The Impact of the 21st Century Cures Act

In the United States alone, kidney failure affects more than 800,000 individuals, most notably those who are considered low-income and minorities.^1-4 Depending on the situation, treatment can require in-center dialysis sessions three times a week, at-home dialysis, or even kidney transplants.

Those with kidney failure can qualify for Medicare coverage via the program’s end-stage renal disease (ESRD) benefit, with coverage taking effect the fourth month of in-center hemodialysis treatment, or at the 90-day mark. As a result of the 21^st Century Cures Act, Medicare beneficiaries with ESRD were allowed to sign up for private Medicare Advantage (MA) plans for the first time, which become effective Jan 1, 2021.^5,6

It’s important to note that prior to the above date, Medicare beneficiaries with ESRD could only enroll in MA plans if they had developed incident kidney failure while enrolled in an MA plan, and if they were enrolled in traditional Medicare (TM).

Keeping all of this in mind, a cross-sectional study published in JAMA Network Open⁷ sought to analyze changes in MA enrollment among Medicare beneficiaries with ESRD in the first two years of the Cures Act, and among those who became newly-enrolled MA in 2021, evaluate the proportion of beneficiaries who changed MA contracts, and the manners in which the contract characteristics changed.

This population-based time-trend study was conducted from January 2020 to December 2022, while the data analysis occurred from August 2023 to March 2024.

In total, there were 718, 252 unique Medicare beneficiaries with ESRD between the years 2020 and 2022. In 2022, there were 583, 203 beneficiaries with ESRD (mean [SD] age, 64.9 [14.1] years, 245,153 females (42.0%); 197, 988 Black [34.0%]; 47,912 Hispanic [8.2%]). The proportion of beneficiaries with ESRD who were enrolled in MA increased from 25.1% (118,601 out of 472 ,234 beneficiaries) in January 2020 to 43.1% (21, 896 of 491,611 beneficiaries) in December 2022.

The boost in MA enrollment was larger in the first year of the Cures Act (12.6 percentage points [pp]; 95% confidence interval, CI 12.3-12.8 pp) compared to the second year of the Act (5.7 pp; 95% CI, 5.5-5.9 pp). Changes between December 2020 and December 2022 ranged between 49.3% for Asian or Pacific Islander beneficiaries (difference = 13.0 pp; 95% CI, 12.2-13.8 pp) and 207.2% for American Indian or Alaska Native beneficiaries (difference = 17.0 pp; 95% CI, 15.3-18.7 pp). Changes were high among partial dual-eligible (difference = 35.5 pp; 95% CI, 34.9-36.1 pp; 134.7% increase) and fully dual-eligible beneficiaries (difference = 22.8 pp, 95% CI, 22.5-23.1 pp; 98.0% increase). Among the 53, 366 beneficiaries enrolled in MA in 2021, 37,439 (70.2%) continued with their contract, 11,730 (22.0%) switched contracts, and 4,197 (7.9%) switched to TM by 2022. When analyzed alongside the characteristics of MA enrollees with ESRD in 2021, those in 2022 were more likely to be in contracts with lower premiums and with a rating of 4.5 stars or higher.

And overall, the percentage of beneficiaries with ESRD that were enrolled in MA increased by 71.7% between the January 2020 and December 2022 timeframe, and the authors note that “few beneficiaries switched from MA to traditional Medicare.”

Overall, the investigators concluded that, “In this cross-sectional time-trend study, we found that among Medicare beneficiaries with ESRD benefits, MA enrollment continued to increase in the first two years of the Cures Act, albeit relatively smaller in magnitude compared with the first year. Black, Hispanic, and American Indian or Alaska Native beneficiaries and those with any dual Medicare-Medicaid coverage continued to enroll MA plans at substantially higher rates in the second year of the Cures Act, highlighting the need to monitor the equity of care for patients with kidney failure as they transition to managed care.”

References

1. United States Renal Data System. 2020 USRDS annual data report: epidemiology of kidney disease in the United States. National Institutes of Health: National Institute of Diabetes and Digestive and Kidney Diseases. 2020. Accessed August 6, 2024. https://usrds-adr.niddk.nih.gov/2020

2. Patzer RE, McClellan WM. Influence of race, ethnicity and socioeconomic status on kidney disease. Nat Rev Nephrol. 2012;8(9):533-541. doi:10.1038/nrneph.2012.117PubMedGoogle ScholarCrossref

3. Nguyen KH, Thorsness R, Swaminathan S, et al. Despite national declines in kidney failure incidence, disparities widened between low- and high-poverty US counties. Health Aff (Millwood). 2021;40(12):1900-1908. doi:10.1377/hlthaff.2021.00458PubMedGoogle ScholarCrossref

4. Vart P, Powe NR, McCulloch CE, et al; Centers for Disease Control and Prevention Chronic Kidney Disease Surveillance Team. National trends in the prevalence of chronic kidney disease among racial/ethnic and socioeconomic status groups, 1988-2016. JAMA Netw Open. 2020;3(7):e207932. doi:10.1001/jamanetworkopen.2020.7932

5. 21st Century Cures Act, HR 34, 114th Cong (2015). Pub L No. 114-255. Accessed August 6, 2024. https://www.congress.gov/bill/114th-congress/house-bill/34/text

6. Centers for Medicare & Medicaid Services. Medicare and Medicaid programs; contract year 2021 and 2022 policy and technical changes to the Medicare Advantage program, Medicare prescription drug benefit program, Medicaid program, Medicare cost plan program, and programs of all-inclusive care for the elderly. Federal Register. January 19, 2021. Accessed August 6, 2024. https://www.federalregister.gov/documents/2021/01/19/2021-00538/medicare-and-medicaid-programs-contract-year-2022-policy-and-technical-changes-to-the-medicare

7. Nguyen KH, Oh EG, Meyers DJ, et al. Medicare Advantage Enrollment Following the 21st Century Cures Act in Adults With End-Stage Renal Disease. JAMA Netw Open. 2024;7(9):e2432772. doi:10.1001/jamanetworkopen.2024.32772