Unintended Consequences of the Hospice Carve-out Uneven Prevalence of Medicare Advantage Enrollment across Hospices Ila H. Broyles, PhD RTI International Qinghua Li, PhD Nan Tracy Zheng, PhD Samantha Zepeda, BS Natalie Chong, BA Ann Larsen, MS Alon Evron, MA Micah Segelman, PhD Jennifer Frank, MPH Franziska Rokoske, PT, MS RTI International Cindy Massuda Contracting Officer Representative Centers for Medicare and Medicaid Services www.rti.org RTI International is a registered trademark and a trade name of Research Triangle Institute.
Acknowledgements Co-Authors Qinghua Li, PhD Nan Tracy Zheng, PhD Samantha Zepeda, BS Natalie Chong, BA Ann Larsen, MS Alon Evron, MA Micah Segelman, PhD Jennifer Frank, MPH Franziska Rokoske, PT, MS This project was funded in part by the Centers for Medicare & Medicaid Services under contract no. HHSM-500-2013-13015I. The statements contained in this presentation are solely those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services. RTI assumes responsibility for the accuracy and completeness of the information contained in this report.
Background: Medicare Advantage and the Hospice Carve-out
Overview of Medicare Advantage and Carve-out Policy Medicare Advantage (MA) is a voluntary program that allows beneficiaries to receive Medicare benefits through a private health insurer. Private insurers receive a capitated payment to cover *almost* all Medicare benefits for enrollees. Unlike other parts of the MA benefit, MA enrollees who elect hospice receive hospice benefits through fee-for-service (FFS) Medicare, so their hospice benefits are “carved - out” of their MA benefits. Recommendations about ending the carve-out (MedPAC, etc.) highlight some of the trade-offs in the current model.
Current Rules: Medicare Advantage and Hospice Beneficiaries who receive MA coverage for their Medicare benefits but wish to elect hospice are not required to drop their MA coverage: – For all services related to their terminal illness, Medicare pays for their hospice benefit through the per diem paid to the hospice provider. – For services not related to their terminal illness (including those of the managed care attending physician), Medicare pays fee-for-service (FFS). – Finally, for any supplemental benefits (which are not original Medicare benefits) and Part D (if-MA-PD plan), the MA plan is responsible for continued coverage and payment and Medicare pays the MA plan a reduced capitated payment. Some beneficiaries may retain their MA coverage, elect hospice, but subsequently decide to revoke their election. In that case, Medicare pays FFS for services received after the hospice revocation date until the first day of the following month.
Implications of the Carve-out Policy MA enrollment has dramatically risen in the last decade from 13% in 2003 to 31% in 2015 of Medicare beneficiaries. This prevalence is uneven across states, ranging from <10% to >50% of Medicare beneficiaries in each state receiving their Medicare benefits through MA plans.
Research Objectives To understand the geographic variation in hospice patients’ enrollment in MA before, during, and after their hospice election. To understand whether certain kinds of hospices are more likely to serve MA enrollees.
