Finally, legislation that offers people with kidney failure a choice in coverage
July 11, 2016
Managing a serious personal health condition can feel like a full time job – one that is highly complex in nature, with no days off, and little room for error. For Americans with kidney failure – also known as End-Stage Renal Disease (ESRD) – managing health is, in fact, one of the most daunting challenges they will ever face. Survival depends on an ability to successfully handle and comply with the many complexities of care.
When you’re sick, day-to-day living can be difficult in and of itself. Yet patients with kidney failure typically have three to four serious medical conditions for which they see different specialists, take eight to ten different medications daily, follow careful diets, and require dialysis treatments at least three times each week for three to four hours at a time. It’s a difficult and challenging road, made even more so when health care is fragmented and uncoordinated.
Fortunately, Congress now has the opportunity to help this group of Americans – 636,000 and growing – by extending to them access to a comprehensive coverage plan that for years has been unavailable to this patient population. The plan — Medicare Advantage (MA) – has been recognized as an outstanding model for coordinated care and improved health outcomes. To date, patients with ESRD have been legally prohibited from enrolling, unless they were enrolled in MA before their kidney failure diagnosis.
As a physician and patient advocate, I feel strongly that a patient should not be discriminated against because of his or her health diagnosis. Dialysis patients should be provided the same opportunity as other Americans to access coordinated care models to help manage complicated disease conditions, and this means lifting the prohibition against ESRD patient access to MA.
Fortunately, a group of bipartisan legislators are standing up for change. These lawmakers have come forward to introduce legislation that would give this vulnerable patient population access to MA, recognizing that ESRD patients deserve (and will certainly benefit from) access to this model of coordinated care. The proposed legislation, aptly named ESRD Choice Act of 2016 (H.R. 5659) – introduced by Reps. Jason Smith (R-Mo.), John Lewis (D-Ga.), Gus Bilirakis (R-Fla.) and Kurt Schrader (D-Ore.) – will give individuals who develop kidney failure the same freedom of choice offered to every other Medicare beneficiary, allowing them to enroll in MA without restriction.
It is important to note that providing ESRD patients access to MA is good both for patients and taxpayers. Data indicate that MA plans, which provide care coordination that is lacking from traditional fee-for-service (FFS) Medicare, have resulted in an 8.5 percent reduction in specialty visits for patients with ESRD. Further, studies have shown that beneficiaries enrolled in MA plans have 30-day hospital readmission rates that are 13 to 20 percent lower than Medicare FFS beneficiaries.
In addition, data show that MA is financially beneficial for dialysis patients. In 2010, Medicare beneficiaries with ESRD were personally responsible for an average of $6,918 annually on health care, and for dialysis patients without supplemental insurance coverage, out-of-pocket costs can exceed $9,000 per year. Unlike Medicare fee for service (FFS) which places no limits on out-of-pocket costs, those costs under MA plans are limited to $6,700 annually – and cost sharing is typically limited to $3,400, lessening patients’ out-of-pocket financial exposure.
Beyond economic benefits, the opportunity to choose coordinated care by accessing MA plans will be immeasurably beneficial for patients whose complicated lives depend on seamless care. Those ESRD patients who choose to enroll in MA plans can look forward to a variety of health plan offerings and services, including case management, disease management programs, transportation and nurse help hotlines – and even dental care benefits are offered among some plans. In many health plans, tools are available to help address health care disparities among minorities, who comprise a disproportionate proportion of ESRD patients.
Offering Americans with kidney failure the added choice of Medicare Advantage – an option already available to millions of other Medicare beneficiaries with different health conditions – is the right thing to do. Patients who opt for MA will see many benefits, including the ability to focus on the business of living, staying healthy, and tackling the more enjoyable challenges life will bring.
As a nephrologist and chair of the nation’s largest advocacy organization for quality kidney care, I applaud lawmakers for taking this long overdue step and hope Congress will promptly enact the ESRD Choice Act of 2016.