Health+Benefits the November 2019 issue

The Hidden Perils of Dialysis Claims

Health benefits risk management is at the intersection of monopoly and intensive regulation.
By John Christiansen

The dialysis marketplace is dominated by two giant multinationals with incentives and the market power to drive up self-insured plan charges, as well as a willingness to litigate to maintain their rates. Health benefits for dialysis are also subject to intense federal regulations, some peculiar to dialysis, which severely limit plans’ options for managing dialysis costs.

A successful risk management strategy for dialysis cost containment therefore requires a careful understanding of not only the laws and regulations that apply but also the players in the market and their various interests and strategies.

At the end of the day it is a matter of informed risk identification and acceptance and an understanding that risk can be reduced but will never be totally eliminated when the financial stakes are as high as they are in the dialysis sector.

Dialysis Basics

Dialysis is a process that filters a patient’s blood when the patient’s kidneys have failed and can no longer perform that function. The most common reason for kidney failure is end-stage renal disease (ESRD) as the culmination of years of progressive chronic kidney disease (CKD). Diabetes and hypertension are by far the most common reasons for CKD. With treatment CKD can be slowed or stopped before the patient reaches ESRD.

Dialysis is a relatively simple process and is predominantly administered in free-standing dialysis centers, though home dialysis is an option for some patients. Dialysis centers need to be supervised by licensed physicians, but the actual treatment can be and usually is provided by technicians. The necessary drugs are well known, and dosing is not usually complex. Dialysis devices need monitoring but are not hard to run. Patients who receive in-center dialysis typically do so three days a week. Dialysis is debilitating, and as a practical matter, patients need a center no more than 30 miles from their home.

The need for dialysis due to ESRD is also one of three conditions that automatically qualify an individual for Medicare. (The other two are age and Lou Gehrig’s disease; the latter is quite rare.) In order to protect Medicare financially, the Medicare Secondary Payer Act (MSP) requires self-insured plans to pay primary to Medicare for a three-month “waiting period” from the onset of dialysis and a subsequent 30-month “coordination period.” Qualified individuals are not automatically enrolled or legally required to enroll in Medicare.

Seventy-three percent of dialysis centers in the United States are owned by the two “large dialysis organizations” (LDOs): DaVita and Fresenius Medical Care (FMC). In many regional and local markets, all dialysis centers are owned by one of these two, and in some markets, one of the companies owns all the centers.

Dysfunctional Market

Seventy-three percent of dialysis centers in the United States are owned by the two “large dialysis organizations” (LDOs): DaVita and Fresenius Medical Care (FMC). In many regional and local markets, all dialysis centers are owned by one of these two, and in some markets, one of the companies owns all the centers. By Department of Justice standards, this is considered a “highly concentrated” market, such that the dominant providers are considered able to exercise substantial control over pricing.

The demand side is also highly concentrated but in ways that only exacerbate the problem. Medicare is the primary coverage for most dialysis patients (62%), and other government programs, such as Medicaid, bring total government program coverage up to almost 90%. Private commercial and self-insured plans therefore make up only a little over 10% of the demand side of the dialysis market and have correspondingly little market power.

Further, Medicare rates aren’t negotiated in the market. The Medicare dialysis payment rate is set annually by Congress based on recommendations by the Medicare Payment Advisory Commission (MedPac). MedPac recommendations are based on an analysis of the adequacy of care given as well as provider profitability and access to capital given current payment levels. The intent is to provide for sufficient funding to support patient care plus a reasonable profit.

The LDOs sometimes complain that Medicare rates are insufficient, and there is a little something to that. In 2016, the average per-treatment Medicare payment was about $189, and the LDOs’ own figures for 2016 indicate their cost per treatment was $226 at DaVita and $271 at FMC. However, their average revenues per treatment were $336 (DaVita) and $345 (FMC), with non-regulated, non-negotiated billed (“rack rate”) charges per treatment to self-insured and commercial plans in excess of $6,500. While many plans are able to access LDO facilities at a negotiated discount via preferred provider organization and other provider networks, these are typically unable to negotiate discounts greater than 20% or 30% (a reduction to $5,200 or $4,550).

Self-insured and commercial plans therefore subsidize Medicare rates to some extent but mostly serve as the major LDO profit center. And annual charges for self-insured plans can therefore easily exceed $1 million per case, even with a PPO discount.

Private commercial and self-insured plans therefore make up only a little over 10% of the demand side of the dialysis market and have correspondingly little market power.

Dialysis Claims: A Low-Probability, High-Impact Risk

The dysfunctional nature of the dialysis market and its financial implications are not necessarily clear to many plans and their advisors, simply because they have not experienced it. For smaller plans in particular there is a relatively low probability that any covered individual will enter ESRD and need dialysis in any given year.

