Critics usually tell the story like this: Commercial insurance pays more for dialysis than Medicare, which covers most patients with end-stage kidney disease (ESKD). Federal law gives patients the right to maintain their commercial insurance coverage for 30 months before exercising their right to participate in Medicare. To maintain the higher reimbursements, dialysis providers participate in a charity, the American Kidney Fund, which pays patient insurance premiums – an agreement approved by the HHS Inspector General. Since the health insurances spread the risk, the dialysis providers reap more reimbursements than they share in the premiums.
2 questions are lost in these accounts. First, why did Congress make the 30 month requirement? (An interviewer for the Freakonomics podcast actually asked this question to an expert – he responded with a joke and the narrator moved on.) Second, why did the Inspector General consent to this practice?
Here is the answer to the first question. The requirement of people with ESKD to enroll in Medicare regardless of age is creating a perverse dynamic in caring for people with chronic kidney disease (CKD). Once an insured’s CKD changes to an ESKD, the insurer may shift the expenses of that sick patient on to taxpayers. This means that the insurer lacks the financial incentive to maintain the patient’s kidney function for as long as possible or to prepare the patient for the transition from CKD-ESKD by creating a fistula, providing information about home dialysis or a preventive transplant. In order to combat the “short-term syndrome” on the part of insurers, Congress in 1981 hooked insurers for some dialysis costs. Over the years, her in-game skin has been increased to 30 months.
We know what happens when a change in coverage is triggered by a deterioration in a patient’s health, exemplified in the worst case by the nursing home repayment phenomenon that plagues people with dual Medicare and Medicaid entitlements. Nursing home care is generally paid at a low rate by Medicaid, but after the patient is admitted to the hospital, he or she returns to post-acute care, which is reimbursed by Medicare at a higher rate. The nursing home benefits from the acute illness and the state is relieved of the costs of long-term care in the post-acute phase, so that both sides are indifferent to high-quality care. The 30 month requirement saves ESKD patients from that purgatory, and no one has suggested an alternative mechanism.
Why did HHS approve the role of providers and the kidney fund in paying premiums? The deterrent effect of the 30-month obligation is lost if the ESKD patient (who typically can no longer work full-time after kidney failure) cannot afford health insurance. During the Great Recession, we learned that access to COBRA is useless without generous subsidies, which is why Congress made a 100% COBRA subsidy for this recent downturn. Without keeping enrollments, ESKD patients would go straight to Medicare, arriving faster and less stable, thereby increasing federal spending.
Fearing that costly ESKD patients or the care providers who cared for them could be verbally abused, Congress added an anti-discrimination provision to the 30 month rule. In recent years, some health care advisors have persuaded a number of employers to disregard this patient protection, while a prominent coalition of employers has lobbied regulators to weaken it. Two federal appeals courts have split over whether protection can be enforced through private litigation. When the people appointed by President Biden arrive at CMS, they will have to deal with this conflict.
We are now facing a critical point in the future of kidney care before ESKD. One way forward holds the promise of a true golden age, with several new kidney preserving drugs entering the market and a bevy of kidney treatment companies using artificial intelligence to identify patients at greatest risk for kidney failure and at high risk Intervene case management to prevent or mitigate delays.
The alternative route is one where the continued defamation of kidney care providers leads to further opposition from payers and political initiatives to lift the 30 month requirement. In this scenario, employers fire the kidney case managers, refuse to report kidney-conserving drugs, and pass an ESKD epidemic to the Medicare program.
The most compelling criticism of dialysis providers is the same criticism so often applied to hospitals and drug manufacturers – health prices in the United States are too high. Economists, payers and policymakers should continue to look for ways to bring prices down without weeding dialysis with superficial and hyperbolic rhetoric.
Most privately insured patients with CKD experience kidney failure between the ages of 50 and 65, and at least one insurer, CareMore, has shown that its intensive treatment for patients with CKD can delay the onset of ESKD by 18 years. The math is simple: the best way for employers and insurers to avoid the cost of dialysis is to invest in retirement, as Congress intended.
source https://dailyhealthynews.ca/a-more-nuanced-view-of-dialysis-providers-gaming-the-rules/
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