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 Table 7.1Prevalent Medicare fee-for-service patient counts and spending for patients aged 65 and older, by diabetes, heart failure, and/or CKD, ESRD excluded, 2016
 Table 7.2Prevalent Medicare Advantage and managed care spending for beneficiaries aged 65 and older, by diabetes, heart failure, and/or CKD, ESRD excluded, 2016
 Table 7.3Prevalent Medicare fee-for-service patient counts and spending for patients younger than age 65, by diabetes, heart failure, and/or CKD, ESRD excluded, 2016
 Table 7.4Prevalent Medicare Advantage and managed care fee-for-service spending for beneficiaries younger than age 65, by diabetes, heart failure, and/or CKD, ESRD excluded, 2016
 Figure 7.1Overall Medicare Parts A, B, and D fee-for-service spending for patients aged 65 and older, by CKD, diabetes, and heart failure, ESRD excluded, 2015 & 2016
 Figure 7.2Overall per person per year spending for beneficiaries aged 65 and older, by CKD stage, ESRD excluded, 2013-2016
 Table AICD-9-CM and ICD-10-CM codes for Chronic Kidney Disease (CKD) stages
 Table 7.5Per person per year Medicare Parts A, B, and D fee-for-service spending for all CKD patients aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2015 & 2016
 Table 7.6Per person per year Medicare Advantage and managed care spending for all CKD beneficiaries aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2016
 Table 7.7Per person per year Medicare Parts A, B, and D fee-for-service spending for CKD patients with DM, aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2015 & 2016
 Table 7.8Per person per year Medicare Advantage and managed care spending for CKD patients with DM, aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2016
 Table 7.9Per person per year Medicare Parts A, B, and D fee-for-service spending for CKD patients with CHF, aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2015 & 2016
 Table 7.10Per person per year Medicare Advantage and managed care spending for CKD patients with CHF, aged 65 and older, by CKD stage, age, sex, race, and year, ESRD excluded, 2016
 Figure 7.3Overall Medicare Parts A, B and D fee-for-service spending for general Medicare population aged 65 and older and for those with CKD, ESRD excluded, 1996-2016
 Figure 7.4Trends in total Medicare Parts A, B, and D fee-for-service spending for CKD patients aged 65 and older, by claim type, ESRD excluded, 2004-2016
 Figure 7.5Total Medicare fee-for-service inpatient spending for CKD patients aged 65 and older, by cause of hospitalization, ESRD excluded, 2004-2016
 Figure 7.6Per person per year Medicare, Medicare Advantage and managed care spending for the CKD patients aged 65 and older, by diabetes, and heart failure, ESRD excluded, 2006-2016
 Table 7.11Overall CKD percentage for Medicare, Medicare Advantage, and Managed Care beneficiaries aged 65 and older, by CKD stage, and year, ESRD excluded, 2006-2016
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Chapter 7: Healthcare Expenditures for Persons with CKD

