Clinical journal of the American Society of Nephrology : CJASN · 2026
Dialysis Organization Perspectives on the Financial Repercussions of the Expansion of Medicare Advantage.
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Brazier Joan F, Tyler Denise A, Shah Ankur D, Trivedi Amal N, Gadbois Emily A
Аннотация
KEY POINTS: Negotiated contracts with Medicare Advantage resulted in differing reimbursement rates and profit margins depending on the size of the dialysis organization. Small dialysis organizations reported absorbing bad debt and expressed concern about financial sustainability and market consolidation. Dialysis organizations described kidney-related medical care costs as substantial even with Medicare Advantage cost-sharing strategies.
BACKGROUND: Following the 2021 policy change that opened Medicare Advantage (MA) enrollment to all Medicare beneficiaries with kidney failure, MA enrollment among this population has risen sharply. However, little is known about the financial and organizational consequences of this expansion for dialysis providers.
METHODS: Administrative leadership and clinical staff from two large national and four small regional dialysis organizations were recruited to participate in semistructured, in-depth interviews. Interviews were conducted with executive, financial, and clinical staff from January 2022 to May 2024. This descriptive qualitative study analyzed interview transcripts using a modified grounded theory and content analysis approach.
RESULTS: Interviews were conducted with 37 administrative leadership and clinical staff from six dialysis organizations. Three main themes were identified reflecting their experiences managing the fiscal repercussions of MA expansion: ( 1 ) contract negotiations with MA plans were described as complicated, with large dialysis organizations securing more favorable rates and profit margins than small dialysis organizations; ( 2 ) although MA out-of-pocket caps were cost-saving for patients with kidney failure, the expenses before reaching maximums were described by dialysis leadership and staff as a significant financial burden for their patients, often leading to medical debt-a cost that small dialysis organizations reported absorbing as bad debt; and ( 3 ) dialysis organizations expressed concerns around the long-term financial impacts of MA expansion noting high health care costs, MA enrollment trends by their patients with kidney failure, and financial instability amid market consolidation for small dialysis providers.
CONCLUSIONS: MA expansion created uneven financial consequences for large and small dialysis organizations, raising concerns about consolidation, sustainability, and care quality. Ongoing monitoring is needed to ensure that the rapid growth of MA does not compromise the financial stability of dialysis providers or access and quality of care for patients with kidney failure.
BACKGROUND: Following the 2021 policy change that opened Medicare Advantage (MA) enrollment to all Medicare beneficiaries with kidney failure, MA enrollment among this population has risen sharply. However, little is known about the financial and organizational consequences of this expansion for dialysis providers.
METHODS: Administrative leadership and clinical staff from two large national and four small regional dialysis organizations were recruited to participate in semistructured, in-depth interviews. Interviews were conducted with executive, financial, and clinical staff from January 2022 to May 2024. This descriptive qualitative study analyzed interview transcripts using a modified grounded theory and content analysis approach.
RESULTS: Interviews were conducted with 37 administrative leadership and clinical staff from six dialysis organizations. Three main themes were identified reflecting their experiences managing the fiscal repercussions of MA expansion: ( 1 ) contract negotiations with MA plans were described as complicated, with large dialysis organizations securing more favorable rates and profit margins than small dialysis organizations; ( 2 ) although MA out-of-pocket caps were cost-saving for patients with kidney failure, the expenses before reaching maximums were described by dialysis leadership and staff as a significant financial burden for their patients, often leading to medical debt-a cost that small dialysis organizations reported absorbing as bad debt; and ( 3 ) dialysis organizations expressed concerns around the long-term financial impacts of MA expansion noting high health care costs, MA enrollment trends by their patients with kidney failure, and financial instability amid market consolidation for small dialysis providers.
CONCLUSIONS: MA expansion created uneven financial consequences for large and small dialysis organizations, raising concerns about consolidation, sustainability, and care quality. Ongoing monitoring is needed to ensure that the rapid growth of MA does not compromise the financial stability of dialysis providers or access and quality of care for patients with kidney failure.