregivers. Descriptions of some of those challenges follow.
Beneficiary Choice:Under an MA plan, a beneficiary no longer retains choice of provider for end of life care – that right is essentially waived when entering an MA plan.
Cost Sharing: MA plans have the freedom to charge beneficiaries different coinsurances from those charged under fee-for-service as long as the package of benefits is actuarially equivalent to what is offered under fee-for-service. This could result in significantly increased beneficiary/family liability relative to hospice services.
Benefits, Coverage, and Continuity of Care:With great frequency MA plans separately authorize distinct portions of Medicare benefits otherwise offered as a bundle under fee-for-service. This practice, applied in hospice, will lead to conflicts that will arise between the patient’s hospice physician/interdisciplinary team and the MA plan over the comprehensive plan of care and appropriateness/approval of distinct services, in addition to delays in approval for services.
Hospice Provider/Benefit Integrity Issues:This proposed change will also have a significant impact on hospice providers and the integrity of the hospice benefit generally.
NAHC and HAA advised the following if Congress does wish to further explore bringing hospice under the MA benefit package:
Coverage of hospice under MA should be explored as a demonstration that compares success across the different type of managed care models. This type of demonstration should include utilization of a broad array of quality measures. In all cases, the quality and coordination of care as patients transition to end-of-life care should be closely assessed as part of the MA plan satisfaction ratings. (Additional and more detailed comments on MA and quality measures are provided later in this these comments.)
If Congress determines that it is advisable for hospice to be brought under the MA benefit package, MA beneficiaries should have the right to disenroll from MA at any time so that they may elect hospice care from the provider of their choice.
MA plans should be required to contract with Medicare-certified hospices based on fee-for-service benefit levels, service delivery model, and payment terms.
The hospice inter-disciplinary group and the patient’s attending physician (if applicable) should remain the ultimate authority on hospice eligibility, the hospice plan of care, and determinations of which conditions are related and unrelated to the patient’s terminal prognosis.
Additional issues related to the current hospice benefit structure and associated requirements must be thoroughly explored to ensure that the integrity of the existing hospice benefit is retained when it is brought under the MA benefit package.
Advance Care Planning
The Policy Options document contains several policies that are closely related to advance care planning and would be of great help to better informing individuals (and their representatives) about their health status so that these individuals could make more informed decisions about the plans for their care. NAHC and HAA commented extensively on these specific policies.
Establishing a One-Time Visit Code Post Initial Diagnosis of Alzheimer’s/Dementia or Other Serious or Life-Threatening Illness
The Committee asked for feedback regarding establishing a one-time visit code post initial diagnosis of Alzheimer’s/Dementia or other serious or life-threatening illnesses, in terms of the scope of diseases that would be considered a serious or life-threatening illness. NAHC stated that “the types of diseases that would fall into the broad category of serious or life threatening are those that are not curable but require medical supervision of at least two visits per year and an ongoing regimen of treatment.” NAHC further stated that “it is best to develop guidelines applicable to all serious and life-threatening illnesses” given the broad scope, rather than developing “criteria for each illness.”
NAHC and HAA’s comments are available here.