Kidney Community silent on legislation that massively benefits people with CKD

Cross posted from DSEN

Kidney Community silent on legislation that massively benefits people with CKD and those that provide our care

By Bill Peckham

I don’t usually pay attention to renal industry stock prices and I am suspect of arguments that rely too much on a stock price or the market generally, but I was curious about DaVita’s stock price on news that the House passed the Senate health insurance reform bill and thus, no matter the fate of the reconciliation sidecar, health insurance reform. DaVita’s stock was up 1.29% today, not a big move but still a 52 week high.

I think this in part reflects a sophisticated understanding of how HR 3590, the Patient Protection and Affordable Care Act, will benefit DaVita and all dialysis providers. On the operations side, millions more people will have private health insurance (health insurance companies are also trading at new highs), that means thousands more people will have private insurance paying for their dialysis for the first 33 months that they require treatment. On the care side, people will now be more likely to start dialysis with a fistula because those identified with advanced CKD will be able to buy into high risk pools at the state level starting in 2011; once the insurance exchanges are established in 2014 people will transition off the state high risk pools(PDF).

When I was first diagnosed with CKD I was looking for my first job after college. Those four months between graduation and hearing the CKD diagnosis were the only four months of my life that I did not have insurance. After President Obama signs this bill today’s Bill Peckhams will be able to stay on their parent’s insurance as they transition from school to a career(PDF).

There are many great things for those that are fighting the dull advance of CKD in our society but for those using dialysis, with Medicare Part D, this bill, post reconciliation, acts to close the donut hole and makes other improvements in Part D coverage(PDF). This is in addition to language specific to the reimbursement of dialysis, calling for the GAO to study the inclusion of oral drugs under the PPS.
This legislation does all of this for the kidney community - increases future profits, improves patient health, provides helpful action that will make adding oral drugs to the PPS in the future less risky for CMS and beneficiaries - I thought there must be a big banner of gratitude and thanks on the Kidney Care Partner’s website. Best. Legislation. Ever! Maybe? Nope.

KCP has not a word to say about the biggest victory for the provision of dialysis since passage of the original Medicare entitlement in 1973. The nation’s premier coalition of patient advocates, dialysis professionals, care providers and manufacturers dedicated to working together to improve quality of care for individuals with Chronic Kidney Disease is silent on the most important CKD advocacy win in a generation.

Instead of elaborately thanking Congress for this huge win for better CKD care they’d like you to send Congress a form letter echoing the letter I commented on last week. People have to follow their own heart but in my book thanking people should come before asking for more.

Thanks for the cross-post, Bill. :slight_smile: You WOULD think there might be a ticker tape parade in the renal community, just over the idea of having more folks insured and not Medicare only. So, the silence is interesting! Gary Peterson (Renalweb) has some interesting thoughts about the ramifications of NOT having lifetime limits on insurance policies–and then extending Medicare Secondary Payer (MSP) provisions for ESRD. Think about it–what might that do to providers’ interest in getting as many working, insured folks as possible HOME? They’re already pushing hard, now, so this could be a real game-changer.

Here’s Gary’s PPS comment - I think extending MSP for those who are or are seeking work makes good sense.

The CBO says that this bill will add about 20 million people previously uninsured (or with hoax insurance) to insurance roles (and about 10 million to Medicaid). If those 20 million adults are average how many would be expected to start dialysis in a given year? According to the USRDS ADR the number of people who start dialysis each year is about 350 per million - so in that group of 20,000,000 you could expect 7,000 to start dialysis.

What would have happened before? Beth I’m guessing you’ve answered questions from people in that group every day for as long as I’ve know you. They’re screwed even if they do have enough quarters of work to qualify for Medicare. If they have any income or are not parenting too they will not have access to Medicaid in the vast majority of states. Some units would eat the first few months until Medicare kicked in, there are high risk pools in some states, I have little doubt that many people died. But now those people will have insurance that pays the units way more than Medicare. It’s normal insurance. Reimbursement is not pegged to Medicare.

Seriously why isn’t KCP celebrating?

So, you seem like you’ve actually read the bill (not many have done that!). From what you’ve seen, is there premium protection for folks with preexisting conditions? I know they can’t be dropped, but does that really matter if the insurance companies are still able to charge 10x the usual rate?

I get calls and emails all the time from pateints, family members, social workers, Networks, etc. trying to find ways to help uninsured or underinsured people who are US citizens or permanent legal residents pay for dialysis when dialysis clinics refuse to accept them unless they have coverage for dialysis. I’ve heard my social worker colleagues lament the time they have to spend on teleconferences explaining situations that can’t be fixed in the current health insurance system which denies coverage or charges premiums that are too high for people to pay. I’ve heard of providers donating money to AKF to get their patients premiums paid for EGHP (including COBRA) premiums so those providers can recoup many times what they’ve donated for as long as possible.

