Benefits newly available under Medicare Advantage are not well-known to consumers and uptake has been limited. At the same time, CMS has propsed funding the hospice benefit differently, which would allow MA plans to “carve in” to this benefit, creating additional uncertainty.
https://doi.org/10.37765/ajmc.2020.42998Starting in 2019, Medicare Advantage (MA) plans were allowed to change with the times and offer new social benefi ts to support patients with serious illness or chronic conditions, such as home-based palliative care.1
But the lack of clarity about these benefits has limited uptake by consumers, experts say. In December, CMS proposed funding the hospice benefit differently, which would allow MA plans to “carve in” to this benefit. Although some say this could help seniors in the long run, in the near term it has created uncertainty about how the government will fund care for the seriously ill.2
Recently, more upheaval came to hospice providers with coronavirus disease 2019 (COVID19), which was addressed in the $2.2 trillion fiscal package; the bill included provisions for hospice to be delivered by telehealth and other relief.3
Amid this unrest, the need for palliative care and hospice grows, especially for those with cancer. Cancer is the 10th most common condition for MA beneficiaries with 5.1% of all benefi ciaries having cancer and 1.3% of all with no other conditions, according to the Medicare Payment Advisory Commission (MedPac), an independent agency set up by Congress to examine issues surrounding Medicare.4 It is also the second leading cause of death in the nation, asserts the Centers for Disease Control.5
Data from CMS show that between 2000 and 2017, the share of Medicare decedents who elected hospice rose from 22.9% to 50.4%, or from 534,000 to 1,492,000. Lengths of stay also jumped, suggesting a need for palliative services whether or not patients are receiving them.2
But when people do sign up for MA plans, the copays and absence of specific services can cause seniors to forego treatment their physicians say they need. The lack of understanding of what palliative care is can often be the first hurdle.
“Consumers may not be aware their health plan has palliative care services. In the current healthcare environment, there is no standard palliative care benefit. Some MA plans are providing palliative services but there is variation in what that includes. Some programs are more telephonic case management,” said Lori Bishop, vice president of Palliative and Advanced Care for the National Hospice and Palliative Care Organization (NHPCO), in an interview with Evidence-Based Oncology™.
NHPCO is urging that the confusion be reduced by requiring MA plans to use a standard defi nition of palliative care, she said. Creating palliative care standards provides guardrails for consumers. “This standardization also protects the plan by ensuring a base level of quality,” Bishop said.
The NHPCO executive said she can tell there is also a lot of confusion among consumers about the diff erences between palliative care and hospice care just from the phone calls she gets “We need to do a better job of connecting people to the right service at the right time. People are getting connected to palliative care sometimes too late and what they really need is hospice care,” said Bishop.
Plans Have Flexibility, but There’s Confusion
MA plans gained the authority to off er expanded benefi ts in 2018, when Congress enacted the Creating High Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act.6 Palliative care was just one of the expanded services permitted under the act.
Today, MA commercial health plans give payers little more flexibility for cancer care than traditional Medicare, said Regional Cancer Care Associates President and Chief Executive Officer Terrill Jordan, who manages 123 physicians in New Jersey, Maryland, Connecticut, Washington, DC, and Pennsylvania. The flexibility comes in the ability to off er different types of arrangements, more alternatives for customers. As an example, Jordan told EBO™ in an interview that MA plans can offer lower premiums in exchange for higher deductibles.
MA plans can pay for home healthcare for high-risk individuals whom traditional Medicare would not cover. As a way to improve care and lower costs, Jordan said the plans can direct patients to wellness programs to control risk factors for cancer such as diabetes and encourage behaviors that can reduce the incidence and severity of cancer, such as losing weight and eating healthier diets.
But in December 2019, the Duke-Margolis Center for Health Policy confi rmed Bishop’s observations,7 reporting that after 2 years only a small number of MA plans were off ering palliative care benefi ts, citing operational challenges and contractual issues. Two years after implementation, the DukeMargolis study found, only 63 plans off er adult day care services and 58 offer palliative care, including “home-based palliative care.7
The report’s coauthor, DukeMargolis research assistant Hannah Crook, said the confusion is acute. “There are some general misconceptions about palliative and hospice care. There’s a tendency for individuals to think they are the same thing or that you have be near the end of life to receive palliative care,” Crook told EBO. “It will be important to continue examining how plans are rolling out palliative care benefits and how plans and providers help individuals understand what is being offered under a palliative care benefit.”
