Pioneering health plan to help kidney patients control health care expenses

When Patty Morris developed kidney disease a few years ago and was acutely ill, she could not drive herself to dialysis.

Her late husband, who is blind, was also ill. Without any other option, the south side resident moved temporarily to a nursing home two separate times for the life-saving therapy she needed to undergo several times a week.

Although Morris, 71, has not needed dialysis for more than a year and currently lives independently, she fears what might happen if her kidney disease progresses once more to the point of requiring dialysis. So when she heard about a new health insurance plan from Indiana University Health Plans for chronic kidney patients like herself that included transportation benefits, she signed up.

In addition to the transportation, Morris likes that the Medicare Advantage plan through IU Health comes with no copay for dialysis should she need it again and no monthly premium. Previously Morris, who worked for the state until she fell ill with kidney disease, paid a premium of almost $400 a month and spent $30 on medications. Now, she counts dental and eyecare coverage among the benefits she will receive.

"No other insurance offers anything for kidney patients," Morris said. "It is a wonderful program ... I really thought this was a gift because it meets all of my needs."

The new plan may meet more than individual needs, IU Health officials say. They hope it will lead to overall decreased costs of care for patients with advanced kidney disease, a condition that accounts for about 7% of Medicare claims costs, according to the Centers for Disease Control and Prevention.

To enroll in the plan, members must be Medicare-eligible, be enrolled in Medicare Part B, which provides outpatient medical coverage, and live in one of the nine Central Indiana counties. Enrollees who are under the care of a participating nephrologist, who belong to the IU Health Plans Care Management program, and who have advanced to stage three of chronic kidney disease or beyond receive additional benefits.

Goal is to break even

A collaboration between IU Health insurance experts and kidney disease doctors, the IU Health Plan focuses on providing benefits that aim to help the beneficiaries slow the disease progression and avoid medical crises that require costly hospitalizations.

"We did the math," said Ed Lee, IU Health Plans Medicare Advantage product leader. "The goal here is not to make money at all but break even. If we can take away a lot of barriers to patients getting the health care they need, the dollars will balance out. ... The things that will keep you healthy, we try to keep that low cost."

IU Health officials say that they are aware of only one other plan in the country, for Arizona patients, that like this one targets advanced kidney disease.

Average patient takes

a dozen medications

For years Dr. Brent Miller, IU Health's clinical chief of nephrology, has watched his patients struggle to afford the high health costs of treatment for kidney care.

Some cannot afford the cost of medications — the average kidney disease patient takes a dozen medicines. Some cannot afford the 20% cost of dialysis that Medicare does not cover, which on average adds up to about $850 a month, leading them to skip sessions and wind in the hospital.

Others cannot afford the copay to see a specialist or do not have transportation to get to their dialysis or appointments.

"The pressure point for each patient is a little bit different," Miller said. "Their overall cost of care is very expensive. ... I didn't realize this was happening in my waiting room, but I have people that are stressed and tearful over a $25 copay to see me."

45K in Central Indiana

have kidney disease

About 250 people had opted for the plan by the Medicare Advantage enrollment ended earlier this month.

As many as 45,000 people in the region may have moderate kidney disease but many of these people don't necessarily know at this point that they are on the road to kidney failure, Miller said.

The initial small number of enrollees does not concern Miller, who said the hope is to expand the program in the future and by so doing prevent the need for dialysis for as many people as possible.

"I'm OK with it being a relatively small program from the beginning because it's so innovative," he said. "This is actually taking care of people so I want to make sure we get it right."

Copays may dissuade

people from care

Over the past decade, Medicare Advantage plans, which are offered by private insurers rather than the government, have been increasing in popularity, said Kosali Simon, distinguished professor at the O'Neill School of Public and Environmental Affairs at Indiana University Bloomington.

Traditionally, end stage renal disease patients were not eligible to enroll in these plans but in 2021, Medicare changed those rules.

Now it makes sense for an advantage plan to get rid of as many copay requirements as possible with an eye toward encouraging people to seek preventive care rather than waiting for a medical crisis, Simon said. Health economics research has shown that in general even the smallest copay can discourage people from routine doctor visits.

"It doesn't matter whether it's $1 or $20, as long as I'm being asked to pay something," she said, "even if preventive care in the long run will save me a lot of pain and expense. ... I simply may not go seek health care that could have resulted in an earlier diagnosis if I feel I need to pay out of pocket."

The plan carries a $90 copay for emergency care and $295 copay for an ambulance.

In the past five years, two new classes of drugs have been introduced that can help prevent the progression of kidney disease — sodium glucose inhibitors and mRNA-based therapies, both of which are expensive, said Sharon Pearce, senior vice president of government relations for the National Kidney Foundation. Patients on the plan who use a preferred retail pharmacy will pay $37 a month for two of the sodium glucose inhibitors that are in the plan's formulary, IU Health officials said. The other type of therapy remains experimental and is not widely available outside of clinical trials.

Future may see similar plans

for those with other conditions

In the future, insurers may target other conditions for similar programs that emphasize the value of care provided and disease outcomes over fee for service. Heart failure and diabetes are two conditions that could be ripe for such programs, Miller said.

For now, though, IU Health Plans are focused on making sure that the new kidney care program proves a success. Over the coming year, IU Health officials will pay close attention to whether they should any benefits or if any of those already offered appear not to be of much use to those on the plan, said Melissa Morse, clinical program manager at IU Health Plans.

Overall though, Morse said the hope is that all the extra benefits offered will result in healthier patients who do not require costly hospital care.

"Economically and for the health of the patient we are better off paying for those things and keeping the patient out of the hospital and keeping patient healthy," she said.