EXPERT DESCRIPTION
We spoke last week with a former General Manager with about ten years of experience for 50+ outpatient dialysis centers in the Cincinnati area. He has had full P&L responsibility for clinics offering HD, PD, and HHD. He was also involved in developing innovative approaches to treatment of CKD.
Overview
We have been skeptical that DVA and other dialysis providers will be able to retain the same level of commercially insured population in states that have passed or are considering legislation to limit third-party premium assistance. Our view has more to do with information exchange on options than it does the Medicare reimbursement levels imposed by state bills like AB290. Our contact confirmed our view:
Field Notes
- Nephrology practices are typically three to five doctors and there is no insurance specialist on staff to educate about options.
- Patients that crash into dialysis are unaware of insurance options and need to make a number of life altering decisions before they can be educated on coverage.
- The first decision a patient faces is whether they can keep working or if they should go on disability.
- The second decision a patient must make is whether or not they should go on home or in-clinic therapy.
- These life decision have to be made in a very short window while the patient is being stabilized.
- Once a patient has determined whether or not they can work and which modality of treatment the plan to use only then can insurance be discussed.
- Insurance decisions are guided by Social Worker or Insurance Manager who present options.
- Medicare Part B is presented as having a 20% percent co-pay, but DVA's tendency to waive or not press collection is usually not advertised.
- If patient does enroll in Part B, the company will make a limited effort to collect (three letters) and then send to bad debt (where reimbursement may be available directly from Medicare).
- COBRA is available for 29 months for patients on an SSI disability.
- If patient enrolls in COBRA, they are directed to National Kidney Fund website for premium assistance.
- Learned from the experience with ACA exchanges that dialysis operators need to not be so influential in determining coverage.
- California State Law (AB290) requires that AKF provide notification of premium assistance that would likely restrict dialysis operators' push for commercial coverage out of concern for coverage denials likely disrupting care.
- When possible, network negotiations would probably include circumstances under which commercial payers will permit third- party premium support.
- Treatments costs run at $220-230 per instance.
- Commercial rate is probably about $500 per instance.
- DVA has played around with commercial rate disclosures over the years in order to become more "street friendly."
- DVA and ARA are looking toward Medicare Advantage opportunity as the solution to chasing commercial reimbursement.
Emily Evans
Managing Director – Health Policy
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