I don’t know why KCP hasn’t written a big “thank you” letter to Congress for extending insurance protections to 20 million more people as some of them currently have or will eventually develop kidney failure requiring dialysis or transplant. They should be able to collect a higher percentage of the charges with health insurance reform.

Most (but not all) social workers on the CNSW listserv have been cheering about the new legislation that could provide secondary (Medigap) coverage for patients who need it but haven’t been able to get it previously. Other social workers have been warning us that waiting times for healthcare will lengthen with more people entering the system. My response is that if I have to wait for my non-emergency healthcare so someone else who needs urgent healthcare can get treatment, that’s only fair. And if more people have health insurance, perhaps they will be able to see healthcare providers (including advanced practice nurses) for non-emergencies in “doc in the box” clinics at pharmacies and shopping malls reducing my waiting time in the ER if I have an emergency need. Perhaps people won’t be waiting 6-8 hours in waiting rooms and dying prior to seeing ER staff.

I’m glad that children will be able to stay on their parents’ insurance plans longer as I worried about my kids and have friends who have struggled to find insurance for their children who had pre-existing health problems that excluded them from coverage. Now those children will be able to keep their parents’ coverage long enough to get through school and get their own jobs with insurance. Hopefully more kids with ESRD will become self-sufficient instead of having to work to prove disability to keep SSI and Medicaid.

I’m thrilled that new law will eliminate caps on lifetime health insurance benefits. This should eliminate the worry that patients have when they see huge monthly charges for dialysis reduce their remaining lifetime benefits by $70-100,000 a month. I’ve opposed extension of MSP primarily because I’ve known and heard of patients who exhausted their commercial health insurance and had to rely on Medicare only. I’ve thought that dialysis providers were either short-sighted in charging so much that patients would be left with Medicare and no commercial secondary coverage or I’ve thought that they must be using actuaries to determine how much they could charge without exhausting benefits before the patient died.

I am concerned about how much insurance companies will raise premiums to compensate for allowing people with pre-existing conditions into the system and eliminating caps on lifetime benefits, both of which will increase their costs and potentially reduce their profits. I suspect the insurance industry will do its best to hide the money they make off healthy people who will now be required to have health insurance and will use it infrequently and they will highlight all the unhealthy people they’ve had to take on and the high cost of their providing healthcare (like dialysis) to justify higher premiums.

I’m also worried that bean-counters in the insurance industry are smart and will figure out ways to get around what should be good things for consumers in the law by choosing to pay fines instead of accepting people with pre-existing conditions that they believe will reduce their profits too much. I’ve heard the fines will be less than the cost of covering some conditions and I suspect that some of those people who may still be excluded will be folks with ESRD.

Some of the changes are years away and there are efforts to overturn the law on constitutional law grounds as well as using the passage of the reform legislation to “kick the bums out” and overturn it that way. Guess we’ll all have to wait and see what happens and try to separate fact from fiction in the messages we hear. Don’t know if I answered your question in my ramblings, but at least I got this off my chest.

There are questions but we’ll start finding out in 2011. The bill includes 5 billion for the high risk pools. When McCain talked about high risk pools his guy thought 7 to 10 billion would cover what they were talking about but that was without the expansion of Medicaid. Opening up Medicaid in every state to people who are single or are not currently parenting and are below 133% of the poverty will sweep up a lot of the people who have chronic illnesses, so 5 billion may be enough. The Medicaid piece goes in to effect in 2014 and will be the most likely piece to be scaled back if Republicans were able to retake the levers of power because it would save the federal government money, over the short term, and poor people don’t have much of a political voice.

I think the expansion of Medicaid access will have the most real world impact. Especially in the south where insurance coverage is spotty and poverty is higher. I do not know if this bill will change how much Medicaid pays … if it addresses the variation from state to state. I am assuming no so Medicaid will still be the worst payer for dialysis in many states when primary and won’t pay the 20% when secondary to Medicare. But again, people who today do not now qualify for Medicaid, and who are Medicare nevers, will have a shot at getting treatment. Today I believe they would have to rely on charity care.

As far as the suit by the Attorneys General that won’t impact this legislation beyond potentially requiring a fix. The argument they are making is that because this bill requires someone sitting on a log to get insurance it is not allowed by the Constitution. The Commerce Clause gives the federal government wide latitude but, the suit asks, because the guy isn’t engaged in commerce - he’s sitting on a log - how can the Federal Government require him to take commercial action - buy insurance from a private company - as opposed to regulating the action he can take, regulating the insurance he can buy. The response is that if a bear comes along and bites off his ear he’ll end up at the ER so it is society’s business and thus the Commerce Clause allows the federal government to make sure he has insurance.