The incidence of ESRD in the working age population is just over 100 cases per million for ages 22-44 and around 600 per million for ages 45-64. While there isn’t good data on point, clearly many of these individuals are covered by a government program or commercial insurance. A plan with 1,000 covered lives would therefore have an incidence of fewer than 0.1 to 0.6 cases per year. Plans may therefore go years without any dialysis claims, especially if their covered population is relatively young. Even quite large plans will have few cases and very limited experience with them.

But charges for dialysis to self-insured claims are typically quite high, and annual exposures easily exceed $1 million. Dialysis cases might not exactly be “black swans,” but for many plans they may be unanticipated, and the plan might not be prepared for the high financial impact of this relatively improbable event.

The Legal Environment

Even a plan that anticipates and wants to prepare for possible dialysis cases may have difficulty developing a sound strategy because the unique legal environment limits and complicates strategic options.

Dialysis is subject to many of the same laws that apply to health benefits in general—the Employee Retirement Income Security Act, various provisions of the Affordable Care Act, the Americans with Disabilities Act and nondiscrimination provisions of the Health Insurance Portability and Accountability Act.

There are well established strategies for working with these laws and implementing plan benefit terms that allow plans to pay dialysis claims at less than provider-billed charges—for example, using specifically designed plan language and consistent methodologies, such as defined “usual and customary” or “usual and reasonable” rate provisions. But these strategies vary in legal defensibility. A few years ago there was considerable litigation, including significant cases by the LDOs, alleging such strategies were unfair trade practices along with other similar claims, and in fact some of them were found to be legally defective. Such challenges may still be made if a plan isn’t careful, but the parameters for defensible dialysis benefits terms and determinations are reasonably well defined. Still, there are two key areas where unanticipated and badly defined legal issues can catch a plan by surprise: the MSP and PPO and other provider network contracts.

The Medicare Secondary Payer Act

The MSP is implemented by a lengthy and somewhat confusing set of regulations designed to keep plans from “gaming” Medicare when it comes to ESRD.

Some of the specific examples of prohibited practices in the regulations are straightforward: a plan cannot terminate coverage for someone because that person has ESRD. Others are less obvious: a plan cannot require people to enroll in Medicare, though it can educate them about their rights and the benefits of doing so. Still other practices are not specifically prohibited, and there is no guidance on these points: can a plan pay someone’s Medicare premiums; can a plan pay one rate during the waiting period and another during the coordination period; can a plan pay dialysis claims based on the rate Medicare pays such claims; and so on.

Since a violation of the MSP can render a plan non-conforming and even be the basis for double damages, these are issues to be approached with care and an understanding of the risks. The LDOs are well aware of MSP vulnerabilities and have sued plans for MSP violations; as of this writing DaVita is actively pursuing a number of cases targeting MSP issues specifically.

Self-insured and commercial plans therefore subsidize Medicare rates to some extent but mostly serve as the major LDO profit center. And annual charges for self-insured plans can therefore easily exceed $1 million per case, even with a PPO discount.

The PPO Contract Problem

PPO and other network contracts pose a different set of issues and risks. PPO contracts are highly variable in content and structure but are usually made up of a set of agreements for a chain of parties including providers, the PPO itself, third-party administrators and plans.

Some PPO arrangements allow plans and/or TPAs to choose to access the network or not, with no consequences if they don’t (other than loss of the discount). Some clearly prohibit plans from paying participating providers anything but PPO rates. Most fall somewhere in the middle, and only case-by-case review can determine whether a plan is in fact obliged to pay participating providers at PPO rates.

This matters for dialysis purposes in particular, because, as noted above, a PPO’s discount from LDO charges may leave a plan with an unacceptable claims exposure. The plan (or its TPA) might not have anticipated dialysis cases or their financial consequences when entering into the PPO arrangement. A plan may therefore need relief from this unanticipated and unacceptable exposure, but the plan (and/or TPA) may be subject to a lawsuit by the provider (and/or PPO) if it doesn’t pay the provider at PPO rates. Many PPOs recognize that they can’t provide acceptable discounts for dialysis services from the LDOs and may be willing to negotiate a dialysis carve-out, but such negotiations require careful analysis of the PPO documentation and an understanding of the PPO’s interests and obligations.

This is also an area that has seen active litigation by the LDOs over the years, and there are a number of active cases as of this writing.

Balancing Act

Self-insured health plans and their advisors need to anticipate dialysis cases. They may be relatively uncommon, but if they happen, they can have severe financial impacts. Once they are anticipated, a risk management strategy can be developed with an appreciation and understanding of the legal requirements and standards that constrain alternatives. Some of these issues are in gray areas, and some of them are in active litigation. Part of prudent risk management is, therefore, making sure the strategy suits the plan’s willingness and ability to accept litigation risks and balancing that against the exposure to dialysis claims risks the strategy is intended to reduce.

John Christiansen is the chief legal officer of Renalogic.

More in Health+Benefits