Federal Court Temporarily Halts California Dialysis Profits Law

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Source: Healio

A federal court in California has granted a preliminary injunction to prevent Assembly Bill 290, which is aimed at limiting dialysis provider profits and premium assistance, from taking effect.

“Considering both the likelihood that A.B. 290 will abridge plaintiffs’ constitutional rights and the extreme medical risks it poses to thousands of [end-stage renal disease] patients, the court finds it obvious that the public interest favors a preliminary injunction, and that the balance of the hardships tilts strongly in plaintiffs’ favor,” the court said in its ruling released Dec. 30.

“I am extremely disappointed to read the court’s order granting the plaintiff’s motions for a preliminary injunction of A.B. 290,” California Assemblyman Jim Wood, D-Santa Rosa, said in an email statement to Healio/Nephrology. Wood is the author of the legislation that was signed by California Governor Gavin Newsom on Oct. 13. 2019.

“It has been my goal to ensure that every Californian has health care, and to do so requires our efforts to contain increasing health care costs that are making coverage unaffordable for many. This injunction is consequential because it emboldens the corporate duopoly of Fresenius and DaVita to continue to gouge the health care system in order to increase their profits,” Wood said.

The court order also provides a reprieve for the American Kidney Fund. The organization had sent letters to patients on dialysis in California who receive premium assistance through its Health Insurance Premium Program, which is funded by dialysis providers, that it would no longer cover those premiums starting Jan. 1, 2020. A.B. 290 required the AKF reveal the names of patients and the providers who were covering the premiums.

The legislation would have restricted payment to dialysis providers by commercial health plans for patient care to no more that the current Medicare rate. Dialysis providers Fresenius Medical Care and DaVita Inc. had spent more than $1 million during the last 2 years trying to defeat the bill, along with a ballot measure in November 2018. That measure was defeated by California voters.

“We are pleased that the court has issued an injunction enjoining A.B. 290, which will enable our patients, who need charitable assistance to afford their health insurance premium, to continue to access such resources,” Brad Puffer, spokesperson for Fresenius Medical Care North America, said in a statement emailed to Healio/Nephrology. “Our focus remains on providing the highest quality of care for our patients and we will continue to advance those efforts despite work by the California legislature to restrict financial assistance.”

“Today, the American Kidney Fund (AKF) joins 3,700 low-income Californians living with kidney failure in applauding the decision by Judge David Carter in the U.S. District Court for the Central District of California to grant an emergency injunction preventing A.B. 290 from becoming law,” LaVarne A. Burton, president and CEO of the American Kidney Fund, said in a statement. “This is important news for patients with kidney failure who depend upon AKF to ensure access to the health care that they must have to survive.

“Because this injunction prevents A.B. 290 from becoming law, pending the outcome of a trial, AKF can continue to serve California’s low-income dialysis and transplant patients who depend on AKF for charitable premium assistance. We will also immediately re-open the program to new grant applicants who qualify for assistance.”

In November, the AKF, Dialysis Patient Citizens (DPC) and two patient plaintiffs filed a suit in federal court in California asserting numerous constitutional challenges against A.B. 290. Fresenius, DaVita and U.S. Renal Care have separately filed suit in the same court, also challenging the constitutionality of A.B. 290.

“On behalf of our patients, we are pleased that the court took the important step of putting a hold on the implementation of Assembly Bill 290, a law that threatens to harm nearly 4,000 low-income, primarily minority Californians on dialysis,” DaVita Kidney Care said in a statement. “While this is a temporary victory for California dialysis patients, we will continue to advocate on their behalf and remain focused on providing high-quality care.” The California Medical Association and the California State Conference of the NAACP filed amicus briefs in support of enjoining A.B. 290 as unconstitutional.

“We are truly grateful to the court for grating so many vulnerable dialysis patients this temporary reprieve,” the CEO of DPC, Hrant Jamgochian, JD, LLM, said in the release. “We know that A.B. 290 still threatens more than 3,700 of the poorest and sickest dialysis patients in California. Health insurance coverage is absolutely critical for patients to continue their dialysis treatments, and if they can’t maintain it, their lives are literally on the line. That is why DPC joined as a plaintiff in this critical litigation, and why we hope this repugnant law never takes effect.” – by Mark E. Neumann

Trump Administration Moves to Shift Patients’ Chronic Illness Costs to Insurers

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Source: The Wall Street Journal

Millions of Americans in high-deductible health plans may find it easier to access insulin, inhalers and other treatments for chronic health problems under guidance released Wednesday by the Trump administration.