So win or loose the bulk of the bill is law. If the courts were to throw out the individual mandate there are numerous solutions including opt systems. I think as written the states could opt out of the exchanges which would in effect opt them out of preexisting conditions coverage. The individual mandate is how MA structured their system and that has withstood court challenges. The idea that this will be repealed is farcical.

The bill includes limits on premiums for the “essential insurance package” (PDF LINK) “Limits on Premiums: The sliding‐scale credits limit individual family spending on premiums for the essential benefit package to no more than 2.0 percent of income for those with the lowest income and phasing up to no more than 9.5 percent of income for those at 400 percent of poverty.” The essential insurance package is what I can’t find a complete description of does it include immunosuppressant drugs? I think so but can’t say for sure.

Beth I don’t think the new law speaks to the Medigap issue - access to Medigap insurance for those with Medicare due to disability or ESRD. I think the Medigap issue was in the House bill - I’d love to be wrong on this one.

Again, if this bill is so great, why was it written until after the election of 2012? My guess is that their thinking is Obama and the Democrats will not have to face the wrath of the voters. If the bill is so great, why not institute it now and save all of that money, yet, they are waiting until after the 2012 election? Obama and the Democrats have made claims that “People are dying.” So, if they are dying, why are they waiting until after the 2012 election? I agree with Bill that the stock prices of the various dialysis companies and health insurance companies rose just after Obama signed the bill. Obama claimed, “That the health insurance companies have run roughshod over the American people.” Yet… The stock prices went up after he signed this health bill. It is a strange way to punish these companies by lifting their stock prices.

The government has never tried to force one American citizen to buy a product from another American citizen, that type of requirement is not found in the U.S. Constitution, anywhere. In other words, judges are using their personal opinions to legislate from the bench. To legislate from the bench using liberal or conservative activism is a dangerous precedent. Judges do not have the right to force their personal beliefs on any American citizen, regardless of their political beliefs. The courts have found “rights” and given the government enforcement powers that are found nowhere in the Constitution. If you are not going to enforce the law, take it off the books.

The giving of any government “freebie” is not worth the cost of liberty. Rightly so, many dialysis patients complain about the actions of the dialysis clinics. However, if you think that is bad, wait until you see the control freak mentality of the government. Medicare denies many more claims than private insurance. I know of a gentleman in my dialysis clinic and Medicare denies things that he needs all of the time, never have had that problem with private insurance.

The public is going to be furious when they see their premiums rise by 300 percent, in other words, there is no free lunch. The profit margin of the health insurance companies is 3 percent per year. In contrast, the average profit for a corporation is 6 percent per year. The profit margin for DaVita is 5.8 percent according to their public filling. In speaking with many hard math individuals, they have stated that you cannot add millions to the insurance rolls and cut costs.

Wall Street Journal
Massachusetts State Treasurer Timothy P. Cahill:

White House Senior Adviser David Axelrod hailed the Massachusetts health-care program as “the template” for the national health-care reform legislation the president signed into law earlier this week. That should be cause for serious concern about this law’s ability to improve our health-care system at an affordable cost.

As state treasurer, I can speak with authority about the Massachusetts pilot program. It has been a fiscal train wreck.

The universal insurance coverage we adopted in 2006 was projected to cost taxpayers $88 million a year. However, since this program was adopted in 2006, our health-care costs have in total exceeded $4 billion. The cost of Massachusetts’ plan has blown a hole in the Commonwealth’s budget. Just last Thursday, Gov. Deval Patrick’s office announced a $294 million shortfall related to health-care costs.

If not for federal Medicaid reimbursements and commitments from Washington to prop up this plan, Massachusetts would be broke. The only reason MassCare has survived is that we have been repeatedly bailed out by the federal government. But that raises the question: Who will bail America out if we implement a similar program?

While everyone should have access to affordable health care, our experience in Massachusetts tells us that the new federal entitlement will burden future taxpayers with unfunded liabilities they cannot afford. Health-care inflation will continue. Mandates will increase insurance premiums. And the deficit will reach frightening levels as the law’s costs greatly exceed the projections of its advocates.

As lawmakers push for changes in the bill, they should start by being honest about its costs and focus on making health care more affordable without bankrupting the country.

Mr. Cahill is the state treasurer of Massachusetts. He is currently running as an independent for governor.

Rep. Dingell Says ObamaCare Will Eventually ‘Control the People’

In their own words, Rep Dingell says that ObamaCare will be used to Control the People. My fellow dialysis patients, does this sound like any group of people that are currently in your life that you hate their attempts to control you?

