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More Health Policy this week! Today, we discuss “SNPs” but this is not a podcast about haircuts during the pandemic. We take a deeper dive into the world of Medicare Advantage and what it means for vulnerable patients facing serious illness and those at the end of life. 

We are joined by UCSF geriatrics fellow Alex Kazberouk to talk to Dr. Claire Ankuda (Assistant Professor at Icahn School of Medicine at Mount Sinai and Palliative Care Physician) and Dr. Cheryl Phillips (President and CEO of the Special Needs Plan Alliance and past president of the American Geriatrics Society). 

We discuss: 

  • Special Needs Plans (SNPs) for older adults – what they are and what they mean for our patients
  • What happens when a Medicare Advantage patient enrolls in hospice and how that may change with the new “Hospice Carve-In”

This is part two of a two part series on Medicare Advantage and healthcare financing. On our prior episode, we heard Dr. Don Berwick’s and Dr. Rick Gilfillan’s critique of Medicare Advantage plans. This week, we bring up a rebuttal to their critique and also talk about quality data and reporting for Medicare Advantage patients. 

Alex plays The Purchaser’s Option by Rihannon Giddens (she has so many terrific songs!). Astute online viewers will also spot an appearance of the Team Canada Tokyo 2021 Olympic Jacket and Cheryl’s dog. 

Eric: Welcome to the GeriPal podcast, this is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today we are honored and delighted to welcome Cheryl Phillips, who is the president and CEO of the Special Needs Plan Alliance and is a geriatrician and former AGS president. Welcome to the GeriPal podcast Cheryl.

Cheryl: Thank you. Thank you. Delighted to be here.

Alex: We’re also delighted to welcome back Claire Ankuda, who is a palliative care physician and researcher at the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai. Welcome back to the Geripal podcast Claire.

Claire: Thank you so much. It’s great to be with you all.

Alex: And returning as a guest host Alex Kazberouk, who’s a geriatrics fellow at UCSF. Welcome back, Alex.

Alex Kazberouk: Thank you. Glad to be back.

Eric: Today this is our part two of two part special and Medicare advantage plans. We’re going to be talking about special needs plans and hospice carve-ins. We haven’t done a lot of policy on GeriPal, so we’re trying to focus a little bit more on some policy, and I’m super excited to talk about this stuff, but before we do, Cheryl, I think you have a song request for Alex.

Cheryl: I do. I have a new favorite artist and her name is Rihanna Giddens. She is a black, both folk singer and poet, and focuses on African American roots to contemporary folk music with her partner who does percussion. And if you haven’t heard them amazing. And so I tossed that to Alex who is hopefully going to figure out how to do one of those.

Eric: And which song, did you have a particular song you requested?

Cheryl: Purchaser’s Option

Alex: The Purchaser’s Option, this is a song about … Rihanna Giddens saw an advertisement in a paper. This is a historical paper from New England advertising for a slave for sale and at the purchaser’s option, the purchaser could purchase her baby as well and was just shocked and appalled by this and wrote a song about what it might be like for this woman at that time. Thank you for this suggestion. Really enjoyed learning more about this artist. Thank you. Here’s a little snippet.

Alex: (singing) “I’ve got a babe but shall I keep him. ‘Twill come a day when I’ll be weeping. How can I love him any less. This little babe upon my chest. You can take my body. You can take my bones. You can take my blood but not my soul. You can take my body, you can take my bones, you can take my blood but not my soul.”

Cheryl: That was beautiful and powerful thank you, Alex.

Alex: Thank you.

Alex Kazberouk: Thank you so much, Alex. As Eric mentioned, this is part two of a podcast on Medicare advantage. And the first one was a conversation with Dr. Don Berwick and Dr. Rick Gilfillan about Medicare advantage plans, their history, how they work, potential upsides and potential downsides and policy solutions. And if anyone is interested, there has been a rebuttal piece to their article published in health affairs that we will link to in the show notes. But this topic today is a little bit different. I will start with Cheryl. Could you quickly summarize what a MA plan is and then also what special needs plans are, which is a focus of the topic today.