  • In this 2018 Annual Data Report (ADR), we introduce information from the Optum Clinformatics™ DataMart for persons with Medicare Advantage and commercial managed care coverage. This will provide a more comprehensive examination of the financial costs necessary to provide care to beneficiaries with chronic kidney disease (CKD).
  • Medicare spending for all beneficiaries who had CKD (12.5% of total) exceeded $79 billion in 2016, an increase of 23% from 2015 (Tables 7.1 and 7.3). When adding an extra $35 billion for end-stage renal disease (ESRD) costs (see Volume 2, Chapter 9: Healthcare Expenditures for Persons with ESRD, Figure 9.2), total Medicare spending on both CKD and ESRD was over $114 billion, representing 23% of total Medicare fee-for-service (FFS) spending.
  • In 2016, Medicare spending for beneficiaries with CKD aged 65 and older exceeded $67 billion, representing 25% of all Medicare spending in this age group (Figure 7.1). Medicare expenditures for CKD were 20% higher in 2016 than in 2015 ($55 billion).This was mostly due to an 18% increase in the ascertainment of CKD.
  • Medicare spending for beneficiaries with CKD who were younger than age 65 (8% of total) exceeded $12 billion in 2016, representing 18% of total spending in this age group (Table 7.3).
  • Growth in total CKD spending has primarily been driven by an increase in the number of identified cases, particularly those in the earlier stages (CKD Stages 1-3).
  • Over half of the 2016 Medicare spending for beneficiaries aged 65 and older was for those who had diagnoses of CKD, diabetes mellitus (DM), or heart failure (HF; Figure 7.1).
  • Over 78% of total Medicare spending for beneficiaries with CKD who were aged 65 and older was incurred by the 71% of these patients who also had DM, HF, or both (Table 7.1).
  • Spending per patient-year for those with all three chronic conditions of CKD, DM, and HF was more than twice as high ($39,506) than for beneficiaries with only CKD ($16,176; Table 7.1).
  • Per-person per-year spending for Medicare Advantage enrollees over age 65 and those enrolled in Optum Clinformatics™ managed care over age 65 was slightly higher, at 79% and 123% of the expenditures for FFS Medicare (Table 7.2).
  • For beneficiaries under age 65, spending was somewhat higher in the Medicare Advantage program than in FFS Medicare, both when averaged across all beneficiaries (12% higher) and among all those with CKD (6% higher; Table 7.3).
  • In the FFS Medicare CKD population, Black/African American beneficiaries continued to exhibit higher spending in all disease categories as compared to Whites and those of other races (Table 7.5). However, Blacks with Medicare Advantage had lower spending than patients of other races (Table 7.6).
  • The analysis of expenses for beneficiaries with CKD indicates the effect of cost-containment efforts in this population, and avenues for potential savings. Reduction in expenditures could be achieved through the prevention of disease progression to later stages of CKD, and prevention of the development of concurrent chronic conditions such as DM and HF.

Introduction

Persons with chronic kidney disease (CKD) but not end-stage renal disease (ESRD) often have extensive healthcare needs and frequently face co-existing illnesses. This chapter assesses the overarching financial cost of caring for persons with CKD through comparison of expenditures in three payment systems. As in previous Annual Data Reports (ADR), the Medicare 5% sample was used to determine spending for Medicare fee-for-service (FFS) beneficiaries. In this chapter, we present recent patterns and longer-term trends in both total claims-based spending and spending by CKD status, patient characteristics such as age, sex, and race, and diabetes mellitus (DM) and heart failure (HF) status.

In this 2018 ADR, we add comparable information from the Optum Clinformatics™ DataMart for persons enrolled in Medicare Advantage and through a large commercial managed care organization. The percent of Medicare beneficiaries enrolled in managed care grew from 13% in 2004 to 33% in 2017 (Kaiser, 2017); 19.0 million individuals were enrolled in an Medicare Advantage plan in March 2017. Addition of this dataset makes our assessment of CKD spending significantly more comprehensive, particularly for the CKD population aged 65 and older. Similarly, the addition of commercial insurance data allows more complete assessment of CKD spending, particularly for those younger than age 65, as commercial insurance was the largest source of payment for this group.

While our analyses provide a sound and valid estimate of the costs of CKD to healthcare systems, when interpreting spending levels and trends in these claims data, the impact of potential under-identification should be kept in mind. Unlike ESRD, where determination is straightforward due to the need for renal replacement services, CKD can be under-identified. There may be valid under-recognition that occurs when patients who have impaired renal function have not yet been tested. Claims-based under-identification can also occur when patients who have been tested and identified clinically do not have a CKD diagnosis listed on an insurance claim. Such under-identification makes the determination of the full economic impact of CKD on a healthcare system challenging.

