July 9, 2020
Summary
Dually eligible beneficiaries in Pennsylvania with end-stage
renal disease (ESRD) are more often people of color and have higher costs
compared to non-duals, but their utilization patterns are similar.
Background
Currently, most Medicare beneficiaries with ESRD receive
coverage through Medicare fee-for-service (FFS). Under the 21st Century Cures
Act, all beneficiaries with ESRD will be eligible to enroll in Medicare Advantage (MA)
starting in 2021. Understanding the demographics, utilization patterns, and
costs of these beneficiaries may help stakeholders prepare for the upcoming MA
eligibility transition. In particular, the population enrolled in both Medicare
and Medicaid (duals) and those who are not (non-duals) may have different
social risk factors, which could have implications for their health outcomes
and service use.
Demographic Characteristics of Duals
Compared to Non-Duals in Pennsylvania
Avalere analyzed the FFS population with ESRD in Pennsylvania
and examined demographic differences between dually eligible and Medicare-only
beneficiaries with ESRD. In 2018, 57% of the approximately 13,600 patients with
ESRD in Pennsylvania were duals; this population was nearly evenly split based
on sex (52% male, 48% female), while the non-dual population skewed toward
males (64% male, 36% female).
Overall, FFS patients with ESRD in the analysis were
disproportionally Black. While an estimated 12% of the population of Pennsylvania is Black,
approximately 31% of patients with ESRD enrolled in FFS were Black. Dually
eligible beneficiaries with ESRD are even more frequently from a racial or
ethnic minority group. As shown in Figure 1, while nearly three-quarters of
non-dual FFS patients were White (73% compared to 22% Black, 1% Hispanic, and
1% Asian), at least half of the duals population with ESRD were from racial or
ethnic minority groups (43% Black, 4% Hispanic, and 3% Asian). Duals more frequently experience food or
housing insecurity or other risk factors that could have implications for their
overall health and treatment needs.
Figure 1. FFS
Beneficiaries with ESRD Race by Eligibility Status, Pennsylvania, 2018
Medicare Spending on FFS
Beneficiaries with ESRD in Pennsylvania
Spending also varied based on the dual status of patients with
ESRD. Average monthly spending on a dually eligible patient with ESRD in
Pennsylvania was 24% higher than average monthly spending for a patient with
ESRD enrolled in Medicare but not Medicaid ($9,321 per member per month [PMPM]
compared to $7,506).
Figure 2. Average PMPM
Medicare Payment and Patient Cost Responsibility for Beneficiaries with ESRD in
Medicare FFS, Pennsylvania, 2018
Services provided to patients with ESRD in Pennsylvania were
dominated by dialysis and inpatient care (see Figure 3). Nearly 33% of all FFS
spending in 2018 for beneficiaries with ESRD in Pennsylvania was for
dialysis—almost all of which was facility-based dialysis. Only 10% of total
dialysis spending was for home dialysis. Inpatient services accounted for 39%
of total spending in Pennsylvania (22% for inpatient medical and 17% for
inpatient surgical services).
Figure 3. Distribution
of Medicare Spending on FFS Beneficiaries with ESRD, Pennsylvania, 2018
While demographics
and average monthly spending differed significantly between dual and non-dual
patients with ESRD in Pennsylvania, utilization patterns were similar between
the 2 groups (see Table 1). Dialysis spending was 34% of total spending for
non-duals and 33% for duals. Non-duals utilized home dialysis at a slightly
higher rate. Spending on home dialysis for non-duals was 12% of total dialysis
spending compared to 8% of dialysis spending for duals. Total spending on
inpatient services was a slightly greater share of total spending for duals
compared to non-duals (41% compared to 38%).
|
Non-Dually Eligible
|
Dually Eligible
|
|
|
Ambulance
|
1.0%
|
1.9%
|
|
Dialysis Home
|
4.2%
|
2.5%
|
|
Dialysis
Outpatient
|
29.7%
|
29.3%
|
|
Durable Medical Equipment
|
0.8%
|
0.8%
|
|
HHA
|
2.2%
|
1.7%
|
|
Inpatient Medical
|
20.8%
|
23.0%
|
|
Inpatient
Surgical
|
16.7%
|
17.5%
|
|
Inpatient Other
|
0.0%
|
0.0%
|
|
Nephrologist
|
3.6%
|
3.4%
|
|
Non-Nephrologist Non-Primary Care
Physician
|
5.2%
|
4.7%
|
|
Non-Nephrologist
Primary Care Physician
|
1.5%
|
1.6%
|
|
Non-Physician
|
1.6%
|
1.7%
|
|
Outpatient
Facility ER
|
0.7%
|
1.0%
|
|
Outpatient Facility Other
|
4.1%
|
3.3%
|
|
Outpatient
Facility Surgery
|
3.4%
|
2.9%
|
|
Part B Drugs
|
0.9%
|
0.6%
|
|
SNF
|
3.5%
|
4.0%
|
|
Table 1. Distribution
of Medicare Spending on FFS Beneficiaries with ESRD by Eligibility Status,
Pennsylvania, 2018
|
||
As MA plans prepare to enroll new patients with ESRD, it will be
crucial for them to understand the characteristics and utilization patterns of
the FFS population with ESRD so that they can effectively manage the care of
these beneficiaries.
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Methodology
To conduct this analysis, Avalere used 100% Medicare Part A and
Part B FFS claims data under a research data use agreement with the Centers for
Medicare and Medicaid Services. Avalere identified enrollees who have a current
reason for entitlement to Medicare due to ESRD and who are enrolled in Medicare
Part A and B in that month. Avalere examined all claims from Medicare FFS. More
specifically, Avalere captured their spending from each claim file type
(inpatient, outpatient, skilled nursing facility, home health, durable medical
equipment, and carrier, which captures physician office setting). Avalere
excluded beneficiaries who received a kidney transplant prior to 2018 and
excluded post-transplant spending for beneficiaries who received a kidney
transplant in 2018.
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