Value-based care

Dive Brief:

• The Biden administration has paused or pulled some models testing value-based payments in healthcare, but the new director of the CMS agency overseeing model testing said the slowdown doesn't equate to waning motivation for its mission.
• Elizabeth Fowler, who took the reins at the Center for Medicare and Medicaid Innovation a few months ago, said CMMI will focus on enacting fewer but more targeted models, speaking in her first public remarks since taking the helm.
• "In my view, we're at a really critical juncture in the path to value-based care," Fowler said at the National Association of Accountable Care Organizations' spring conference on Tuesday, asking stakeholders for patience as CMMI reviews paused models and outlines a path forward.

Dive Insight:

CMMI was founded a decade ago with the passage of the Affordable Care Act, with an aim to move the needle toward paying for quality of care instead of quantity in healthcare. Though modernizing the entrenched system isn't easy, there's a clear role for the agency and its alternative payment models to spur that shift coming out of COVID-19, Fowler said.

Fowler has a long background in health policy, having previously held leadership roles at HHS and helped draft and implement the ACA as a Senate staffer, which underpins much of President Joe Biden's healthcare agenda.

Her remarks come after CMMI paused a number of models for review, including the Geographic Direct Contracting Model and the Primary Care First Serious Illness Population Model. CMMI has also delayed the start dates for the Kidney Care Choices model, among others.

​"I understand that collectively these announcements may have raised questions about where the center is headed next," Fowler said, before reiterating CMMI's support for its mission. "True innovation means failing until we get things right."

As CMMI reviews past models and revamps its strategy, the agency is aiming to think more creatively as the space has gotten increasingly more complex as many models overlap, Fowler said. Because of this, evaluating models isn't necessarily going to drive development moving forward.

The Medicare Payment Advisory Commission recommended in October that CMMI condense the sheer number of trial programs and create more targeted long-term goals for its alternative payment models.

In the past, CMMI has focused on certifying models and enacting them in Medicare, and that focus can be limiting, the newly minted director said. Only four models have actually become a permanent part of Medicare since CMMI's founding.

CMMI has tested upwards of 50 models, yet few have resulted in cost savings or better quality of care, causing a bipartisan group of legislators to call for more oversight of the agency over a year ago.

Fowler also urged providers to get more involved in the shift to value-based care and take on more risk. However, she said she was leery of enacting sweeping incentives for providers, and is open to different carrots and sticks to nudge them in the right direction.

"What happens when the model goes away and the payment ends?" Fowler said. "Payments for the sake of payments may not generate that transformation that we're seeking."

Moving forward, CMMI has numerous priorities, including taking a greater focus on health equity, working harder to align different payers on value-based care efforts and strengthening the nation's flagging primary care infrastructure, all while working with incoming HHS Secretary Xavier Becerra and Biden's health team on key issues, including drug pricing.

"We need to find a way to bring everyone along. We can't have fee-for-service remain a comfortable place to stay," Fowler said.

Dive Brief:

• CMS is delaying the start of the first performance year for its kidney care payment model until January 2022, with the goal of giving participants more time to implement infrastructure and operational changes.
• The Kidney Care Choices model announced in 2019 was originally scheduled to start Jan. 1 of this year before being delayed to April 1 due to the pandemic. But CMS said in a recent update it's pushing back the implementation timeline again to give participants more leeway in preparing to take on the financial and population health accountability required in the model.
• The five-year model uses four capitated payment options to incentivize providers to better manage care for Medicare patients with chronic kidney disease and kidney failure, with the goal of delaying the onset of dialysis and incentivizing kidney transplants. It is the second Trump-era payment model that President Joe Biden's health administration has recently tweaked.

Dive Insight:

Revamping kidney care was a key focus of the Trump administration's Center for Medicare and Medicaid Innovation, the CMS agency that trials new ways of paying for healthcare in a bid to inject more value into the system.

CMMI, now under the new leadership of Biden appointee and one of the Affordable Care Act's congressional architects, Elizabeth Fowler, likely has no plans to change course on cutting costs in Medicare kidney care. The current system encourages in-center hemodialysis for kidney disease patients, an expensive treatment path that contributes to the patients making up a disproportionate share of Medicare spending.

