Medicare Advantage Transparency Efforts Could Impact Hospices

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Recent efforts to increase transparency within Medicare Advantage may impact hospice reimbursement.

The U.S. Centers for Medicare & Medicaid Services (CMS) recently released a Request for Information (RFI) on ways to improve data sharing and increasing transparency in Medicare Advantage.

The effort to increase data insight comes at a time when the Biden-Harris administration is ramping up efforts to improve quality and access by reducing health care and prescription drug costs.

The White House recently announced an aim to crack down on health care price gouging to ensure equitable access and promote competition among providers. This includes preparation of a bill that would increase data transparency for supplemental benefits under Medicare Advantage.

Greater transparency for individuals enrolled in Medicare Advantage could lead to the development of improved quality measures in serious illness and end-of-life care, according to Edo Banach, partner at Manatt, Phelps & Phillips LLP and strategic advisor of Edo Solutions LLC.

“This is another step in the administration’s goals that attempt to make sure Medicare Advantage plans are being held accountable,” Banach told Hospice News. “Part of that is making sure we continue to make Medicare a more equitable and accessible program in every way. It’s important that we have a level of insight and transparency in Medicare Advantage data to have more flexibility to add supplemental benefits that serve more diverse populations. That is something we’re going to get with enhanced transparency and more robust data.”

If enacted, the bill, which contains proposed amendments to the Social Security Act, would require Medicare Advantage plans to report enrolled beneficiary data on supplemental benefits, such as palliative care, as well as patients aligned with the hospice component of the value-based insurance design (VBID) demonstration.

If enacted, the proposed changes would take effect Jan. 1, 2027, stipulating that MA plans submit beneficiary data such as the types of services received, provider identification, utilization rates and payments – including costs on both the payer side and the out-of-pocket costs for beneficiaries.

The recent RFI from CMS indicates that regulators plan to take data transparency to the next level when it comes to developing more flexible payment parameters in and around end-of-life care, Banach said.

As value-based reimbursement takes shape in hospice through avenues such as VBID, the scope of quality data transparency in Medicare Advantage will play a role in shaping future hospice payment and outcomes, according to Banach.

“It’s not just about enhanced transparency, but going a step further around greater flexibility and payment incentives around it,” Banach said. “What’s really necessary are these binding, sticky requirements that will allow providers to get paid more and have more flexibility in their services. With hospice carved into VBID, we’re still seeing how that’s playing out. It’s important for that data to be shared and really help inform consumers and providers [on] the benefits available and what people are actually getting. Transparency is crucial to how we determine which benefits are being provided, and whether they are being provided equitably for people who are 65 and older.”

Increased data transparency efforts come at a critical time as the hospice carve-in continues to unfold, according to Fred Bentley, managing director of ATI Advisory. Part of the drivers behind CMS’ recent move to extend the VBID demonstration until 2030 included an aim to address health-related disparities among serious and critically ill populations, he said.

Setting the bar around transparency requirements in Medicare Advantage could help ensure more equitable access to quality end-of-life care, Bently stated.

“What this signals is that if and when hospice does get carved into Medicare Advantage, these transparency requirements will set the tone and direction for how hospice is integrated in MA,” Bentley told Hospice News. “It’s having requirements that look at tighter utilization management controls [and] address concerns around limited and restrictive access. It’s about ensuring MA plans try to steer their members toward high-value providers and away from low-value providers with increasingly aggressive steps to better manage adequate access for hospice beneficiaries as part of that.”

CMS has strengthened its focus on health equity in recent years. The Center for Medicare & Medicaid Innovation (CMMI) in 2021 announced a “strategy refresh” that included prioritizing health care equity in payment model design.

The Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) program was among the first new models to use this approach. The program requires participating entities to develop an equity plan that identifies health disparities that could affect their patient population, as well as action items to address those concerns. The ACO REACH program also institutes a health equity benchmark adjustment for payments to ACOs serving higher numbers of beneficiaries from underserved communities.

Nevertheless, barriers exist. Among them are challenges with technology, according to the National Hospice and Palliative Care Organization (NHPCO).

The organization recently penned a letter to CMS and the U.S. Department of Health and Human Services (HHS) urging regulators to address technology interoperability issues that pose barriers to increased data transparency and high quality hospice care.

“MA is a new system for many hospice providers and it requires education, training and time to work within the new system,” Ben Marcantonio, COO and interim CEO of NHPCO, said in the letter. “Hospice providers were not included in interoperability initiatives and funding. Due to this, many hospices have minimal access to data outside of their program, so any requirements from [Medicare Advantage Organizations (MAOs)] for population data will be limited from hospice providers. Hospice providers would need updated software to access and share this information.”

Improving access to high quality hospice for Medicare Advantage beneficiaries will require systems that can gather and report more up-to-date patient data, according to Marcantonio.

“To minimize confusion for enrollees, MAOs need to verify the data and information they are sharing with providers,” Marcantonio wrote. “Providers have stated the provider directories being shared with enrollees are frequently out of date and difficult to decipher. In addition, providers have received lists of enrollees eligible for palliative and transitional concurrent care benefits so out of date, the enrollee has died or has disenrolled from the MA plan.”