Medicare Advantage Special Needs Plans Tied to Better ESRD Outcomes

By Lisa Rapaport

September 16, 2020

(Reuters Health) - Patients with end-stage renal disease (ESRD) have lower care utilization rates and mortality with Medicare Advantage special needs plans than with fee-for-service coverage, a recent study suggests.

Researchers examined data for matched cohorts of patients with ESRD who either enrolled in Medicare Advantage special needs plans (SNP) or remained in fee-for-service Medicare plans and served as controls. One cohort looked at mortality 36 months after SNP enrollment among 441 SNP enrollees and 8,519 matched fee-for-service controls; another cohort looked at utilization 12 months before and after SNP enrollment among 370 SNP enrollees and 6,096 matched fee-for-service controls.

Compared with fee-for-service controls, adjusted average mortality rate among SNP members was lower (HR 0.51). SNP enrollees also had lower adjusted inpatient days (4.61 v 12.5), inpatient admissions (1.01 v 1.65), skilled nursing facility days (1.88 v 7.39), skilled nursing facility admissions (0.22 v 0.36), and home health days (3.01 v 8.71).

"Our findings suggest that we can significantly improve outcomes for a very vulnerable population by changing the way we pay for and deliver ESRD care," said senior study author Dr. Amol Navathe, a staff physician at the Philadelphia VA Medical Center and an assistant professor of medicine and health policy at the Perelman School of Medicine at the University of Pennsylvania.

Special needs plans are required to develop integrated care models for patients with ESRD, meaning that the various clinicians and healthcare organizations are required to have systems to care for patients collaboratively, Dr. Navathe said by email.

There are a number of ways that comprehensive, integrated care models could reduce mortality and utilization: fewer complications related to dialysis access (such as infections), better management of other illnesses such as heart disease, diabetes, and high blood pressure, improved adherence to dialysis and medications, and fewer medication errors, Dr. Navathe said.

"We found a trend toward fewer admissions for ESRD complications such as electrolyte disturbances and heart failure exacerbations," Dr. Navathe said. "We also found a trend towards better dialysis adherence, which in turn might have prevented admissions for ESRD complications."

More research is needed to determine the durability and replicability of the results across different time frames and a wider variety of health plans, the study team writes in Health Affairs.

One limitation of the study is that matching may not have been sufficient to eliminate all the confounding associated with some patients choosing a SNP, said Vincent Mor, a professor in the department of health services, policy, and practice at Brown University School of Public Health in Providence, Rhode Island.

"The fact that many of the SNP patients came from Los Angeles or other parts of California and the authors chose not to select control cases from those areas means that whatever is unique about the California market was unlikely to be replicated in the selection of control fee-for-service cases living in other parts of the country," Mor, who wasn't involved in the study, said by email.

"The SNPs for dialysis patients is a new and relatively small phenomenon that hasn't been studied much," Mor added. "Patients entering the SNPs were less sick and used less services than did those who remained in fee-for-service."

SOURCE: Health Affairs, online September 8, 2020.