Viewpoint

Restricting third-party payments discriminates against patients on dialysis

Kidney disease has a frightening way of leveling the playing field – rich, poor, black or white, no one plans for the eventuality of losing the function of an essential organ. Although we know certain demographic groups are affected more frequently than others, for the most part, CKD and kidney failure are scarily indiscriminate with universal impact. When the kidneys go, no matter the size of one’s bank account, the options are the same if active therapy is the chosen route: a transplant or life-sustaining dialysis care.

Although CKD and ESRD do not discriminate, large U.S. insurers are working hard to create a double standard – one that allows wealthy patients who can pay out-of-pocket the right to obtain private health insurance, while prohibiting less affluent individuals from doing the same. It is an effort that undermines patients’ fundamental right of choice and creates a new pre-existing condition exclusion: being poor.

Allen R. Nissenson

Available options

Although there are not a great number of choices when it comes to treating kidney failure, since the creation of Medicare’s ESRD benefit in 1972, Americans have been afforded options when it comes to their insurance coverage. For some, Medicare is the best option; but for others, maintaining private insurance through their employer, COBRA or an individual plan is ideal. Private insurance often provides better, more robust coverage than government programs. Some patients have family members who also require coverage – making it logical to retain one private plan, rather than duplicate cost-sharing requirements across different plans. In nearly half of the states, patients who qualify for Medicare because of ESRD may not be able to access Medigap plans and, therefore, wish to rely upon private insurance, which may have more favorable cost-sharing obligations or expanded coverage. Out-of-pocket costs are high even with Medicare coverage and often run more than $7,000 per year; if patients with ESRD and their family members have separate coverage, this number can be more than double.

Regardless of the reason, historically, patients with kidney failure have been given the right to choose what works best for them and their families, but only for a limited duration of up to 30 months under the Medicare Secondary Payer (MSP) statute.

The option for private insurance coverage has always been there, but if some insurers have their way, it will only be available for the wealthy. The MSP statute already restricts this right and caps the duration for which any health plan must provide for coverage. No matter how long these patients have paid for private health care insurance, they cannot keep it. They must transition to Medicare for primary coverage. This results in a substantial taxpayer subsidy for the insurance plan. Yet they want to push as many patients as possible onto government coverage as soon as possible.

For the rest – Americans who might not be able to readily afford private premiums – insurers are employing questionable tactics to force those patients into Medicare, whether they like it or not. Insurers are asking the government to help by outlawing charitable premium assistance programs – programs that have provided financial assistance to Americans with HIV/AIDS and ESRD for more than 50 years.

For thousands of patients who need help financing care or who would like to maintain private coverage but can’t afford the premiums, charitable premium assistance programs have filled a void. These are crucial in helping patients receive lifesaving care and retain autonomy in selecting the health plan of their choice.

Charitable assistance

The American Kidney Fund, for example, has assisted low-income patients in paying their health insurance premiums for more than 20 years under the federally sanctioned Health Insurance Premium Program, which began in 1997, operating under guardrails provided by the Office of the Inspector General at HHS.

As part of its charitable premium assistance program, AKF has provided premium assistance for Medicare, Medigap, individual and group health care coverage. In 2017, AKF helped more than 74,000 people pay for all forms of public and private health insurance, and more than 60% of the charitable assistance was to help patients pay their premiums for Medicare Part B and Medigap. Another 25% was for employer-provided health plans, including COBRA. Only 12% of patients with ESRD who received assistance from AKF in 2017 were enrolled in a commercial plan, including just 4% who were in Affordable Care Act Exchange plans.

AKF’s charitable assistance allows those who are otherwise marginalized, particularly minority patients, to exercise their right to select a health plan that best meets their needs. It is alarming that health plans want to discriminate against them – merely because they rely upon a charity for assistance rather than an employer, family member or some other form of support. No matter what you call it, the actions of these health insurers are nothing short of discriminatory. Boldly, these insurers are seeking federal approval to disallow this critical program.

It is no secret that, for years, some health insurers have sought to restrict access to insurance in a manner that treats patients on dialysis unfairly. Members of the kidney care community have raised the issue with policymakers – highlighting how health plans sometimes require or incentivize patients with kidney failure to drop their private coverage or make it secondary to Medicare and/or Medicaid before they are required to do so.

Certain exchange plan issuers have misled patients by suggesting that federal law requires patients with ESRD to enroll in Medicare 4 months after a diagnosis. Some have incentivized patients to shift to Medicare by paying the patient’s Medicare co-insurance amounts or other cost-sharing obligations. Others have increased patients’ co-insurance obligations by dropping the plans’ payments to providers to rates at or slightly above the Medicare rates, putting patients in the position of being responsible for paying the remainder of the rates plans negotiated with providers.

Defies logic

Pushing patients off private coverage and into Medicare is wrong and it defies logic that health insurers think the government should allow their discriminatory behavior. In fact, eliminating a patient’s right to select his or her own coverage would have immediate and negative impacts on patients with kidney failure.

For the small number of patients who use charitable premium assistance to maintain commercial coverage, a Medicare-only option could increase financial burden, reduce access to providers of choice, especially for family members, cause disruption in care management, especially for other chronic diseases, and even reduce the chance for a transplant. It has to stop.

For our part, Kidney Care Partners has asked HHS to work with the Office of Civil Rights and the U.S. Department of Labor to enforce antidiscrimination laws to protect patients on dialysis, regardless of their economic status. In a nation that is working hard to reject discrimination on many levels, it is important we seriously address what is happening to some of the poorest patients with kidney failure. We cannot allow people with kidney failure – who face many other obstacles – also to be subjected to inequalities when it comes to life-sustaining care.