Under-recognition of CKD can affect estimates of CKD-related expenditures in several ways. Identification of persons with CKD using ICD-9-CM and ICD-10-CM (International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification) diagnosis codes will result in an underestimate of total CKD expenditures, as early in the disease process formal diagnoses of CKD are not commonly documented or may not even have been identified clinically (Grams, 2011). Assuming that under-identification occurs most often in the earliest and least costly patient cases, spending estimates per patient per year (PPPY) calculated solely from the claims-based diagnoses of CKD are likely to be biased upwards. To the extent that under-identification is not constant over time, interpretation of trend data for both total and PPY expenditures should be made in this context.

In addition, it is not possible to attribute healthcare expenditures solely to kidney disease with any accuracy; the costs of CKD are influenced by its interactive nature and associations with other chronic conditions such as DM and hypertension (HTN), and with cardiovascular diseases (CVD) such as coronary artery disease, cerebrovascular disease, peripheral arterial disease, and HF. In order to understand better the complexity of how these conditions contribute to costs, we often present and compare results for patients with varying combinations of CKD, DM, and HF.

Similar issues of CKD under-identification are also discussed in this 2018 ADR in the following chapters in Volume 1: Chapter 1: CKD in the General Population; Chapter 2: Identification and Care of Patients with CKD; and Chapter 3: Morbidity and Mortality in Patients with CKD.

Methods

This chapter uses data from three primary sources including beneficiaries of general Medicare, those enrolled in Medicare Advantage plans, and a cohort of individuals enrolled in a commercial managed care plan.

The Medicare 5% sample provides information on FFS beneficiaries aged 66 and older. Roughly 98% of Americans aged 65 and older qualify for Medicare, and as a result, analysis of Medicare data is representative of beneficiaries age 65 and older.

Medicare prescription drug coverage through Part D plans is also included in this chapter. Note that beneficiaries have many options to purchase prescription drugs, so the claims filled through the Part D plan may not represent all medications prescribed to Medicare beneficiaries.

In addition to reporting on the population aged 65 and older, beginning in 2014, we have added information on beneficiaries younger than 65 who generally were Medicare-eligible due to disability. Data from the Optum Clinformatics™ DataMart is presented for those both younger than 65, and 65 and older.

The Optum Clinformatics™ DataMart includes a cohort of individuals with commercial managed care plans. Optum Clinformatics™ data provides paid medical and prescription claims and enrollment information for national participants in the commercial managed care plans of a large U.S. health insurance company. The data was purchased from OptumInsight, and participants are enrolled in both a medical and a prescription plan. There was a complete refresh of data for all years for Optum this year in comparison with last year. Optum also added new claims sources, which contributed to the increase in claim counts and the difference in this year’s counts compared to the 2017 ADR.

The methodology we employed to calculate costs related to CKD (excluding ESRD) utilizes ICD-9-CM and ICD-10-CM diagnosis codes to define the point prevalent CKD cohort. We included only those beneficiaries classified as having CKD on January 1 of each given year, to avoid possible association with acute kidney injury (AKI). How to best integrate the costs of AKI patients into CKD calculations is a continuing area for research, due to the potential for transition from AKI to CKD.

In this chapter, we defined costs as insurance expenditures rather than true economic costs, using claims from Medicare Parts A, B, and D as based on the 5% Medicare sample for calendar years 1996-2016 and from 100% of the Optum Clinformatics™ dataset for calendar years 2006-2016. To account for differences in pricing across health plans and provider contracts, Optum Clinformatics™ applies standard pricing algorithms to claims data. These algorithms were designed to create standard prices that reflect allowed payments across all provider services.

Details of this data are described in the Data Sources section of the CKD Analytical Methods chapter. For an explanation of the analytical methods used to generate the study cohorts, figures, and tables in this chapter, see the section on Chapter 7 within the CKD Analytical Methods chapter. Downloadable Microsoft Excel and PowerPoint files containing the data and graphics for these figures and tables are available on the USRDS website.