Kidney Care Choices builds on an existing model, the Comprehensive End Stage Renal Disease Care Model, in which dialysis facilities, nephrologists and other providers form accountable care organizations to better manage care for patients with end-stage renal disease. Kidney Care Choices adds on top of that four payment options with varying degrees of risk for different providers to manage the care of Medicare beneficiaries with chronic kidney disease and ESRD.

The start date of the model's first performance year, where providers are required to assume financial risk, is now Jan. 1, 2022. Providers interested in participating in KCC already applied in the fall of 2019, and selected applicants began building out their infrastructure and prepping for the model late last year.

CMS is now extending that implementation period through 2021, to better "enable model participants to prepare to take on financial and population health accountability," the update reads.

According to yet another under-the-radar update earlier this month, Biden's CMMI is also reviewing the Geographic Direct Contracting model, which was first announced in December. The voluntary model is meant to test if a geographic-based approach to care delivery can lower costs in Medicare, while improving beneficiary health outcomes.

CMMI generally enjoys bipartisan support, but has faced some criticism for its sweeping authority to test payment models without congressional oversight, and few successful models to show for its decade of effort. CMMI has tested 54 models over the past 10 years, but only five have saved a significant amount of money and just two have expanded nationwide, previous former CMMI head Brad Smith said in September.

Sponsored content

By Geneia

As we wrote in our recent white paper, How a phased approach to value-based vare works: For health plans, health systems and their value-based partners, physicians are the heart of healthcare delivery, and health plans, health systems and hospitals that are succeeding in value-based care have engaged and activated their network of providers.  

That said, most healthcare organizations are struggling with provider adoption and engagement. A lack of provider engagement, for example, is often cited as the reason for slower than expected adoption of value-based care. 
Is it any wonder burned out physicians burdened by suboptimal EHRs are reluctant to change? 

After all, far too many physicians are burned out. Geneia’s national survey of physicians in 2019 found:

• Eight in 10 (84%) say the quality time doctors are able to spend with patients has decreased in the last 10 years.
• More than three-quarters (77%) know a physician who is likely to stop practicing medicine in the next five years due to burnout.
• Nearly three-quarters of surveyed physicians (74%) say the challenges of practicing medicine in today’s environment have caused them to consider career options outside of clinical practice.
• An overwhelming majority (83%) say they are personally at risk for burnout at some point in their career.

Eight ways to improve physician adoption and engagement

Over the years of working with health plans, hospitals and physician practices, we've learned some important lessons about what works. Here are eight ways to improve physician adoption and engagement:

1. Listen. Ensure physicians know they’ve been heard. The physicians Geneia surveyed said one good way to do this is to put more purpose, clarity and intention behind physician engagement surveys. Offer concrete examples of ways the survey results have or will impact change.  
2. Invest in physician time-savers like scribes who, among other things, allow providers to engage more fully with patients during visits. Other popular physician time-savers are pre-visit planning, pre-visit lab testing and care team huddles. 
3. Empower the care team – medical assistants, nurse care managers, care coordinators and others – and administrative staff to do more, allowing healthcare organizations to reserve physicians’ time for improving the patient relationship, diagnosis and treatment. If given the right information and tools, the care team and administrative staff are perfectly equipped to identify risk, coordinate care, manage open care gaps, motivate and engage patients, and perform recordkeeping.  
4. Acknowledge that physicians need more time and resources to care for patients who have complex healthcare needs, and create the infrastructure to support these patients and the providers who care for them. 
5. Consider a phased approach that prioritizes early wins for providers as one of the health plans we profiled in our recent white paper, How a Phased Approach to Value-Based Care Works: For Health Plans, Health Systems and Their Value-Based Partners, did.  
6. As early as possible, involve providers in any decision-making process for health IT they’ll be expected to use, such as a shared analytics platform. To the extent possible, allow providers to drive the selection process.  
7. Pilot health IT solutions with a subset of providers to work out the kinks and ultimately cultivate physician champions who can influence other providers. Involve the pilot group in the implementation process as early as possible. 
8. Recognize that health IT training is not a 'once-and-done'during implementation, but is an ongoing effort to increase physician adoption. 

