A corner of the health insurance industry that has enjoyed years of rapid growth and lucrative returns will soon face a challenge that threatens to upend that success.
Medicare Advantage insurers are gearing up to receive a potential flood of new members with permanent kidney failure, or end-stage renal disease, who will be able to enroll in the private alternative to traditional Medicare for the first time in 2021. Tens of thousands of these very sick, costly patients are expected to take advantage of the option.
While many Advantage insurers currently cover a few hundred end-stage renal disease, or ESRD, patients who developed the condition while already enrolled, the prospect of adding hundreds or thousands more to their rosters will put care and cost-management skills to the test.
Insurers who successfully manage the patients, who are in the final stage of chronic kidney disease, could do well financially; others could be squeezed and forced to hike premiums or cut benefits. “Health plans are going to have to change operationally in many ways,” said Jane Scott, a senior clinical consultant at Gorman Health Group, which advises Advantage plans.
New York-based insurer Emblem Health is preparing for new kidney disease members by striking up value-based care arrangements to drive better health outcomes. Michigan-based Priority Health is training its care managers to be able to better serve patients with ESRD. Humana is expanding its ability to facilitate dialysis at home instead of in a clinic, and for more than a year, CVS Health has been working on a clinical trial for a home hemodialysis device.
All insurers and dialysis providers are calling for higher payment rates from the federal government, but their pleas have so far landed on deaf ears.
“If you are a smaller health plan, a regional plan with less than 50,000 members, if you get more than your fair share (of ESRD patients), I think it would be very hard financially for these health plans to survive,” said Jill Selby, a corporate vice president at California-based SCAN Health Plan, which has offered a Medicare Advantage special needs plan for ESRD patients since 2006.
People with permanent kidney failure, including those under age 65, have long been eligible to enroll in the traditional Medicare program, which covers dialysis treatments, kidney transplants and other services. Dialysis removes waste and fluid from the blood when the kidneys are no longer working.