Currently, people in high-deductible plans with pretax health-savings accounts have to pay down their deductible before their insurance covers treatment for chronic diseases such as diabetes or high blood pressure.

The change will allow insurers to begin providing coverage for those treatments, such as glucose or blood-pressure monitors, before the deductible is paid. Insurers have pushed for this flexibility because people who don’t get ongoing treatment for a disease can have their condition worsen, leaving insurers paying even more for their care.

The guidance was issued by the Internal Revenue Service and the Treasury Department and is specific to high-deductible health plans linked to special pretax health savings accounts, or HSAs. These savings accounts have taken off in recent years and now are used by more than 20 million people facing steep deductibles.

Under the new guidance, patients in these plans with HSAs could save money because insurers would provide coverage for treatments for chronic conditions such as regular diabetes vision screening or medications even if people haven’t paid down their deductible, which can sometimes be in the thousands of dollars, senior White House officials said.

The change has long been sought by employers, insurers and patient advocacy groups.

“Failure to address these chronic conditions has been demonstrated to lead to consequences, such as amputation, blindness, heart attacks, and strokes that require considerably more extensive medical intervention,” according to the guidance.

Because the change is being issued as a guidance, it doesn’t require a formal rule-making process and could be incorporated into health plans being offered in 2020.

Some critics have said changes could spur the spread of high-deductible plans with the pretax health savings accounts. They say the trend is hurting consumers because they force them to pay more for their own care or put off treatment. But support for easing the restrictions on what the plans can pay for, pre-deductible, has been strong and building in recent years from those who say people with chronic conditions are unfairly bearing the financial brunt under the plans now.

The change will benefit some of the 133 million people who have ongoing medical problems such as diabetes and marks the second phase of a broader push the Trump administration announced last week to improve kidney disease treatment.

The goal is largely to ensure consumers in these plans can afford and obtain treatment for chronic conditions such as diabetes and heart disease to stave off more costly, debilitating health problems, senior administration officials said.

“It’s a really smart way to decrease the out-of-pocket costs for millions,” said Katy Spangler, co-director of the Smarter Healthcare Coalition, which has pushed for the change.

High-deductible health plans have become increasingly commonplace and have shifted more of the financial burden for health care to consumers. The IRS defines the plans as having a deductible of at least $1,350 for an individual in 2019 or $2,700 for a family. The idea behind the plans is to help curtail spending by requiring patients to have more of their own money at stake.

Accompanying HSAs were created in 2003. Employers, workers and others can contribute to the account with pretax dollars. People in high-deductible plans can then use their HSAs to pay for eligible treatments or care at any time without federal tax liability or penalty.

Critics of HSAs have said they largely benefit higher-wage workers who can afford to contribute to the accounts. Republicans have pushed to increase the use of HSAs, saying they are a possible fix for the burden of high health-care costs in the U.S. People can invest in the accounts and grow them over time.

The guidance is likely to enjoy some bipartisan support. Sens. John Thune (R., S.D.) and Tom Carper (D., Del.) have introduced legislation that would let high-deductible high plans used with HSAs cover chronic-disease care prior to consumers reaching their deductible.

The guidance means certain medical treatments or services for people with chronic conditions will essentially be considered preventive, according to the senior White House officials.

There will be some conditions: The service or item must prevent a health condition such as diabetes from getting worse. It must be low-cost, such as testing strips. Patients would have to be facing a strong likelihood they would encounter significantly more health costs to treat a condition if the service or item isn’t provided.

The guidance stems from President Trump’s June 24 executive order on price disclosure in health care. The order called for guidance to expand HSAs to maintain the health status of people with chronic conditions.

The administration has wanted changes to plans that qualify for HSAs for some time. Last year, the White House said any plan to shore up the Affordable Care Act should include changes to high-deductible plans with HSAs so they can cover treatment for chronic conditions before deductibles are met.

