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MA plans must prepare now for influx of members with ESRD

How MA plans should prepare for the influx in members with ESRD

4 min read

MA plans must prepare now for influx of members with ESRD

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This blog is sponsored by Healthmap.

Beginning in 2021, the 21st Century Cures Act will allow people with end-stage renal disease to select an MA plan during open enrollment regardless of their previous coverage. This is expected to significantly increase the proportion of MA plans’ members with ESRD, bringing new care needs and associated costs. SmartBrief recently spoke with Joe Vattamattam, CEO at Healthmap Solutions, to find out more about what plans should expect and how they can help these members slow the progress of ESRD.

What should MA plans expect in terms of additional membership and costs related to the 21st Century Cures Act?

MA plans need to begin preparing now to be ready when coverage starts on Jan. 1, 2021. There are about 120,000 ESRD patients currently enrolled in an MA plan, representing about 0.65% of all enrollees and around 5% of MA spending. However, the Cures Act opens the door for approximately 600,000 previously ineligible ESRD patients to enroll in a MA plan. If all do, the proportion of claims attributable to ESRD members as a percentage of the total would increase from 5% to 20%. The risk is real.

But plans that prepare now will be able to provide better care, outcomes and experience for members at a lower cost through:

  • Early identification to slow disease progression
  • Migrating appropriate ESRD patients to in-home dialysis, a less costly and often better treatment option than in-center dialysis
    Identifying those at risk of a preventable or unplanned medical event and intervening before it happens.

What might MA plans not be thinking of but should with respect to CKD/ESRD?

Many hospitalized COVID-19 patients developed acute kidney injury. It is well established that AKI increases the risk for developing chronic kidney disease in the year following hospitalization. CKD is asymptomatic until the condition progresses to its most serious stage, ESRD. At this point, the condition is irreversible, requires complex care management and is costly to treat. Keeping an eye on this population of patients will be important, both for keeping them healthy and keeping costs in check.

How can plans identify at-risk patients and slow disease progress?

Plans can disrupt the ESRD timeline by using advanced technology integrated with clinical expertise to identify those at risk of kidney disease and disease progression. Putting this data, along with clinical insights and effective care plans, into the hands of providers can ensure patients get the right care at the right time and in the right setting. Plans can also support patients through compassionate care that empowers and engages them and guides them to community support services that they may need to stay healthy and connected to their care.

The legislation requires the HHS secretary to consider changes to the Star Rating system to include a quality-specific ESRD measure. How can plans ensure they are providing the best quality care?

Plans should measure and report patient progress against value-based, quality and outcomes metrics. Having the most up-to-date information on a patient’s health and progress and that of the full population under management lets a health plan know what is working and what is not. Modifications to care and treatment plans can be made to optimize quality and outcomes for each patient, and to best manage costs.

How will CMS premiums be affected by taking these steps?

Appropriate coding will better reflect the severity of the population, thus increasing premiums. In addition, closing quality care gaps will increase quality scores which should have an impact on premiums, particularly for Medicare Advantage plans. 

Are plans prepared to make the changes necessary ahead of the implementation of the Cures Act?

Many plans would benefit from working with an ESRD solution provider that focuses on patients before they have ESRD. Plans should seek out a partner with proven results, advanced technology, clinical expertise and complex care management experience. A good partner can help plans identify at-risk members, work collaboratively with providers and engage and empower patients in their care.

A solution provider’s capabilities should be scalable, customizable and able to be seamlessly integrated into a health plan’s existing infrastructure and systems.

Healthmap uses clinical big data resources, high-powered analytics and proactive patient-centered care management across a spectrum of flexible specialty care management solutions, which include Medical Cost Management, Quality Reporting/Close Care Gaps, and Risk Adjustment/Revenue Optimization.