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    Nguyen KH, et al. Medicaid expansion and medicare-financed hospitalizations among adult patients with incident kidney failure. JAMA Health Forum 2022; 3:e223878. doi: 10.1001/jamahealthforum.2022.3878

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  • 2.

    Nguyen KH, et al. Medicare Advantage enrollment following the 21st Century Cures Act in adults with end-stage renal disease. JAMA Netw Open 2024; 7:e2432772. doi: 10.1001/jamanetworkopen.2024.32772

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  • 3.

    Longino K, Palevsky PM; National Kidney Foundation. Letter to The Honorable Chiquita Brooks-LaSure. September 6, 2022. Accessed October 17, 2024. https://www.kidney.org/sites/default/files/2022-09-06_physician_fee_schedule_final.pdf

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Policy and Payment Changes on the Horizon for Kidney Care

Bridget M. Kuehn
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Shifts in health care coverage for patients with kidney diseases and growing use of value-based payment models are creating new opportunities and potential challenges for nephrologists and people living with kidney diseases.

Those changes were highlighted during ASN's Nephro-Economics in 2024 symposium in September. Speakers at the symposium highlighted the impact of a growing number of states embracing the Medicaid expansion and an increasing numbers of patients opting for Medicare Advantage plans offered by private insurers. They also discussed the efforts by the Centers for Medicare & Medicaid Services (CMS) to increase enrollment of clinicians in its value-based care payment models and the inadequate reimbursement rates for nephrologists.

Medicare Advantage growth

Medicare provides coverage for the majority of people living with kidney failure, yet a rapid shift toward coverage by private Medicare Advantage plans could have trade-offs for patients and nephrologists.

“Medicare provides crucial coverage to more than 90% of Americans with kidney failure, but there can be substantial out-of-pocket costs with traditional Medicare,” explained Kevin Nguyen, PhD, assistant professor in the Department of Health Law, Policy, and Management at Boston University School of Public Health, MA.

These costs may arise from premiums, deductibles, or copays. Supplemental insurance may help to cover some of these costs or provide additional benefits like dental care or long-term care benefits, he noted. But people with kidney diseases may be denied supplemental insurance or charged a higher premium, except in the few states that require supplemental insurers to offer coverage to this patient population, he said.

Patients who meet certain income thresholds may also be eligible for Medicaid, depending on their state's rules and whether the state opted into the Medicaid expansion program. An analysis by Nguyen and his colleagues found that Medicaid expansion overall led to decreased hospital admissions during the high-risk period, 3 and 6 months after initiating dialysis (1). Patients in expansion states were also more likely to initiate dialysis with an arteriovenous fistula or graft. He noted that reductions in hospitalizations for complex patients in Medicaid expansion states could benefit from Medicare, which is the primary payor for kidney failure care. The potential cost reductions could also create an incentive for more states to expand Medicaid.

A growing number of people with kidney failure are embracing Medicare Advantage plans offered by private insurers. These plans offer trade-offs over traditional fee-for-service Medicare plans, which are accepted by almost any clinician, hospital, or dialysis facility in the country. Medicare Advantage plans may have low premiums and fewer out-of-pocket costs and offer additional services like dental coverage or food-delivery services, but they have more limited networks of clinicians and health facilities, Nguyen explained.

Medicare Advantage plans became available for people experiencing kidney failure in January 2021 as part of the 21st Century Cures Act. Overall, CMS anticipated that 30% of enrollees with kidney failure would opt for Medicare Advantage plans in 2021, yet only less than half had switched by 2022 (2). Enrollees who were White and those with other chronic conditions were least likely to leave traditional Medicare. By contrast, enrollees who were American Indian or Alaska Native, Black, or Hispanic made the switch in higher proportions. Individuals who were partially or fully dual eligible for Medicaid also were more likely to choose a Medicare Advantage plan over traditional Medicare.

Most participants who switched to Medicare Advantage stayed in the program, but about one-quarter of them switched to a different Medicare Advantage plan. Black patients were more likely than patients from other racial and ethnic groups to switch to a different Medicare Advantage plan. But the implications for kidney failure care are unknown.

“It will be crucial to monitor the adequacy of dialysis facility networks in Medicare Advantage contracts and assess health outcomes among individuals who switched,” Nguyen said.

