MA Plans Face Cost and Care Challenges When ESRD Patient Enrollment Surges

Joe Vattamattam, Chief Executive Officer

An important news story just broke in Modern Healthcare magazine on a subject we at Healthmap Solutions have been talking about for some time:  the “21st Century Cures Act”.  The article, ”Medicare Advantage insurers to be tested by a flood of patients with permanent kidney failure,” lays out the very real cost and care challenges the Cures Act poses for Medicare Advantage (MA) plans and the imminent implications that may put plans in financial jeopardy if steps aren’t taken now to prepare.

The Cures Act

The Cures Act opens the door for previously ineligible End State Renal Disease (ESRD) patients to enroll in a MA plan starting this fall with coverage beginning in January 2021. There are approximately 726,000 people in the U.S. living with ESRD, an irreversible, complex and costly condition that requires a patient to receive dialysis or a kidney transplant to survive.

The Risk is Real

According to CMS, there are approximately 120,000  ESRD beneficiaries enrolled in MA plans currently. These beneficiaries gained coverage under limited circumstances, such as having enrolled in a MA plan prior to being diagnosed with ESRD and they represent about 0.65% of total enrollees and about 5% of total MA plan spend. Should every eligible beneficiary with ESRD enroll in a MA plan during open enrollment this fall, that number would increase to approximately 2.7% of enrollment and it is estimated that claims attributable to ESRD would increase to 20% of claims. These projections don’t include COVID-19 acute kidney disease patients whose long-term health prognosis is currently unknown.

Get Ready Plan Needed Now

Open enrollment is just a few months away. To assist MA Plans in understanding the issue and taking the appropriate steps to prepare, Healthmap Solutions offers a “Cures Act how-to guide” We encourage you to give it a read.

Our Population Health Management solutions, and Kidney Health Management programs specifically, deliver the powerful combination of high tech/right touch care that is key to overcoming the financial and clinical challenges the Cures Act presents.

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