America's Benefit Specialist December 2023

NABIP POLICY SERIES

• Just two companies own 80 percent of all dialysis facilities in the United States. • Between 2012 and 2019, the initiation of dialysis care for privately insured patients with kidney failure increased employer plans’ average monthly spending from $5,025 to $19,654. • Spending on dialysis for patients in commercial plans in the first year of treatment was $238,126—compared to $80,509 spent on Medicare patients. • Many proposed dialysis facility acquisitions that would otherwise be blocked over 95% of the time are blocked less than 5% of the time when exempt from premerger notification requirements. • If proposals to compel employer plans to cover ESRD services were to pass, two providers with market dominance would achieve record profits while countless employer plans would be bankrupt by high claims.

Continued from page 14 are higher for patients receiving dialysis in for-profit and larg er chain size facilities than in nonprofit or smaller facilities. Legislation has recently been proposed that was intend ed to ensure that ESRD patients are protected under the Medicare Secondary Payer Act (which is meant to prevent Medicare from paying for medical expenses that could be covered by other insurance plans). However, these proposals would go beyond the intentions of the Secondary Payer Act and explicitly compel all employer-based plans to cover ESRD services. If such legislation were to pass, two providers with market dominance would achieve record profits while count less employer plans would be bankrupt by high claims. and healthcare engagement tools, content and resources to navigate the healthcare system. These tools include five decision aids and three FH Total Treatment Cost tools that offer clinical and cost information related to the care and treatment of conditions that affect older adults. Guided by a Project Advisory Board including patients, healthcare providers, clinicians, academic researchers and community-based stakeholders, FAIR Health’s initiative seeks to offer a valuable foundation for shared decision making—the process by which patients, caregivers and pro viders decide on care and treatment, balancing clinical ev idence with patients’ preferences and values—and health care engagement for older adults, family caregivers and care partners. In 2024, building on the tools and resources developed during the project’s planning phase, FAIR Health will launch a national dissemination campaign and pilot the tools with older patients and family caregivers at the point of care through collaborations with four Age-Friendly Health Systems sites.

THE SOLUTION Two dialysis providers control 80 percent of the ESRD market. Using their market dominance, these providers are able to negotiate extraordinarily high claims and thus increase the cost of dialysis for employers and patients alike. The answer to the problem is not to compel group health plans to cover dialysis at these two companies’ facilities—the answer is to foster healthy competition in the ESRD market, thereby lowering healthcare costs for commercial plans, the Medicare program, and patients.

PRODUCT NEWS

SIDECAR HEALTH EXPANDS MAJOR-MEDICAL GROUP OFFERING TO GEORGIA Sidecar Health has announced expansion of its ACA-com pliant major medical employer health insurance plans into Georgia following a year of strong growth in Ohio. “Typical insurance models pass cost to consumers by way of prior authorizations, restrictive formularies and narrow networks. By removing these obstacles, we are making a meaningful impact on how members access care,” said Pat rick Quigley, CEO. On average, employers switching to Sidecar Health are saving 20% on premiums versus their prior plan. The first Georgia-based employers made the switch to Sidecar Health on October 1. More info can be found at sidecarhealth.com.

34 ABS | benefitspecialistmagazine.com