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To learn more about how to improve your provider adoption, check out these additional resources: 

• Geneia White Paper: How a Phased Approach to Value-Based Care Works: For Health Plans, Health Systems and Their Value-Based Partners
• Geneia Case Study: Practice Transformation Helps Commonwealth Physicians Achieve Value-Based Care Success
• Geneia Best Practices: Selecting the Right Analytics to Build Physician Adoption and Trust
• Geneia Report: Physicians Still Miserable: Seven Solutions to Address Burnout

As the coronavirus sickens tens of thousands of Americans while pressuring the bottom lines of medical providers, analysts worry the pandemic could also hit pause on the decades-long march toward value-based care, as hospitals and doctors look to recoup revenue in the short-term instead of putting more dollars at risk.

Massive health systems and independent physician offices alike are diverting funds to shore up resources like personal protective equipment, ventilators and staff to prepare for an expected influx of COVID-19 patients or to cope with those already there. Expenses are skyrocketing as providers halt non-essential visits including lucrative elective procedures like joint replacements, winnowing down a major source of revenue.​

Clinicians in value-based payment arrangements face higher levels of financial risk than their fee-for-service counterparts. Money spent preparing for the coronavirus and treating COVID-19 patients will be a sunk cost and they could be dinged financially again at the end of the year when their spending and performance is evaluated.

Already, the coronavirus is leading providers to think about exiting the models.

A survey published this week of more than 220 accountable care organizations nationwide found almost 60% are likely to drop out of their risk-based model to avoid financial losses. Some 77% are "very concerned" about the coronavirus' impact on their 2020 performance.

"The value-based movement is at a critical juncture," wrote National Association of ACOs CEO Clif Gaus in a letter to CMS Administrator Seema Verma last month.

Fee-for-service still dominates — roughly 40% of healthcare payments made in 2018 were under fee-for-service, according to the Health Care Payment Learning & Action Network (LAN) — but it's been on the downswing. One in three healthcare payments currently flows through some sort of alternative payment model, and that has been projected to grow.

Among the four main types of value-based arrangements — shared risk, global capitation, bundled care and shared savings —​ most require an upfront financial commitment. And providers are unlikely to put more capital at risk given the current economic situation, analysts told Healthcare Dive, instead focusing on making up the losses they sustained during the outbreak by ramping up capacity.

Doctor's offices and hospitals will reschedule delayed procedures and even operate on weekends to recapture as much revenue as possible before they're likely to consider taking on more risk.

"Even if you're not in the hotspots, you are preparing right now. This puts on hold a lot of the initiatives that have been on the value-based side of things," Jefferies senior healthcare analyst Brian Tanquilut told Healthcare Dive. "I don't think the value-based discussion goes away, but I think it will take a recovery of the hospital system before it can go there."

Pleas for loss waivers

The National Association of ACOs told CMS in mid-March that ACOs in Medicare's flagship ACO program the Shared Savings Program, along with other shared risk models like the Next Generation ACO model and the upcoming Direct Contracting initiative, could face losses beyond their control because of the pandemic.

CMS did pause some reporting requirements for value-based initiatives late last month. The agency pushed back the deadline for groups participating in the Medicare ACO program, Merit-based Incentive Payment System and the Hospital Readmissions Reduction Program to report quality data, or waived reporting entirely for the fourth quarter of 2019. The relaxation was framed as a way to help value-based organizations free up time and resources amid the pandemic.

But provider groups including NAACOS and the American Hospital Association have lobbied aggressively for the Trump administration to forgive all ACO losses for 2020. CMS is reviewing their request.

But all normal rules have gone out the window, experts say, and it's almost impossible to move the needle toward value in the future when providers are facing a tsunami of patients now.

"This is not about managing a population. This is about doing everything you can to keep these people alive," Dean Ungar, vice president of Moody's Investors Service, told Healthcare Dive. "Coronavirus is really a five-alarm fire. But if your building's on fire, that doesn't really tell you how to maintain your business in normal circumstances."

Silver lining?

Some, however, are more optimistic that the unique financial challenges brought on by the pandemic highlight the problems with the traditional fee-for-service model and could even nudge providers toward value-based arrangements down the line.

"If all of your revenue is based on patients walking in the door, when they can't walk in the door anymore, you're kind of up the creek without a paddle," Dan Bowles, SVP of growth and network operations at accountable care organization Aledade told Healthcare Dive. "You need to find a way to create non-visit-based revenue."