California Assembly Passes Bill to Restrict Dialysis Profits

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Source: Healio

The California Assembly voted 46-15 to pass A.B. 290, a measure that would limit dialysis provider and rehabilitation center profits operating in the state when insurance premiums are covered by third-party payers.

The bill now moves on to the state Senate for consideration.

“We need to stop third-party health care providers from profiteering by taking advantage of vulnerable and unsuspecting patients who need life-saving treatment,” Assemblyman Jim Wood, the author of A.B. 290, said in a press release. “Their profit-inflating schemes do nothing to improve the care of kidney patients or those recovering from addiction. This legislation will hold these two industries accountable while safeguarding critical financial assistance to patients in need.”

The legislation limits the amount of payment for medical services for dialysis providers and rehabilitation centers to the Medicare rate when patients have premiums paid by third-party payers, such as the American Kidney Fund.

The legislation was passed by the Assembly Health Committee on March 19 – a committee chaired by Wood – by an 11-2 vote, and the Appropriations Committee passed the bill on May 16 by a 12-3 vote. No votes were recorded on the bill from 19 legislators during the full assembly vote.

The bill is supported by Health Access California, the California Labor Federation, Service Employees International Union California, California Association of Health Plans and the Association of California Life and Health Insurance Companies, according to a press release from the California Association of Health Plans. The bill now goes to the California Senate for consideration.

The Dialysis is Life Support coalition, made up of doctors, hospitals, dialysis patients and caregivers, along with business and community groups, denounced the legislation, saying in a statement that passage of A.B. 290 “puts insurance companies one step closer to maximizing their profits while putting vulnerable dialysis patients in California at risk.”

“Short term, A.B. 290 directly threatens the financial security of nearly 4,000 dialysis patients in California,” spokesperson Kathy Fairbanks said in a press release. “If A.B. 290 is enacted, the non-profit American Kidney Fund has stated it will be forced to stop providing assistance to patients in California, driving up the cost of care for low-income patients who rely on financial grants from the organization.

“Long term, A.B. 290 threatens dialysis clinic access for the more than 70,000 dialysis patients in California where dialysis clinics have some of the highest government quality ratings in the country. Shifting even a few patients from private insurance to government programs upsets the dialysis ecosystem and will reduce funding to dialysis clinics across the state,” she said. “Many California patients will have no choice but to dialyze in hospital emergency rooms at much higher cost to the health care system and taxpayers.”

Why Proposition 8 Is One of the Most Contentious, and Confusing, Ballot Measures in Play

Rich Pedroncelli / AP Photo

Source: Capital Public Radio

Roughly 140,000 Californians spend the equivalent of a part-time job — 12 to 20 hours a week — in a dialysis clinic, where a machine functioning as a kidney filters waste out of their blood.

It’s a tricky procedure — and right now it’s at the center of a heated political battle between labor unions and dialysis companies.

Californians will vote in November on Proposition 8, which would regulate dialysis clinic spending. It’s a move that could either improve patient conditions or degrade them, depending on who you ask.

So far, it’s the most expensive proposition on the ballot, with supporters putting in $20 million and opponents fighting back with $99 million as of October 11.

The measure would cap what clinics can spend on overhead and administrative costs, versus actual care.

One of the largest health care labor groups on the West Coast — Service Employees International Union – United Healthcare Workers West — put it on the ballot. Their members say clinic owners are overcharging for low-quality care, and that Prop. 8 will force dialysis companies to spend more on patients, including hiring additional staff.

The opposition campaign, backed by two of the state’s largest dialysis companies, argues that spending limitations could make it harder for clinics to stay afloat.

Los Angeles resident Tangi Foster, who’s working with the “Yes on 8” campaign, said she’s visited multiple dialysis clinics over the last decade and that employees seem overwhelmed and exhausted. She says this makes her feel unsafe.

“These people have to save our lives,” she said. “ I don’t think it’s fair to them, nor is it fair to us as patients, for them to carry this kind of workload.”

Opponents of the measure argue it is a power-play by labor groups trying to unionize dialysis workers.

