Supreme Court ruling on dialysis lays groundwork for coverage limits

The Supreme Court’s decision, which gave the green light to private health plan limited dialysis coverage, could pave the way for other insurers to cut costs for kidney and other Medicare-covered treatments.

The High Court dismissed a complaint about low compensation from an employer’s health plan for dialysis, which the plaintiff claims discourages providers from joining his network and effectively encourages insurers to enroll in Medicare instead.

This legal solution offers a scenario that other group health plans could follow by designing benefit packages in a way that encourages people with end-stage renal disease to opt out of private insurance in favor of Medicare, which is available to everyone with chronic kidney disease, regardless of age. . And the consequences can go beyond dialysis patients.

“This is a precedent that could have far-reaching implications that could affect not only people with kidney failure and those in need of treatment, but potentially other benefits of Medicare,” said Dr. Joseph Vassalotti, chief medical officer of the National Kidney Foundation and professor. at the Icahn School of Medicine at Mount Sinai.

If more insurance companies adopt reimbursement policies similar to Marietta Memorial Hospital’s employee health plan and more people switch to Medicare, dialysis centers could close because a public concern doesn’t allow them to pay enough, Vassalotti said. On Tuesday, the Centers for Medicare and Medicaid proposed a 3.1% increase in the Medicare rate for dialysis providers in 2023.

According to the latest data from the US Kidney Data System, 37 million people in the US have kidney disease, and 97% of those who develop the disease are on dialysis.

According to the US Renal Data System, the annual cost of treating end-stage renal disease in 2019 was $53,717. Patients with chronic kidney disease often have several other conditions such as diabetes, heart disease, and lung disease. Many of them are elderly, frail and face socioeconomic barriers to accessing health care.

Medicare pay-for-ESRD members must pay 20% of their dialysis costs. Beneficiaries can purchase additional policies, although some states limit the availability of these plans to people under 65. Beneficiaries can also choose Medicare Advantage plans, which have more limited networks than traditional Medicare, but also require a lower cost share for dialysis.

From 2015 to 2018, 13% of patients with chronic kidney disease only had private health insurance, according to the US Renal Data System. Nearly 37% were enrolled in both private plans and Medicare, and 37.5% were on Medicare only.

“No one dies in the emergency room while waiting for coverage. Medicare will pay,” said Jen Jordan, a Medicare Secondary Payer Act attorney. “The only fear I would have is that the plans might be more inclined to write out more simple benefits now that they know the Supreme Court is upholding that outcome.”

In a ruling released Tuesday, the high court dismissed a 2018 lawsuit from dialysis provider DaVita that challenged Ohio’s Marietta Memorial Hospital employee benefit plan for employees with end-stage renal disease.

According to DaVita, the plan violates the Medicare Secondary Payer Act, which requires the state program to reimburse only for services not covered by members’ other health insurance. Under federal law, employer-sponsored health insurance plans must cover workers with kidney failure for 33 months before Medicare becomes the primary payer.

But the Supreme Court ruled 7-2 that the plan is legal because it doesn’t explicitly distinguish between benefits for people with and without chronic kidney disease. Judges Elena Kagan and Sonia Sotomayor disagreed, writing that ambulatory dialysis is a “nearly ideal” indicator for diagnosing end-stage renal disease, making the plan discriminatory against these patients.

“Congress will have to fix the statute that the court violated,” Andrew Conkling, board president of industry-backed advocacy organization Dialysis Patient Citizens, said in a press release. “We will return to Congress with other ESRD patient advocates to clear the rules immediately once and for all.”

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