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AHIP, Blue Cross, SEIU Seek Action on Dialysis 'Gaming'

News  |  By John Commins  
   April 17, 2018

Insurers, unions, consumer groups urge CMS to re-issue a rule on steering in the individual market and prohibit third-party premium assistance payments made by a financially-interested party.

An unlikely ad hoc group of insurers, businesses, unions, and consumer groups want the federal government to crack down on what they say is the inappropriate steering of Medicaid and Medicare-eligible patients with end stage renal disease into higher-paying commercial coverage.

The group said dialysis providers are "gaming" a provision in the Affordable Care Act that allows them to provide premium assistance for patients enrolled in Exchange plans through a "financially interested third party – the American Kidney Fund."

In exchange for the premium assistance, the dialysis providers collect higher reimbursements from commercial plans, even though the patients are Medicare- or Medicaid-eligible.  

"What may appear to be innocent assistance to a patient, may in fact be an effort to change that individual’s coverage and caregiving in a way that benefits the third party or others, and not the patient," the ad hoc group said in a joint letter to Health and Human Services Secretary Alex Azar.

American Kidney Fund President and CEO LaVarne A. Burton said the letter to Azar is the latest shot in a long-term, coordinated "discrimination strategy against ESRD patients."

"It’s appalling," Burton said. "The real steering playbook is outlined in today’s letter spearheaded by insurers, employers and labor unions: let’s get these people off employer-provided insurance and let’s push them onto the government rolls whether that works for them or not."

The letter to Azar was signed by groups including America’s Health Insurance Plans, Blue Cross Blue Shield Association, Families USA, National Partnership for Women & Families, National Association of Wholesalers-Distributors, and Service Employees International Union.

The group has called on the Centers for Medicare & Medicaid Services to re-issue its rule on steering in the individual market and prohibit third-party payments made directly or indirectly by a financially-interested party. They also want policymakers to protect the employer market from inappropriate steering.

"This gaming of the Affordable Care Act’s guaranteed issue rules generates significant profit for dialysis providers engaged in these schemes. J.P. Morgan estimated that the return on 'charitable' donations by dialysis providers to the American Kidney Fund likely exceeds 500%," the letter said.

In 2016, J.P. Morgan reported that 6,400 Qualified Health Plans purchased through the AKF drove an estimated $1.7 billion in adverse selection. This steering into the employer market generates $450 million a year in operating income for one dialysis provider that the letter did not identify.

"When third parties with conflicts of interest and who gain financially intervene in the provision of health insurance benefits in a manner that changes the financial balance inherent in the relationship between payers and plan beneficiaries, to the detriment of the healthcare system, the results can be adverse for the individual being assisted, for other plan beneficiaries, and for the sustainability of commercial health plans as a whole," the letter said.

On Tuesday afternoon, AKF sent a rebuttal letter to Azar that accused the health plans, business groups, unions and consumer groups of "misleading statements, omissions, half-truths and outright falsehoods."

"The letter has one true purpose: to limit the health coverage options of people with kidney failure by forcing them off private insurance and onto government health programs," the AKF letter said.

AKF Responds

Here is Burton's entire statement:

"For years, if not decades, some very profitable business groups and health insurance providers have tried and pursued a discrimination strategy against ESRD patients. It’s appalling.

The real steering playbook is outlined in today’s letter spearheaded by insurers, employers and labor unions: let’s get these people off employer-provided insurance and let’s push them onto the government rolls whether that works for them or not.

Unfortunately, many times, only when people have a personal experience (family or friend) with ESRD do they realize the difficult health care decisions patients have to make. To the powerful groups that spearheaded this letter, ESRD patients are a cost that they want shifted elsewhere. To us, they are men, women, husbands, wives, mothers and fathers who deserve the dignity to have the health care that best suits their personal and family situation, even if they need charitable help to pay for it.

Our goal is to make health coverage possible for those who can least afford it when they get kidney disease. With very few exceptions, these are patients with little to no meaningful assets. Certainly not enough to afford health care without tremendous out-of-pocket costs. We help patients with any type of insurance plan they’ve chosen, public or private. It’s ironic that the same insurers who say all ESRD patients belong on Medicare are, at the same time, denying charitable premium assistance that allows Medicare patients to afford the Medigap plans that protect them from personal financial ruin.

These groups don’t understand what these patients experience. They just look at cost and say it should be someone else’s problem to bear. 

Healthcare coverage cannot just be for healthy people. This letter should send a chill down the spine of every person with a chronic disease. Which disease will be rejected by insurers and employers for health coverage next--cancer, diabetes, obesity or asthma?  Because they won’t just stop with kidney failure.  

This outright discrimination against ESRD patients, who are disproportionately members of minority groups, has to stop. It’s a life and death situation, and like previous Administrations, Congresses and courts, we believe Secretary Azar will reject this cynical effort to deny health coverage to people who need it most."

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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