When it comes to palliative care off erings in MA plans, Crook said there is a wide variability. “One plan may off er a comprehensive suite of services with medical, social, spiritual, and other supports,” she explained.
Palliative Care Not Selected
The Duke-Margolis authors noted that starting with their 2019 offerings, MA plans were given new fl exibility to off er benefits that improve people’s health and ability to live independently, including in-home palliative care, even if those benefits are not traditional medical services.
But the authors found the takeup rate by the plans for palliative care was much smaller than the number one supplemental benefit increased: caregiver support. They predict that in-home palliative care will continue to be a low priority for plans in the starting years of the new fl exibility as they set their sights on “low-hanging fruit” that are less costly and easier to deliver.
However, the authors said the detailed off erings of palliative care by plans are not being revealed in initial data. “For example, one plan may off er a holistic suite of services under its palliative care benefit, including home-based services by specialty-trained palliative care clinicians, a 24/7 call center, a multidisciplinary team with social workers and chaplains, and integrated pain management. Another plan’s palliative care benefi t may only include more basic services, such as a hospital-based consultation with a clinician (regardless of training) who discusses a person’s goals of care,” the report states.
Before the advent of the new fl exibility in Medicare Advantage, the authors said a palliative care benefit was almost exclusively offered by Medicare-Medicaid Plans, and those that did were steadily declining.
With the CMS change, 15 standard MA plans noted that they off ered a “palliative care” benefit, and 8 indicated they off ered a “home-based palliative care” benefit in 2019. The numbers increased to 61 (including 58 standard MA plans) plans claiming they off ered a palliative care benefit for 2020, with all plans specifying it as “home-based palliative care.”
The academics predicted an increase in the number of MA plans off ering palliative care services beginning next year. That will be due to another anticipated change: the MA Value-Based Insurance Design (VBID) pilot, which was fi rst presented last year then outlined in a CMS proposal for a carve-in in January.2
What Is the MA VBID Pilot?
Right now, when a person with MA coverage needs hospice, a “carve out” provision allows fee-for-service (FFS) Medicare to cover certain services. Hospice providers say the system has worked well, but the CMS website says this results “in a convoluted set of coverage rules for MA enrollees,” and that the current system “fragments accountability for care and fi nancial responsibility across the care continuum.”8
Under the MA VBID initiative, insurers that offer MA plans are required to test wellness and health planning components, and beginning in 2021 they have the option of adding hospice benefi ts to the Part A package.
Stakeholders have concerns. Long before the disruption of COVID-19, NHPCO had asked for a delay, saying that although the idea for the carve-in makes sense long-term, there was not enough time to prepare for such a major change.9 There were also complaints that the Center for Medicare and Medicaid Innovation had not off ered enough details about what it wanted before MA plans were to apply to take part.
The Duke-Margolis authors see the MA VBID as an improvement, saying plans will be able to offer members a longer continuum of serious illness care, with palliative care preceding hospice. Many MA plan executives they spoke with, especially those with off erings in a number of regional markets, were looking at implementing small-scale pilots.
“This approach allows the plans to carefully monitor implementation and gather data that can inform benefi t pricing. If these eff orts are successful, they can be brought to scale and to different markets as formal benefi ts,” according to the report.7
Ongoing Challenges With MA in Cancer
Whatever the fate of the hospice carve-in, MA plans have their critics, including one oncologist with experience developing alternative payment models. “If all the Medicare Advantage programs went away tomorrow, I would be thrilled. They have all the disadvantages of commercial insurance without enough money to manage patients,” said Barbara L. McAneny, MD, immediate past president of the American Medical Association, who developed the COME HOME oncology care model at the New Mexico Cancer Center.
Prior authorization in MA and all forms of commercial health insurance harms patients, wastes time and money, and creates burdens for medical staff, McAneny said. She has never known an MA plan to deny a request, so the delays prove pointless, serving only to keep patients from getting treatments when they need them. By contrast, Medicare FFS pays quickly and doesn’t make oncologists preauthorize all the tests.
“Get rid of prior authorizations. Care should come on systems that are electronic, instant, and evidence-based on medical evidence, not financial evidence,” she said.
She also objects to a recent CMS change that allows MA plans to permit step therapy, which allows plans to deny more expensive drugs even if physicians believe they are the most effective. “It’s terrible,” she said. “Fail first is costing patients quality and quantity of life by using old drugs.”
