Late Referrals to Hospice and the Opportunity for Innovation around the Six Month Designation & Concurrent Care: The median length of stay in hospice is less than three weeks and more than one-quarter of patients referred to hospice die within a week. This short length of stay is not in the best interest of any stakeholder. It limits the clinical benefits associated with hospice care, stresses our patients, families, and organizations, and constrains the benefits that the payer community could achieve with more appropriate use of the hospice benefit.

Late referrals are driven by three phenomena:

1. Physicians are unable to accurately prognosticate a six-month survival; 
2. Eligibility linked to prognosis has promoted the public’s perception that hospice is solely care for the actively dying and there is a cultural reluctance to openly address issues related to death and dying; and
3. The creation of hospice as a full-risk managed care benefit without the potential for any payment to support costly disease-modifying therapy provides no margin for hospice agencies to assume high-cost patients.

The new demonstration sponsored by the Center for Medicare and Medicaid Innovation (CMMI) — the Medicare Care Choices Model (MCCM) — illustrates the Centers for Medicare & Medicaid Services (CMS)’s recognition of these issues and many NPHI members will be participating in the demonstration.

• NPHI supports a broader process of review that could lead to program changes or pilot projects that go beyond MCCM. NPHI supports efforts to develop and evaluate models in which hospice eligibility is linked to the diagnosis plus a demonstrated need for specialist palliative care.
• Additionally, we support efforts to develop other types of payment models that would allow for concurrent care with disease-modifying therapies, such as outlier payments for specific therapies. To actualize these models, NPHI supports efforts to modernize the certification methodology based on the six-month designation of prognosis, which relies excessively on demonstration of decline. Other factors should be taken into account, such as data related to epidemiology or treatment duration and patient and family need for services.

Face-to-Face Requirement: NPHI recommends modernizing the implementation of a face-to-face requirement to account for other innovations in healthcare delivery, such as telehealth. Other policies could increase flexibility by allowing hospices to utilize nurses, physician assistants, or other qualified health professionals to complete the face-to-face encounter.

Innovation in Medicare Advantage: NPHI is currently creating a nation-wide demonstration pilot to test the concept of carving the hospice benefit into Medicare Advantage (MA). This pilot will identify what type of contracting requirements and safeguards would be necessary to protect the integrity of the Medicare hospice benefit and the full scope of hospice services. As legacy hospice providers, NPHI members have unparalleled experience in delivering interdisciplinary, quality care under the existing benefit. NPHI is testing the carve-in of the hospice benefit to the MA program so that the integrity of the benefit and the full scope of hospice services are protected and provided regardless of the payer.

Outlined below are categorical safeguards that should exist in any carve-in, but strongly recommend that our pilot be allowed to be fully implemented to test these ideas and gather data for Congress to consider.

• Access: There are well-established networks of community-integrated hospice providers throughout the country – and any consideration of a carve-in for hospice benefits should build on these existing, integrated networks and not create incentives to dismantle them.
• Quality: Quality, measured based on outcomes and patient and family satisfaction, should play a substantial role in the design of a potential MA hospice benefit. Quality metrics should be considered both in MA contracting policy and in the revision of the MA star rating program.
• Reimbursement: Concerns exist that direct negotiation of rates with MA plans directly for hospice services could result in larger, for-profit providers, potentially with lower quality indicators, underbidding for services to gain a market advantage – thereby excluding community-based not-for-profit providers. This would further compromise the ability of this critical group of not-for-profit, safety-net hospice providers from continuing mission-critical operations in many parts of the country, and have adverse spillover effects on care for the fee-for-service population.
• Minimizing Administrative Burdens: The design of a carve-in’s approach to provider contracting should minimize administrative burdens to hospice providers, especially not-for-profit, safety-net community-based providers for whom existing administrative burdens threaten the viability of the programs.