Some hope the pandemic could help the value-based movement in the long term as practices look for ways to uncouple revenue from patient volume. And, as medical costs continue to rise, accounting for 19% of the country's GDP, any pause in the shift to value-based care due to the coronavirus is likely to be a short detour, not a complete derailment.

"Maybe some providers are going to see it in a different light when their business kind of dries up — see that there's a benefit to it," Ungar said. "Ultimately, it's a trend of where things are going, but it's a big ship and it's moving slowly."

And value-based care arrangements were built predominantly for the populations being hit hardest by the coronavirus: those with serious underlying medical conditions like chronic lung disease or severe obesity.

If those vulnerable patients were being treated in value-based arrangements, it's possible more COVID-19 cases could have been caught earlier before they became life-threatening, Moody's analyst Stefan Kahandaliyanage told Healthcare Dive. That could renew industry's focus on managing the health of those most at-risk from novel infectious diseases in the future.

"Costs are very high and there's been a pandemic," Kahandaliyanage said. "Let's get more healthy before the next pandemic comes."

The healthcare industry is increasingly embracing the idea that a slew of economic and social factors greatly influence medical outcomes, taking on issues from loneliness to food security. 

Experts say the move is long overdue. But some say social service organizations should be taking point on managing social determinants of health, and have charged payers and providers with barreling forward on the issue without bringing necessary local partners on board.

"Why don't we follow instead of lead from the clinical perspective, and listen to the people who have been working on this for a lot longer than we have?" Jamo Rubin, president of social risk factor company Signify Community, said Tuesday at the Health Datapalooza conference in Washington.

Most high-profile payers are already tackling SDOH, including Kaiser Permanente, Intermountain Healthcare, UnitedHealth Group, Humana, CVS Health, Anthem, Molina and more. On the provider side, hospitals spent roughly $2.5 billion on SDOH programs from 2017 to 2019, and analysts expect that figure will increase as value-based care picks up momentum and due to federal expansion of coverage for non-traditional services.

Payers acknowledge that social service organizations are critical to addressing the needs of a community on all aspects beyond direct medical care, but say such local players don't have the needed heft to keep tabs on the needs of an entire population.

And, as the U.S. pivots to a more holistic view of health, experts say traditional healthcare companies are still figuring out whether they're leaders or followers in tying traditional medical care to a patient's socioeconomic wellbeing.

"Certainly, on some of the policy or joint convening work, maybe you have a place at the table," Anand Shah, vice president of social health at integrated health system Kaiser Permanente, said. "But it doesn't make sense for the health systems or payers to be driving these conversations."

Though managing SDOH isn't historically a part of medical care, the incentive shift away from paying for service and volume to paying for quality and value has pushed payers and providers in that direction. A late 2018 study found that one in every five patients struggles with a high-risk health problem related to their socioeconomic status.​

Some payers think they should be at the helm of crafting SDOH interventions, arguing small agencies don't always have the bandwidth to cover the social needs of a group of beneficiaries.

"We need to start treating social determinants like critical gaps in care," Andrew Renda, associate vice president for population health at Humana, said. "If we don't start treating them like that, they'll be relegated to this nonprofit, grant-funded stuff."

Roughly one in eight human services community benefit organizations was financially insolvent in 2017, according to the Alliance for Strong Families and Communities, a nationwide association of CBOs. The VP of Medicaid policy for UnitedHealthcare called those results "insightful and terrifying" Tuesday.

"What happens if that sector starts to crumble further?" UnitedHealthcare Community & State's Kevin Moore said. "In all these conversations, the focus on the local Mom and Pop place — they don't have the bandwidth."

If a large amount of patients is pushed into a pipeline of organizations that rely predominantly on grants, CBOs could be forced to fold or selectively choose what healthcare companies they work with. That could stop payers and providers from analyzing the effects of an SDOH intervention across an entire patient population.

The multi-trillion dollar health industry by comparison, has resources dwarfing the CBO space. By using its infrastructure, payers and providers could greatly expand the gateway to social services, they say.

For example, North Carolina, a state that has experimented with various Medicaid payment models, is working to embed in its government EHR a link to human service resources like local food banks or domestic violence shelters, according to state HHS Secretary Mandy Cohen.

A role for both

However, though payer executives note they could act as a navigator for social services in an area, they do agree CBOs are critical partners toward the eventual goal of stopping people from coming into the medical system for preventable conditions.

