The judges confirmed the refusal of insurance coverage for outpatient dialysis


The court rejected DaVita Inc.’s claim that low health insurance refund rates violated federal law. (APN photography via Shutterstock)

The opinion from Tuesday in Marieta Memorial Hospital employee benefit plan against DaVita Inc. set out a roadmap for private insurers to shift the cost of terminal kidney disease to Medicare, as the court approved a private health plan that separates outpatient dialysis for low reimbursement, a plan that is likely to push these patients out of the private market and into Medicare.

The case involved a statute for the coordination of benefits, which distributes the cost of medical care between private health plans and Medicare. In this particular case, the law obliges private insurers to cover the cost of dialysis for the first 30 months after the patient is diagnosed with end-stage renal disease. Recognizing that insurers may try to exclude these (expensive) clients from their private plan and enter Medicare’s publicly funded system, Congress has banned insurers from discriminating against patients with end-stage renal disease. In particular, the statutes provide that the plan “may not discriminate between the benefits provided by persons with end-stage renal disease and other persons covered by such a plan”.

Marietta had the bright idea that she could solve this problem by providing unusually low levels of reimbursement for outpatient dialysis costs. This is an effective way to reduce the cost of patients with end-stage renal disease, as about 99.5% of patients receiving outpatient dialysis have end-stage renal disease. DaVita (one of the two largest dialysis providers in the United States) objected, arguing that discrimination against patients receiving outpatient dialysis is the same as discrimination against patients with end-stage renal disease. The lower courts agreed, but the Supreme Court rejected the argument by a 7-2 vote.

Judge Brett Cavanaugh’s opinion justifying this result was short – not exactly seven pages. He uses a strictly literal approach to the statute. For him, the only thing that matters is that Marietta “provides the same benefits, including the same benefits for outpatient dialysis, to people with and without end-stage renal disease.” Accordingly, he argues, the plan does not “distinguish between the benefits it provides between individuals” with and without end-stage renal disease.

Cavanaugh characterizes DaVita’s assertion that “the law allows liability … if.” [a] The restriction of benefits has different effects on people with end-stage renal disease. “He easily rejected this claim, citing the text of the statute as” requiring [an] asking whether a plan provides different benefits “rather than examining” the effects of non-differentiating plan conditions that treat everyone equally “. For Cavanaugh, the opposite interpretation of DaVita is unbearable because “it will ultimately require group health plans to maintain some (undefined) minimum level of benefits for outpatient dialysis,” something that Congress clearly did not intend.

Judge Elena Kagan’s disagreement (joined by Judge Sonia Sotomayor) argues that the decision “flies in the face of common sense”, explaining that “[o]Repeating outpatient dialysis is an almost perfect proxy for end-stage kidney disease. a tribute to the Jews remains on the yarms, even if friends of other religions can sometimes benefit from one at Bar Mitzvah.

Perhaps the most important thing the judges could not agree on was whether to describe the type of kidney disease as “end stage” (with a dash) or “end stage” (without a dash). The majority, following New York Times style, uses a hyphen; dissent, following the practice of Congress, does not.

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