Supreme Court overturns lower court ruling supporting higher dialysis payments to DaVita

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The U.S. Supreme Court has overturned a lower court ruling on a lawsuit filed by DaVita Inc. against an Ohio hospital system claiming its health plan discriminates against employees requiring medical care. dialysis care.

In its 7-2 vote, Supreme Court justices argued that all employees of Marietta Memorial Hospital’s health benefits plan were offered the same coverage for outpatient dialysis. “The question in this case is whether a group health plan that provides limited benefits for outpatient dialysis — but does so uniformly for all plan participants — violates Medicare’s secondary payer law,” wrote Judge Brett M. Kavanaugh giving the majority opinion. . “We agree with Petitioner Marietta and the United States as Amicus Curiae that the answer is no.”

Source: Adobe Stock.

Source: Adobe Stock

The Supreme Court ruling overturned the judgment of the United States Court of Appeals for the 6th Circuit which sided with DaVita, agreeing that Marietta’s limited reimbursement for dialysis treatment had a disparate impact in patients with end-stage renal disease.

“Alongside the kidney care community, we are deeply disappointed by today’s Supreme Court decision to overturn important protection for Americans with chronic kidney disease,” said Javier Rodriguez, CEO of DaVita. , in a press release. “The [Medicare Secondary Payment Act] The MSPA was created to protect some of the most vulnerable patients in the health care system who deserve unfettered access to the coverage best suited to their individual health needs.

“Today’s narrow interpretation of this law limits its ability to achieve this goal. Dialysis patients deserve better, and we will continue to advocate for patient choice in care and coverage,” Rodriguez said in the statement.

In an amicus brief, the Kidney Care Council (KCC) wrote: “In seeking to overturn the 6th Circuit’s decision, the petitioners are arguing for an outcome that would nullify the protections and purposes of the [MSPA], by interpreting this law as allowing group health insurance plans to discriminate against people with chronic kidney disease who require dialysis. Such an outcome would mark a sharp break with the status quo, encouraging private insurers to shift the financial burden of treating patients with ESRD to Medicare – an outcome clearly contrary to the text and purpose of the MSPA.

“This would not only place a burden on the Medicare Trust Fund in contradiction to the MSPA, but would seriously erode the stability and viability of the model for providing dialysis care to ESRD patients in the United States,” the KCC wrote.

Limited coverage

DaVita sued Marietta’s health care plan in 2018, arguing that the company’s limited coverage for outpatient dialysis differentiates people with and those without ESRD.

According to the decision, Congress amended the Medicare Secondary Payer Act to make Medicare a “secondary” payer of an individual’s existing insurance plan for certain medical services, including dialysis, in an effort to curb rising costs of kidney care.

“Given the significant health care costs for people with end-stage kidney disease, Congress has recognized that a [insurance] plan could attempt to circumvent the law’s primary payer obligation by denying or reducing coverage for someone with end-stage kidney disease, thereby forcing Medicare to bear more of those costs,” Kavanaugh wrote. “To prevent such circumvention, the law imposed two specific constraints on group health plans. First, a plan “cannot differentiate the benefits it provides between people with end-stage kidney disease and other people covered by that plan on the basis of the existence of end-stage kidney disease, the need for ‘kidney dialysis or any other situation’. in another way.

“Second, as relevant here, a plan” may not take into account whether an individual is entitled or eligible for “medicare due to end-stage renal disease,” Kavanaugh wrote.

“Section 1395y(b)(1)(C) does not permit disparate impact liability, and the Marietta Plan coverage terms for ambulatory dialysis do not violate §1395y(b)(1)(C) because these terms apply equally to all covered individuals,” Kavanaugh wrote. “Because Marietta Plan terms apply equally to individuals with and without [ESRD]the plan does not “differentiate the benefits it provides between individuals” with and without end-stage renal disease,” Kavanaugh wrote.

Dissenting view

Writing the dissenting opinion, Justices Elena Kagan and Sonia Sotomayor wrote, “The MSPA says a group health plan ‘cannot differentiate the benefits it provides between people with end-stage kidney disease and other people covered by this plan on the basis of having end-stage renal disease, the need for kidney dialysis or otherwise.

“The majority argue that the plan here doesn’t ‘differentiate’ so much because it draws distinctions only between dialysis and other treatments – not between people with end-stage kidney disease and people who don’t. reached.

“This conclusion flies in the face of both common sense and statutory text,” Kagan and Sotomayor wrote.

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