"You can't decide a local health strategy from an ivory tower," Humana's Renda said at a panel on SDOH at Datapalooza.

Proponents of social services groups think their voices should be louder in the national conversation around SDOH, arguing local groups have their finger on the pulse of a community and often know a person needs socioeconomic help before they make it onto the healthcare system's radar.

"With all due respect to my physician colleagues, in four years of medical school and then residency, I never learned one thing about what happens to people after they get discharged," Signify Community's Rubin said. "What I did learn is, once they've entered the medical system, it's too late."

In an effort to prompt physicians to engage with social needs, CMS introduced coding for SDOH factors in 2016. But adoption of the so-called Z codes has been lackluster. According to a late January report from CMS, in the first two years the codes were available in Medicare fee-for-service claims, they were used for only 1.4% of beneficiaries.

Yet there's a role for payers, providers and CBOs on identifying SDOH needs and connecting patients with resources in their communities, experts say. For example, doctors can identify need and refer patients to community organizations, and payers can reimburse for CBO services.

Just a quarter of hospitals and 16% of physician practices screen for all five factors CMS has prioritized: food insecurity, housing instability, utility needs, transportation needs and interpersonal violence, according to a JAMA study published in September. But a clear majority of Americans want their doctors to ask them about their social needs.

With the current need to address SDOHs, "I don't think we have the luxury to try to figure out if one specific sector should take responsibility," Moore said, noting a slew of players should be working to create touchpoints to connect people to the care they need, whether social or medical.

"That's what we're trying to work to — not who gets credit."

Dive Brief:

• CMS granted some leeway Sunday for reporting data in connection with its numerous value-based payment programs, citing the coronavirus outbreak that threatens to overburden the U.S. healthcare system, 
• The agency provided either deadline extensions for reporting data connected to the projects — which include the Medicare ACO program, Merit-based Incentive Payment System and the Hospital Readmissions Reduction Program — or waived them entirely for the fourth quarter of 2019. Financial penalties for failures to report were also waived, although upside incentive payments remain in place.
• CMS framed the rules relaxation as an exercise in cutting red tape, but the agency was aggressively lobbied by numerous provider organizations in the days before the decision was announced.​

Dive Insight:

In an extraordinary time, CMS made the unusual move of granting leniency regarding the reporting of data connected to its 19 initiatives intended to improve quality of care throughout the entire Medicare system.

Virtually all of the initiatives require rigorous data collection by physicians, hospitals and other members of the provider community. That is often the source of frequent grumbling among those who had to pony up for EHR systems and other pricey items in order to comply or face lower Medicare payments.

CMS announced Sunday that it was extending 2019 data submission deadlines for ACOs participating in the Medicare Shared Savings Program from March 31 to April 30 of this year. Any providers who miss the deadline won't receive a financial penalty for failing to do so. It also granted the same leniency to participants in the Quality Payment Program and the affiliated MIPS. CMS added that it was reviewing 2020 reporting requirements as well.

CMS said it was also exempting reporting of fourth quarter 2019 data for 11 hospital-based quality programs and six post-acute programs, including the Hospital Readmissions Reduction Program, the Hospital Value-Based Purchasing Program and the Skilled Nursing Facility Quality Reporting Program. Submission of data is optional but will be counted if it is submitted.

For the hospital programs, data for the first half of 2020 will mostly not be counted. If data for the first quarter is provided by participants in the Hospital-Acquired Condition Reduction Program and the Hospital Value-Based Purchasing Program, it will be counted.

"In granting these exceptions and extensions, CMS is supporting clinicians fighting coronavirus on the front lines." CMS Administrator Seema Verma said in a statement.

CMS was lobbied by a variety of provider organizations prior to announcing the decision, including the National Association of ACOs (NAACOS), the American Medical Group Association, America's Physician Groups and the American Hospital Association.

America's Physician Groups and Premier sent a letter to congressional leaders and HHS Secretary Alex Azar early last week. "The unprecedented surge in demand and shortfall of products that we are expecting requires a major shift in focus for our organizations," the letter read in part. "While providers are actively working to confront head on the threat of the coronavirus, they are also concerned that that they will be face serious financial consequences under these programs as a result of factors not under their direct control."

A Wednesday letter signed by 10 different provider trade organizations, including NAACOS, AHA, MGMA and the American Academy of Family Physicians, among others, was addressed to the chair and ranking members of the House Energy and Commerce and Ways & Means committees.

