The Medicare hospice benefit is not included in the Medicare Advantage (MA) benefits package. MA enrollees who elect hospice remain in their MA plans, but fee-for-service (FFS) Medicare pays for their hospice services. This carve-out of hospice from MA fragments care accountability and financial responsibility for MA enrollees who elect hospice.
In March 2014, the Commission recommended including hospice in the MA benefits packages. The Commission believes a goal of the MA program is to move away from fragmented payment arrangements, and towards providing an integrated and coordinated benefits package. The hospice carve out is inconsistent with this goal. Broadening the bundle of services for which MA plans are accountable give plans the incentive to consider the needs of their members more completely and to provide better coordinated care to meet those needs. Additionally, given MA plans’ flexibility, incorporating the hospice benefit may also incentivize plans to develop innovative benefit designs for people with advanced illnesses.
Operationalizing the inclusion of hospice in MA
If hospice were included in the MA benefits package, MA plans would be required to cover the scope of hospice benefits as defined in the Social Security Act and meet the hospice benefit structure requirements. For example, as defined in the Social Security Act, hospice care need to be provided under a written plan of care established and reviewed by the patient’s attending physician, the hospice medical director, and by the hospice interdisciplinary medical group. MA plans must contract with Medicare-certified providers who are required to abide by the Medicare conditions of participation. And as with other Medicare services, MA plans would be required to meet network adequacy standards to ensure that they have enough hospice providers in their networks to meet the needs of their members. And of course, the beneficiary would still need to elect hospice care.
Quality metrics and conditions of participation
Like other aspects of the Medicare benefit, quality metrics would be necessary to ensure adequate benefits and high quality of hospice care. The Commission has stated that claims-based quality measures could be used to reduce provider reporting burden and be a promising source of information on the quality of hospice care. One measure the Secretary could monitor is the number of skilled visits (visits by a nurse, therapist, social worker or physician) that an MA decedent receives during hospice compared to FFS hospice decedents. A second measure could track the number of skilled visits that a decedent received during their last few days of life; as the last two day of life are a high-need time for hospice decedents.
MA decedents have consistently utilized hospice services at a higher rate than their FFS counterparts. In 2014, 50.8% of MA decedents used hospice compared with 46.8% of FFS decedents. If the Secretary were to see a substantial decline in the national rate of MA hospice utilization relative to FFS after hospice was incorporated in the MA benefit package, corrective action could be taken. MedPAC would also continue annually evaluating the hospice benefit, and would reevaluate the policy as necessary.