Cheryl: Absolutely. And I suspect most people listening know what an MA plan is, even though they may not use those words. We’ve used the words like Medicare managed care, Medicare HMO. Early nineties, actually these go back to the eighties, but in the early nineties, I think the mantra was they were neither managed nor care, but Medicare advantage or MA plans have truly exploded for lots of reasons that Don Burwick described, but also for lots of good reasons because you have a prepaid or called capitated payment model. It’s not decapitated, but per person per month. And then that gets shared with the health plan level. And sometimes it’s done at a capitated level with the docs and other clinicians, or sometimes it’s just a discounted fee for service, which is usually not very effective but that’s ma in the big picture. About 43% of Medicare eligible adults are now enrolled in an MA plan.

Cheryl: And it’s particularly attractive for low income individuals because there’s often no co-pays, there’s often little out of pocket expenses or less out of pocket expenses and added benefits. We won’t go into all the complicated structures of MAs, but with that lower cost also comes some downsides, a restricted network. So you have to go to the doctors within the contract and some other restrictions in terms of access to services. But what I want to talk about is a subset of MA plans called special needs plans, or sometimes referred to as SNPs. When I told my family I was running the SNP Association, I think they thought I was becoming a hair stylist, but special needs plans are a subset of MA and there are three types. The largest one is for those who are dually eligible for Medicare and Medicaid. It’s predominantly older adults, but there’s also younger people disabled and about a third of people who are enrolled in dually eligible or D-SNPs also have a serious mental illness as part of their disability.

Cheryl: A D-SNP or dually eligible SNP covers an array of ages and disabilities. And there are a little over 3 million people who are enrolled in dual SNPs. The second type of special needs plan is called a C or chronic condition special needs plan. And that’s for an individual who has one of 17 identified because we know there’s only 17. I’m being facetious, but CMS has designated 17 categories and groups of diagnoses that are eligible for D-SNPs. And then the third type is I or institutional SNPs, which are … The C-SNPs are a little over 350,000 in enrollees. The I-SNPs are around 100,000. They’re predominantly in nursing home settings, but we’re also starting to see the growth of institutional level SNPs in assisted living in some community housing. Overall, special needs plans are unique because they have additional quality requirements.

Cheryl: They have additional requirements in what’s called a model of care, so much like a PACE program. You have to describe the population that you’re serving, how you’re going to of them, the kinds of providers and networks that you need to serve them. You also need to do an individual health risk assessment on an annual basis. You need to have care coordination as part of it. So it really focuses ideally on that individual who’s deemed to be the most frail, the most vulnerable. These are not nirvana, there are goods and bads, and I’m sure we’ll go back and forth in the conversation about what are some of the strengths and what are some of the challenges. But to me, it is the opportunity, particularly for geriatric health professionals to align policy payment and delivery redesign. Because when we have tried to look at systems of care for older adults, we sometimes do one or two, but we need a mechanism that allows for all three of those to work concentrically. And that’s truly the way special needs plans are intended to be. That’s a little bit at a high level.

Eric: Can you give me a couple examples of names of special needs plans?

Cheryl: Sure. There’s some wonderful ones that many of the audience may be familiar with. Commonwealth Care Alliance in Boston is known for serving high risk, low income, often unhoused people with serious chronic conditions. They do that through a special needs plan structure. The SCAN Health Plan in Southern California that is now rolling out a medical plan for street medicine for those unhoused individuals. SCAN does much of their work through a special needs plan structure. Those are a couple of high level examples. There are special needs plans in 46 states plus a district of Columbia. So I dare say just about wherever you are, there’s a special needs plan.

Cheryl: Now some of them may not be as effective at targeting the most vulnerable in the group as the two that I mentioned, but many of them are doing remarkable work at a local level. Another good example is UCare in the Twin Cities in Minneapolis, focusing on an incredibly ethnic diverse population, identifying what are community needs for serious chronic illness and doing it through community partners and they do it in over 30 languages. The potential for special needs plans to focus and target and partner with physicians and other community providers is really one of the hallmarks in the strengths of the special needs plan.