Spending for CKD and Related Chronic Comorbidities

Beneficiaries Aged 65 and Older

Fee-For-Service Medicare

Examining FFS Medicare spending reinforces CKD’s reputation as a cost multiplier. Beneficiaries with recognized CKD represent 13% of the point prevalent aged Medicare population, yet accounted for 25% of total expenditures (Table 7.1).

We examined 2016 costs in relation to beneficiaries’ CKD stage, age, sex, race, and concurrent disease, focusing on DM and HF. These conditions, in addition to CKD, represent some of the costliest chronic disease populations for Medicare. For example, HF affects 9% of beneficiaries in the FFS Medicare population, but accounts for 20% of expenditures. Thirty-five percent of overall expenditures were directed toward the 24% of beneficiaries with DM.

In those aged 65 and older, per-person per-year (PPPY) costs were 93% higher for patients with CKD only, versus those with no CKD, DM, or HF ($16,176 vs $8,400). Costs for those with CKD and DM were 54% higher than for those with DM only. Similarly, expenditures for those with CKD and HF were 46% higher than for those with HF alone. For beneficiaries with CKD, HF, and DM, costs were 49% higher than for those with only HF and DM. Overall, people with diagnoses of any condition of CKD, DM, and/or HF accounted for one-third of the Medicare aged 65 and older population, but over half of total programmatic costs.

Table 7.1 Prevalent Medicare fee-for-service patient counts and spending for patients aged 65 and older, by diabetes, heart failure, and/or CKD, ESRD excluded, 2016

Medicare Advantage and Commercial Managed Care Coverage

CKD was also a cost multiplier for individuals 65 and older who were beneficiaries of Medicare Advantage or commercial managed care plans. The Medicare Advantage population was similar to FFS Medicare, with 15% having CKD and those with CKD accounting for 24% of spending. The managed care population had a lower prevalence of CKD (8%), but those with CKD also accounted for an outsized (17%) proportion of spending.

Per-person per-year spending in these populations was somewhat higher than that for FFS Medicare (Zuckerman, 2017). In this dataset, Optum Clinformatics™ Medicare Advantage spending was 79% of those receiving FFS Medicare, with managed care beneficiaries at 123%. Such differences can arise from plan effects (e.g., care management activities of Medicare Advantage plans) or patient selection (e.g., those over 65 with commercial coverage are often still employed). Spending for those with CKD only was 72% ($13,418 vs $7,813) and 132% ($22,124 vs $9,527) higher than for those with no CKD, DM, or HF in the Medicare Advantage and managed care populations.

Table 7.2 Prevalent Medicare Advantage and managed care spending for beneficiaries aged 65 and older, by diabetes, heart failure, and/or CKD, ESRD excluded, 2016

Beneficiaries Younger than Age 65

Fee-For-Service Medicare

For the FFS Medicare population under age 65 only 8% had CKD, but those individuals accounted for 18% of spending. One-fourth had one or more of CKD, DM, and/or HF, accounting for almost 44% of spending for this group (Table 7.3). Much of these expenditures, however, were for those who had DM, at 22% of the population and 34% of spending.

Table 7.3 Prevalent Medicare fee-for-service patient counts and spending for patients younger than age 65, by diabetes, heart failure, and/or CKD, ESRD excluded, 2016

Medicare Advantage and commercial Managed Care Coverage

The Medicare Advantage population under age 65 was similar to the FFS Medicare population. Thirty-three percent of the Medicare Advantage beneficiaries had one or more of CKD, DM, and/or HF, accounting for 49% of spending for this group (Table 7.4). The managed care population under age 65 was much less likely to have CKD, DM, or HF (6%) than the Medicare Advantage population (33%).

For those under age 65, spending was somewhat higher for beneficiaries in the Medicare Advantage program, both when averaged across all beneficiaries (12% higher: $16,358 vs $14,558) and among all with CKD (1.9% lower: $32,571 vs $33,214; Tables 7.3 and 7.4). Consistent with our other findings, average spending for those with CKD was considerably lower (27% lower for those with CKD: $24,214 vs $33,214) in the managed care population than in the Medicare FFS and Medicare Advantage populations.