"To enable these front line clinicians and care teams to continue to focus on providing high quality, coordinated care to patients, we urge you to preclude the financial impact or shared loss repayment for all ACOs and other value-based program participants based on costs accrued related to COVID-19 care and during this public health crisis," it read.

NAACOS CEO Clif Gaus said: "Some ACOs have spent years investing in the infrastructure and cultural changes needed to succeed in value-based care models. Just as we're starting to see serious, positive results, a catastrophic pandemic like this could wipe out years' worth of shared savings and threaten our decade-long movement to accountable care models."

Dive Brief:

• Blue Cross Blue Shield of Michigan and seven major health systems have entered into a new payment arrangement that financially rewards providers for hitting certain targets but also penalizes them for misses.
• The model will apply to roughly 30% of BCBS of Michigan's total commercial and Medicare Advantage market. The nonprofit insurer covers 4.7 million Michigan residents through various products.
• The new payment arrangements are set to begin Jan. 1 and last for five years. The health systems that have signed on include Ascension Michigan, Henry Ford Health System and Trinity Health.

Dive Insight:

The move is a step away from fee-for-service arrangements, which still cover most services despite the industry's push toward more holistic payment models. As the cost of healthcare continues to rise, providers and payers are looking for alternative models and better incentives that will ultimately curb the cost of care.

Instead of paying for volume, insurers are looking to reimburse providers for value. But uptake is still slow as an overwhelming number of providers are not taking on downside risk in alternative payment arrangements.

About 90% of value-oriented payment arrangements were built off fee-for-service infrastructure, meaning no downside risk was employed, according to a recent report from Catalyst for Payment Reform. "The results of these analyses are disappointing and a wake-up call that we are moving too slowly and essentially missing the mark," Robert Galvin, CEO of the firm Equity Healthcare and CPR board chairman, said in a statement.

In the new Michigan deal, providers will be expected to increase quality of care, avoid unnecessary tests, scans and emergency room visits, reduce complications and re-hospitalizations and improve coordinating patient care across all points of service.

The leaders of BCBS of Michigan said the new payment arrangement, dubbed Blueprint for Affordability, is just the first wave of new payments. "Together with these health organizations, and others we hope will come aboard soon, Blue Cross seeks to permanently change the trajectory of health care costs in Michigan and make health care more affordable for people and employers," CEO Daniel Loepp said in a statement.

CMS has also been working to push the healthcare system toward more value-based arrangements through numerous initiatives, including Accountable Care Organizations.

CMS Administrator Seema Verma has said organizations need to take on more downside risk and sooner.

A final rule from last year, shortened the amount of time ACOs can enjoy only the upside risk, or bonuses for hitting targets, essentially pushing them to take on downside risk sooner. Verma said then the "results show that ACOs that take on greater levels of risk show better results for cost and quality over time."

Dive Brief:

• The number of Medicare Advantage members enrolled in plans with value-based payment designs more than tripled from 2019 to 2020, CMS said Thursday.
• Approximately 1.2 million beneficiaries joined plans in the Value-Based Insurance Design Model for coverage next year offered by 14 MA organizations across 30 states and Puerto Rico. That's up from only 440,000 beneficiaries, 10 MA organizations and seven states in 2019.
• CMS also opened up applications Thursday for MA plans to test allowing MA enrollees to access the Medicare hospice benefit starting in 2021, in an attempt to coordinate care for MA beneficiaries in palliative and hospice care.

Dive Insight:

CMS has been pushing to enroll more Medicare beneficiaries in value-based plans in a bid to lower costs while improving quality. The VBID Model allows payers to test alternative payment strategies in MA plan design. This can include targeting plan design based on an enrollee's chronic condition or income status, among other socioeconomic characteristics.

A slew of large payers are participating in the model that CMS innovation center CMMI launched in 2017, including CVS Health-owned Aetna, UnitedHealth Group and Humana.

CareOregon, Capital District Physicians' Health Plan, Highmark Health, Innovacare, Medical Card System, New York City Health and Hospitals Corporation, Sentara, UPMC Health System, WellCare and Blue Cross Blue Shield in Michigan and Rhode Island are also participating in the VBID Model for 2020.

