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Former CMS Chief Verma: VBID Demo Meant to Fix Hospice Inconsistencies

Thought Leader: Seema Verma
February 14, 2022
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When the U.S. Centers for Medicare & Medicaid Services (CMS) unveiled the hospice component of the value-based insurance design (VBID) demonstration in 2019, one of its main goals was to bring length-of-stay consistency.

That’s according to former CMS Administrator Seema Verma, who discussed the VBID demo – also known as the hospice Medicare Advantage (MA) carve-in – last week during the Home Care 100 conference.

“When it came to hospice, I think the issue there was looking at the data – and the volatility in the data,” Verma said. “We weren’t seeing consistency across the board.”

The VBID model for hospice officially began in 2021, with 53 MA plans participating. That relatively small group of MA hospice pioneers has more than doubled in 2022 to 115 plans, with a collective geographic footprint of 461 counties.

Broadly, VBID is testing a new MA option to hospice care, which previously had only been available in a fee-for-service Medicare context. Unlike some mandatory CMS demonstrations, participation in the model is voluntary for payers and providers alike.

As for that lack of consistency, Verma pointed to the fact that some hospice patients remain on service for several months while others receive just a few days of end-of-life care.

The average Lifelong Length of Stay (LLOS) for Medicare patients enrolled in hospice in 2018 was 89.6 days, according to the National Hospice and Palliative Care Organization (NHPCO). The Median Length of Service (MLOS) that year was 18 days.

Yet a decent-sized chunk of the hospice population – about 8%, according to Verma – has a length of stay of more than 180 days. Meanwhile, nearly 30% of patients have an average length of stay of seven days or less.

One of the No. 1 complaints that families report on Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys is that they wished their loved one had entered hospice sooner, according to CMS.

That’s where the VBID demo could theoretically help, Verma explained.

“It was to address the fact that [we wanted] to create more of a continuum between palliative care and hospice, to have some quality measures,” she said. “I don’t know that in this case they were looking at trying to address cost.”

Additionally, from a patient perspective, Verma said the MA carve-in makes sense for the individuals who don’t want to switch from their private insurance to FFS Medicare.

“I think that there … are some benefits to patients having their benefits managed by one person or by one entity,” she added. “It’s bumpy when all of a sudden, we’re, you know, putting you in hospice – and that’s not run by your health plan anymore.”

The remarks from the former head of CMS come as some hospice providers begin to express frustration and concern over the MA carve-in. Those skeptics include Agrace Hospice & Supportive Care CEO Lynne Sexten, who touched on the topic during the Hospice News Elevate conference in November.

“A lot of organizations — mine included — are chasing after value-based contracts in palliative care and other types of post-acute services,” Sexten said. “MA is this bright new shiny coin in hospice, but the way that the design is being executed is wholly a failure in the first six months, in my humble opinion.”

Others have certainly been more positive. Humana Inc. (NYSE: HUM) operates the most MA plans offering hospice via the carve-in, but it also participates in the VBID demo as a provider.

“Our experience has been that it’s delivering just about exactly what we thought it would deliver in the first year,” Humana executive Kirk Allen previously told Hospice News.

If flaws are exposed, CMS and the Center for Medicare & Medicaid Innovation (CMMI) have the ability to fine-tune the VBID concept moving forward.

The hospice carve-in is a four-year demonstration.Typically, models are looked at over a five-year period, with the first year or two being dedicated to observation.

“I think it’s early. It’s only been a couple of years, and so there’ll be some changes with that,” Verma said. “I think if the industry doesn’t like how things are going, I would always encourage them to talk to CMMI.”

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