Eric: I think it sounded like from our last podcast, there’s the potential for this to really impact patients, but there’s also seems to be a very big growing interest also from a Wall Street perspective. Is that right?

Cheryl: Yes, but maybe not so much in special needs plans. Certainly Wall Street is very interested in MA, Medicare advantage or Medicare HMO. It takes some effort to put up a special needs plan and the margins are less. One of the games, and I know that Don Berwick and that Rick Gilfillan referred to this, is that if you have a special needs plan that is a small plan and because you’re dealing with very, very high risk individuals, they may be low income, adherence to treatments may be low. They may not score well on quality measures. You fold that plan into your larger Medicare advantage plan, where the quality scores are higher, you get more money, yada yada.

Cheryl: Where plans have tried to boost their quality scores, they’ve done that through merging plans. One of the concerns that we have is that the measurement of quality, and I know we’ll touch on this when we look at hospice as well, but the measurement of quality really doesn’t get to what is quality for some of the most vulnerable individuals. If you’re living under a bridge, yes, colonoscopies are important, but is that how you would measure the quality of your healthcare?

Cheryl: Especially if they don’t speak your language and you can’t access them in any way. I don’t know if that really answered, but so Wall Street is looking. There’s dollars to be made, but right now there’s kind of a dance. And in fact, the new rule just came out or the proposed rule. CMS is trying to pull apart what are special needs plans or at least the dual special needs plans from the general Medicare advantage plans so that we can better understand some of this quality measurement.

Eric: And let me ask you, Cheryl, when you read Don Berwik’s and Rick’s health affairs article, what’d you think of it?

Cheryl: Well, first of all, I have huge respect for them both. I’ve been a groupie of Don’s for a long time. I did a quality fellowship at Intermountain and he was one of the faculty. I think it was rather one sided. And I think it overly promoted ACOs. And in full disclosure, they have financial interests in ACOs as well. Who is really pure in this whole financial interest game. Accountable care organizations, just like we could beat up managed care for being neither managed nor care, accountable care organizations were often not accountable, nor did they coordinate care.

Cheryl: It really was a game about attribution and how do we control our spending and put ourselves in the best risk environment. Both of these are examples of what the worst of incentives can be, but under the positive side for both ACOs and managed care is when you have alignment of payment that is supposed to be accountable for the population that you’re serving and you’re responsible for both the cost and the quality for those outcomes, you can potentially do a much better job of coordinating that care than you do under a fragmented fee for service.

Eric: And I really like the rebuttal that will also have a link in the health affairs. The one part of it that I thought was a little bit disingenuous was there’s a section on the finite number of diagnosis for each person. During our last podcast, they talked about how Medicare advantage plans find codes, they find diagnosis. For example, they gave an example of, doing a carotid ultrasound to find asymptomatic carotid disease as a billing code. In the health of errors rebuttal, they said there’s a finite diagnosis and that finding diagnosis can actually be very knowledgeable and extremely useful indeed necessary for optimal care delivery. I think that that’s probably true in some ways, but I think we all know, especially in geriatrics, just because you’ve diagnosed the diagnosis doesn’t mean it actually is going to improve care.

Cheryl: And the older adult is not the some of their diseases. However, one of the things that Don dismisses, but that we hold as part of a geriatric principle, special needs plans often have care teams that go to the home. When they go to the home, they end up finding much more information in doing a thorough assessment including a functional assessment that we as geriatric health professionals believe in, will uncover other needs and that is also code finding. If code finding leads to an improved care plan and a person centered approach to care, then I think it has value to the person. I’m not worried about the health plan, I’m really thinking about the individual we’re trying to serve. If just screening for carotid disease does nothing to change the outcome then you’re just mining for dollars.

Alex Kazberouk: What else is different if I’m a patient in a SNP plan, because I think for your average person on the street, it’s hard to sort of wrap your mind around different payment models in the plans. On the ground good book looks different.