Kidney disease has a frightening way of leveling the playing field – rich, poor, black or white, no one plans for the eventuality of losing the function of an essential organ. Although we know certain demographic groups are affected more frequently than others, for the most part, CKD and kidney failure are scarily indiscriminate with universal impact. When the kidneys go, no matter the size of one’s bank account, the options are the same if active therapy is the chosen route: a transplant or life-sustaining dialysis care.

Although CKD and ESRD do not discriminate, large U.S. insurers are working hard to create a double standard – one that allows wealthy patients who can pay out-of-pocket the right to obtain private health insurance, while prohibiting less affluent individuals from doing the same. It is an effort that undermines patients’ fundamental right of choice and creates a new pre-existing condition exclusion: being poor.

Allen R. Nissenson

Available options

Although there are not a great number of choices when it comes to treating kidney failure, since the creation of Medicare’s ESRD benefit in 1972, Americans have been afforded options when it comes to their insurance coverage. For some, Medicare is the best option; but for others, maintaining private insurance through their employer, COBRA or an individual plan is ideal. Private insurance often provides better, more robust coverage than government programs. Some patients have family members who also require coverage – making it logical to retain one private plan, rather than duplicate cost-sharing requirements across different plans. In nearly half of the states, patients who qualify for Medicare because of ESRD may not be able to access Medigap plans and, therefore, wish to rely upon private insurance, which may have more favorable cost-sharing obligations or expanded coverage. Out-of-pocket costs are high even with Medicare coverage and often run more than $7,000 per year; if patients with ESRD and their family members have separate coverage, this number can be more than double.

Regardless of the reason, historically, patients with kidney failure have been given the right to choose what works best for them and their families, but only for a limited duration of up to 30 months under the Medicare Secondary Payer (MSP) statute.

The option for private insurance coverage has always been there, but if some insurers have their way, it will only be available for the wealthy. The MSP statute already restricts this right and caps the duration for which any health plan must provide for coverage. No matter how long these patients have paid for private health care insurance, they cannot keep it. They must transition to Medicare for primary coverage. This results in a substantial taxpayer subsidy for the insurance plan. Yet they want to push as many patients as possible onto government coverage as soon as possible.

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For the rest – Americans who might not be able to readily afford private premiums – insurers are employing questionable tactics to force those patients into Medicare, whether they like it or not. Insurers are asking the government to help by outlawing charitable premium assistance programs – programs that have provided financial assistance to Americans with HIV/AIDS and ESRD for more than 50 years.

For thousands of patients who need help financing care or who would like to maintain private coverage but can’t afford the premiums, charitable premium assistance programs have filled a void. These are crucial in helping patients receive lifesaving care and retain autonomy in selecting the health plan of their choice.

Charitable assistance

The American Kidney Fund, for example, has assisted low-income patients in paying their health insurance premiums for more than 20 years under the federally sanctioned Health Insurance Premium Program, which began in 1997, operating under guardrails provided by the Office of the Inspector General at HHS.

As part of its charitable premium assistance program, AKF has provided premium assistance for Medicare, Medigap, individual and group health care coverage. In 2017, AKF helped more than 74,000 people pay for all forms of public and private health insurance, and more than 60% of the charitable assistance was to help patients pay their premiums for Medicare Part B and Medigap. Another 25% was for employer-provided health plans, including COBRA. Only 12% of patients with ESRD who received assistance from AKF in 2017 were enrolled in a commercial plan, including just 4% who were in Affordable Care Act Exchange plans.

AKF’s charitable assistance allows those who are otherwise marginalized, particularly minority patients, to exercise their right to select a health plan that best meets their needs. It is alarming that health plans want to discriminate against them – merely because they rely upon a charity for assistance rather than an employer, family member or some other form of support. No matter what you call it, the actions of these health insurers are nothing short of discriminatory. Boldly, these insurers are seeking federal approval to disallow this critical program.

It is no secret that, for years, some health insurers have sought to restrict access to insurance in a manner that treats patients on dialysis unfairly. Members of the kidney care community have raised the issue with policymakers – highlighting how health plans sometimes require or incentivize patients with kidney failure to drop their private coverage or make it secondary to Medicare and/or Medicaid before they are required to do so.

PAGE BREAK

Certain exchange plan issuers have misled patients by suggesting that federal law requires patients with ESRD to enroll in Medicare 4 months after a diagnosis. Some have incentivized patients to shift to Medicare by paying the patient’s Medicare co-insurance amounts or other cost-sharing obligations. Others have increased patients’ co-insurance obligations by dropping the plans’ payments to providers to rates at or slightly above the Medicare rates, putting patients in the position of being responsible for paying the remainder of the rates plans negotiated with providers.

Defies logic

Pushing patients off private coverage and into Medicare is wrong and it defies logic that health insurers think the government should allow their discriminatory behavior. In fact, eliminating a patient’s right to select his or her own coverage would have immediate and negative impacts on patients with kidney failure.

For the small number of patients who use charitable premium assistance to maintain commercial coverage, a Medicare-only option could increase financial burden, reduce access to providers of choice, especially for family members, cause disruption in care management, especially for other chronic diseases, and even reduce the chance for a transplant. It has to stop.

For our part, Kidney Care Partners has asked HHS to work with the Office of Civil Rights and the U.S. Department of Labor to enforce antidiscrimination laws to protect patients on dialysis, regardless of their economic status. In a nation that is working hard to reject discrimination on many levels, it is important we seriously address what is happening to some of the poorest patients with kidney failure. We cannot allow people with kidney failure – who face many other obstacles – also to be subjected to inequalities when it comes to life-sustaining care.