MA Sees ‘Rapid Rise’ Among ESRD Population: Report

A new report by ATI Advisory said since 2016 when Congress opened up Medicare Advantage (MA) more widely to people with end-stage renal disease (ESRD), enrollment among this population has soared, growing faster than federal regulators anticipated.

The rising demand means nephrologists, dialysis providers, and other clinicians serving those with ESRD are exploring strategies to build more sophisticated payer-contracting capabilities. The report said MA organizations also need sufficient networks of providers and clinically appropriate approaches to care coordination and utilization management.

Cures Act Is the Trigger

The 21st Century Cures Act (Cures Act), signed into law on Dec. 13, 2016, changed the landscape of Medicare payment for beneficiaries with ESRD, ATI said.

“Before the Cures Act, Medicare beneficiaries with ESRD were largely prohibited from enrolling in MA plans, though those already enrolled could remain after their diagnosis. A small number of beneficiaries could enroll in ESRD-specific chronic condition special needs plans [C-SNPs] where available,” the report said.

The Cures Act removed the MA enrollment restriction for people with ESRD, allowing all individuals with the condition to enroll in any MA plan regardless of when they were diagnosed or their prior coverage.

“This change, effective for plan years beginning Jan. 1, 2021, laid the groundwork for the rapid rise in MA enrollment among people with ESRD,” ATI said.

Number Crunching

At the time the Cures Act was passed, CMS estimated that MA plan enrollment would increase by 83,000 beneficiaries with ESRD over six years, of whom 41,500 would enroll in 2021. ATI Advisory analyzed the 2020–2026 Master Beneficiary Summary File (MBSF) data to understand the actual growth in MA enrollment among this population. ATI’s analysis found that enrollment exceeded CMS’s original projections for the first year and has been climbing ever since.

Between January 2020–January 2026, MA enrollment among beneficiaries with ESRD grew from around 125,000 to almost 280,000 beneficiaries.

“This figure represents more than 50 percent of all Medicare beneficiaries with ESRD and nearly double original projections. MA enrollment has quickly redefined how care is delivered for this population, and this growth is expected to continue,” ATI said.

What the Trend Means

The report said the significant growth in MA enrollment among beneficiaries with ESRD has major implications for the providers and plans who serve them. Prior to the Cures Act, payment to nephrologists, dialysis providers, and others delivering healthcare to people with ESRD was determined primarily by Medicare fee-for-service payment policy, which is standardized across beneficiaries with predictable adjustments for geography, clinical complexity, and other factors.

Now that the majority of beneficiaries with ESRD are enrolled in MA, nephrologists, dialysis providers, and MA plans are balancing administrative demands, ATI said, including:

• Negotiating payment rates and other contracting terms for ESRD-related services;

• Navigating prior authorization and other utilization management approaches; and

• Managing and participating in provider networks while monitoring how they affect patients’ access to dialysis facilities and specialists.

Demands Rise, Too

As the number of people with ESRD enrolling in MA continues to increase, operational demands are likely to intensify, requiring enhanced partnerships between nephrology practices, dialysis organizations, and MA organizations to provide accessible, high-quality care, the report said.

“ATI’s analysis underscores that MA is now a central financing mechanism for ESRD care, and that payment, network design, and utilization management decisions in MA will shape outcomes for this high-need population,” the report said.

Understanding how MA plans structure care for this group will be essential to ensuring access, quality, and cost predictability keep pace with enrollment growth, ATI added.

Comments or questions? Contact Patrick Connole at pconnole@parkplacelive.com.