Cheryl: It’s insanely hard. It will be a different experience depending on the special needs plan type you have. Let’s say you had a fully integrated dual special needs plan. You’re dually eligible. That means that in the states where those plans exist and there’s 11 states right now, you now functionally have your Medicare and Medicaid under one plan. You’re not having to Jostle between Medicaid covers this, Medicare covers that you have a plan coordinator and a plan oversight that is managing both of those services. If you are you in an institutional SNP in a nursing home, instead of a fee for service doctor that comes out every 60 days and maybe a nurse practitioner every 30 days, you now have a nurse practitioner that’s frequently on site that’s coordinating your care that may be treating you within the nursing home community rather than sending you out just to get the three days with a head in the bed and go through the cycle of maximizing your Medicare days.

Cheryl: If you have a C-SNP, a chronic SNP, a good example is the Aids Foundation. This is a C-SNP that’s targeting people with severe HIV aids. You now have a care network of both docs and community providers, and a process of care and assessments and access to services that you’d have to navigate it on your own under a fee for service. Those are three examples of what it might look like.

Claire: I had a question, thinking about this and how sort of from a patient perspective, how are most patients finding themselves enrolled in SNPs? We know, especially for a seriously old patient population with dementia, navigating this is terribly different. Is this from advertisements? Are they getting letters? And then what we know about people leaving, are they more likely to leave SNPs than other types of MA plans?

Cheryl: A very good question and one of my frustrations is there’s a cacophony out there of people figuring out what to do for themselves, their spouses, their loved ones, their parents, even PACE that we love. As a geriatrician, a PACE program to me is the model and yet only 55,000 people are enrolled in PACE programs around the country and most people have no idea, they think it’s a race car. How do people find-

Alex: Compared to about 4 million almost in specials needs plan?

Cheryl: In SNPs. So that gives you a relative relationship of PACE program of all inclusive care of the elderly and special needs plans. The way most people find them is frankly through a broker. That’s that person, those 1-800 numbers. Remember the ads that we were so sick of in November and December, Joe Namath and whoever else was hawking, sign up, call up for your MA, you can get added benefits. You can get this, you can get that. A lot of those were selling D-SNPs because they’re the largest most popular. And CMS in their proposed rule has said, not all that advertising was necessarily, completely transparent and people still didn’t know what they were getting. Claire, back to your point, it’s still incredibly difficult. In some communities, there is a close partnership with a physician groups, the community service networks and the health plan. And they work together in identifying people appropriate for a special needs plan, but very often it’s by accident or by broker or by word of mouth. Now, most people stay, I can give you numbers by plans, but many of the plans are well over 96% retention from year to year.

Eric: And one thing with the Medicare advantage plan is that at the end of life, and correct me if I’m wrong, Claire, there is a drop off as far as number of enrollees switching from Medicare advantage to traditional Medicare, is that right Claire?

Claire: Yes. Thank you for that introduction to the hospice carve-out. There actually is a drop off for two reasons. One is that we know that people at the end of life, in the last year of life about double the rate of leaving Medicare advantage plans in general. Now this is not SNPs are the minority of MA plans. This is not speaking specifically to SNPs. I’d imagine the data might look different, I’m not sure, but in general-

Eric: Before you go into that, is the data, Cheryl, do we have any data because that was one of Claire’s questions. Do we have any data on drop out in SNPs?

Cheryl: We don’t at the end of life. We can look at overall dropout, but that’s pretty distorted. And I agree with Claire that what we need is data on special needs plans maybe in the last six months or the last year of life. And we don’t have that data, at least I don’t, I’ve been looking for it.

Claire: There is actually a great GAO report, the government accountability office is the congressional watchdog. They issue various reports trying to understand spending and quality in all areas of government. And they actually had a report come out about the high rates of leaving MA at the end of life and talking about the costs that MA plans besides the experience of the patient and the family, the costs that MA plans are avoiding from people leaving at the end of life when they tend to use more healthcare, they tend to be sort of more expensive to plans. That’s one portion of the population leaving MA plans in general at the end of life.

