The American Society of Nephrology (ASN) provided comments and critique of the proposed rule on Medicare Advantage (MA) for 2021 and 2022 on April 6, 2020. In 2021, by law, MA plans will be open to patients with kidney failure as opposed to those who were already enrolled in MA plans before advancing to kidney failure and remain enrolled after kidney failure.   

ASN has long supported allowing kidney failure patients to have access to these plans. Many MA plans offer care coordination services, transportation to appointments, mental health care, and dental coverage (which is essential for patients seeking to be accepted on a transplant waitlist), as well as other services, that can make MA plans preferable to the traditional Medicare fee-for-service plan for many patients. Care coordination services for patients living with chronic conditions – such as kidney failure – often lead to better patient outcomes and improved quality of life. 

The focus of ASN’s comments were two issues:

• Maximum out-of-pocket (MOOP) limits
• Network adequacy* time and distance requirements for dialysis patients and providers
   

Medicare posed four specific questions that raise a host of implications for patients with kidney failure in MA. Medicare asked the following:

Therefore, we are considering several options about how to improve our proposal as it relates to measuring and setting minimum standards for access to dialysis services. We solicit comment on:

(1) Whether CMS should remove outpatient dialysis from the list of facility types for which MA plans need to meet time and distance standards;

(2) allowing plans to attest to providing medically necessary dialysis services in its contract application (as is current practice for DME, home health, and transplant services) instead of requiring each MA plan to meet time and distance standards for providers of these services;

(3) allowing exceptions to time and distance standards if a plan is instead covering home dialysis for all enrollees who need these services; and

(4) customizing time and distance standards for all dialysis facilities. ^[1]

ASN noted that the timing of these questions was particularly unique since ASN and others in the kidney community have made numerous requests for increased flexibility in care delivery for patients with kidney diseases—especially those with kidney failure—in light of the COVID-19 pandemic and the need to reduce exposure to the virus.

ASN President Anupam Agarwal, MD FASN, commented “ASN encourages CMS to maintain protections for patients and avoid a wholesale removal of time and distance protections (T&DPs). However, ASN realizes significant changes in care delivery are forthcoming with the expected finalization of the ESRD Treatment Choices (ETC) model, the introduction of innovative devices for dialysis care delivery, greatly expanded telehealth, and the entrance of new providers into the kidney space. In such a dynamic environment, it seems logical to ASN that network adequacy in the future might be achieved differently than it was in the past.” 

ASN acknowledged that access to care in the future that might be adequate in terms of T&DPs but might permit MA plans to offer a different mix of care options to achieve that adequacy. 

ASN encouraged CMS to additionally consider:

• Using a nuanced approach that considers how network adequacy might be achieved in the future before modifying T&DPs.
• Recognizing unique challenges that patients with kidney failure face due to the need for frequent travel to a dialysis facility, when considering network adequacy.
• Remaining open to the idea of future care delivery looking different than the current predominance of in-center dialysis care with the entrance of new providers.
• Ensuring patients have options among which to choose.
• Dealing with transplant patients separately.
• Ensuring latitude for managing chronic illness by covering such services as meals and transportation.
• Reconsidering maximum out-of-pocket expenses (MOOPs) for this patient population.
• Risk adjusting MA plan quality metrics to align with the ESRD Quality Incentive Program (QIP).
• Protecting the integrity of the US Renal Data System (USRDS) by ensuring the inclusion of MA data.
• Monitoring effects of the proposed rule’s approach to dealing with organ acquisition costs.
  
   

ASN also expressed its concerns to Medicare that the ESRD benchmark proposed for CY 2021 is inadequate to cover the costs associated with ESRD coverage for patients with kidney failure due to the $6,300 difference between the fee-for-service (FFS) out-of-pocket expenditures and the MA MOOP limit. ^[2] Dr. Agarwal continued commenting “ASN believes the current ESRD reimbursement is not sufficient to prevent premium increases across MA plans and will limit patients’ ability to benefit from MA’s supplemental benefits and care coordination services that are especially valuable for patients with kidney failure and other chronic conditions.”

Also, on April 6, Medicare finalized the rate sheet for MA and left the CY 2021 ESRD methodology unchanged meaning ASN’s concern on this issue remains. ASN will keep KNO readers informed on how these issues progress.