C-TAC acknowledges CMMI’s recent decision to end testing of the Hospice Benefit Component of the Value-Based Insurance Design (VBID) Model. There were executional reasons for payers and providers to do so and we will continue to work with the agency, providers, payers, and policy makers on ways to improve care of those with serious illness and their families using our core model principles.
Background
VBID is a test of value-based payment for Medicare Advantage (MA) plans started in 2021. (MA is the public-private Medicare option in addition to traditional Medicare that has been steadily growing, now covering 52% of Medicare beneficiaries). CMS is committed to shifting all their programs into value-based payment models by 2030, including MA.
VBID Model Goal and Elements
VBID’s goal is testing a broad array of complementary MA health plan innovations designed to reduce Medicare program spending, enhance the quality of care for beneficiaries, including those with low incomes such as dual-eligibles, and improve the coordination and efficiency of health care delivery. The model was extended to run for 9 years, through 2030 to allow adequate time to fully test and evaluate changes.
VBID’s Hospice Benefit Component
One aspect of VBID that was added in 2021 was allowing participating MA Organizations (MAOs) to include the Medicare hospice benefit in their benefits package. This was done as hospice has been excluded, or carved out, of MA. Under the Hospice Benefit Component of the VBID Model, participating MAOs retained responsibility for all original Medicare services, including hospice care. The Hospice Benefit Component of the Model implemented a set of changes recommended by the Medicare Payment Advisory Commission (MedPAC), the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), and other stakeholders.
The Hospice Benefit Component aimed to address fragmentation in coverage rules for MA enrollees who elect hospice, and whether coverage of the Medicare hospice benefit by MAOs would lead to increases in quality of care while maintaining budget neutrality or reducing costs. The policies included within the Hospice Benefit Component, such as requiring comprehensive palliative care and enabling concurrent care and hospice-specific supplemental benefits, provided a unique opportunity for collaboration between MAOs and palliative and hospice care providers to reduce fragmented care for those with serious illness. The carve-in challenged MAOs and hospice providers to collaborate to improve care, promote greater care coordination, and advance health equity and transparency.
Challenges with the Hospice Component
From the beginning, however, there were concerns about the feasibility of including hospice in MA. First, this requires selection of hospices for the typically limited provider networks MA operates with. There was concern that some hospice providers with small censuses, for instance, might not be selected to be in the MA network, which could limit access to their services. At the same time, participating hospices were concerned that they would now have to work with multiple payers in their area, as opposed to just Medicare, which could be administratively challenging if only a small number of patients were served by each payer. Perhaps as a result, providers and plans have been dropping out of the model and CMMI needed to determine what services would be required this spring to allow plans to prepare and notify enrollees of them in time.
Therefore, and after carefully considering recent feedback about the increasing operational challenges of the Hospice Benefit Component and limited and decreasing participation among MAOs that may impact a thorough evaluation, CMMI decided to conclude the carve in effective December 31, 2024, 11:59 PM. CMS will not accept applications to the previously released CY 2025 Request for Applications for the Hospice Benefit Component of the VBID Model.
Implications for Care for Serious Illness
C-TAC has long worked with CMMI to find ways to address the needs of those with serious illness participating in their models. This is what prompted C-TAC’s development of the Core Principles for Models for those with serious illness and their family caregivers. CMMI incorporated all of those principles in their newly announced GUIDE Dementia Care Model.
Now we must continue to work together to incorporate these principles into other models. C-TAC is in close and regular contact with CMMI, as evidenced by the participation of some of their key leaders at C-TAC’s 2023 Summit. CMMI for their part has gained valuable insights and perspectives about the Hospice Benefit Component from MAOs, palliative and hospice providers, people with Medicare, their caregivers, and advocates, among others. CMS sought feedback from these stakeholders regarding how testing of the inclusion of the Medicare hospice benefit in the MA benefits package is enhancing the quality and safety of care for individuals enrolled in participating MA plans and those results were reported last fall.
CMMI made clear in their announcement that their decision to discontinue the carve in does not indicate whether the test met its goals. They will continue evaluations of this component and, hopefully, those findings will help guide policy going forward. Despite the operational challenges and limited participation, the carve in played a significant role in transforming the delivery of serious illness care in the MA program through meaningful partnerships between MAOs and hospice providers. CMMI also said they gained valuable insights into creating a seamless care continuum in the MA program for Part A and Part B services, inclusive of the Medicare hospice benefit. The lessons learned from this continue to inform collective efforts for meeting the needs of those with serious illnesses for the future.