There’s no question that this bill is flawed, NDXUFan12. I agree with you that an individual mandate to buy a private product is appalling, and that MA was a bad state to model this bill after–Hawaii would have been a far better choice. Perhaps if the Republicans had tried to be helpful instead of just obstructionist, they would have come up with something better.

Many provisions of this law roll in over a period of up to 4 years–largely because it takes time to do things like set up insurance exchanges in 50 states with 50 different sets of laws. MOST complex bills don’t go into effect right away.

Regardless, this bill has now been signed into law. I suspect there will be a number of tweaks to it–and it’ll be interesting to see what the costs really DO look like and whether better premium protections will be put in place. I would still very much like to see a single payer system–or at least a public option to ensure competition. Who knows?

Okay, you’ve had your chance to comment in general about this bill. Please note that any further posts you make must be relevant to the topic of HOME dialysis. If they are not, I will delete them. This is not a forum for general political discussion, even of the healthcare bill.

In response to Bill’s question about the silence of the kidney community related to the recently passed health reform legislation, I received an email from the National Kidney Foundation on Friday. I searched on the NKF site and found the message below at I wouldn’t be surprised to see other comments from the kidney community as organizations have time to review and digest the provisions.

[I] Health Care Reform Update

With Senate approval of health care reform on March 25, 2010, we wanted to highlight some of the provisions contained in the underlying bill and in the corrections bill (or “reconciliation bill”). (The legislation signed by President Obama on March 23, 2010 was the underlying health reform bill and identical to what the Senate passed on December 24, 2009; the corrections bill made changes to the underlying bill, under agreement with House and Senate leaders.)

The National Kidney Foundation (NKF) did not advocate for or against a specific health care reform bill throughout the process. However, we signed various letters of support on specific provisions (such as eliminating lifetime benefit caps) that were coordinate by coalitions and organizations. We believe that the legislation will benefit Americans with kidney disease or at risk of developing it. Here are some of the well-known features of the health care reform package that should have a positive impact on the population we serve.

1- Enhanced access to health insurance for individuals who are identified as having pre-existing medical conditions (including living organ donors) and who have been barred from coverage, or who could only obtain health insurance with premiums they cannot afford.

2- Elimination of annual and lifetime caps on the cost of services that health insurance will cover. (This could ensure continued access to care and to all treatment options for individuals who have been on dialysis for several years and received two or more kidney transplants.)

3- Reduction in out of pocket expenses for Medicare beneficiaries who have prescription drug coverage through Part D, by closing the “coverage gap” or “donut hole” by 2020, beginning next year.

4- Health insurance premium assistance for individuals or families earning less than 400% of Federal Poverty Level (approximately $88,000 a year for a family of four).

5- An estimated 31 million fewer Americans will be uninsured by 2019 than what would have occurred without reform, resulting in 94% of non-elderly having coverage (this estimate excludes unauthorized immigrants).

6- Prevention services expanded to include coverage of annual wellness visits.

7- Most coinsurance requirements for Medicare prevention services and wellness programs are eliminated.

8- Medicare Accountable Care Organizations created to better coordinate care.

Many of you monitored our efforts to expand Medicare coverage of immunosuppressive drugs for kidney recipients. NKF pursued a concerted effort, with many other organizations representing transplant candidates, recipients, and health care professionals, to leverage the health care reform movement in order to obtain relief from the 36 month limitation on Medicare coverage of the medications needed to prevent transplant rejection. The initiative bore fruit when a provision to expand Medicare coverage for these expensive immunosuppressive medications was included in the health care reform bill approved on the floor of the U. S. House of Representatives in November, 2009. However, the immunosuppressive provision was not contained in the Senate passed bill in December, nor was it included in the “corrections” or reconciliation package that the Senate approved on March 25, 2010. Nonetheless, we are optimistic this is only a temporary setback, as evidenced by the House support in November.

We are committed to pursue every opportunity, whether this year or next, to achieve this extension of Medicare coverage for transplant medications. The gradual expansion of Medicare benefits for transplant recipients over the last 25 years gives us further confidence that we will be able to claim victory in the near future. We hope we can count on every member of the NKF Board of Directors and our professional and patient advocates in our efforts to meet this challenge.

We will monitor the implementation of the health reform provisions to make sure that individuals with kidney disease or at risk of developing it will achieve the maximum benefit from these positive developments. If you have any questions about the legislation, please contact Dolph Chianchiano or Troy Zimmerman
Thank you.[/I]

Here are multiple comparison articles on the heatlh reform legislation, including a summary of the final legislation. BTW, there are exceptions to the mandate for people to have health insurance.

Well it’s something. They kind of bury the lede: [I]We believe that the legislation will benefit Americans with kidney disease or at risk of developing it

[/I]I wrote to ask specifically, why the immunosuppressant drug coverage is still needed.