JustCare

Tag: CMMI

  • Medicare Advantage: Hospice care is a juggle

    Medicare Advantage: Hospice care is a juggle

    Insurers clearly have not figured out how to profit from the Medicare hospice benefit, which offers comfort care for people who are terminally ill. Caitlin Owens reports for Axios that a government trial to include the Medicare hospice benefit in Medicare Advantage is ending six years sooner than planned because insurers and hospice agencies alike cannot make the benefit work to their liking. The Centers for Medicare and Medicaid Services, CMS, which oversees Medicare, claims the pilot was not a failure. What would you call it?

    Right now, if you are enrolled in a Medicare Advantage plan and elect the Medicare hospice benefit–choose to forgo curative treatments for your condition in favor of palliative care–traditional Medicare covers the hospice services, even though you are still enrolled in a Medicare Advantage plan. [N.B. Unfortunately, the hospice benefit is only truly available to people who have someone to take care of them at home and ensure their safety when the hospice aides are not there. The hospice benefit does not provide 24 hour care.]

    Juggling between traditional Medicare for your hospice care and Medicare Advantage for all unrelated health care services can be a bear. And, it can be a big bear for the more than 800,000 people enrolled in Medicare Advantage who elected hospice in 2022–about half the Medicare Advantage enrollees who died in 2022.

    In 2021, the Center for Medicare and Medicaid Innovation (CMMI) launched a pilot to permit insurers offering Medicare Advantage to coordinate hospice care for their enrollees directly. The question is whether Medicare Advantage plans can make getting hospice services easier for their enrollees, bring down costs, and improve quality of care. The pilot was scheduled to run through 2030.

    The Medicare Advantage hospice experiment will now end in 2026. Neither UnitedHealth Group nor Elevance, two of the biggest insurance companies offering Medicare Advantage, who had been part of the pilot, wanted to continue participating. Only 13 insurers were participating.

    For the most part, hospices agencies were pleased that the insurers pulled out. Insurers were not paying them adequately and their administrative burdens were significant. But, without a hospice benefit, Medicare Advantage cannot provide seamless care at the end of life; it makes Medicare Advantage accountability and enrollee costs all the more complicated for hospice enrollees.

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  • Traditional Medicare’s fee for service payment system contains costs better than other payment models

    Traditional Medicare’s fee for service payment system contains costs better than other payment models

    Since establishment through the Affordable Care Act, the Center for Medicare & Medicaid Innovation (CMMI) has been testing new ways to deliver and pay for care in Medicare, Medicaid and the Children’s Health Insurance Program, with the goal of reducing spending and improving care quality. A new report from the Congressional Budget Office (CBO) indicates that, over the last ten years, CMMI’s pilot programs cost more than Traditional Medicare with a fee for service payment system.

    CBO looked at evaluations of 49 CMMI delivery and payment models, alternatives to Traditional Medicare’s fee-for-service payment system, and found that Medicare spending is up $5.4 billion between 2011 and 2020. At the time Congress created CMMI, lawmakers believed that CMMI would save the government money in its first decade. They believed a $7.5 billion investment in new models would result in $10.3 billion less spending.

    In this next decade, CBO projects $1.3 billion in net additional spending as a result of CMMI’s pilot programs rather than the $77.5 billion in net savings originally projected. Based on this information and, even more so, what we know about some of the models CMMI is testing, it’s not clear that CMMI is offering the value people hoped it would.

    It’s no surprise that CMMI’s alternative payment models are costing more than Traditional Medicare’s fee for service payment system. The big models all rely on multiple third-party intermediaries to oversee care. These intermediaries drive up administrative costs and are often profit-making entities, such as private equity firms, or large non-profit systems.

    What’s worrisome is that some of the CMMI payment models, such as the ACO REACH model, incentivize companies to withhold needed care in order to maximize profits. That’s a recipe both for driving up Medicare spending and for endangering the health and well-being of older adults and people with disabilities.

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  • How should Medicare innovate to improve quality and reduce spending?

    How should Medicare innovate to improve quality and reduce spending?

    Donald Berwick, MD, former head of the Centers for Medicare and Medicaid Services and Richard Gilfillan, MD, former head of the Center for Medicare and Medicaid Innovation (CMMI) write in JAMA Network about the value of CMMI, a creation of the Affordable Care Act that has just reached its tenth year of operation.

    Before CMMI, there was no governmental agency charged with looking scientifically into how best to reshape our nation’s health care financing and delivery systems. Specifically, CMMI is supposed to test new ways of delivering and paying for care that bring down spending while maintaining or improving quality or improve quality while either not increasing spending or reducing it.

    CMMI has significant resources to work with. It has $20 billion to test new models of delivering and paying for care over 20 years, or $1 billion a year. The Secretary of Health and Human Services (HHS) has authority to bring CMMI models to national scale that fit within the parameters of its work, without requiring legislation.

    Between 2010 and 2020, CMMI tested 54 models. Some of these models focused on better care for individuals and better population health, while spending less. Some tested new models of delivering primary care, including medical homes and accountable care organizations. And, some models tested new ways of paying for care, through bundled payments for a group of services over a period of time, instead of through a payment for each service delivered.

    One independent review found that fewer than ten percent of the models tested led to significant reductions in spending. CMMI reports on its website that nearly 10 percent of models tested improved quality and/or reduced costs.

    Beyond that, the tests showed where the savings could be found and where not, as well as where and how the system could be gamed. As of now, CMS has certified four models to be scaled nationally, including a national diabetes prevention program.

    Berwick and Gilfillan recommend that CMMI model tests should be aligned with an HHS and CMS strategic plan for improving health and health care value and promoting equity. They also recommend that, over time, the ACO model should apply to all clinicians and hospitals, which would be paid a capitated rate for the total cost of care. They recommend CMMI test models that focus on social determinants of health, in partnership with other executive branch departments, such as the Department of Transportation and the Department of Housing and Urban Development. They recommend that CMMI test new models of care delivery. And, they recommend increased public-private partnerships to promote better health care and the public health. The entire evaluation process should be public.

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