While payers and Medicare Advantage proponents applauded
elements of the Medicare Advantage rule which will increase plans’ revenues by
nearly one percent, many expressed concerns about the proposed rule’s approach
to chronic disease management costs for patients with End-stage renal disease
(ESRD).
The proposed rule mainly
focuses on prescription drug pricing. It gives Part D plans the ability to
negotiate pricing, promote less expensive generic through a new specialty tier,
and allow patients to compare drug prices for the one that best fits their
needs and wallet.
But aside from that, this proposed rule also addresses the population of patients with the severe stage of chronic kidney disease called
end-stage renal disease in which until now has been largely excluded from
Medicare Advantage coverage.
End-stage renal disease is a serious condition
that requires invasive and urgent chronic disease management. At this stage, the
organs have completely shut down as explained by the American Kidney Fund (AKF). The patient will, later on, need dialysis or a kidney transplant. There is no cure for ESRD, but
people who have this may live long while on dialysis or after having the transplant.
Costs of chronic disease management at this stage are high. The average cost to cover Medicare beneficiaries with ESRD in 2016 was roughly over
$67,000.
Currently, patients with ESRD have only been eligible to enroll
in Medicare Advantage plans under certain exemptions and if they develop ESRD
while on a Medicare Advantage plan they can keep their Medicare Advantage plan.
However, the proposed rule seeks to increase patients’ options for chronic
disease management and implements certain payment changes for Medicare
Advantage plans with regard to ESRD.
CMS states in its 2021 Medicare
Advantage and Part D Advance Notice Part II Fact Sheet that effective
January 1, 2021, Medicare Advantage organizations will no longer be responsible
for organ acquisition costs for kidney transplants for Medicare Advantage
beneficiaries. Such costs will be excluded from Medicare Advantage benchmarks
and covered under the fee-for-service program instead. However, some payers and
Medicare Advantage proponents have expressed concerns that the payment to
Medicare Advantage plans will not effectively cover the costs of treatment.
However, the President and CEO of America’s Health Insurance
Plans (AHIP), issued a reserved statement on
the matter.
“We are concerned that some proposals could undermine the
critical funding that protects millions of Americans’ access to the benefits
and care they need, including individuals with kidney disease who are newly
eligible to enroll in Medicare Advantage,” Eyles explained. “We will continue
to review the advance rate notice and the proposed rule, and we look forward to
sharing important feedback with CMS during the comment period.”
Also, the President and
Chief Executive Officer of BM, Allyson Shwartz, said in a press release, “It is
unclear whether the proposed regulation offers the changes needed to address
issues previously identified by BMA in the treatment of MA coverage for End-Stage
Renal Disease (ESRD) patients who are eligible for enrollment beginning in
2021,”.
The study she is referring to is conducted by Avalere on behalf
of BMA in December 2019. The study looked at the current Medicare Advantage
reimbursement rate for the small population of Medicare Advantage beneficiaries
with ESRD. The researchers found that payments to Medicare Advantage plan for
ESRD was based on a methodology that is distinct from the reimbursement model
for the rest of the plans’ enrollees. The model draws on state-level data, as
opposed to county-level data.
As a result, the current ESRD payment model fails to account for
state-wide treatment cost variations with serious implications for this
particular disease. Because of this, Medicare Advantage plans experience
significant ESRD reimbursement rate fluctuations year over year. The study used 2018 fee-for-service claims data on Medicare
beneficiaries with ESRD by metropolitan statistical area and set the data
against 2018 state-level ESRD Medicare Advantage benchmarks.
Medicare spending on beneficiaries with ESRD proved higher
then the Medicare Advantage benchmarks such that, particularly in urban regions
with high Medicare Advantage penetration, Medicare Advantage plans were
underpaid.
Neither BMA nor AHIP executives expressed confidence that the new proposal will resolve these payment model flaws, but both organizations are
reviewing the rule to provide feedback.
Across the industry, there has been a major push to provide more
options for patients with chronic kidney disease. There is even pressure coming
from outside of the industry, with an executive order related
to the issue in July 2019.
The condition has stirred up legal strife within
the healthcare industry as some claim that certain organizations take advantage
of patients’ reliance on dialysis.
BMA and AHIP have advocated for the role that Medicare Advantage
can play in resolving some of the tensions for patients.
“ESRD patients have complex and costly needs and Medicare
Advantage is well-suited to provide high-value care to this population, because
of the coverage and care it offers to chronically ill beneficiaries,” the BMA
brief explained.
“However, as these findings suggest, Medicare Advantage plans in
areas with the most ESRD patients would likely be underpaid in the current
payment system. Without adequate payment, Medicare Advantage plans may be
forced to raise consumer costs, reduce supplemental benefits, or limit service
areas—not just for ESRD patients, but for all enrollees.”
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