The column below reflects the views of the author, and these opinions are neither endorsed nor supported by WisOpinion.com.
Of the many aspects that figure into choosing the right health care plan, access and cost are generally at the top of the list. Finding a plan that allows you to access all the treatments you need, when you need them, can be a difficult and trying process. This is especially true for patients with end-stage renal disease (ESRD), as policy makers have traditionally made decisions without much regard to how it will affect these patients. The issue hits close to home for me; I was diagnosed 13 years ago with polycystic kidney disease, and I’ve seen the struggles and emotional toll it takes on patients and families.
Unfortunately, these difficulties still hold true today, as new policies governing Medicare Advantage plans once again threaten the level of care open to ESRD patients both here in Wisconsin and across the U.S. This year was meant to signal the start of a new era improving care for dialysis patients. Thanks to the 21st Century Cures Act, which passed through Congress in 2016 and was signed into law with substantial support from both sides of the aisle, thousands of ESRD patients were set to become eligible for Medicare Advantage plans that weren’t previously an option for them. Open enrollment was set to take place in October.
The passage of the Cures Act signaled a landmark victory for ESRD patients nationwide. Since Medicare Advantage plans are offered through private insurance companies, they often can provide plans with more benefits, usually at a lower out-of-pocket cost than patients could otherwise find through Medicare, which many ESRD patients were forced to rely on up until the Cures Act was passed. Unfortunately, recent actions by the Centers for Medicare and Medicaid Services have completely undermined this victory, going directly against what Congress envisioned when it passed the Cures Act.
In May, with less than six months before ESRD patients across the country could begin enrolling in Medicare Advantage plans, CMS changed the network adequacy requirements for dialysis facilities covered by those plans. Traditionally, dialysis facilities covered in Medicare Advantage plan networks were governed by rules based on the time or distance a patient would need to travel to their local center. Now, however, those rules have been eliminated in favor of a standard that is reliant on a “prevailing community pattern of health care delivery.”
This change has a glaring weakness. Such a standard is normally reserved only for treatments that do not require frequent travel on the part of the patient. Of course, this is very much the opposite of what dialysis entails. A significant portion of ESRD patients need to visit their clinic several times a week, while each treatment alone can last for three or more hours.
Rather than protecting patients, this decision is yet another made by CMS that incentivizes risky cost-cutting practices on the part of insurance companies and allows them to reduce the number of dialysis facilities included in their Medicare Advantage plan networks. It all but ensures there will be fewer clinics included in plan networks, effectively preventing ESRD patients from enrolling in the plans that they fought so hard to earn eligibility for. This holds particularly true for the dialysis patients living in more rural parts of Wisconsin, many of whom are already facing difficulties in finding centers close enough to where they live.
This move has naturally been met with fierce opposition from patients, who are pushing policymakers to realize how it will inevitably hurt dialysis patients. One major patient group, Dialysis Patient Citizens, has even filed a lawsuit against CMS in the hopes that it will be overturned.
For the sake of ESRD patients across Wisconsin, I hope CMS will recognize the mistake it has made and see the price patients will inevitably pay because of this rule change and reverse course. President Trump has said he prioritizes making healthcare accessible and affordable to all. If he wants to carry Wisconsin again in this year’s election, he should ensure his administration’s actions reflect those goals. As of now, this is a move that not only flies in the face of past Congressional action, but which more importantly makes comprehensive care harder for dialysis patients to access.
— Hamilton was diagnosed with polycystic kidney disease 13 years ago. She is active in raising awareness on the issues facing kidney disease patients. Kristen resides in Wauwatosa.