The American Kidney Fund has denied claims, published in a Dec. 25 article in the the New York Times, that it shows favor in approving applications for premium assistance to those dialysis providers who have paid into the AKF’s Health Insurance Premium Program––a violation of the federal agreement that set up the program over 20 years ago.

“We never condition our issuing of grants on whether a provider has contributed, and fully 40 percent of dialysis providers with patients receiving help from AKF don’t contribute anything to AKF,” the organization said in response to the article. “We currently have HIPP grant recipients who are treated at more than 200 dialysis companies, spanning the full range of providers from small independent clinics, to mid-sized companies, hospital clinics, and the largest dialysis organizations.”

New York Times reporters Katie Thomas and Reed Abelson cited comments from social workers at small dialysis clinics who said they were discouraged to apply for the premium assistance fund because their providers had not contributed to the assistance program. That’s contrary to an Office of Inspector General agreement with the AKF and dialysis providers that set up HIPP, requiring that the AKF must  offer premium assistance to all qualified patients regardless of whether their provider had paid into the program.

AKF CEO LaVarne A. Burton told the Times that the charity treated all patients equally, and that the fund had never denied anyone assistance if they qualified financially. She acknowledged, however, that the charity pushed clinics hard to donate, particularly if they applied on behalf of patients. The Fund believes “there is a moral obligation for providers to contribute to the organization, “ Burton told the Times.

Premium assistance leads to higher payouts

Dialysis providers have been under fire from health care plans and the Centers for Medicare and Medicaid Services for allegedly “steering” patients away from Medicaid and Medicare insurance and into commercial plans offered by the Affordable Care Act so providers can charge higher prices for dialysis treatments. The AKF has been criticized for helping the providers by offering premium assistance for patients choosing those commercial plans without questioning whether the plan is better for the patients.

Under a final rule released on Dec. 12, CMS has placed new requirements on dialysis providers who counsel patients on health plans. Specifically, the CMS rule states:

  • Dialysis facilities will be required to make patients aware of potential coverage options and educate them about the benefits of each to improve transparency for consumers.
  • Facilities must ensure that plan issuers are informed of and have agreed to accept the payments.

The agency is also creating a new patient right standard that requires dialysis facilities that provide premium assistance directly or through a third party to provide information that explains how plans in the individual market will affect the patient’s access to and costs for the providers and suppliers, services, and prescription drugs that are currently within the individual’s care plan, as well as those likely to result from other documented health care needs. This must include:

  • An overview of the health-related and financial risks and benefits of the individual market plans available to the patient (including plans offered through and outside the exchange).
  • An explanation of coverage of transplantation and associated transplant costs.
  • Dialysis facilities must ensure that insurers are informed of and have agreed to accept the payments.

“CMS’ stated goal in issuing the IFR [interim final rule] is to create a more transparent process for patient education and referral to nonprofits for charitable assistance for health insurance premiums,” the agency said. AKF CEO Burton said in a statement issued in response to the rule, “We wholeheartedly support that goal—but in reality, the IFR effectively removes kidney patients from the insurance decision-making process. It leaves to insurers the decision of whether to provide ACA coverage to low-income kidney patients who need charitable assistance to afford premiums.”

The final rule is effective Jan. 15.

Below is the AKF’s full response to the New York Times article:

“An article in the business section of Sunday’s New York Times presented a factually incorrect and unfair picture of the American Kidney Fund (AKF) and the lifesaving work that we do through our Health Insurance Premium Program (HIPP). We have reached out to the Times to request corrections on the most serious factual errors and misleading statements. In the wake of this article there are several key points that we feel are essential to emphasize:

• Since we are a charitable organization, we do ask all providers to contribute to our program—but we never require it.

• We have never turned away a patient who is financially qualified to receive a grant, and we never will turn away such a patient.

• We never condition our issuing of grants on whether a provider has contributed to AKF, and fully 40 percent of dialysis providers with patients receiving help from AKF don’t contribute anything to AKF.

• There is no “earmarking” of donations.

• HIPP has firewalls in place to protect the integrity of the program.

