Study Identifies Concerns About ‘Deceptive’ Medicare Advantage Marketing to Patients With End-Stage Kidney Disease

Choosing between traditional Medicare and any number of Medicare Advantage (MA) plans can be difficult, especially with the advertising onslaught during the nine-week annual open enrollment period — and even more so for patients with end-stage kidney disease (ESKD) who have complex medical needs.

MA was not available to people with ESKD until the 21^st Century Cures Act expanded eligibility on Jan. 1, 2021. Now more than half of those with ESKD are enrolled in MA plans, roughly the same fraction as the Medicare population overall. Researchers wanted to understand the impact of marketing tactics that resulted in such a large increase in a small amount of time.

The mass marketing approach used to advertise MA is pervasive and intensifies during open enrollment, according to the results of a qualitative study published June 17 in JAMA Network Open.

The rapid growth in MA overall in the past decade has been accompanied by a parallel rise in consumer complaints that the marketing of the plans is aggressive, confusing, and overwhelming, with suggestions that nonsubscribers are “missing out” on cash benefits, according to corresponding author Joan F. Brazier, M.S., a project director at Brown University School of Public Health’s Center for Gerontology & Healthcare Research in Providence, Rhode Island, and her colleagues. They referenced a 2023 report that found an average of six to nine Medicare-related advertisements per hour aired on television during the open enrollment period.

For this study, Brazier and her colleagues interviewed 56 executives and staff from eight MA plans, five kidney care management (KCM) companies and six dialysis organizations (DOs) between Jan. 21, 2022, and May 1, 2024. No patients were included.

The research paper reported that leadership and staff from dialysis organizations often considered MA marketing to be deceptive, saying that the plan benefits were often inadequate for their patients. Addressing underlying comorbidities, medication changes, shifts in dialysis modalities as the disease progressed, access to transplantation and availability of palliative care services all are critical for ESKD medical care, they said.

DO interview subjects also reported that many of their patients were switching to MA plans to receive monetary gift cards and supplemental benefits. One DO staffer likened the gift cards to “bribes.” People with ESKD who signed up for MA plans often later switched back after discovering that their nephrologists were out of network or that transplantation centers did not have agreements with the plans, the kidney healthcare professionals told the researchers.

Interestingly, although interview subjects from all types of participating organizations reported on the ethical boundary to not influence personal choice in insurance selection, “this clear line blurs,” the study reports, “over the definitions of marketing, education, and communication about MA products.” Indeed, no one used the term "marketing": MA executives referred to "communications" or "messaging," KCM executives used "outreach," and DO leadership and staff educated patients and developed educational materials.

“As policymakers consider further refining rules around MA marketing practices, they should consider clearly defining ‘marketing,’ ‘communication,’ ‘outreach,’ and ‘education’ to reduce deceptive marketing practices,” the authors write.

Eugene Lin, M.D., M.S.

An invited commentary cautioned that “while it may be tempting to flatten this story into a simple one of plans and organizations maximizing corporate profits,” three subtler points emerged from the interviews:

One, writes Eugene Lin, M.D., M.S., the author of the commentary and an assistant professor at the University of Southern California's Keck School of Medicine and the USC Price School of Public Policy in Los Angeles, is that the MA market “is a patchwork of winners and losers.” The biggest dialysis chains are able to negotiate large markups from MA plans, providing an incentive for their insurance benefit teams to steer patients toward MA, while small, independent DOs lack that power.

Second, some clinical staff expressed clear discomfort at potentially misleading patients, corroborating the broader medical literature showing that their professionalism “can act as a bulwark against maximizing financial profits if detrimental to patients.”

Third, it’s unclear whether MA plans profit from enrolling patients with ESKD given the high markups paid to the large dialysis chains. Before the Cures Act, according to Lin, representatives of MA plans voiced concerns about financial stress that enrolling many patients with ESKD could bring.

No studies have so far compared outcomes in ESKD between MA and traditional Medicare after the Cures Act.

“The unfortunate reality is that patients’ preferences and outcomes are often ignored in favor of financial gain. Those responsible for educating patients often have financial conflicts of interest that do not necessarily parallel patients’ best interests,” Lin concludes, adding, “To ensure that patients are not harmed by the Cures Act, policymakers and researchers should establish guardrails penalizing misleading advertising, monitor outcomes in MA, and investigate why half of patients with ESKD are enrolling in MA.”