Medicare Advantage

Soon, ESRD patients will be permitted to enroll in Medicare Advantage (MA) plans, potentially bringing major changes to ESRD care and how patients experience it. DPC lobbied Congress to change the law to permit ESRD patients the choice to elect such plans. Under current restrictions, which will end in 2021, the only dialysis patients in MA plans are those whose kidneys failed while they were already enrolled in a plan.

Congress had previously enacted many changes to Medicare managed care that made MA plans more attractive relative to fee-for-service Medicare, including an out-of-pocket maximum that is lower than the cost sharing most dialysis patients are responsible for in a year. Medicare beneficiaries in MA plans do not need to purchase Medigap insurance, which will be of particular benefit to patients in states that do not mandate Medigap issuance to under-65 Medicare beneficiaries. Premiums for MA plans average about $30/month, far less expensive than Medigap supplements.

MA plans also have a reputation for coordinating the care of patients with complex needs. An insurer that keeps such patients out of the hospital will earn more money, aligning financial incentives to avoid complications. MA plans also have more flexibility to address patients’ individual needs than the relatively rigid and siloed fee-for-service program.

It is DPC’s expectation that some Medicare Advantage issuers will build on partnerships they already have with some large dialysis organizations to coordinate patients care. We are generally optimistic in anticipating that these programs will bring greater care coordination and improved outcomes. However, we recognize that unintended consequences are possible, and there is a long and unfortunate history of managed care organizations stinting on expensive care. CMS needs to be on top of this transition, to anticipate and prevent any problems for beneficiaries. A top DPC priority in the coming years will be ensuring that this transition brings a broad selection of high-quality choices for dialysis patients, and that insurers act in good faith and do not discourage high-cost patients from choosing or staying in their plans.