Transcript of Full Interview with Bob Tavares

February 2023

by Adam Kaufman, PhD

I was fortunate to interview Bob Tavares, Chief Commercial Officer of Health Pivots for the Scale Health Podcast episode on Medicare. Bob shared the interesting example of the evolving Hospice benefit for the episode, but the conversation covered so much more. 

Adam: I'm glad to welcome Bob Tavares from Health Pivots. Bob, tell us a little about yourself and the company.

Bob: Thanks for having me Adam. We've known each other for over a decade now and you know I've been at this healthcare thing for about 25 years. I think both of our careers, we've gotten the opportunity to dive really deep into certain domains. You certainly with diabetes; me really trying to understand what's working, what's not working. 

I've gone deep into musculoskeletal - what causes back pain, what are the different treatment options, what actually works? I've had the opportunity to dive into bariatric surgery… really all sorts of different healthcare verticals and unpack them and try to understand where are we today? And end of life care in general, with Hospice being one flavor of end of life care has been my passion for a long time, and almost exclusively for the past three years.

I've been in sort of the analytics and measurement space this whole time. My first full-time role in healthcare analytics company we had the audacity to measure hospital quality back in 2000. That was very controversial as there were no hospital report cards; there were no hospital compare tools for Medicare. It was this notion that you could measure and differentiate and then set goals for improvement. That concept just didn't exist. To think that it's basically 20 years since we thought we could measure quality and make decisions, and contract on it, and that patients had access to that kind of stuff. It is surprising.

We've made a lot of strides in transparency and in measurement and sometimes I feel like we haven't gotten anywhere. We're talking about Medicare and Medicare Advantage(MA) - original Medicare versus Medicare Advantage. And you know, there's a raging debate as to whether Medicare Advantage, despite all of its advantages… they cannot negotiate contracts with providers for more favorable rates. Fee for Service Medicare can't put their economies to scale to work the way a Medicare Advantage plan can. Medicare doesn't do prior authorizations and… despite all of those advantages that MA plans have, there's still a raging debate as to whether or not they actually cost less than Medicare. Depending on which article you read, which research study you read, it's either been a wonderful success or a complete failure, and in fact causes more harm - readmission rates have not gone down the way we suspect, but really they were just diverted into observational stays as opposed to in-patient stays.

So we have a crisis of measurement, and it's such a good reminder for those of us who think deeply about value-based care, that if we can't define value, if we can't measure it, then we can't put in place mechanisms to actually contract on it and, and move towards it.

Adam: I think most people don't understand or respect how complicated a process that is. And calling out scholarly articles that come to almost diametrically opposed conclusions on the same topic is a good example of how hard this is.  So maybe you can speak to how end of life care has been thought of by Medicare, what's changing in policy and, and what that might mean for Medicare Advantage plans.

Bob: So end of life care is not just limited to patients. It's really whenever you have a terminal illness - you have a prognosis of death and your condition will worsen and there's no cure. It is a time when you should start having goals of care conversations.  You should have goals of care conversations throughout your life, but particularly what do you want out of your care and your care experience? Do you wanna die in the hospital? Do you want to fight to the end? Do you wanna die at home with your loved ones by your side? Not in pain, managing the symptoms of your condition as opposed to focusing on cures.

You start focusing on comfort and on quality of life, not quantity of life. And ironically, oftentimes, patients who choose a less aggressive path end up living longer. Your body takes a real toll going through some of these curative treatments, and I've had too many personal experience with family members who were overly aggressively treated right up until the day before they died. So unfortunately, end of life care and hospice care are sort of synonymous in some people's viewpoints. I draw a wider lens.

The hospice benefit has been around about 40 years or so. The first hospice in the country was in Connecticut. I think Connecticut Hospice. And now we have thousands of hospices. And almost all of hospice care is paid for by Medicare. When you are a Medicare Advantage member - United Healthcare, Humana, Aetna… those Medicare Advantage plans are accountable for all healthcare spending except hospice care. For the most part it's the last carve out. They're not liable for the hospice costs and when you elect hospice, you leave your Medicare Advantage plan and you go back on original Medicare. 

