There are few things in our health care system that are more unfair than surprise medical bills. Consumers think they have good coverage and are getting treatment in their health plan network only to get a huge unexpected bill in the mail because it turned out that something like the anesthesiologist at their recent surgery wasn’t covered.
How were they to know that? As you’re sitting on the gurney about to be rolled into surgery, do you need to do a provider roll call asking each to confirm their network status?
The worst of these examples often has to be with air ambulances sending patients bills for tens of thousands of dollars they had no reason to expect. As the patient lays there with burns over 60 percent of their body and they need to be transferred to the regional burn center, are they supposed to say, “Before you put me on the helicopter, what is this going to cost?”
Now, every politician I know of says that all of this needs to end.
But, they are yet to end it.
Both sides on this issue have legitimate concerns.
Insurance companies, employers, and union plan sponsors (payers) find themselves caught between their customers and health care providers in these circumstances. Some of these providers actually have business strategies to purposely not be in a network looking to charge anything they want in these situations. That is not to say health plans couldn’t be doing a lot better in making their networks clear to patients. Why in this world of real-time data can’t health plans and providers confirm that all providers who are part of my procedure are in the network at the point of service?
Hospitals, doctors, and other providers worry that some of the proposed solutions would de facto toss them into the payers’ networks at the network’s typical payment rates, thereby disenfranchising them from being able to negotiate what their payment rates should be.
Like everything else in the American health care system, it’s complicated.
When you have two sides offering legitimate but diametrically opposed arguments, the solution can only come through compromise. And, I will suggest, when such a circumstance occurs in a matter involving public policy, it is the role of the legislature to impose a compromise that, as its first priority, meets citizen needs.
Led by Senate Health Committee Chair, Lamar Alexander (R-TN) and the House Energy and Commerce Chair Frank Pallone, Jr. (D-NJ) and ranking member Greg Walden (R-OR), it sure looked to me like a powerful bipartisan group in Congress did just that.
They offered a solution to this problem that was responsive to both sides’ arguments and would end up holding patients harmless from all of this.
If a patient is out of network and the provider refuses to accept the plan’s payment:
The provider would have to accept a minimum payment reflecting the plan’s market-based median in-network negotiated rate for the service in the geographic area where the service was delivered.
This compromise would force the provider to accept a payment amount, but it would be the median of all amounts that had already been negotiated in good faith in that market with a large number of providers.
But, providers could still have a reasonable objection arguing they should be able to negotiate their own rate, and perhaps their circumstances justify a higher rate than the median.
Of course, they can always enter negotiations with the payers to be in their network in the first place.
But failing that, the proposed compromise would also give providers an out:
If the median in-network rate payment was above $750, the provider or the insurer could elect to take the matter to binding arbitration with an independent dispute resolution service. To keep people from gaming the system, a party could not go to arbitration for the same service more than once in 90-days.
This is what I would call a compromise. Neither side gets all that they want, both get something reasonably resembling what they have asked for (payers wanted a median rate, providers wanted arbitration), and the consumer/patient caught in the middle no longer has to suffer from all of this.
So, what has been the response to this so far:
Insurance companies, employers and union plan sponsors don’t like it — the Coalition Against Surprise Medical Bills — said anything with arbitration wasn’t good enough, “The result of arbitration is that consumers, employers, unions, and taxpayers pay the price” pointing to what they said was abuse by providers in an existing New York arbitration system.
On the other side, providers generally objected. The American Hospital Association said the proposal would offer an “arbitrary … reimbursement rate,” jeopardize patient access to hospital care,” and “provide a huge windfall to commercial insurance companies at the expense of community hospitals.”
Under pressure from the payer lobby on one side and the provider lobby on the other, leading members of Congress have been leery of supporting the proposed compromise. For example, the ranking Democrat on the Senate health committee, Patti Murray (D-WA), didn’t join in support of the bill reportedly because Democratic Senate Minority Leader Chuck Schumer (D-NY), responding to hospital lobbying in his state, waived her off.
Much has been made of the current toxic political environment in Washington, DC, and the inability to get things done because of it.
But here is an example of bipartisan leaders in Congress hammering out a reasonable compromise in spite of that.
But so far, and with time running out on this Congress being able to get something done this year, when year-end must pass pending bills provide a vehicle for passage, old fashioned special interest greed politics still outranks finding a solution for regular people.
I sure hope none of these politicians, more interested in carrying the water for the special interests than worrying about their constituents, don’t need an air ambulance over the holidays.
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