Carved-in or Carved-out? The Perspective of Medicare Advantage Leaders on the Hospice Benefit (RP300)

Outcomes 1. To understand the basic structures of the MA-hospice carve out and VBID models2. To identify the potential challenges and opportunities of VBID and gaps in evidence around VBID. Key Message Medicare Advantage (MA) plan leaders describe variation in the degree that they collaborate with hospice agencies, and many describe the current carve-out of hospice from MA as problematic. While all see the implementation of a carve-in of hospice as having potential opportunities, they also raised multiple concerns. Importance Medicare Advantage (MA) insures 51% of Medicare beneficiaries, with disproportionate enrollment of Hispanic and Black beneficiaries. While hospice is “carved out,” or not under the purview of MA, a trial of a hospice “carve in” and expanded benefits for people with serious illness is being tested as part of Value Based Insurance Design (VBID). The influence of VBID on end-of-life care in MA is unknown. Objective(s) To assess the perspectives of MA leaders on the carve-out of hospice and the VBID model. Scientific Methods Utilized We conducted qualitative interviews with leaders from MA organizations across the United States. Interviews focused on organizational perspectives and strategy regarding hospice use in the carve-out, and perceived challenges and opportunities in VBID. We used both deductive and inductive analytic approaches to identify themes through iterative coding. Results Leaders from 18 MA organizations interviewed (7 participating in VBID) described strategies to increase early hospice enrollment, particularly the use of palliative care, but varied in their degree of engagement and collaboration with hospice agencies, and in their framing and implementation of palliative care. MA leadership endorsed optimism for VBID in the increased flexibility it offers to deliver hospice as well as opportunities to directly improve hospice quality through oversight. They also raised concerns around threats to the current benefit and operational burden. Participants expressed that their potential success in VBID was strongly influenced by the characteristics of their local hospice and MA markets. Conclusion(s) MA leaders varied in their engagement with hospice, and the degree that they saw the current carve-out of hospice as problematic and the carve-in as an opportunity for the organization. Impact This research study is the first to examine the perspectives of MA leaders on hospice use, which is critical given the expanding reach of the MA program, likely future universal hospice carve-in, and racial disparities in hospice use. Keywords Hospice/ Models of palliative/hospice care delivery