By Bill Peckham
Advocacy is a tricky business. You need both a worthy goal and a solution that is fair and free from ulterior motives. Right now in both Kentucky and Indiana there is legislation moving through the respective statehouses called the Dialysis Patient's Bill of Rights.
The goal of this legislation is to allow people on dialysis to receive treatment at the dialysis unit of their choosing. Right now if your dialysis is paid for thorough private insurance the insurance company, in effect, has final say on where you can receive dialysis (this applies to about 10% of the people on dialysis. Those in the first 33 months of treatment who are not already on Medicare and who have insurance coverage, their own or their spouses, through work).
No one would like to be told where to dialyze by an insurance company and it would be very frustrating to live in a rural area with few units and to be told that you have to drive miles away to get dialysis. I would hate to drive past local units to go to some unit two towns over just because of insurance policies. I think it is a worthy goal to help people in this situation receive dialysis at a nearby unit. However, is the Dialysis Patient's Bill of Rights a fair solution? And are there ulterior motives behind the legislation? To get a handle on what is going on in this opaque business of in network and out of network units, it's instructive to look at one example that is in the public record.
Last year National Renal Alliance (NRA) sued Blue Cross Blue Shield of Georgia (BCBSG). NRA announced that they were suing because BCBSG had cut their payments for routine dialysis by 88%. The Atlanta Business Chronicle reviewed the case, and the lawsuit fillings are available online. In the fillings (pdf) NRA discloses (on page 23) that their usual and customary charges were $2,900 per treatment (for just the treatment (on page 31 they suggest the negotiated in network rate is about $700 to $800)); in the Atlanta Business Chronicle story they summarize the situation:
Medicare rates, which set the industry standard for reimbursements, range from $200 to $250 per treatment, Sanders said. Blue Cross has received charges from National Renal for dialysis treatments that range from $2,000 to $9,000 per treatment.
This gives you an idea of what is at stake. The dialysis providers would like to get $9,000 per treatment (once medications and labs and the rest of the separately billables are included); the insurers would like to pay $250. To be in network, NRA and BCBSG would negotiate a price somewhere in the neighborhood of $750. If they can't reach an agreement BCBSG can say we'll just pay $350, and NRA can say we won't do it for that and the patients will have to drive right past their local NRA unit to a unit in BCBSG's provider network, which might be thirty minutes or an hour away.
The solution offered in the Dialysis Patient Bill of Rights is blunt. It would require insurers in BCBSG's position to allow their beneficiaries to dialyze where they want and BCBSG would have to pay whatever is billed - the $9,000 if that is what's billed. The Dialysis Patient Bill of Rights tilts the negotiating dynamic heavily in the provider's direction. This legislation would make it less likely for insurers and providers to reach an agreement on prices. I don't think it is in the interests of patients to advocate for exorbitant dialysis rates. Blind greed should not be abetted. And the state should not intervene to make normal business practices less likely to continue.
Still there is a problem. A better solution and one that acts in the interest of fairness for all parties can be imagined. The legislation should allow prices to be set through mediation instead of fiat. If a patient elects to dialyze at a facility not in their insurer's network and the provider and the insurer can not reach a satisfactory agreement on prices then the matter would go to mediation. The legislation could prescribe the mediation process and who pays for what. Knowing that failure to reach an agreement will result in mediation would motivate both parties to reach a private agreement, and that would be the best outcome for all concerned. Advocates should think about what's fair for all parties and not just sign on to the first solution offered.