Claire: The other larger portion is that MA currently has a hospice carve-out. In other words, hospice is not covered by someone’s MA plan. If you’re a patient and you’re enrolled in Medicare advantage and you elect hospice, what happens is that the majority of your care moves over to traditional Medicare or fee for service Medicare as part of the hospice program. If you just want-

Eric: Why? Is that just to make people’s lives much more complex and confusing.

Claire: It certainly makes things more complex. I think the underlying principles, and we’ll talk about this more in what’s called the carve-in that’s being trialed is this idea that hospice should be available to everyone without the same sort of restrictions and parameters that exist within Medicare advantage.

Cheryl: Well, and if I can jump in, CMS, set this up on purpose, and it’s the same thing with a PACE program. You have to disenroll from PACE to enroll in hospice because CMS believed that we would start double dipping in Medicare benefits. And so it is by structure that you have to disenroll from one Medicare program to get into another, which then creates a bizarre set of discontinuous care at the end of life.

Eric: Why didn’t it say it has to be a benefit for Medicare advantage plans to offer hospice?

Claire: I mean, well, and I guess one point about the carve-out is that it’s not a complete carve-out of if you have some cost saving benefits for example, from your MA plan, maybe under your MA plan, you pay less copays for certain things. Those benefits actually do carry over as you transition into hospice. But I think as Cheryl was saying, for historical reasons, CMS really, really wanted to keep hospice as a separate benefit that was more uniform across all people at the end of life.

Cheryl: There was also a distrust that people would misuse hospice, which I always found incredibly bizarre. And for those of us now, you guys are all youngsters. I’m grandma here. Remember the battles of getting hospice as a provider type and a payment type under Medicare. And the belief was that people would just flood into hospice like everybody was just anxious to die. They were very explicit in creating a separate benefit structure. It had to be equitable and equal to all Medicare beneficiaries, but you couldn’t double dip.

Alex Kazberouk: Right now, if I’m a patient in Medicare advantage, just to make sure that I understand this correctly and I decide to enroll in hospice, do I completely sever my ties with the Medicare advantage plan, the doctors I have gotten to know and just enroll in hospice?

Claire: You don’t completely sever. I’ll say that point for a sec, but you don’t completely sever. If you have cost saving benefits like reduced copays or cost sharing, those stay with you. If you’re being treated for conditions that are not related to your terminal diagnosis, that actually still falls under the MA plan, but the majority of your care, the hospice part of your care is provided under fee for service. Now, when we’re talking about that transition, it’s not like when this happens to patients that they’re going to an office to fill out paperwork. This is really on the administrative side, in terms of plans and Medicare. It’s not that families have to go through a disenrollment process the same way they do, if let’s say a patient chooses to leave their MA plan.

Eric: Okay. That was the carve-out. Now there’s something called a carve-in.

Claire: There is a carve-in being tested. This is under something called VBID, which is the value-based insurance design program. The way that CMS is doing this is very, very carefully because many reasons, but in part there’s been a lot of worries from the hospice community about this carve-in and how this will go for our patients. The idea is certain hospice and MA organizations or what really it’s driven by the MA organizations volunteered to be part of this program where now hospice is overseen by the MA plan.

Claire: And again, that’s not for all MA plans right now it’s really just being child in a select number of programs. And then it’s grown already. It will continue to grow. It’s unclear what the timeline is for this to be adopted as a carve-out or a carve-in for everyone. Whether that will happen and when that will happen is really up in the air as well as what it will look like. Because part of this process is that CMS, Medicare is really closely watching what happens in terms of extensive survey work and reviews and data collection as well as reconsidering what does this look like in terms of other structures of the carve-in?

Eric: Well, what are you worried about with a carve-in? It feels like to me like, hey, putting it all on a one umbrella seems like a good idea.