Rethinking 2008 health care

By 2030, CMS plans to have 100% of its beneficiaries being cared for through value-based care arrangements with clinicians and health systems. That shift is part of a growing effort to both improve care and curb the high costs of kidney care for CMS. Suzanne Watnick, MD, FASN, professor of medicine at the University of Washington, Seattle, and ASN's health policy scholar in residence, explained that patients receiving renal replacement therapy account for fewer than 1% of Medicare beneficiaries yet 6%–7% of all Medicare spending (3). That is more than 1% of the federal budget or more than $50 billion a year. “We have responsibility for using those hard-earned taxpayer dollars wisely,” she said.

Value-based payment models may be one way to do that. Yet, Watnick noted that many payment models are still stuck in a 2008 time warp. At that time, the Medicare Improvements for Patients and Providers Act (MIPPA) was passed to help curb expenditures on overuse of drugs like erythropoietin-stimulating agents and to promote greater use of home dialysis. Watnick noted that MIPPA has helped reduce excessive use of drugs and that home dialysis is now used by about 15% of patients. Additionally, she noted that dialysis organizations learned how to use payments under the models to increase access, preserve quality, and not increase cost, which she said was a good lesson for the field of nephrology.

But Watnick said that more needs to be done to tie payments to quality measures and to continue improving care to meet today's and tomorrow's standards. “Our patients deserve better,” she said. She noted that more can be done to increase the number of patients able to access home dialysis and incentivize continued improvements and innovations in kidney care.

“Anemic” payment growth

Some changes in payment models expected in 2025 may impede some of those goals. Watnick noted that current policy proposals could decrease reimbursement for home dialysis visits for patients with acute kidney injury by $8, in part, to offset the costs of training for these patients. She said that she and her colleagues at ASN have commented on the proposals to ensure equal access to home dialysis for patients with acute kidney injury.

Other notable changes include the bundling of payments for phosphate binders to dialysis facilities, which, she explained, will have dialysis facilities acting as a pharmacy. She noted that although this change may increase access to these medications for Medicare patients who do not have drug coverage through Medicare Part D, it is unclear how it will affect access to these medications for patients in skilled nursing facilities.

Woefully anemic updates to the physician fee schedule for nephrologists are another concern, Watnick said. She noted that nephrology faces rising costs and staffing shortages, yet there is no inflationary adjustment for nephrologists’ payments. “How do you have a negative [profit] margin and maintain a viable business?” she questioned. “This is something that needs to be tackled in the future.”

She said that the challenge with advocating for greater pay is that many policy changes must be budget neutral, so increased reimbursements in one area may mean decreased reimbursements in another. Additionally, she noted that the Medicare Payment Advisory Commission (MedPAC), which independently assesses physician payment advocacy, acknowledges that current payments provide negative margins but argues that there is still good access to outpatient dialysis. But Watnick suggested that advocacy by nephrologists can help shift the conversation. “We have a voice,” she said. “Advocacy does help.”

Watnick noted that one potential avenue for addressing these concerns is to more strongly tie quality metrics to reimbursement. She suggested that bundles could be expanded to promote better care coordination and a wider array of patient options beyond in-center dialysis, including more home dialysis and preemptive transplants. She also emphasized the need for more advanced care planning, for care to prevent emergency department visits and hospitalizations, and to provide palliative care. Leveraging technology may also help nephrologists proactively monitor patients and help prevent more expensive care episodes.

She argued that it may be time for an act of Congress to overhaul the current system for kidney care, which emphasizes in-center dialysis using technology that dates back decades. Instead, she said there needs to be a push to make dialysis obsolete, embrace new technology and innovation, and emphasize care that improves outcomes while reducing costs. She noted that steps like vaccinating patients against COVID-19 to prevent hospitalizations both improves patient outcomes and cuts costs. “We need to do better,” Watnick emphasized. “There are all kinds of things we can do to improve the future direction of [kidney care].”

References

  • 1.

    Nguyen KH, et al. Medicaid expansion and medicare-financed hospitalizations among adult patients with incident kidney failure. JAMA Health Forum 2022; 3:e223878. doi: 10.1001/jamahealthforum.2022.3878

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Nguyen KH, et al. Medicare Advantage enrollment following the 21st Century Cures Act in adults with end-stage renal disease. JAMA Netw Open 2024; 7:e2432772. doi: 10.1001/jamanetworkopen.2024.32772

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Longino K, Palevsky PM; National Kidney Foundation. Letter to The Honorable Chiquita Brooks-LaSure. September 6, 2022. Accessed October 17, 2024. https://www.kidney.org/sites/default/files/2022-09-06_physician_fee_schedule_final.pdf

    • PubMed
    • Search Google Scholar
    • Export Citation
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