Healthcare Utilization of End Stage Kidney Disease Medicare Advantage Beneficiaries Post Cures Act

• In Event: Responding to High-Need Populations: Medicare Policy in Action

Abstract

Importance End-stage kidney disease (ESKD) imposes a significant burden on patients and the healthcare system, with high costs and complex care needs. The 21st Century Cures Act (the Cures Act) expanded Medicare Advantage (MA) eligibility to ESKD beneficiaries in 2021, leading to a rapid increase in enrollment. However, it remains unclear whether managed care effectively addresses the intensive healthcare needs of this population.

Objective To examine changes in hospitalization and emergency department (ED) visit rates among ESKD beneficiaries enrolled in MA before and after the expansion of eligibility under the Cures Act.

Design, Setting, and Participants This cross-sectional observational study analyzed data from 346,044 ESKD MA beneficiaries from 2017 to 2023. Prior to 2021, the pre-Cures Act period, MA enrollees with ESKD must have received their diagnosis only after enrolling in MA. In the post-Cures Act era, ESKD MA beneficiaries now include those with ESKD prior to MA enrollment, as well as those newly diagnosed after MA enrollment. We used interrupted time-series (ITS) analysis to assess changes in care utilization among ESKD MA beneficiaries, with two intervention points: the onset of COVID-19 and the Cures Act implementation. Monthly hospitalizations and emergency department (ED) visits were the primary outcomes, with demographic and socioeconomic variables taken into account. Sensitivity analyses were conducted to account for potential selection effects by stratifying by age group (under 65 vs. 65 and older) and restricting the ITS sample to existing ESKD MA enrollees who enrolled in MA before 2021 as a placebo test.

Exposures Expansion of MA eligibility to ESKD beneficiaries under the 21st Century Cures Act.

Main Outcomes and Measures Sociodemographic factors, hospitalizations, and ED visits.

Results Before the Cures Act, ESKD MA beneficiaries had a mean age of 72.3 years, with 48% female, 9.1% holding a bachelor’s degree or higher, and 42% reporting household incomes below $40,000. The post-Cures Act group, primarily composed of newly eligible enrollees, was younger (mean age 68.0 years), had a lower proportion of women (45.7%), fewer individuals with a bachelor’s degree or higher (7.7%), and more with household incomes below $40,000 (47.7%).

Following the Cures Act, hospitalizations decreased by 0.012 per person per month (p<0.05), representing a 7.5% decline relative to the baseline rate of 0.221 hospitalizations per person per month. However, a gradual upward trend emerged, with an incremental increase of 0.001 hospitalizations per person per month (p<0.01) over time. ED visits showed no immediate change but demonstrated a similar upward trajectory. Stratified analyses indicated that reductions in utilization were largely driven by younger beneficiaries (<65 years), while the placebo test found no significant changes in utilization among pre-existing enrollees.

Conclusion and Relevance These findings suggest that expanded MA eligibility has drawn in a lower SES but younger population of ESKD beneficiaries who may benefit from MA’s enhanced financial protections. Yet questions remain as to whether this coverage ultimately improves or compromises care for this high-need population, underscoring the need for further investigation into clinical outcomes and long-term impacts.

Authors

• Sih-Ting Cai, Indiana University
  Presenting Author

• Hailemichael B Shone, Indiana University
  Non-Presenting Co-Author

• Kosali Simon, Indiana University
  Non-Presenting Co-Author