Claire: Yeah. That’s a great question. I’m worried about a couple things and I think part of this, it reminds me of a patient. I was on service in our palliative care unit a couple weeks ago, and I had a patient who was actually not a managed Medicare plan on a managed Medicaid plan. And this was someone who really had very specific needs at the end of life, where they really needed expert ID medications and wound care, a high level of needs. And they also had a primary caregiver in their life who’s a family member who had really taken on the lion share of caregiving, who was actually providing extensive hours every day of direct care. And this is someone who lived in the Southern part of New York and also had other caregiving duties and also was a night shift worker so working the night shift.

Claire: And in this managed Medicaid plan, the facility that I thought best met the patient’s clinical needs and was in reasonable proximity, which I’m define as an hour drive or an hour ride on the subway was out of network. Frankly, all the facilities that were nearby and met the patient’s needs were out of network. The really only in network option was several hours of a commute away. And so I think in terms of what people are worried about, one part of what people are worried about are networks of hospices and how that will look. In the carve-in, just like in other parts of Medicare advantage, plans will have networks. So they’ll have lists of physicians or home health agencies. They have list of skilled nursing facilities that patients can go to. That will soon happen with hospices and the costs may be on the patient more if you choose for an out of network hospice agency.

Claire: What we know about Medicare advantage is that people in MA, when you compare even within the same zip codes, there was some great work out of Brown that showed when you compare home health agencies that people in MA go to, compared to those in traditional Medicare, they go to lower quality home health agencies. They go to lower quality, skilled nursing facilities, and that’s determined by quality ratings by the star ratings.

Claire: I think one of my fears is that same thing will happen with hospice, is that MA plans will include in their network hospices who are lower quality. And that’s not because they’re nefarious, it’s because they’re motivated by profit. And so hospices that are providing less expensive care that are maybe visiting patients less, they’re going to be more likely to be a network. That is the darkest version of what I’m afraid of, that is my fear, but I think, how do you define an adequate network in terms of distance from a patient or family member is one question another is how do you really measure quality and make sure that quality of care received by hospices and networks is up to SNP.

Cheryl: Yeah. I would add in that about a third of our SNP Alliance members, SNP plans are not for profit health plans. And I think it’d be very interesting to look at the community based or regional based, not for profit health plans. For example, the Commonwealth Care Alliance, elder care, Metropolitan Jewish Home in your area, Greater New York, the SCAN Health Plan, those are of health partners. Those are examples. Ucare, all examples of not for profit that are also struggling with this hospice relationship for real reasons and I think sometimes received reasons. One question that I have for you Clare is what happens to the individual after they die? Under the hospice benefit there’s that entire bereavement package that goes with the family. I’m not sure that goes with the MA contract.

Claire: That’s a good question. I haven’t specifically looked into that. I would imagine that bereavement is a required part of the hospice benefit. I can’t imagine CMSA would allow it to be dropped from MA.

Cheryl: Except the MA’s relationship is with the member and once the member’s gone or dead, their relationship is not with the family. I don’t know. I think that’s get to be determined.

Claire: I would imagine that that would be on the hospice agency’s responsibility, the same way it is under fee or service Medicare. I haven’t specifically looked into how [inaudible 00:32:15] would function, but I’d imagine it would be the responsibility of the hospice agency, the way it is now under traditional Medicare.

Eric: And Cheryl, how are SNPs doing currently? Are SNPs any different as far as hospice utilization or how they’re using it versus general?

Cheryl: Another way, and we didn’t talk about this because I didn’t want to get too complicated, but PACE programs and special needs plans have another way of using hospice and that is by subcontracting with them. Instead of disenrolling from the plan and enrolling into the full hospice benefit, the special needs plan can contract with the hospice agency and providers to do the core services. And that’s what many special needs plans, particularly that take care of the most vulnerable, frail older adults with complex needs. They will work to keep that person within the special needs plans through the trajectory of their end of life journey, but will often use hospice providers, hospice networks, and contract with them rather than shifting the entire financial risk under the hospice benefit. Does that make sense?

Claire: Yeah.

Cheryl: Instead of me giving you the whole bucket, I’m basically paying you to take care of a part of it.

