I have private insurance through my husband’s employer. I am 53 years old and ordinarily would not qualify for Medicare for quite some time. I don’t understand why, after thirty months on dialysis, I have to rely on Medicare as my primary insurer. And why 30 months? Why not 40 months or 50 months? Frankly, I do not like having to rely on the American taxpayer to pay for my treatment if I already have private insurance THAT MY HUSBAND AND HIS EMPLOYER ALREADY PAY FOR…it seems redundant.
If you are over 65 or do not have private insurance and have esrd, then Medicare should be there for you. But some of us could save the taxpayer money if we could rely more on our private insurance. Is it that the insurance companies lose money on us after 30 months? I’d be really grateful if someone could explain to me the history of this set up. Thanks!
Many dialysis patients who have employer group plans have a limit on how much that plan will pay over their lifetime. Dialysis charges to commercial plans have gone up considerablly over the years so that now some dialysis providers are billing employer plans $80,000 or more a month. At this rate, someone could exhaust their lifetime benefits in their insurance plan with dialysis charges alone. This could leave someone who is a long-term dialysis survivor or transplant candidate with no employer coverage to pay primary or secondary for ESRD care. A study in the 1990s that looked at the effects of extending Medicare secondary payer found that in those who were covered by employer plans, some dialysis patient workers and spouses who were the employees through which a patient had coverage lost their jobs or believed they were otherwise discriminated against in hiring because of the cost of ESRD care. Some were even told that by employers/potential employers.
If you exhaust your lifetime benefit in your employer plan or your husband loses his job and his health coverage and you’re interested in a transplant, you may find it hard to find a program willing to transplant you if all you have is Medicare. Transplant programs believe patients without adequate insurance won’t be able to afford the care and drugs needed to keep the transplant so they rule those who are economically disadvantaged from getting transplants.
Having Medicare limits what the dialysis provider can bill the patient. If you had an employer plan and Medicare and your plan pays 100% of what Medicare allows for dialysis and other dialysis-related charges, the dialysis clinic cannot bill you. As a primary payer, Medicare pays 80% of outpatient charges after an annual deductible. You’ll still need to have coverage for the 20% so it’s good if you have some cash benefits left in your employer plan to pay the 20% and for other services your plan covers.
Dialysis providers lobbied every session of Congress for an extension of Medicare secondary payer. They paint this as cost savings to Medicare when actually their goal is to make higher profits. I expect this change will come up in the current Congress and considering the deficit and cost cutting sentiment, it’s possible Medicare secondary payer will be extended to 48, 60, or even indefinitely. Assuming health reform is not repealed, down the road there will be some protection if Medicare secondary payer is extended as health reform requires insurance companies to gradually expand and eventually eliminate caps on annual and lifetime benefits. However, that could affect premiums if insurance companies do not get an influx of healthy people who don’t use their insurance benefits to counter ESRD patients who use those benefits at a high level.
The dialysis providers that bill insurance companies $80,000 a month…is that a fair charge, or is that just how much they can get away with? Don’t insurance companies know what a fair charge is?
Dialysis providers lobbied every session of Congress for an extension of Medicare secondary payer. They paint this as cost savings to Medicare when actually their goal is to make higher profits. I expect this change will come up in the current Congress and considering the deficit and cost cutting sentiment, it’s possible Medicare secondary payer will be extended to 48, 60, or even indefinitely.
Would insurance companies not lobby against this? To which big corporate interest will Congress eventually bow down to?
Heh heh heh. There are two main sources of revenue for dialysis companies: Medicare and employer group health plans (EGHPs). Medicare has traditionally paid so little that folks who have Medicare only (with no Medigap, Medicaid, or private policy to pay the balance) actually cost clinics $5-10/treatment more than they were paid.
So, they went to the cash cow: EGHPs. Each clinic has what they call “payer mix”–the “mix” of patients who have EGHPs vs. Medicare. When Renal Care Group (RCG) was bought by Fresenius a few years back, the price was based on their superior payer mix–which was based at least in part on RCG providing better care so more people could keep their jobs–and their EGHPs. EGHPs can be billed at a higher rate than Medicare. One reason that large dialysis providers are so hot on home dialysis (contrary to many people’s beliefs that they are barriers to it) is that folks who get good treatments really ARE more likely to keep their jobs & EGHPs. So, home treatments are a win-win for dialyzors and providers. We pointed this out to them when we started this site. That’s part of the reason they support our work!
At this point, most of the insurance companies have caught on. Dialysis is on their radar screen–dialysis and cancer are the two most costly illnesses. They make arrangements with networks of dialysis providers and negotiate a rate that is higher than Medicare pays–but quite a bit less than $80/K mo. Also, clinics don’t necessarily get what they charge…
Having Medicare to pay for dialysis really is a huge plus. Back in the 1960s when dialysis first started in the US (in Seattle), it was very costly and insurance companies considered it “experimental” and wouldn’t pay for it. The government set up a number of pilot sites to do dialysis and study the results. These sites were small and funding was limited, so not everyone whose kidneys failed could get dialysis. There were “Life and Death committees” made up of citizens and clergy who would review the medical files of prospective candidates and decide whether they would get the live-saving treatment and live–or not. This was an extremely uncomfortable situation for Americans, who do NOT like healthcare rationing. Congress took up the question of dialysis. Clyde Shields dialyzed on the floor of Congress. Senator Vance Hartke famously said, "60% of those on dialysis can return to work but require retraining, and most of the remaining 40% require no retraining whatsoever. These are people who can be active and productive, but only if they have the life-saving treatment they need so badly.” Based on this promise of active, tax-paying citizens, Medicare was extended to people with ESRD.
Beth makes an excellent point about not using up your lifetime insurance benefit. It doesn’t take much dialysis at commercial rates to do that. Having Medicare protects your ability to have a transplant in the future, or other healthcare.
OK, thanks for the explanations…my head is exploding. As you know, the new Congress is in session, and I have a new US Representative that I want to write to, but I’m not sure what I should be saying. I want to lobby for optimal dialysis but beyond that, I’m thrashing around a bit, and I don’t want to be incoherent. Perhaps I should focus on asking him not to repeal the new healthcare law (he is Republican) so that at least the lifetime caps would be removed and stay removed. Which other salient points should I include in this letter, keeping in mind that he probably knows nothing at all about dialysis. I want to inform him, question him, beseech him but not overwhelm him.
I understand how dialysis could use up one’s private insurance; my policy, fortunately, does not have a lifetime cap…at least not for now.