When patty morris developed kidney disease a few years ago and was seriously ill, she couldn’t drive until dialysis.
Her late husband, who is blind, was also ill. With no other options, the South Side resident temporarily moved to a nursing home twice for the life-saving therapy she had to undergo several times a week.
Although Morris, 71, has not needed dialysis in over a year and is currently living independently, she fears what could happen if her kidney disease once again progresses 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 her that included transportation benefits, she signed up.
In addition to transportation, Morris likes the Medicare Advantage plan through IU Health comes without a co-payment for dialysis if she needs it again and without a 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 past $30 on drugs. Now, her benefits include dental and vision care coverage.
“No other insurance offers anything for patients with kidney disease,” Morris said. “It’s a wonderful program…I really thought it was a gift because it meets all my needs.”
The new plan can meet more than individual needs, IU Health officials say. According to Centers for Disaster Control and Prevention.
To enroll in the plan, members must be eligible for Medicare, be enrolled in Medicare Part B, which provides outpatient medical coverage, and live in one of nine Central Indiana counties. Enrollees who are cared for by a participating nephrologist, who belong to the IU Health Plans Care Management Program, and who have reached chronic kidney disease stage three or beyond receive additional benefits.
The goal is to break even
A collaboration between IU Health insurance experts and kidney disease physicians, the IU health plan focuses on providing benefits to help beneficiaries slow disease progression and avoid medical crises that require costly hospitalizations.
“We did the math,” said Ed Lee, the IU Health Plans Medicare Advantage product leader. “The goal here is not to make money at all, but to break even. If we can remove many of the barriers preventing patients from getting the healthcare they need, the money will balance out. … The things that will keep you healthy, we’re trying to keep that cost low.”
IU Health officials say they know of only one other plan in the country, for Arizona patients, which like this targets advanced kidney disease.
The average patient takes
a dozen drugs
For years Dr. Brent Miller, Health UI Clinical Head of Nephrology, has seen his patients struggle to afford the high costs of kidney care treatment.
Some cannot afford the cost of medication – the average patient with kidney disease takes a dozen medications. Some cannot afford the 20% cost of dialysis that Medicare does not cover, which on average is about $850 a month, causing them to skip sessions and go to the hospital.
Others can’t afford the co-payment to see a specialist or don’t have transportation to get to their dialysis or appointments.
“The pressure point for each patient is a little different,” Miller said. “Their overall cost of care is very expensive. … I hadn’t realized this was happening in my waiting room, but I have people who are stressed and in tears because of a $25 co-pay to see me.”
45K in Central Indiana
have kidney disease
About 250 people had signed up for the plan when Medicare Advantage enrollment ended earlier this month.
Up to 45,000 people in the region may have moderate kidney disease, but many of those people don’t necessarily know at this point that they’re on the path to kidney failure, Miller said.
The initial small number of enrollments does not concern Miller, who said the hope is to expand the program in the future and thus avoid the need for dialysis for as many people as possible.
“I’m okay with it being a relatively small program from the start because it’s so innovative,” he said. “It’s actually taking care of people, so I want to make sure we’re doing it right.”
Copays can deter
care people
Over the past decade, Medicare Advantage plans, which are offered by private insurers rather than the government, have grown in popularity, said Kosali Simonprofessor emeritus at O’Neill School of Public and Environmental Affairs to Indiana University Bloomington.
Traditionally, patients with end-stage kidney disease were not eligible to enroll in these plans, but in 2021 Medicare changed those rules.
Now, it makes sense for a benefit plan to get rid of as many co-pay requirements as possible in an effort to encourage people to seek preventative care rather than wait for a medical crisis, said Simon. Health economics research has shown that, in general, even the smallest copayment can discourage people from seeing a doctor regularly.
“No matter what $1 or $20, as long as I am asked to pay something,” she says, “even though long-term preventative care will save me a lot of pain and expense. … I just can’t go for health care that might have resulted in an earlier diagnosis if I feel like I have to pay out of pocket.”
The plan carries a $90 co-payment for emergency care and $295 co-payment 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 blockers and mRNA therapies, both of which are expensive, he said. Sharon PearceSenior Vice President of Government Relations for the National Kidney Foundation. Patients on the plan who use a preferred retail pharmacy will pay $37 per month for two of the sodium glucose blockers listed on the plan formulary, IU Health officials said. The other type of therapy remains experimental and is not widely available outside of clinical trials.
The future may see similar plans
for those who have other conditions
In the future, insurers may target other conditions for similar programs that emphasize the value of care provided and disease outcomes rather than fee-for-service. Heart failure and diabetes are two conditions that could be ripe for such programs, Miller said.
For now, however, IU health plans are focused on making the new kidney care program a success. Over the coming year, IU Health officials will pay close attention to whether they should receive benefits or if any of those already offered do not appear to be of much use to those participating in the plan, said Melissa MorseClinical Program Manager at IU Health Plans.
Overall, however, Morse said the hope is that any additional benefits offered will result in healthier patients who don’t require expensive hospital care.
“Economically and for the health of the patient, we better pay for these things and keep the patient out of the hospital and keep the patient healthy,” she said.
