In just the past couple of days, I’ve learned some interesting things about health insurance companies. One is that under the Federal ERISA law (Employee Retirement Income Security Act) of 1974, individuals are no longer allowed to win damages if they sue health insurance companies–they can only win the amount of the unpaid claim.
What this means in practice is that they have nothing to lose by turning you down. If they say “no” to everything, only a fraction of the folks they decline will take any action to get them to pay–so they win. The first answer from a health plan, then, will nearly always be no.
BUT…what health plans hate more than anything else is hospitalization. They make their money by collecting your premiums and paying out as little as possible. Cancer and ESRD are two of the diagnoses that cost them the most. So, the first point to make to them is that longer/more frequent HD cut the hospitalization rate.
Here is a new study showing significantly fewer hospital days in folks treated with nocturnal HD for 2 years vs. a group who stayed on standard in-center. (Bold is mine):
Clin Nephrol. 2008 Jan;69(1):33-9.
Reduction in cardiovascular related hospitalization with nocturnal home hemodialysis.
Bergman A, Fenton SS, Richardson RM, Chan CT.
Department of Medicine, Division of Nephrology, The Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
BACKGROUND: Cardiovascular disease remains the leading cause of death among patients with end-stage renal disease (ESRD). Nocturnal home hemodialysis (NHD) (5 - 6 sessions per week; 6 - 8 hours per session) is a novel form of home-based renal replacement therapy, which has been shown to improve several cardiovascular risk factors. The impact of NHD on hospitalization rate has remained unclear. We hypothesized that augmentation of small and middle molecular clearance by NHD would result in a reduction of dialysis related or cardiovascular specific hospitalizations. METHODS AND RESULTS: In this controlled cohort study, we studied 32 NHD patients (age: 43 +/- 2 [mean +/- SEM]) 1 year before and 2 years after conversion to NHD and 42 CHD patients (mean age: 44 +/- 2) (matched for age, dialysis vintage and controlled for comorbidities) during the same time period. The primary outcome was the change in a composite of dialysis or cardiovascular related admissions rate before and after conversion to NHD. Secondary outcomes included changes in all cause hospitalization rate, visits to emergency, reasons and duration of hospitalization and dialysis-related biochemical parameters. During the study period, dialysis or cardiovascular-related admission rate was stable for the CHD control cohort (from 0.48 +/- 0.14 [baseline] to 0.40 +/- 0.12 [end of study] admission per patient year, p = NS). In contrast, conversion to NHD is associated with a decrease in our composite endpoint (from 0.50 +/- 0.15 to 0.17 +/- 0.06 admission per patient year, p = 0.04). Cardiovascular disease (37%) was the principal cause for hospitalization in the control population. In comparison, vascular access related admission was the primary cause of admission for the NHD cohort (56%), p = 0.001. Of the biochemical parameters, NHD is associated with a decrease in plasma phosphate (from 1.7 +/- 0.1 to 1.3 +/- 0.1 mM, p = 0.01) and an improved control of anemia (from 114 +/- 2 to 122 +/- 3 g/l, p = 0.02). CONCLUSION: Conversion to NHD is associated with a decrease in dialysis and cardiovascular-related hospital admission. The clinical and mechanistic relevance in uremic patients of improved phosphate and anemia management requires further examination.
Who have you talked to at the insurance company? You need to get past the “bean counters” – the folks with no medical backgrounds who just push papers around. Ask for a supervisor, and then a supervisor’s supervisor. See what you can get them to put in writing. If you haven’t read the fine print of the policy, it’s not a bad idea to do that as well–they may not know their own policy.
We are also happy to talk with insurance companies. So, if you can find your way to a real person with a medical background, put them in touch with us.