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HHS Must Address Adverse Selection in Medicaid, Medicare Renal Care

AHIP and its members are urging HHS to improve management and reduce adverse selection in Medicaid and Medicare renal care.

AHIP is urging HHS to improve adverse selection in Medicaid, Medicare renal care.

Source: Thinkstock

By Thomas Beaton

- AHIP is urging HHS secretary Alex Azar to address adverse selection related to Medicaid or Medicare end stage renal disease (ESRD) in order to ensure that vulnerable beneficiaries continue to receive appropriate healthcare services.

AHIP asserted that steering Medicaid and Medicare beneficiaries into commercial coverage may create unsustainable premium and care costs for current commercial member populations.

“The undersigned groups share the goal of ensuring that our members and employees receive high-value care while keeping premiums affordable and sustainable,” AHIP said. “These recent disclosures have raised serious concerns and threaten to interfere in our collective ability to provide affordable health coverage.”

The group argued that providers are steering patients with ESRD into commercial health plans for financial gain instead of maintaining adequate renal care available through Medicaid or Medicare.

AHIP explained that providers may be incentivized to earn higher reimbursement amounts by moving patients from public payer coverage into commercial coverage.

“As demonstrated by evidence collected during an earlier rulemaking related to the [federal marketplace] Exchanges, dialysis providers are paying premiums through a financially interested third party—the American Kidney Fund—for ESRD patients in order to steer them away from Medicaid and Medicare and into commercial Exchange plans so that they can profit from the higher reimbursement rates paid by these issuers,” AHIP cautioned.

AHIP explained that financially motivated adverse selection creates gaps in critical ESRD care and life-saving procedures.

The letter argued that these practices create barriers to care coordination for all ESRD patients and barriers to kidney transplants for low-income individuals. Low-income individuals are especially affected as their premium costs increase and affordability becomes an additional barrier to ESRD care, AHIP said.

In addition, AHIP suggested that providers are gaming the employer-sponsored insurance market by maximizing profitability for ESRD care.

“One financial report reveals that this steering into the employer market generates $450 million a year in operating income for a single dialysis provider,” AHIP said.

The group cited financial estimates from JP Morgan & Chase that found third-party organizations urged individuals to elect COBRA coverage instead of other health plan options to maintain high profits.

AHIP urged CMS to use rulemaking procedures and take further actions to address the financial interests of third-parties in regard to ESRD care.

“For this reason, while rules governing third-party payments should enable legitimate organizations who are acting in good faith to provide consumer support, we strongly urge that CMS re-issue its rule on steering in the individual market and prohibit third-party payments made directly or indirectly by a financially-interested party,” AHIP concluded.

“When third parties with conflicts of interest and who gain financially intervene in the provision of health insurance benefits in a manner that changes the financial balance inherent in the relationship between payers and plan beneficiaries, to the detriment of the healthcare system, the results can be adverse for the individual being assisted, for other plan beneficiaries, and for the sustainability of commercial health plans as a whole,” the organization continued.

“We urge you to scrutinize these recent disclosures and to work collaboratively with us to ensure our employees and members receive the most appropriate coverage to which they are entitled.”


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