Comparing Dialysis Provision and Outcomes Between Medicare Advantage and Fee-for-Service Medicare

7.摘要 大多数终末期肾病(ESKD)需要透析的患者都获得了医疗保险，其中大多数 参加按服务收费(FFS或传统)的联邦医疗保险。联邦医疗保险优势(MA)，当私营保险公司 协调联邦医疗保险福利，是FFS联邦医疗保险的替代方案。然而，在2021年前，患有ESKD的患者 只能在开发ESKD之前注册。因此，只有22%患有ESKD的医疗保险患者有 MA计划，相比之下，没有ESKD的医疗保险患者的比例为36%。《21世纪治疗法案》向所有人开放硕士学位 2021年患有ESKD的患者，专家预计MA将有大量的注册人数。MA的支持者 争辩说，它可以更好地协调慢性病的护理，从而改善结果并减少 在非ESKD人群中的成本。目前尚不清楚这些发现是否适用于ESKD和MA研究 ESKD的结果明显稀少，尽管其迫在眉睫的重要性。一个关键的解释是缺乏 现有的研究数据。美国肾脏数据系统(USRDS)，用于大多数透析的数据集 研究，几乎只包含关于FFS Medicare的数据。此外，因为MA计划和透析 提供商就透析付款谈判专有合同，MA透析报销有大量 差异，使得跨并购计划和提供商的比较变得困难。因此，研究人员将注意力集中在 主要是FFS联邦医疗保险。我们将使用MA索赔数据和USRDS数据集之间的新链接来 调查MA透析人群的结局。除了是首批研究项目之一， 在MA中广泛研究透析，我们的工作将开发一个研究基础设施，将使未来的研究 MA和ESKD更容易获得。一项关键的创新是确定一个可比的透析治疗单位(和所有 相关服务)跨MA计划和提供商以及FFS Medicare。在目标1中，我们将调查 在非透析人群中，MA患者可从改善护理协调中获益。 我们将研究MA是否会在透析开始时改善结果(例如，开始透析 门诊患者)，以及MA和ESKD的流行患者是否住院较少或 更低的死亡率。作为改善护理协调的潜在机制，我们将探索MA患者是否 与传统的每周三次透析相比，更有可能接受额外的门诊透析 时间表。目标2将评估并购市场的异质性。我们将研究市场集中度如何在 透析设施、透析链和MA计划水平修改了我们在目标1中的发现。例如，透析 地区性竞争对手很少的供应商可能拥有更大的市场力量，因此可能会抵制 MA计划的护理协调和成本节约举措。拟议中的工作将形成更大规模的 研究工作，包括R01应用，旨在研究《21世纪治疗法案》和 扩大美国透析人群的MA资格。

7. ABSTRACT Most patients requiring dialysis for end-stage kidney disease (ESKD) obtain Medicare, with the majority enrolling in fee-for-service (FFS or traditional) Medicare. Medicare Advantage (MA), when private insurers coordinate Medicare benefits, is an alternative to FFS Medicare. However, prior to 2021, patients with ESKD could only enroll prior to developing ESKD. Consequently, only 22% of Medicare patients with ESKD have an MA plan, compared to 36% of Medicare patients without ESKD. The 21st Century Cures Act opened MA to all patients with ESKD in 2021, and experts anticipate a large influx of enrollment into MA. Proponents of MA argue that it results in better care-coordination of chronic diseases, leading to improved outcomes and reduced costs in the non-ESKD population. It is unclear whether these findings extend to ESKD, and research on MA ESKD outcomes are conspicuously sparse, despite its imminent importance. A key explanation is a lack of available research data. The United States Renal Data System (USRDS), the dataset used for most dialysis research, almost exclusively contains data on FFS Medicare. Additionally, because MA plans and dialysis providers negotiate proprietary contracts for dialysis payment, MA dialysis reimbursements have substantial variation, making comparisons across MA plans and providers difficult. Thus, researchers have focused primarily on FFS Medicare. We will use a novel linkage between MA claims data and the USRDS dataset to investigate outcomes in the MA dialysis population. In addition to being one of the first research projects to broadly study dialysis in MA, our work will develop a research infrastructure that will make future research on MA and ESKD more accessible. A key innovation is identifying a comparable unit of dialysis treatment (and all related services) across MA plans and providers, and with FFS Medicare. In Aim 1, we will investigate whether patients with MA accrue the benefits of improved care-coordination seen in non-dialysis populations with MA. We will study whether MA results in improved outcomes at the start of dialysis (e.g., starting dialysis as outpatients) and whether prevalent patients with MA and ESKD experience fewer hospitalizations or have lower mortality. As a potential mechanism for improved care-coordination, we will explore whether MA patients are more likely to receive extra outpatient dialysis sessions over the conventional thrice weekly dialysis schedule. Aim 2 will assess heterogeneity in the MA market. We will study how market concentration at the dialysis facility, the dialysis chain, and the MA plan levels modify our findings in Aim 1. For instance, dialysis providers with few regional competitors may have more market power and, consequently, might be resistant to care-coordination and cost-saving initiatives by MA plans. The proposed work will form the impetus for a larger research effort, including an R01 application, aimed at studying the impact of the 21st Century Cures Act and of expanding MA eligibility for the dialysis population in the United States.