Now there are certainly some commercially insured younger patients who have hospice - your Blue Cross plans, your commercial insurance plans, Cigna… they're paying for hospice, but the vast majority of hospice care is delivered to Medicare aged beneficiaries, as you might expect. 

So as a result, you elect the hospice benefit you leave Medicare Advantage, you're back on original Medicare. Therefore, Medicare has paid the bills; Medicare has been largely the sole provider of revenue to hospice care. 

Adam: And just to make sure we're clear, you not only leave the Medicare Advantage Plan for the hospice care, you leave completely. So you stop being a Medicare advantage plan member at that point and all of your care, every service - it's unlikely, but if you happen to need a another service at that point outside of hospice, that is back into fee for service Medicare completely as well. 

Bob: Yeah, Medicare's paying for all the total cost of care, with some very minor exceptions. Now keep in mind when you elect hospice, you're foregoing your right to curative care. So hospitalizations are very rare, but they do happen.  You're supposed to treat those in place. 

Adam: For the audience there were a number of other carve outs and, I think you're implying that sort of slowly, those have been removed. So a brief history of why there were the carve outs to begin with or why there's a hospice carve out?

Bob: We might want to tap into another expert on how did hospice get carved out in the first place. But I think the notion there is if you think about the levers that a Medicare Advantage plan has that Medicare just does not… I mean to fall out of favor with Medicare, to not be an in-network provider you have to pretty much commit fraud - the bar is very, very low for performance. With Medicare Advantage plans they can carve under performing providers out of their network altogether. They can negotiate discounts.  They can do things like prior authorization, utilization management. So the provider has to seek an authorization in order to do an MRI. And with regular Medicare they don't have cost containment, quality oversight, looking at medical necessity, and so forth.  I think when you think about end-of-life care, hospice care in particular, I think Medicare just didn't want that care to be managed in that way. And as a result, it's been paid for by Medicare directly. 

Adam: And so what is changing now?

Bob: So for the past few years, there's been a program called VBID - Value-Based Insurance Design.  Earlier we were talking about that hospital reduction remission, the hospital remission reduction program was mandatory. Every hospital was subject to it immediately back in 2013 I think it was. And so there was no control group. There was just this massive experiment, and I think years later we're saying, gee, it may have been more preferable, had it been rolled out in half of the markets so that we can look at what happened to readmission rates absent of this payment model.

So in any case, this is an optional program. Health plans volunteered to participate, and so there’s probably about 20 health plans and they could select which markets they want to participate in. Medicare is running this program out of the Centers for Medicare & Medicaid Innovation, CMMI.

It’s an experiment with hospice carved into the Medicare Advantage budget, asking what if those health plans could create high performing hospice networks, negotiate discounts and perhaps more importantly, experiment with other types of care - moving away from end of life care, being hospice care to the coordination of community-based palliative care.  How do we get the concept of palliative medicine introduced earlier in that trajectory? And so, and I think one of the exciting things is not just experimentation at the point of hospice or not, but potentially earlier in the patient journey.

One of the challenges when the plan doesn't manage hospice is they may not have the same energy to think about how do you move from pre-hospice and what's happening in your journey prior to that into hospice. So, it probably opens up some of that conversation earlier from the specialty of palliative care -  the principles of palliative medicine, which include just good conversations and how do we have earlier goals of care conversations with patients.

Medicare has been paying for advanced care planning as a visit type and it's woefully underutilized. At Health Pivots, we have all that data. We're an analytics company, we're a measurement company.  We have essentially built a tool to sit on top of de-identified Medicare claims for over 30 million Medicare beneficiaries - all of the fee for service data - and we can see how much uptake there is for advanced care planning. Now you could be doing advanced care planning in your practice and not be billing for it, and so it won't show up. We do see some practices taking advantage of annual wellness visits and some not, some taking advantage of billing for advanced care planning and some not. Usually there's a pretty good correlation where providers start really incorporating annual wellness visits and they'll incorporate advanced care planning as a systematic program or approach. But it's woefully underutilized.