They also worry that, if the measure passes, funding for certain positions would be in jeopardy. That’s because it would create two categories for dialysis company spending: “allowable” and “other” costs. Anything that goes over the limit in the other category would have to be paid back to insurance companies.

“These things are going to result in the closure of clinics, and they are going to result in less access for patients,” said Dr. Luis Alvarez, a practicing physician and board member for a dialysis clinic group called Satellite Healthcare. “To me, that is really a terrible, terrible thing.”

The allowable category would include “non-managerial” staff that provide direct care to dialysis patients. Opponents say jobs that are key to delivering patient care, such as medical director or nurse manager, could be excluded and face a funding cut.

Prop. 8 would also require clinic operators to report spending to the state, and forbid them from turning away patients based on their insurance payer.

The California Department of Public Health received 577 complaints about dialysis clinics and found 370 deficiencies during a two-and-a-half-year period between 2014 and 2017 — roughly 18 complaints and 12 deficiencies per month, according to an analysis by nonprofit journalism site CalMatters.

Those included complaints that patients’ vital signs weren’t checked by staff every 30 minutes, as required by law, and that translation services were not provided to non-English-speaking patients.

One grievance accused staff members of failing to check the connection between a patient and machine, even though blood was inappropriately oozing from the patient’s medical port, according to the CalMatters story.

DaVita, one of two major dialysis companies in California, has faced multiple lawsuits in recent years from the families of patients who died at their clinics.

If the measure passes, the decision on how clinics can spend their budgets will fall to the state and to the courts. The nonpartisan Legislative Analyst’s Office said in its assessment that the measure’s vague language makes its fiscal impact difficult to determine.

“If the measure is ultimately interpreted to have a narrower, more restrictive definition of allowable costs, the amount of rebates chronic dialysis clinic owners and operators are required to pay would be greater,” the office wrote in the California voter guide.

The office said clinic groups might need to “scale back operations in the state.”

Ken Jacobs at the UC Berkeley Center for Labor Research and Education pointed out that just two dialysis companies control 70 percent of all clinics in California. And because very few laws require them to be transparent about their costs, prices will just continue to climb.

“I think we’re going to see a lot more attention on these issues in the future,” he said. “The ballot initiative specifically addresses [market consolidation] in a particularly profitable industry in terms of the dialysis centers. But the issues its raising are issues that go well beyond this particular case.”

Opponents feel the measure is too drastic and doesn’t belong on the ballot. Supporters have tried legislation before — bills to require staffing ratios in dialysis clinics and impose a revenue cap on clinic operators failed in prior legislative sessions.

Still, much of the Prop. 8 debate brings into question whether the voters should be the ones to decide how to fix these problems.

Commentary: Critical-illness insurance can protect savings

A critical-illness insurance policy can help “bridge the gap” in health coverage, writes Rod Rishel of AIG Consumer Insurance. Such policies offer a lump-sum payment that can help guard retirement savings and also provide continuity for small businesses, Rishel writes.

ThinkAdvisor (free registration) (3/28)

California Has the Most LTCi Policyholders

In California, more than 600,000 are covered under a traditional long-term care insurance policy, according to the American Association for Long-Term Care Insurance. “This is certainly due to the size of California as well as the fact that the state has been very active in making residents aware of the importance of planning. While the California Partnership program has little relevance to consumers today, in former years it was valuable protection that I strongly advocated and which was actively marketed by insurance professionals,”   explains Jesse Slome, executive director of the American Association for Long-Term Care Insurance (AALTCI). Roughly seven million Americans have traditional long-term care insurance protection and another million have coverage under a linked-benefit or alternative product.

“A significant number of the inbound phone calls we handle and the online request for information come from Californians. Admittedly, there are fewer specialists today than there were a few short years ago, but there are still good avenues available for those who want to get information and compare their choices and options,” he said. For more information, visit www.aaltci.org or call 818-597-3227.