Table 7.4 Prevalent Medicare Advantage and managed care fee-for-service spending for beneficiaries younger than age 65, by diabetes, heart failure, and/or CKD, ESRD excluded, 2016

Spending for CKD by Stage and Patient Characteristics

Among the FFS Medicare population aged 65 and older, between 2015 and 2016 total spending for Parts A, B, and D rose by $8 billion, to $271 billion. Total spending for CKD patients rose by $11.2 billion, to $67.2 billion (Figure 7.1).

Further, total Medicare expenditures were higher for beneficiaries with CKD than for beneficiaries with ESRD ($67.2 billion vs. $35.4 billion; see Volume 2, Chapter 9: Healthcare Expenditures for Persons with ESRD). Expenditures for beneficiaries with CKD now represent 24.8% of all Medicare Parts A, B, and D non-ESRD spending.

Expenditures increased for all covered groups, but the highest growth rates occurred in those with CKD and DM, followed by all CKD, and then CKD and HF and DM. The spending increase appears to be driven by a rise in the proportion of beneficiaries with recognized CKD (see Table 7.7 and Volume 1, Chapter 2: Identification and Care of Patients with CKD, Figure 2.2).

Figure 7.1 Overall Medicare Parts A, B, and D fee-for-service spending for patients aged 65 and older, by CKD, diabetes, and heart failure, ESRD excluded, 2015 & 2016

All CKD patients 65 and older required increased care as they progressed to later stages of disease (Figures 7.2.a-c; see Table A for CKD definitions). In the FFS Medicare population, PPPY expenditures in 2016 ranged from $19,074 for those in Stages 1-2, to $29,151 for those in Stages 4-5. In the Medicare Advantage population, expenditures increased from $17,756 in Stages 1-2 to $26,314 in Stages 4-5. The managed care population was similar, with expenditures of $27,289 in Stages 1-2 to $35,886 in Stages 4-5.

Group trends in PPPY spending from 2013-2016 were mixed (Figures 7.2.a-c). FFS Medicare saw PPPY expenditures increase 1.7% overall for individuals with any CKD, but the increase was most dramatic for those in Stages 4-5, rising by 6.3%. However, PPPY spending dropped 15% over this period for Medicare Advantage beneficiaries with CKD. Spending for managed care beneficiaries moved without clear patterns, but it should be noted that in 2016 the Optum Clinformatics™ population of managed care enrollees with CKD was relatively small (N=17,864). Overall PPPY spending was slightly higher in 2016 than in 2013, but spending on beneficiaries in Stages 1-2 decreased by 2%, while expenditures on beneficiaries in Stages 4-5 decreased by 15%.

Figure 7.2 Overall per person per year spending for beneficiaries aged 65 and older, by CKD stage, ESRD excluded, 2013-2016

Table A ICD-9-CM and ICD-10-CM codes for Chronic Kidney Disease (CKD) stages

Table 7.5 presents PPPY Medicare FFS spending for Parts A, B, and D services, for beneficiaries with CKD (but not ESRD), by stage of CKD. In 2016, PPPY costs reached $22,369 for FFS Medicare CKD patients aged 65 and older, a slight increase from 2015 ($22,314). The spending was increased slightly across all the CKD stages. During this period, the distribution of identified patient years also shifted towards the less severe and less costly stages. In 2016, costs for beneficiaries with Stages 4-5 CKD ($29,285) were 48% greater than for beneficiaries with Stages 1-2 CKD ($19,737). Although the number of beneficiaries with unknown/unspecified CKD stage increased, this still accounted for one-third of all cases of CKD. The PPPY costs for those unknown/unspecified were similar to the overall CKD population.