However, America’s Health Insurance Plans (AHIP) Vice President for Medicare Policy Greg Berger said MA is one of the nation’s most successful healthcare programs with over 23 million participants and a 93% satisfaction rate—satisfaction due to more benefits, better access, and better value to seniors.
He said peer-reviewed research has found MA plans have outperformed the traditional Medicare program on 16 out of 16 clinical quality measures, including breast and colon cancer screening. Berger acknowledges that prior authorization has flaws, which AHIP wants to cure. The trade group noted most physicians still use manual processes to request prior authorizations, despite the common availability of online submission portals.
In January, AHIP launched the Fast Prior Authorization Technology Highway (Fast PATH) to speed up prior authorization requests, responses, and information exchange. Anthem, Blue Shield of California, Cambia Health Solution’s affiliated health plans, Cigna, Florida Blue, and WellCare, who have over 60 million people in their plans, have signed up.10
With Surescripts technology, doctors will have critical information at their fingertips when a patient is in the offi ce to help prescribe medications. “Reducing surprises at the pharmacy counter and making it more likely the patient will receive and take the medication. Together, this should promote better patient outcomes,” the AHIP
The greatest challenge faced by health plans, providers, and consumers alike with MA plans and cancer care is the rapid increase in drug costs, said Andrew Hertler, MD, chief medical offi cer at New Century Health.
Spending on cancer drugs in the United States reached nearly $57 billion in 2018, which represented a 2-fold increase from 2013, he said. Cancer care now represents 12% of all costs for Medicare populations and is rising annually at 8% to 10%, said Hertler, who advises on costs for 8000 oncologists in 39 states.
He estimates about one-fourth of cancer patients delay getting a test or treatment due to cost.
“Too often I hear stories of patients in Medicare Advantage plans who cannot afford their co-payment for drugs, even though the maximal out of pocket would seem quite modest,” he said.References
1. CMS finalizes Medicare Advantage and Part D payment and policy updates to maximize competition and coverage [press release]. Baltimore, MD: CMS newsroom; April 1, 2019. cms.gov/newsroom/press-releases/cms-finalizes-medicare-advantage-and-part-d-payment-and-policyupdates-maximize-competition-and. Accessed March 27, 2020.
2. Center for Medicare and Medicaid Innovation. Introduction to the CY2021 hospice component: VBID model information session. innovation.cms.gov/Files/slides/vbid-hospiceintervention-slides.pdf. Accessed March 27, 2020.
3. Parker J. Senate approves stimulus package with relief for hospices. Hospice News. hospicenews.com/2020/03/26/senate-approvesstimulus-package-with-relief-for-hospices/. Published March 26, 2020. Accessed March 27, 2020.
4. Report to Congress: The Medicare Advantage program: status report. Chapter 13. Published May 2014. medpac.gov/docs/default-source/reports/mar14_ch13.pdf. Accessed March 27, 2020.
5. Centers for Disease Control and Prevention. Leading causes of death. CDC website. cdc.gov/nchs/fastats/leading-causes-of-death.htm. Updated March 17, 2017. Accessed March 27, 2020.
6. S.870. Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017. 115th Congress.
7. Crook H, Olson A, Alexander M, Roiland R, Japinga M, Boucher N, Taylor Jr DH, Saunders R. Improving serious illness care in Medicare Advantage: new regulatory flexibility for supplemental benefits. Duke Margolis Center for Health Policy. healthpolicy.duke.edu/sites/default/files/atoms/files/dukereport_supplementalbenefits_for_final_signoff.pdf. Published December 2019. Accessed March 27, 2020.
8. Centers for Medicare and Medicaid Services. Medicare Advantage Value-Based Insurance Design Model. CMS website. innovation.cms.gov/initiatives/vbid/. Updated March 24, 2020. Accessed March 27, 2020.
9. Parker J. Hospice CEOs voice misgivings on Medicare Advantage. Hospice News. hospicenews.com/2020/03/11/hospice-ceos-voice-misgivings-
on-medicare-advantage/. Published March 11, 2020. Accessed March 27, 2020.
10. Donaldson C. New Fast PATH initiative aims to improve prior authorization for patients and doctors. Washington, DC: AHIP Newsroom; January 6, 2020. ahip.org/new-fast-path-initiative-aims-to-improve-prior-authorization-for-patients-and-doctors/. Accessed March 27, 2020.