Claire: I think that that brings up sort of another aspect of the carve-in, which could be a positive thing is that it gives flexibility to MA plans, which SNPs already had a lot more flexibility, but to the remainder of MA plans, to provide more palliative care services or hospice like services. So that obviously could be a major benefit in terms of expanding that, and it clearly is an opportunity for growth within our fields. And yet we don’t know how that will be used. And I think one concern is, will that be a substitution for hospice when it’s seen as less costly, for example, when an MA plan doesn’t want to pay the amount they’ve negotiated with a hospice and network, they could say no, they could encourage a patient to instead have another form of palliative care that may not be the same in terms of quality.

Claire: I think with all of these things, this is the complexity of Medicare advantage is there is great opportunity for quality improvement. There is also a lot of risk for bad behavior and financially motivated behavior. I think the SNPs, my guesses are better for this than other plans, but I think there’s probably tremendous variation.

Cheryl: And so we recognize in all, because frankly I was involved in overseeing where there was reckless behavior in hospice programs that were for profit. And that was a whole mess. The palliative care relationship though and we know we don’t want to mix up the nomenclature, the hospice equals palliative care and palliative care equals hospice. I think that’s one we’ve all been through and the public struggles with, but in the nursing home setting, palliative care is almost nonexistent under fee for service. There’s no mechanism. Diane Meyer and I have talked about this at length. An I-SNP now gives a structure to pay for a palliative care team because you have a capitated prepaid model, it makes financial interest to the health plan because it’s better care at the appropriate setting and not relying on acute care for symptom management, but it’s better care for the individual, but you now have a mechanism to do that.

Cheryl: I think if I can put words into Claire’s mouth, but I think both of our expressions are when you use a model for its financial advantages to the extremes, the person loses the payer wins. When you use payment models that truly optimize a coordinated person-centered care delivery design, the person wins. And very often it is a capitated, which frankly, that’s what hospice is or a managed care model that says we’re going to use some aggregate dollars here to do the best thing at the right setting at the right time for the right person. I think it’s up to us as healthcare professionals to be part of that conscience and to be expressive in both policy, but also on the care delivery side that if we don’t have strong advocates, business wins.

Claire: Yeah. In thinking about the incentives, the incentives really show us where to go here. There’s a great Joan Tino blog. And I think it was the JAMA health services journal. I’m going to butcher this but the bank robber quote of-

Cheryl: Willie Sutton. Yes.

Claire: Thank you. The certain quote of, you follow the money, and I think that in thinking about incentives, what we know about quality of care at the end of life, really perfectly aligns with what you would expect from incentives. For example, one quality measure we think of a lot is use of intensive services like ICU stays in hospitalization. Well, it turns out those are also really expensive types of care. MA plans are really, really good at avoiding hospital use and ICU stay. We see this there’s a JAG study, a Joan Tino JAG study looking at this ACOs did nothing, but MA plans really reduced rates of hospitalization and ICU care among older adults in nursing homes with dementia. The areas of quality that I worry about more are things where higher cost care is also higher quality.

Claire: Thinking about even within hospice, MA plans are very good at getting people into hospice, because at this point they’re carved out. Those tend to be high cost individuals where they do not enroll in hospice. So they’re great at that, but I really worry about things like visits in the home. We know hospice themselves, as Cheryl was saying, especially for profit hospices have unfortunately displayed patterns such as not making visits at the end of life. And visits are expensive. Visits are just staffing and staffing is expensive. And so things like that that maybe they don’t save, they may be costly for MA plans to provide, but they also provide better care for patients and their families. I worry about those. And I think those are the areas we really have to target quality measurement.

Alex Kazberouk: And how good is that data and how transparent is the data around these outcomes within MA plans?

Claire: Terrible and not.

