Kidney Failure Patients Drive Up Individual Market Spending

When the Affordable Care Act banned individual market insurers from denying coverage to people with pre-existing conditions or charging them higher rates, it created a new option for patients with end-stage renal disease (ESRD), who previously could not access affordable plans in that market. But the ACA’s reforms also opened the door to a practice that has stirred up controversy in the health care sector: dialysis facilities steering patients to higher-reimbursing private plans by indirectly subsidizing their premiums. While attempts to ban such behavior have failed so far, a new study offers reasons why policymakers may want to take another shot at addressing the issue.

The study, published in JAMA Internal Medicine, examined 2016 data from ACA-compliant on- and off-exchange health plans, finding that patients with ESRD comprised just 0.10% of individual market member months but 3.3% of spending. For such patients, average monthly spending on dialysis and other services was 33 times that of patients without ESRD, “underscoring the incentive for [dialysis] facilities to encourage individual market enrollment,” the study stated.

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Leslie Small

Leslie Small

Leslie has been working in journalism since 2009 and reporting on the health care industry since 2014. She has covered the many ups and downs of the Affordable Care Act exchanges, the failed health insurer mega-mergers, and hundreds of other storylines spanning subjects such as Medicaid managed care, Medicare Advantage, employer-sponsored insurance, and prescription drug coverage. As the managing editor of Health Plan Weekly and Radar on Drug Benefits, she writes and edits for both publications while overseeing a small team of reporters who also focus on the managed care sector. Before joining AIS Health, she was a senior editor for the e-newsletter Fierce Health Payer, and she started her career as a copy editor at multiple local newspapers. She graduated with a dual degree in journalism and political science from Penn State University.

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