At its most recent meeting - held November 7-8 - the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare payment policy, discussed ways to ensure better synchronization across Medicare delivery systems, including fee-for-service (FFS), Medicare Advantage (MA), and Accountable Care Organizations (ACOs). During the meeting, MedPAC staff sought the Commissioners’ guidance on whether to conduct additional study on the advisability of including hospice services as part of MA plans’ benefit package. Members of the Commission expressed support for the concept of eliminating this “fragmentation”, and it is anticipated that they will discuss the issue further at a forthcoming meeting in December or January.
Since its start as a benefit under Medicare, hospice has been available exclusively as a FFS benefit. It is believed that the reasoning for exclusion of hospice from coverage by private plans under Medicare is due to the fact that there was insufficient data on hospice costs to establish an add-on to private plan rates for hospice care. Instead, MA enrollees who choose to elect hospice care historically have been referred to a hospice provider that is paid under the Medicare FFS program. While on hospice care the patient continues to pay MA premiums and retains coverage of supplemental benefits and Part D, if enrolled, for non-hospice prescriptions, but is covered under the FFS program for standard Medicare benefits under Part A or Part B in addition to hospice services. If a MA beneficiary is nearing the end of life but chooses not to elect hospice, the MA plan is responsible for care.
MedPAC views the coverage structure as confusing for beneficiaries and contrary to the goal of consistency in policy, regardless of the delivery structure under which the beneficiary receives care. MedPAC staff used the following graph as part of theirpresentation to illustrate the fragmentation of coverage rules for Medicare beneficiaries enrolled in MA-PD plans:
COVERAGE RULES FOR MA-PD ENROLLEES WHO ELECT HOSPICE ARE FRAGMENTED:
|
|
FFS |
MA-PD |
|
Prior to hospice enrollment |
|
• All part A, B, and D services, and any supplemental benefits |
|
MA-PD enrollee elects hospice |
• Hospice • Part A and B services unrelated to the terminal condition |
• Part D drugs unrelated to terminal condition • Any supplemental benefits (e.g., reduced cost-sharing) |
|
MA-PD enrollee disenrolls from hospice
|
• Until the end of the month, all PartA and B services |
• All Part D drugs • Any supplemental benefits (e.g., reduced cost sharing) • Beginning the next month after disenrollment, Part A and B services |
MedPAC staff suggested that “broadening the package of services that MA plans are responsible for to include the full continuum of end-of-life care may promote care coordination and incentivize plans to focus more on efforts to improve quality, efficiency, and satisfaction with care for patients with advanced illnesses. It’s also possible that some plans may choose to experiment with covering concurrent hospice and curative care…”
Staff also acknowledged that including hospice coverage under MA could mean that beneficiaries have fewer choices among hospices since MA plans would likely contract with a smaller number of hospice providers than are available in a particular market. Given that under the current payment structure MA plan are still paid at a higher percentage than the cost of care under FFS Medicare, MedPAC staff suggested that bringing hospice under the MA benefit may be most appropriate in 2017, at which time the Affordable Care Act (ACA) requires payments under FFS and MA payments to equalize.
A transcript of the entire meeting is available here. The MA/hospice discussion takes place on pp. 332-382.
The National Association for Home Care & Hospice (NAHC) and its affiliated Hospice Association of America (HAA) will be closely engaged on this and other important hospice issues, and will provide updates in future issues of NAHC Report and Hospice Notes.
