Effects of Expanding Medicare Advantage Enrollment toPersons with End-stage Renal Disease

点击翻译按钮获取中文摘要

Project Summary The over 500,000 Americans with dialysis-dependent kidney failure, also known as end-stage renal disease (ESRD), suffer from high mortality rates, severe morbidity, impaired quality of life, and frequent hospitalizations and readmissions. The burden of ESRD falls heavily on disadvantaged communities, with higher incidence rates and lower access to nephrology care among racial/ethnic minority populations and those living in high-poverty neighborhoods. Changes in coverage and payment financing policies in the Medicare program have had substantial consequences for access to care and health equity in the ESRD population. For instance, Medicare's decision in 1973 to extend coverage to Americans with irreversible kidney failure led to marked reductions in deaths due to kidney disease and decreased racial disparities in access to dialysis. Effective January 1, 2021, Medicare will open up enrollment of ESRD patients in private Medicare Advantage (MA) plans. Historically, persons with ESRD have been ineligible to join MA plans except under limited exceptions. Eighty-three thousand persons with ESRD (14% of Medicare's ESRD population) are projected to join an MA plan within two years. Unfortunately there is little evidence to guide policymakers about the consequences of managed care for persons with ESRD, variations across plans, and the implications for disparities in kidney health. More broadly, MA enrollment has more than quadrupled over the past 15 years, yet fundamental questions about the value of managed care for persons for serious health conditions remain answered. Our long-term objective is to understand the effects of payment and financing changes on the quality, equity, and outcomes of care for persons with ESRD. This mixed-methods study, the next step in our agenda, will investigate the impact of the Medicare program's expansion of MA enrollment to the ESRD population on dialysis care, hospitalizations and mortality. Our specific aims are: 1. Examine MA plans' approaches to managing care for persons with ESRD by conducting qualitative interviews with representatives from MA plans, dialysis organizations, and dialysis facility staff in geographically diverse markets. 2. Estimate the impact of expanding MA coverage to patients with ESRD on mode of kidney replacement therapy, hospitalizations and mortality. 3. Identify variations in the impact of Medicare Advantage on ESRD outcomes by patient and plan characteristics. The project is innovative because we leverage an unprecedented policy experiment in the Medicare program and the availability of plans across counties to derive causal estimates of the impact of managed care for dialysis patients. This project will have a positive impact by producing timely evidence about the role of MA plans in delivering care for persons with ESRD, a population with complex health needs and social risk factors. We address survival, hospitalizations, and the use of home dialysis, outcomes that have been prioritized by the nephrology community, the Medicare program, and the 2019 Executive Order on Advancing American Kidney Health.