We think it is important to specifically address a number of factually incorrect statements and implications in the Times article:

  • We do ask all providers to contribute to our program—but we never require it. The structure of HIPP is simple, and was laid out in a positive 1997 Advisory Opinion from the United States Health and Human Services Office of Inspector General. Dialysis providers may contribute to HIPP to help support the great many people in this country who are on dialysis and can’t afford their health insurance premiums. If a provider chooses to donate, their donation goes into one funding pool at AKF. From that pool, our staff awards grants to patients in need on a first- come, first- served basis. Patients are free to change dialysis providers at any time. They do need to re-submit their information to AKF so that we can ensure their grant coverage continues. The grant follows the patient regardless of where they are treated. Significantly, the Advisory Opinion explains that AKF will provide grant funding to a patient even if their provider has not contributed to the program. We have always followed that requirement to the letter.
  • We have never turned away a patient who is financially qualified to receive a grant. It does not matter if their dialysis provider contributes to AKF—we have never turned down a patient in need. We exist to serve all dialysis patients, and have done so for close to half a century. We treat all patients the same.
  • We never condition our issuing of grants on whether a provider has contributed, and fully 40 percent of dialysis providers with patients receiving help from AKF don’t contribute anything to AKF. We currently have HIPP grant recipients who are treated at more than 200 dialysis companies, spanning the full range of providers from small independent clinics, to mid-sized companies, hospital clinics, and the largest dialysis organizations. In determining whether to issue a grant, we look only at whether a patient meets our financial need criteria—the patient’s household income may not exceed expenses by more than $600 per month. If the patient meets this criteria and if they have submitted a full and complete application, we will accept them into our program and pay their health insurance premiums for the full plan year, uninterrupted, regardless of whether their dialysis provider contributes to AKF. The Times’ interview with an independent Midwestern dialysis center administrator confirmed that AKF continued to provide support for patients he referred to us even though he chose not to contribute to HIPP.
  • There is no “earmarking” of donations. Every contribution we receive goes into one funding pool, from which we award grants to patients in need. We help patients equally, whether or not their provider has made a donation to AKF, and providers have no way of dictating how we spend their donated funds.
  • HIPP has firewalls in place to protect the integrity of the program: When providers contribute to AKF, we have absolute control over what we do with the funds. Their donations do not follow individual patients, but instead, support the overall funding pool.
  • Our patient services staff who award grants do not have access to our revenue data. They don’t know whether a patient who is applying for assistance is treated at a facility that has donated to AKF.
  • AKF does not report to the public the names of providers who have contributed, or how much they have contributed. This is a protection against patient inducement; it ensures that patients are not selecting a provider because they think doing so will result in them receiving HIPP assistance.
  • We require every renal professional to complete the same training module before submitting applications on behalf of patients. Every person who wishes to submit grant requests is required to complete our training module first. This uniform process protects patients by ensuring renal professionals understand our program and submit all of the necessary materials in a complete manner so that we may process grants in a timely fashion. The straightforward training takes approximately 30 minutes to complete, and it is provided to individuals at no charge. Once an individual has completed the training, they are registered in our grants management system and can submit grant requests on behalf of patients.

Of greatest concern to us in this article was the fact that several renal professionals at smaller and independent dialysis clinics told the Times they believe that AKF gives special favor to patients who are treated at the largest dialysis companies. This is simply not the case, and we want to correct the record, as well as take ownership of any way that AKF itself may have contributed to this misperception.

HIPP entered a period of financial instability about five years ago. Because providers cannot earmark donations for individual patients, and are under no obligation to contribute to AKF, we started to see a significant uptick in providers who were sending patients to us without making any contributions to the program. Providers have every right to do this, but so many providers were sending patients to us for HIPP assistance that the program was quickly reaching a point where it would become insolvent and unable to continue helping current patients—a situation that would have been disastrous for existing grant recipients who would lose their health coverage as a result.

For the next several years, we embarked on an effort to reach out to all of the providers with patients in our program. We worked intensively to educate them about the need to contribute if the program were to continue for all patients. We explained to these providers the structure of the program and our philosophy that this is a charitable operation; we think that dialysis providers have a moral obligation to support a nonprofit that is helping a patient population that is 80 percent unemployed. At the same time, regardless of whether or not these providers actually contributed to AKF, we continued to assist their patients.

After we began to educate providers about the need to support the program, many of them began to contribute to the program for the first time, and the program turned around. The program continues to run an annual deficit, but we have been able to close the funding gap enough that the program is once again stable. A stable HIPP program is absolutely critical to the 80,000 people who depend on it each year for their health coverage.

We regret that our past communications to dialysis providers in trying to educate them led some individuals to believe that we would only assist certain patients; this could not be farther from the truth. In fact, we treat all patients the same. We have never turned away a patient who is financially qualified to receive a grant. It does not matter if their dialysis provider contributes to AKF—we have never turned down a patient in need. Earlier this year, we revised our HIPP program guidelines to remove language in which we asked providers to contribute because we did not want there to be any confusion around the fact that such contributions are, in fact voluntary. We also developed a new patient-facing HIPP brochure that outlines how the program works, emphasizing the fact that patients can receive HIPP assistance no matter where they have dialysis.

We are committed to continually improving our communications with patients and renal professionals to ensure the entire renal community understands how our program works, including most importantly that our program is available to any patient in need.”