With Affordable Care Act, more patients retain private insurance at dialysis start
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Key takeaways:
- Medicare enrollment for patients initiating dialysis dropped by 20% from 2012 to 2017.
- Quarterly dialysis spending was more than double with private insurance vs. Medicare.
Among Colorado residents initiating dialysis, fewer enrolled in Medicare after the start of the Affordable Care Act in 2014 than before the legislation increased private and Medicaid coverage options, according to study data.
In addition, first-year quarterly dialysis spending for patients with private insurance was more than double that for patients with Medicare from 2012 to 2017.
“After the ACA, a greater proportion of patients initiating dialysis in Colorado opted for not only private insurance coverage, but also Medicaid. This was due, in part, to ACA-related marketplace plans and Medicaid expansion,” Virginia Wang, PhD, MSPH, associate professor in population health sciences and associate professor in medicine in the department of population health sciences at Duke University School of Medicine, told Healio. “The latter is a surprise, given the potential for benefits as dual Medicare-Medicaid enrollees and suggests patients in Colorado had different reasons to forego Medicare enrollment.”
To assess whether increased insurance access contributed to declining Medicare enrollment for patients with end-stage kidney disease starting dialysis, researchers linked annual data from the U.S. Renal Data System and the Colorado All Payer Claims Database on all patients younger than 65 years not already enrolled in Medicare (N = 2,005). They compared data for the years before the ACA ( 2012 and 2013) with the first years of the ACA marketplace and Medicaid expansion (2014 and 2015) and later years of ACA (2016 and 2017).
Over time, a smaller percentage of patients initiating dialysis enrolled in Medicare: 70.6% vs. 50.6% in the pre- and post-ACA periods, respectively. Similarly, fewer patients switched from private insurance to Medicare after the first year of dialysis: 68.1% before ACA, 52.2% in the first ACA period and 45.8% in the second ACA period. Fewer patients switched from Medicaid to Medicare after the first year of dialysis: 68.9% before ACA, 58.3% in the first ACA period and 54.6% in the second ACA period.
In adjusted analysis, patients were 17% less likely to enroll in Medicare during 2014 to 2015 (risk ratio = 0.83; 95% CI, 0.76-0.91) and 23% less likely during 2016 to 2017 (RR = 0.77; 95% CI, 0.70-0.84) compared with before ACA.
Throughout the study period, costs associated with dialysis care during the first year were higher for patients with private insurance ($26,351 to $29,781 per quarter) than for those with Medicare ($10,039 to $12,741).
“For organizations providing dialysis, patients’ expanded access to private insurance afforded opportunities to receive [more] favorable dialysis payments than would be paid by Medicare,” Wang and colleagues wrote.
Further research should assess factors that influence patient decision-making regarding choice for insurance coverage, Wang told Healio.
“The clinical consequences of patient’s insurance coverage are critical for assessing the value of dialysis care for payers — this includes patients, their families and society.”
The researchers highlighted concerns about the effectiveness of federal policy to improve dialysis access, quality and outcomes.
“Medicare has been a powerful lever for encouraging improvements in kidney care that benefit both Medicare and non-Medicare enrollees,” they wrote. “Medicare’s universal insurance coverage ... comes at substantial social cost but is also necessary for ensuring access and quality of life-sustaining treatment for all patients in the U.S. with kidney failure.”
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