Spending for Black beneficiaries with CKD exceeded that for Whites by 9.6%, a slightly increase over the 9.1% disparity observed in 2015. Per capita spending for Whites increased slightly while per capita spending for Blacks stayed the same.

Table 7.5 Per person per year Medicare Parts A, B, and D fee-for-service spending for all CKD patients aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2015 & 2016

Table 7.6 presents overall PPPY spending for Medicare Advantage and managed care beneficiaries with CKD (but not ESRD) by stage of CKD (see Table A for definitions). In contrast to the FFS Medicare population, for these patients spending generally decreased with age and was substantially lower for Blacks than Whites, by 24% for those covered by Medicare Advantage and 28% in the managed care population.This is an area for further research.

Table 7.6 Per person per year Medicare Advantage and managed care spending for all CKD beneficiaries aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2016

Tables 7.7 and 7.8 present PPPY spending for beneficiaries with both CKD and DM. These tables show similar results as in the overall CKD population. Among the 2016 FFS Medicare beneficiaries with these two conditions, PPPY spending for Blacks was $26,168—5.6% greater than the $24,788 incurred for Whites. Yet, spending by Medicare Advantage was 27% lower for Blacks than Whites and 33% lower for the managed care population.

Table 7.7 Per person per year Medicare Parts A, B, and D fee-for-service spending for CKD patients with DM, aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2015 & 2016

Table 7.8 Per person per year Medicare Advantage and managed care spending for CKD patients with DM, aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2016

Tables 7.9 and 7.10 present PPPY spending for beneficiaries with CKD and concurrent HF. The presence of HF greatly increased the costs of care for persons with CKD. Persons with both CKD and HF cost 62% more ($36,291) than the average CKD patient ($22,369). These results were consistent with those seen in the previous tables. In 2016, FFS Medicare PPPY expenditures for Black beneficiaries with both conditions reached $39,825—12.0% higher than the $35,690 PPPY for their White counterparts. In contrast to FFS Medicare, Black Medicare Advantage beneficiaries required 14% less spending than did their White counterparts, and Black managed care beneficiaries 21% less.

Table 7.9 Per person per year Medicare Parts A, B, and D fee-for-service spending for CKD patients with CHF, aged 65 and older, by CKD stage, age, sex, and race, ESRD excluded, 2015 & 2016

Table 7.10 Per person per year Medicare Advantage and managed care spending for CKD patients with CHF, aged 65 and older, by CKD stage, age, sex, race, and year, ESRD excluded, 2016

Over time FFS Medicare beneficiaries aged 65 and older with recognized CKD have accounted for an increasing share of Medicare expenditures, expanding from 5.8% in 2000 to 14.1% in 2008, and 24.8% in 2016. Much of this growth was due to the increased ascertainment of CKD as shown in Volume 1, Chapter 2: Identification and Care of Patients with CKD, Figure 2.2. Persons aged 65 and older with CKD accounted for 2.1%, 8.8%, and 11.2% of the FFS Medicare population in 2000, 2008, and 2016.

Figure 7.3 presents total expenditures on Parts A, B, and D services for Medicare FFS beneficiaries with CKD, DM, and HF. In 2016, expenditures for CKD patients reached $67.2 billion, accounting for 24.8% of the total spending for all FFS Medicare beneficiaries. Care of beneficiaries with CKD and concurrent DM required $38.9 billion in 2016, or 41.5% of the total FFS Medicare spending on DM. Spending on HF in the FFS Medicare population was $55.1 billion in 2016. Of this, $27.3 billion (49.5%) was spent on the CKD patient population with HF. Medicare expenditures for CKD were 20% higher in 2016 ($67 billion) than in 2015 ($55 billion).This was mostly due to an 18% increase in the ascertainment of CKD.Although 2016 represented a change in coding (ICD-9 to ICD-10), the reason for this increase is not known.