Cheryl: We don’t have the right measures so we’re relying on HEDIS measures, which again, I already talked about that’s wonderful for your younger commercial population. It was totally inappropriate for a vulnerable complex needs end of life care patient. We also rely on self-report tools that all throw out there are worse than useless because they are not in your language. They ask insane questions like, do you still go bowling? Many of our patients never went bowling. Don’t know what bowling is. And if you’re dying, that’s probably not your number one question. And then you get a small, small, small, small number of responses, and then you make extrapolations to an entire plan, and then you pay them based on that. But we aren’t asking questions about social determinants. We aren’t asking questions about what their values and priorities for end of life are if they are in that category, we’re not asking functional questions. Even if we were transparent with the quality measures that we have, I think they’re useless for this population.

Claire: Yeah. I agree. Sorry, that’s the trial of the carve-in. They’re really trying to make progress in improving these measures and specifically expanding a post step interview of the family and friends of beneficiaries who die, which is something that happens in the hospice program to really get sort of more relevant tested high quality directly relevant to end of life care measures. But quality is an issue and this is where I know we started talking about diagnosis inflation, but diagnosis inflation also makes this really hard because you want to adjust for the severity of illness, even in patients in the end of life. And if you have inflated diagnoses, it does make quality measurement also very challenging to compare apples to apples across different patient populations.

Eric: Okay, Claire, I’m going to go to you. Final questions. I got two different questions for each of you. Sorry, Cheryl, you’re not going to get a magic wand, but I got a different question for you. Okay, Claire, you got a magic wand around hospice carve-ins, but what we should do in the future, what’s the path forward, what are you going to use that magic wand for?

Claire: Yeah. My magic wand is the thing I just talked about. Frankly, I would love this across all beneficiaries in Medicare. I think we need to survey family and friends, the closest proxy after everyone dies, not just those in hospice to get direct patient reported feedback on quality of care.

Eric: Kind of like what the VA does. There’s the brief family survey. Everybody who dies it’s people who die in the hospital or home based primary care, but really doing a brief family survey on everybody.

Claire: Yes, exactly like what the VA does.

Eric: All right. Sure. Cheryl, I’m going to give you one quick magic wand. If you had a magic wand, what would you use it on?

Cheryl: It would be on measurement and what I would like, we don’t want to adjust for poor quality based on poverty or other disparities, but if we could have substitute measures for subset populations and we could test them in the populations that we’re serving. Right now we have neither.

Eric: Yeah. Not just for those who like bowling?

Cheryl: Right. Yeah. Not just for those who like bowling.

Eric: All right, Claire, I got one last question. And Cheryl, one last question for you. You got a lot of trainees listening to this palliative care fellow, geriatric fellows. Why should they consider working for a special needs plan?

Cheryl: Because in many ways, let’s go back to wide PACE. You have identified a high risk population, which is part of what is our passion. You are working more closely with a health plan in a way that is person centered and targeted, and you’re accountable for that whole person, not just for their disease state. To me, it is the primary care of health plans is you’re focusing on the entire person.

Eric: And is there a website I can go to, to learn more about special needs?

Cheryl: Well, there is.

Eric: Or like an Alliance of them.

Cheryl: There is – it’s And if anybody wants to reach out to me individually, I’m happy to share, but I am passionate that this is an opportunity for geriatric health professionals to have a voice in how care is delivered for some of the most vulnerable older adults we serve.

Eric: Well, I want to thank both of you for joining us. I learned a ton today. If you asked me in November of last year what a SNP plan was, I thought it would be something about vasectomies. I think I have a much better idea now, but before we end, Alex, you want to give us a little bit more. What’s band?

Alex: Purchaser’s option by Rihanna Giddens. Here’s a little bit more.

Alex: (singing) Day by day I work the line. Every minute overtime. Fingers nimble, fingers quick. My fingers bleed to make you rich. You can take my body. You can take my bones. You can take my blood, but not my soul. You can take my body, you can take my bones. You can take my blood, but not my soul.

Eric: Cheryl, Claire, Alex K. – big, big thank you for joining us today. That was a great podcast. I really appreciate it.

Claire: Thank you.

Claire: Thanks so much for the invitation.

Eric: And big thank you Archstone Foundation for your continued support and to all of our listeners for supporting the GeriPal podcast.

Eric: Bye everyone.

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