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

项目摘要 50多万美国透析依赖型肾衰竭，也被称为终末期肾功能衰竭 疾病(ESRD)，死亡率高，发病率严重，生活质量受损，经常 住院和再入院。ESRD的负担沉重地落在弱势社区身上， 少数族裔人群的发病率较高，获得肾脏内科治疗的机会较少 那些生活在高度贫困社区的人。承保范围和支付融资政策的变化 医疗保险计划对ESRD获得医疗保健和医疗公平产生了重大影响 人口。例如，1973年，联邦医疗保险决定将覆盖范围扩大到患有不可逆转肾脏的美国人 失败导致肾脏疾病死亡人数显著减少，获得治疗的种族差距缩小 透析。自2021年1月1日起，Medicare将开放ESRD患者在私人Medicare中的登记 Advantage(并购)计划。从历史上看，患有ESRD的人没有资格加入MA计划，除非符合以下条件 有限的例外。8.3万终末期营养不良患者(占医疗保险终末期营养不良人口的14%) 预计将在两年内加入并购计划。不幸的是，几乎没有证据来指导政策制定者 ESRD患者管理性护理的后果，不同计划的差异，以及对 肾脏健康方面的差异。更广泛地说，在过去15年里，硕士研究生入学人数增加了四倍多。 然而，关于对严重健康状况的人进行管理性护理的价值的根本问题仍然存在 回答。我们的长期目标是了解支付和融资变化对 ESRD患者护理的质量、公平和结果。这项混合方法的研究，我们的下一步 议程，将调查联邦医疗保险计划将MA登记扩大到ESRD的影响 人口对透析护理、住院治疗和死亡率的关注。我们的具体目标是：1.审查并购计划 通过与ESRD代表进行定性访谈来管理ESRD患者护理的方法 来自不同地域市场的MA计划、透析组织和透析设施工作人员。2.预算 终末期肾病患者扩大MA覆盖范围对肾脏替代治疗模式的影响 住院和死亡率。3.确定Medicare Advantage对ESRD结果影响的变化 根据患者和计划的特点。这个项目是创新的，因为我们利用了前所未有的政策 在医疗保险计划和跨县计划的可用性方面进行试验，以得出以下结果的因果估计 管理式护理对透析患者的影响。这个项目将产生积极的影响，及时生产 MA计划在为患有终末期肾病的人群提供护理方面所起作用的证据 健康需求和社会风险因素。我们解决生存、住院和家庭透析的使用问题， 肾内科社区、医疗保险计划和2019年优先考虑的结果 关于促进美国肾脏健康的行政命令。

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.