Figure 7.3 Overall Medicare Parts A, B and D fee-for-service spending for general Medicare population aged 65 and older and for those with CKD, ESRD excluded, 1996-2016

Most spending for CKD patients was incurred for inpatient and outpatient care, physician/supplier services, and care in skilled nursing facilities. Spending for Part D increased a great deal in recent years. The proportion of total FFS Medicare expenditures required to provide inpatient care was 33% in 2016, while outpatient costs were predictably lower at 12%. Physician/supplier service costs amounted to 23%, spending for skilled nursing facilities was 10%, while spending for Part D reached 13% (Figure 7.4). In the Medicare non-CKD population, these expenditure percentages were 29% to provide inpatient care, 15% for outpatient, 28% for physician/supplier services, and 7% for skilled nursing facility care (not shown).

Figure 7.4 Trends in total Medicare Parts A, B, and D fee-for-service spending for CKD patients aged 65 and older, by claim type, ESRD excluded, 2004-2016

Hospitalization expenditures accounted for a large proportion of spending for CKD. Of the 2016 inpatient hospitalization spending for those with CKD, 23% resulted from admissions to treat infections, and 27% from cardiovascular conditions, with the remaining 50% resulting from all other causes (Figure 7.5).

Figure 7.5 Total Medicare fee-for-service inpatient spending for CKD patients aged 65 and older, by cause of hospitalization, ESRD excluded, 2004-2016

Figure 7.6 illustrates PPPY costs for CKD patients aged 65 and older by the presence of DM and HF. In 2016, PPPY costs for CKD patients varied greatly by the presence of these comorbidities. CKD patients without DM and HF required $18,525 PPPY from FFS Medicare. Those with DM in addition to CKD averaged $22,751 PPPY, and beneficiaries with both CKD and HF cost $29,664. Expenditures for those with all three conditions reached $40,075 PPPY in 2016 for FFS Medicare. Spending was also higher as comorbidities increased in the managed care populations.

Figure 7.6 Per person per year Medicare, Medicare Advantage and managed care spending for the CKD patients aged 65 and older, by diabetes, and heart failure, ESRD excluded, 2006-2016

Table 7.11 shows the distribution of CKD stages by payer. For all payer types, reporting has become more specific since stage specific reported began in 2007, with the percentage of CKD cases of unknown stage declining over time. Nonetheless, over 20% of cases for each payer type were still of unknown stage in 2016. The distribution of cases with reported stage became somewhat less severe over time. The percentage of cases in the Stages 1 & 2 and Stage 3 categories grew between 2007 and 2016. Conversely, despite the increase in stage-specific reporting overall, the percentage of cases in Stages 4 & 5 actually declined.

Table 7.11 Overall CKD percentage for Medicare, Medicare Advantage, and Managed Care beneficiaries aged 65 and older, by CKD stage, and year, ESRD excluded, 2006-2016

References

Centers for Medicare & Medicaid Services (CMS). Medicare & Medicaid Statistical Supplement: 2013 Edition. https://www.cms.gov/Research-Statistics-Data- and-Systems/Statistics-Trends-and- Reports/MedicareMedicaidStatSupp/2013.html. Accessed July 12, 2017.

The Henry J. Kaiser Family Foundation. Medicare Advantage. http://kff.org/medicare/fact-sheet/medicare- advantage. Accessed July 12, 2017.

Morgan G., Laura P., Elizabeth H., Rajiv S., Gary M., Desmond W., and Neil P. Validation of CKD and related conditions in existing datasets: a systematic review. Am J Kidney Dis 2011 January; 57(1): 44-54. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2978782/pdf/nihms219374.pdf

S. Zuckerman, L. Skopec, and S. Guterman. “Do Medicare Advantage Plans Minimize Costs? Investigating the Relationship Between Benchmarks, Costs, and Rebates.” The Commonwealth Fund, December 2017. https://www.commonwealthfund.org/publications/issue-briefs/2017/dec/do-medicare-advantage-plans-minimize-costs-investigating