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Managed care leaders who have been watching the rapid expansion of Medicare Advantage (MA) enrollment among patients with kidney failure since the 21st Century Cures Act took effect in 2021 will find a useful data point in a poster presented at the National Kidney Foundation 2026 Spring Clinical Meetings in New Orleans. Adam S. Wilk, PhD, associate professor at Indiana University School of Medicine, and colleagues reported that dialysis patients enrolled in MA in three Southeastern states had significantly lower odds of receiving a kidney transplant referral within one year of dialysis initiation, compared with traditional Medicare enrollees, although differences in subsequent steps did not reach significance after adjustment.
The analysis drew on United States Renal Data System records linked to the Early Steps to Transplant Access Registry for the Southeast (ESTAR), covering 56,775 adults who began dialysis between 2015 and 2021 across Georgia, North Carolina, and South Carolina. The mean age was 60.4 years, 43.8% were women, and 53.5% were Black. The team examined three sequential transplant pathway milestones: referral within 1 year of dialysis initiation, evaluation within 6 months of referral, and wait-listing within 1 year of evaluation start.
Of the cohort, 22,007 received a transplant referral, and 11,256 began the evaluation process. Patients enrolled in MA had a subdistribution hazard ratio of 0.93 (95% confidence interval, 0.89 to 0.97) for receiving a referral, compared with traditional Medicare enrollees. After adjustment for patient- and community-level differences, no significant differences between MA and traditional Medicare emerged for evaluation start or wait-listing. A subgroup analysis showed that patients under age 65 enrolled in MA carried the referral disadvantage.
Wilk attributed the referral gap to prior authorization requirements and network design within MA plans, citing prior Office of Inspector General findings of inappropriate MA prior authorization denials. He suggested that federal regulators may need to set network adequacy requirements for transplant hospitals within MA plan networks and to require public disclosure of network and prior-authorization criteria. Patients and care teams should weigh the access tradeoffs and out-of-pocket protections of MA enrollment when a transplant is on the table, he noted.
