Project Summary
The over 500,000 Americans with dialysis-dependent kidney failure, also known as end-stage renal
disease (ESRD), suffer from high mortality rates, severe morbidity, impaired quality of life, and frequent
hospitalizations and readmissions. The burden of ESRD falls heavily on disadvantaged communities, with
higher incidence rates and lower access to nephrology care among racial/ethnic minority populations and
those living in high-poverty neighborhoods. Changes in coverage and payment financing policies in the
Medicare program have had substantial consequences for access to care and health equity in the ESRD
population. For instance, Medicare's decision in 1973 to extend coverage to Americans with irreversible kidney
failure led to marked reductions in deaths due to kidney disease and decreased racial disparities in access to
dialysis. Effective January 1, 2021, Medicare will open up enrollment of ESRD patients in private Medicare
Advantage (MA) plans. Historically, persons with ESRD have been ineligible to join MA plans except under
limited exceptions. Eighty-three thousand persons with ESRD (14% of Medicare's ESRD population) are
projected to join an MA plan within two years. Unfortunately there is little evidence to guide policymakers about
the consequences of managed care for persons with ESRD, variations across plans, and the implications for
disparities in kidney health. More broadly, MA enrollment has more than quadrupled over the past 15 years,
yet fundamental questions about the value of managed care for persons for serious health conditions remain
answered. Our long-term objective is to understand the effects of payment and financing changes on the
quality, equity, and outcomes of care for persons with ESRD. This mixed-methods study, the next step in our
agenda, will investigate the impact of the Medicare program's expansion of MA enrollment to the ESRD
population on dialysis care, hospitalizations and mortality. Our specific aims are: 1. Examine MA plans'
approaches to managing care for persons with ESRD by conducting qualitative interviews with representatives
from MA plans, dialysis organizations, and dialysis facility staff in geographically diverse markets. 2. Estimate
the impact of expanding MA coverage to patients with ESRD on mode of kidney replacement therapy,
hospitalizations and mortality. 3. Identify variations in the impact of Medicare Advantage on ESRD outcomes
by patient and plan characteristics. The project is innovative because we leverage an unprecedented policy
experiment in the Medicare program and the availability of plans across counties to derive causal estimates of
the impact of managed care for dialysis patients. This project will have a positive impact by producing timely
evidence about the role of MA plans in delivering care for persons with ESRD, a population with complex
health needs and social risk factors. We address survival, hospitalizations, and the use of home dialysis,
outcomes that have been prioritized by the nephrology community, the Medicare program, and the 2019
Executive Order on Advancing American Kidney Health.