Current Picture: Medicare Advantage and the Hospice Carve-out
Sample and Study Design Data Sources: – Medicare hospice claims – POS File with hospice characteristics merged onto patient-stays – Enrollment Database with MA enrollment and other beneficiary characteristics Sample: 3.5 million hospice enrollees with hospice discharges in 2013-2015 and who elected hospice after January 1, 2012 Methods: – Descriptive analysis: patient-level MA enrollment before, during, and after hospice election – Multivariate analysis: hospice-level analysis of proportion of patient-stays with MA enrollment
Prevalence of MA Enrollment among Hospice Enrollees MA Enrollment among Hospice Enrollees Roughly one-third of hospice 2% <1% enrollees had MA enrollment concurrent with their hospice enrollment 29% – Almost all of these patients were enrolled in MA for their entire hospice election 69% Most hospice enrollees with concurrent MA enrollment were previously enrolled in MA No MA Enrollment Continuous MA Only MA Before Only MA Concurrent
Geographic Variation in MA Enrollment: Hospice Enrollees Large state variation in hospice enrollees with MA enrollment, ranging from >50% of hospice patients in Hawaii, Minnesota, and Puerto Rico to <10% in Delaware, New Hampshire, Vermont, and Wyoming STATE HEAT MAP INSERTED HERE
Patient Characteristics by MA Enrollment Hospice Patient MA Enrollees Non-MA Enrollees Characteristics (N= 1,036,496) (N= 2,510,929) 84% 88% White* Female* 56% 58% Received care from… Non-profit Hospice* 42% 41% For-profit Hospice 45% 45% 92% 86% Urban Hospice* Hospice with 34% 33% Participation Pre-2000* MA enrollees listed here have some MA enrollment during the time they elected hospice (“concurrent MA”) *Chi-squared test indicated significant differences, p<.01
Hospice Characteristics and MA Enrollment Analytic Approach: Regression Analysis – Sample: 4,395 hospices with patients discharged in 2013-2015 – Dependent Variable: Proportion of the hospice’s patients with MA enrollment – Independent Variables: Average age of patients Proportion of female patients Proportion of non-hispanic white patients Urban (categorical) Non-profit/for-profit/government owned (categorical) Participation prior to 2000 (categorical) Hospice size (categorical by quintile) – Linear regression with robust standard errors, state fixed-effects
Hospice Characteristics and MA Enrollment Wide variation in hospices’ proportion of patients with MA coverage (0-100%) with a median of 25% of patients – 53 hospices with >80% of patients with MA coverage had a median total stays in the three year period of 100, geographically diverse, etc.
Hospice Characteristics and MA Enrollment Adjusting for the state of hospice location, increased MA penetration was associated with certain hospice characteristics: • Urban providers had a 6.8 percentage point increase in the percent of patients with MA (p<.05). • Hospices operating for >15 years had 1.6 percentage point increase in the percent of patients with MA (p<.05). • The largest 20% of hospices had a 5.4 percentage point increase in the percent of patients with MA relative to the smallest 20% of hospices (p<.05) Independent Variables Coefficient -0.138** Proportion Non-Hispanic White Proportion Female -0.0122 -0.00096 Average Age Non-profit Hospice 0.0081 Government Hospice 0.0057 0.068** Urban Hospice 0.016** Hospice Participation Year Pre-2000 *Indicated significant differences, p<.05
MA Enrollment after Hospice Live Discharge MA after live discharge – 30% of patients live discharged were subsequently enrolled in MA 5% of all patient-stays – 99% of these had MA coverage during their hospice election and most for their entire hospice election – Hospices’ percent of total patient -stays with MA after live discharge: Mean: 7.5% Median: 4.6% Max: 100%
Implications: Medicare Advantage and the Hospice Carve-out
MA Enrollment and Hospice Delivery Observed variability in MA penetration across hospices may affect hospice delivery – MA enrollees may have access to a different set of palliative care and supportive services compared to FFS patients before hospice election – Payments to MA plans for MA enrollees who elect hospice may alter hospice election patterns MA enrollment may then affect the timing of hospice enrollment and the types of patients who elect hospice – Analysis suggests that MA patients are more likely to enroll with certain kinds of hospices, although the reason for that is not clear – Unknown whether MA penetration by hospice also varies with quality of hospice care Public reporting of hospice quality information in the HQRP may amplify those patterns, if they exist
MA Enrollment and Hospice Delivery Variability in MA penetration across hospices may affect future research and quality measure development – Utilization and diagnosis information is commonly used for risk adjustment – Data suppression for MA enrollees before and after hospice election due to lack of FFS claims – Limited utilization and diagnosis information (due to suppression) may affect future risk adjustment
More Information Ila Broyles Franziska Rokoske 919-485-2759 919-541-8833 ibroyles@rti.org frokoske@rti.org
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