Employees Appreciate Voluntary Insurance Benefits

Seventy-nine percent of employees see a growing need for voluntary insurance compared to last year. And of those, 60% say the need is driven by the rising cost of medical services, according to an Aflac survey. Employees who are offered voluntary benefits report higher satisfaction with their jobs and their benefits. Employees whose work site offers voluntary benefits are more likely to say the following:

  • They are prepared to pay for out-of-pocket expenses not covered by major medical/health insurance related to an unexpected serious illness or accident (73% versus 56%).
  • They are extremely or very satisfied with their jobs (73% versus 57%).

New Law Voids Life Insurance Suicide Exclusion for Terminally Ill

dignity

The End of Life Option Act, Assembly Bill X2-15 (Eggman) is now in effect. Under the new law, if a terminally ill Californian, who meets the criteria in the law, takes medication to end their own life, it is not considered a suicide, so life insurance policy exclusions for suicide do not apply. Under the Death with Dignity law, patients of sound mind who who have a terminal illness and meet certain qualifications can request aid-in-dying medication. Commissioner Jones said, “Terminally ill patients in California now have a choice when facing end-of-life decisions and do not have to worry that the choice will cause them to lose their life or health insurance or annuity policy…This law will make it possible for those who meet the protections in the new law to have the option to get a prescription for an aid-in-dying drug from their physician.” Consumers and their families with questions about the new law or its application are encouraged to contact the department online or 800-927-4357. 

Bill Offers Alternative to Obamacare

A health plan introduced by two Republicans promises to make good on what it calls ObamaCare’s three broken promises: universal coverage, cost control, and protection for the chronically ill. Yet the proposal spends no more money than the current system and it repeals almost all of ObamaCare’s regulations. Pete Sessions (R-TX), Chairman of the House Rules Committee and one of the sponsors of the legislation said, “ObamaCare tries to tell everyone what to do – every doctor, every patient, every employer and every employee. Our goal is to liberate people by empowering them to make their own choices and by freeing the marketplace to meet their needs.” The Senate version of the bill has been introduced by Sen. Bill Cassidy (R-LA).

The centerpiece of the proposal is a health insurance tax credit that applies dollar-to-dollar to insurance premiums and deposits to Health Savings Accounts. The credit will be the same for everyone, regardless of income. The tax credit sets a floor under the insurance people will have. Everyone will have access to insurance that looks a lot like well-managed, privately administered Medicaid, said John Goodman, a health economist who helped prepare the plan. People will have more options if they and their employers spend additional money – but those dollars will be unsubsidized.

The sponsors say the plan gives employers and employees new tools to control costs and that they will be able to convert waste, fraud and abuse into higher take-home pay by being smarter buyers of health care. Also, because of free market risk adjustment, health plans will specialize in the treatment of chronic conditions and will compete to solve those problems. The Sessions/Cassidy proposal is the freest enterprise reform ever introduced in the U.S. Congress, said Goodman. It minimizes and streamlines the role of the federal government and eliminates perverse incentives caused by federal tax and spending policies and unwise regulations. Even though introduced by Republicans, Goodman says there is much in the bill that Democrats will like. It has a much better chance of actually becoming law than any Republican proposal that I have seen so far. Goodman is the author of A Better Choice: Healthcare Solutions for America, the source of many of the provisions in the plan.

Healthcare Issues Among Millennials

Transamerica Center for Health Studies (TCHS) finds that Millennials are struggling with the cost of healthcare while facing some health issues at a young age. The survey reveals the following:

  • The most common reason that the 11% of uninsured Millennials didn’t get coverage before the ACA deadline is that they did not know how to apply for insurance.
  • 60% of the uninsured are women; and 68% of the uninsured are unemployed.
  • 21% of Millennials can’t afford their routine healthcare expenses. An additional 26% can afford it, but with difficulty.
  • 70% say that cost is very important when looking for healthcare.
  • 66% of Millennials say that a $200 a month premium is not affordable.
  • Nearly half of Millennials skip care to reduce their healthcare costs.
  • More than half of Millennials have a chronic illness or health condition. The most common conditions are depression (17%), weight issues (15% overweight and 7% obesity), and anxiety disorders (14%).
  • 64% rely on their mom/step-mom as their primary source for health advice and healthcare guidance; 36% rely on their dad/step-dad; and 26% rely on their spouse or partner.

Last Updated 11/18/2020

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