Medicare Advantage Enrollment Increased Disproportionately In Chain-Owned Dialysis Facilities After The Cures Act

The 21st Century Cures Act, which took effect in January 2021, allowed Medicare beneficiaries with end-stage renal disease to enroll in Medicare Advantage (MA) plans. The dialysis industry is highly concentrated, with two large chains providing 75 percent of Medicare dialysis treatments. Their market dominance allows them to negotiate substantially higher dialysis reimbursements from MA plans than from traditional Medicare, making MA enrollment financially beneficial to them. Applying a difference-in-differences approach to Medicare enrollment and claims data from the period 2017-22, we found that MA enrollment increased by a 5.7-percentage-point higher rate among patients treated in chain-owned facilities relative to those treated in independent facilities after the Cures Act, for an increase of 130 percent of the pre-Cures Act mean within chain facilities. The differential MA growth in chain facilities was larger for racial and ethnic minority, dual-eligible, and rural patients. These findings suggest that the Cures Act may increase the financial strength of chain facilities, with disproportionate increases in MA enrollment among low-income and racial and ethnic minority populations with kidney failure who are treated in these facilities.