“Leading payors we work with are showing an ESKD enrollment increase of approximately 50% since January of 2021,” said Will Stokes, Chief Strategy Officer at Strive Health. “Many forward-thinking MA plans sought out partnerships to account for this influx. Those that didn’t will need to plan for how they’re going to provide care for this incredibly complex population.”
ESKD beneficiaries have disproportionately higher medical costs than the average MA plan member. An analysis from USRDS shows that the average per member per year cost for Medicare ESKD members is steadily increasing. The latest data shows the average per–member per-year cost as about $100,000, which is significantly higher than that of the average Medicare beneficiary.
Considering the rate at which ESKD enrollment in MA plans is expected to increase and the average cost of care per member, MA organizations will be faced with a growing cost burden that will require specialized attention
ESKD beneficiaries typically have multiple comorbid conditions, which result in higher healthcare costs and more complex patient care. According to Wakely, the average ESKD medical loss ratio is about 112% (compared to the average non-ESKD/non-Hospice MLR of 86.6%). This suggests that the current ESKD payment model fails to cover claim expenses, and complexity of care is an important factor in the gap. As ESKD enrollment increases, MA organizations will need to consider specialized complex care programs for ESKD in order to continue to meet their MLR targets.
ESKD is complex and often treated by a mix of primary care physicians, nephrologists and several other specialists (depending on the profile of comorbidities). Because of this complexity, it is important for MA plans to partner and integrate with care providers who directly manage their ESKD beneficiaries.
Value-based contracts in particular help payors align their incentives with the provider community. They offer a few key benefits: risk sharing between the payor and provider, increased patient engagement with high quality providers in their network, and alignment among the provider community around key quality performance metrics for ESKD care.
Partnering with a specialized organization might seem like a heavy upfront investment, but MA organizations can see significant returns through cost savings and improved patient care with the right partnership. For medical groups with financial risk, primary care physicians often manage ESKD beneficiaries with four or more comorbidities. Both the patients and physicians can benefit from additional specialized support for ESKD. A specialized provider may provide predictive analytics, care management expertise, and high-quality care resources that might not otherwise be available.
The 21st Century Cures Act will continue to have significant implications for MA organizations, especially when it comes to financial risk from ESRD beneficiaries. To help MA plans size and scope how policy changes for kidney disease will change their business, Strive offers custom opportunity assessments. The more deeply health plans understand the changes, the more readily they can stay ahead of the curve. To get an opportunity assessment, fill out our contact form or email firstname.lastname@example.org.
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