Seniors account for a disproportionately large share of healthcare spending and more are using hospice: 1.5 million Medicare beneficiaries were enrolled in hospice care in 2017, a 4.5% increase from the prior year.

Despite this, the Medicare hospice benefit hasn't been overhauled since it was added as a Medicare covered benefit almost four decades ago, according to the Medicare Payment Advisory Committee. During that time, hospice spending has continued to mount, growing more than 400% between 2000 and 2012 alone.

The average hospice length of stay has increased from 53 days to 89 days, while the median length of stay has remained flat at 17 days, according to CMS.

In the new model, MA beneficiaries can elect the hospice benefit in their MA plan, but they'll still have access to the hospice benefit in traditional, fee-for-service Medicare. The goal is to give seniors additional access to palliative care, transitional concurrent care and hospice-specific supplemental benefits, CMS said.

Currently, MA beneficiaries who want to receive hospice benefits get the majority of that coverage through FFS Medicare, while their MA coverage is only responsible for supplemental benefits. That hospice "carve-out" from MA can result in a web of rules that complicates coverage and makes it difficult to determine who's accountable for their care.

Experts have foreseen this folding-in for a while now, with Dan Mendelson of Avalere Health telling Healthcare Dive last year the siloing of MA and hospice benefits "makes no sense."

And hospice is a lucrative area for payers, sparking a recent flurry of M&A. Humana has been particularly aggressive in that arena, acquiring home health and hospice giant Kindred in 2017 for $4.1 billion, hospice operator Curo for $1.4 billion in April last year and hospice pharmacy and PBM Enclara earlier this month.

Dive Brief:

• Despite the hype surrounding the importance of social determinants of health, just a quarter of hospitals and 16% of physician practices screen patients for social needs that affect health outcomes, according to a JAMA study published Wednesday.
• Providers that serve more economically disadvantaged patients, practices with exposure to payment reform models and academic medical centers were most likely to screen for all five factors CMS has prioritized: food insecurity, housing instability, utility needs, transportation needs and interpersonal violence.
• Patients were most likely to be asked about interpersonal violence and least likely to be asked about utility needs, according to the report.

Dive Insight:

Social determinants of health are top of mind throughout the healthcare industry. Hospitals and practices are teaming with local communities to improve circumstances for patients, as these factors are closely and deeply tied with individual health outcomes.

Payers, meanwhile, recognize that patients not struggling with access to transportation and housing are more likely to follow through with treatments and seek preventive care that can save money down the line.

And there's reason to believe patients are open to more intervention. A survey earlier this year found that about 93% of those questioned said they wanted their doctors to ask them about access to meals and 83% wanted to be asked about safe and stable housing.

The JAMA study authors noted that while screening for social needs hasn't historically been considered a part of the medical process, increased attention to value-based care and holistic, team-based treatments have pushed providers in that direction.

"The role of physicians and hospitals in meeting patients' social needs is likely to increase as more take on accountability for cost under payment reform. Physicians and hospitals may need additional resources to screen for or address patients' social needs," they wrote.

But some high-profile organizations are making the effort. For example, Kaiser Permanente launched a social health network aimed at reducing homeless, food insecurity and other concerns in May. The program, called Thrive Local, will connect to the health system's EHR and be made available to nearby community-based organizations.

And UnitedHealthcare and the American Medical Association are working together to create more than 20 new ICD-10 codes that address social determinants and would trigger referrals to social and government services.

In the JAMA report, hospitals cited lack of financial ability, time and incentives as major barriers to screening for social determinants.

An invited commentary published with the research noted overcoming those hurdles will be key to making population health programs more accessible.

"Ultimately, the adoption of social risk screening is likely to be advanced both by well-designed financial incentives and by addressing potential adoption barriers," wrote Rachel Gold, an investigator at the Kaiser Permanente Northwest Center for Health Research, and Laura Gottlieb, associate professor of family and community medicine at the University of California, San Francisco.

"A diverse array of such barriers may be encountered; for example, evidence-based interventions may not be available, clinic leadership and staff may lack an understanding that social risk data can help improve care outcomes, and there may be inadequate staff training in how to conduct such screening," they wrote.

The researchers noted, however, that it's unclear whether better screening of social factors would lead to improved care or lower spending because of scant research in the area.

The study reviewed information from nearly 2,200 physician practices and more than 700 hospitals.