Empassion CEO: Medicare Advantage Can Help With Hospice Program Integrity

Robin Heffernan, CEO of Empassion Health, argues that Medicare Advantage (MA) structures can improve hospice program integrity and reduce health care spending, drawing parallels from the home health industry's experience with fraud and waste.

Heffernan detailed the home health program-integrity crisis of the 1990s, when largely private equity-driven growth saw providers expand from about 6,000 to roughly 10,000 between 1991 and 1997, with home health spend rising from about $3.5 billion-$4 billion in 1991 to $16 billion in 1997. OIG studies found about 40% of providers did not meet reimbursement thresholds, prompting a six-month moratorium on new providers, increased audits, and tightened scrutiny by 1999.

She said putting the home health benefit into Medicare Advantage and allowing plans to create networks and conduct utilization management brought spending down from $16 billion to $7 billion, with fewer hospitalizations during home health episodes for MA members versus fee-for-service and plans made financially accountable for the category.

Heffernan criticized the current hospice carve-out from Medicare Advantage, saying it creates a fragmented system because patients leave their MA plan and return to original Medicare when they elect hospice. She said CMS's hospice VBID program had the right intention of plan accountability through the end-of-care journey but was flawed because plans could not perform utilization management or create networks.

Heffernan said it is inevitable that MA plans will eventually have accountability during hospice and advised hospice providers to build relationships with MA plans, since roughly half of their volume is likely to come from them. From Empassion's experience in a high-needs ACO, she said 70% of members died on hospice, with fewer late, unplanned transitions into hospice and fewer very long stays.