MA Special Needs Plans May Lower ESRD Spending, Improve Outcomes

Medicare Advantage special needs plans (SNPs) may help control healthcare spending for patients with end-stage renal disease (ESRD), a recent study published by Health Affairs found.

CMS established a Medicare Advantage SNP for ESRD patients in order to help coordinate care and cover their needs through alternative payment models. Special needs plans target specific high-cost populations to serve them with high-quality, low-cost care.

For ESRD SNPs specifically, participating Medicare Advantage plans have to receive CMS approval on a care delivery model that incorporates a coordinated care team, health risk assessments, personalized care, and other features to drive quality.

“Our study results suggest that SNPs may be an effective alternative financing and delivery model for patients with ESRD, which is important evidence amid a dynamic policy landscape and limited data to inform policy decisions,” the researchers found.

Researchers used data from CareMore Health from 2010 to 2013 combined with national data as available to compare mortality and utilization levels between fee-for-service patients and special needs plan enrollees.

The lack of data available on Medicare Advantage plans limited the results’ universality and kept researchers from delving into other aspects of ESRD patient healthcare spending.

Researchers had two cohorts of study subjects: patients that they studied for utilization trends and patients that they studied for mortality rates.

A few characteristics set SNP enrollees apart from fee-for-service patients from the beginning, whether they were in the mortality or the utilization cohort.

SNP enrollees were more likely to live in highly populated environments. They received dialysis more often than their counterparts. They also received less care from inpatient and skilled nursing facilities and were admitted to these sites less often than fee-for-service patients.

However, there were some commonalities between the mortality and utilization SNP and fee-for-service groups.

They were mainly male, Hispanic, and dually eligible. They tended to live in urban environments, a trend which has played a role in the controversy surrounding a recent CMS Medicare Advantage ESRD payment ruling. Most had multiple comorbidities, cited diabetes as the cause of their ESRD, and had been living with ESRD for several years.

Ultimately, three years after SNP enrollment, SNP enrollees had a higher rate of survival than their counterparts in fee-for-service Medicare.

In addition to exhibiting lower mortality, SNP enrollees continued to demonstrate lower utilization of high-cost services such as a lower rate of inpatient stays.

Whereas fee-for-service patients spent on average 12.5 days per year in an inpatient setting, SNP enrollees spent only a third of that at an inpatient facility (4.6 days). Fee-for-service patients spent on average a little over a week in a skilled nursing facility each year, but SNP individuals spent under two days in those spaces.

SNP enrollees had about fifteen more dialysis days per year than fee-for-service patients.

The researchers identified a few ways in which SNPs might provide superior models of care that lend themselves to these results, including that higher access to dialysis decreases infections and that better care coordination and chronic disease management lead to stronger comorbidity management, fewer complications, and better medication adherence.

The results seem to corroborate these conclusions. ESRD SNP patients had fewer inpatient admissions due to complications and a trend toward more dialysis days than fee-for-service Medicare beneficiaries.

“This finding may also allay concerns that the financial incentives introduced by capitated payment could lead to decreased use of dialysis,” the researchers added.

However, they recommended more research into the main drivers behind why SNPs might be more successful in reducing mortality and utilization.

“The magnitude of the association between SNP enrollment and reductions in mortality and utilization observed in this study exceeds those seen in evaluations of the ESRD Disease Management Demonstration6 and the Comprehensive ESRD Care Model. This suggests that SNPs may be a uniquely effective payment and delivery model,” the researchers noted.