Medicare Advantage: Challenges for people with ESRD and proposed improvements

The original purpose of Medicare Advantage (Part C), established as the “Medicare+Choice” program in 1997 and renamed Medicare Advantage in 2004, was to provide an alternative to original Medicare by offering equivalent coverage delivered by private health plans subject to Centers for Medicare & Medicaid regulation. These plans often include supplemental benefits and lower cost-sharing for enrollees while maintaining the same level of coverage as original Medicare (Parts A and B).

Over time, plans grew more aggressive in their marketing of Medicare Advantage products. Many Medicare Advantage plans employ brokers and pay them a commission tied to the number of people they enroll. Congress and CMS in the prior Administration worked together to finalize rules that scrutinize and regulate broker behavior more closely and that cap commissions that may have incentivized aggressive sales tactics.

Policymakers recognized that beneficiaries may encounter unsolicited calls, misleading advertisements, and pressure to enroll, which may result in confusion and hinder an individual’s ability to make informed decisions about what coverage best meets their needs.

In part because of historic high-pressure marketing strategies employed by plan brokers, more than 50% of people on dialysis have opted for Medicare Advantage since the program became available to them in 2021.

In my experience as a patient advocate leader and have had kidney disease myself, I have observed that many times, after signing Medicare Advantage agreements, enrollees with End Stage Renal Disease (ESRD) are unaware of restrictions those agreements imposed on them.

One of the more common and startling discoveries for new enrollees is that they must switch dialysis units, often without the support and guidance needed for them to make a new treatment choice.

Consequently, people who need treatments may confront longer travel times to new dialysis clinics located further from the enrollee’s home and may in some instances be forced to switch doctors. It is extremely problematic that Medicare Advantage plans are not required to offer enrollees a list of convenient dialysis clinics to choose from since CMS does not impose any “network adequacy” requirements on Medicare Advantage plans. I am also aware of many enrollees’ experiences that involve unnecessary emergency department care when no vascular surgeons are available to support their dialysis access.

Medicare Advantage frequently falls short of the goal of providing integrated, seamless care with cost-sharing support and supplemental benefits that original Medicare does not provide.

As the founder and CEO of the Renal Support Network, my hope for Medicare Advantage is that the "market optimism" expressed by some insurance CEOs in recent earnings calls and public statements is coupled with genuine compassion and empathy for enrollees with ESRD. This combination can lead to meaningful improvements in access, coverage, and overall quality of life.

Lori Hartwell is the Founder and CEO of the Renal Support Network (RSN) and a dedicated patient advocate who has personally experienced kidney disease and transplant.