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Comparison of Dually and Non-Dually Eligible Patients with ESRD

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
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
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
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%).

Table 1. Distribution of Medicare Spending on FFS Beneficiaries with ESRD by Eligibility Status, Pennsylvania, 2018
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%

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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