And so the question is, is it happening? What percentage of patients have their advanced directives place? And more importantly, are they in the right place? Are they shared? Is care being guided based on those wishes?

And so the pilot is promising in that regard. 

Adam: So the pilot started when and roughly what percent - whether you want to measure it by physicians or people covered by Medicare, are going be in this pilot so we get a sense of the scale of it?

Bob: I want to say we're in year three of the program. I'd venture to guess that it would impact a low single digit percentage of Medicare beneficiaries.  They're rolling it out in select markets, in fact, select counties. So I think the number of hospices that are engaged and involved, the amount of beneficiaries that it might impact I'm suspecting is a very, very small percentage. But it's an experiment.

Adam: A nice example of how innovation sort of gets done within Medicare.  It's an experiment as you're saying. Do you have a sense of if it goes well, how fast it rolls into Medicare Advantage nationally, or if it goes poorly they shut it down?

Bob: I don't have a crystal ball. But I suspect that both plans and hospice providers should plan for universal carve in of the benefit within years. It's not next year, but it's not 20 years kind of thing. 

Adam: Really interesting. Last question – this is taking a very significant industry and re-configuring who's paying for it and how it is structured, that clearly opens up challenges for existing providers and opportunities for them. Any thoughts of what that might mean for innovators working around end of life and hospice and where risks and opportunities might be for them?

Bob: I want to point out a couple things that I haven't touched on yet. In the hospice market there's tremendous variation in how that care is delivered today. In some markets there is a certificate of need laws like in Florida. There might be 40 to 50 unique hospice organizations serving the entire state of Florida; you can't just open up shop in Miami-Dade County and say I'm a new hospice. You have to demonstrate that there's a need that the county's being underserved and it needs a new competitor. So as a result, there's relatively few providers of that care, and when we look at the data, the quality's quite good. Contrast that to where you're sitting in California. There's no certificate need laws, and I'm not here to advocate for or against certificate need, but I can say that the data speaks for itself. There's over a thousand providers relative to the 50 that are in Florida. 

And take live discharge rates as an example- the live discharge is essentially that the patient was enrolled in hospice and they were no longer able to be re-certified. You can only stay in hospice for six months and then you have to be re-certified if in fact you need to stay in the program. In Florida, if you took all 50 providers, you're probably looking at 5%-20% live discharge rates. In California the range is 5%-100% percent.

Adam: Wow. 

Bob: And it's not just one outlier - 80, 90, a hundred percent of their patients being discharged alive. There's hundreds and hundreds and hundreds out of the thousand in California that have extremely high live discharge rates. So we can think of that as a quality measure, and the quality is all over the board. 

Adam: And just coming back to this change between fee for service and Medicare Advantage, could these health plans managing the hospice benefit look at live discharge rate and organize, for lack of a better word, that market to drive towards higher quality in a way that maybe fee for service Medicare could not?

And if we thought about innovators in hospice or hospice support, recognizing this change would be important for where their business is going. I think for your business and others that are looking at quality measures, both providing to hospice providers and to the plans to think about how to help structure that. This is actually quite a large industry - hospice, right? 

Bob: Yep. It is a multi-billion dollar industry, which is a small piece of healthcare. 

Adam: But because healthcare as a industry is so big, a small piece can be very meaningful and obviously very impactful for those folks who go into it?

Bob: Yeah. And this is essentially a type of care that the vast majority of us and the people listening today are going to encounter, right? It is the universal death and taxes. And this is about how we want to experience that end of life.

There's optimism that Medicare Advantage plans can add a level of oversight and improvement and at the same time make sure there's not a degradation of that experience. Today, hospice care is very comprehensive. It includes bereavement support, it includes chaplains, social workers. It is a comprehensive, holistic program, and not just for the patient, but for the family as well. And we don't want that to get degraded due to cost cutting and for reasons like appeasing shareholders.

The other thing I wanted to share is that innovating around improving the end of life experience is something that has to be done at a local level. You have to keep in mind how very different access and coordination and quality are from market to market. 

Adam: Bob, this has been spectacular. Thank you. 

Bob: It's my pleasure.

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