Patients get unexpected year-end cheer — new curbs on surprise medical bills

billsurprisemedica-300x167The do-little U.S. Senate and the House gave Americans an unexpected cause for glee at year’s end. Lawmakers approved long sought relief from “surprise medical bills,” the charges, too often whopping in size, that individuals and families rack up for care from all kinds of providers that their health insurers have not approved.

Multiple legislative committees and influential lawmakers compromised so Congress could mostly resolve this consumer nightmare as part of the 5,600-page bill that both provides desperately needed coronavirus relief and funds the government.

The legislative action exempted one costly area considered still too complex and fraught for Congress to deal with — pricey emergency transport by ambulances. The vehicular services, for which consumers can get staggering bills, are run by so many different providers, including local governments, and operate under such a patchwork of regulations that lawmakers decided against dealing with this extreme expense.

Still, as health policy Larry Leavitt of the nonpartisan Kaiser Family Foundation observed on social media of the overall congressional action:

“Patients are the big winner here, gaining  [needed] protection … They’ve effectively been held hostage as well-funded health care industry groups battled over how much out-of-network providers would get paid.”

The online news site Vox recapped what is at stake:

“Multiple studies have found that about one in five emergency room visits result in a patient being charged for out-of-network care. According to the Kaiser Family Foundation, even 16% of admissions to an in-network hospital still lead to out-of-network charges because one of the doctors seen by the patient wasn’t part of their insurance plan network. As Sarah Kliff documented extensively for Vox, those surprise bills can have balances in the tens of thousands of dollars — even if, for example, somebody got hit by a city bus and was taken to a hospital while unconscious.”

Vox reported that lawmakers, who have held hearings and tried to strike deals to resolve this patient headache, long have gotten stuck, for example, in determining “what an insurance plan would pay to an out-of-network hospital or doctor or ambulance service.” The news site said:

“One side of the debate (roughly represented by the first three committees to reach a deal and the health insurance lobby) wanted to default to something close to the average in-network price that is paid for the billed services in the area. The other side (represented by [some House leaders] and the hospitals) wanted to use a third-party arbitration process to come up with a fair payment.”

Vox quoted the Brookings Institution’s Loren Adler, who reported on Twitter, a summary of the compromise lawmakers reached:

“Surprise billing would be barred for out-of-network emergency care, for most out-of-network care at in-network facilities, and for air ambulances. The patients would be asked to pay only their in-network obligations for the care they received, and that is the end of it for them. The question then becomes what the insurer will pay the provider. There would initially be a 30-day period during which the insurance plan and the health care providers could try to negotiate a payment for the out-of-network claims. If they don’t reach an agreement, then arbitration would be the next step. The independent arbiters would primarily consider the average in-network charge for the services in question, as well as other information provider by the insurer and provider. Both sides would make an offer, and the arbiter would pick one based on the guidance stipulated in the bill. Nobody would call it a perfect plan — ground ambulances are notably excluded from the prohibition on surprise billing — but most health policy experts seem to see it as a marked improvement over the status quo. ‘All in all, this takes consumers out of the middle of surprise billing disputes, almost certainly at least won’t increase costs, and I’d argue should allow the market to improve over time,’ Adler wrote. ‘That’s a win in my book, even if it’s not my ideal solution.’”

The sudden specter and rapid rise of surprise medical billing, from a patient perspective, has been an abomination that could only occur in the exploitative parameters of the U.S. health system. Insurers, working with employers, were eager to corral costs in job-provided policies. And so, they herded patients into “narrow networks” of providers, with whom insurers cut favorable deals for themselves on costs. This started to rile patients, who found that they were cut off from familiar doctors and hospitals they had long gone to. They also saw that institutions and specialists with big names and reputations too often were accessible only in the priciest insurer networks.

The providers then quickly countered, with many declining to deal with insurers and employers. Instead, they sought to protect their cut, hitting patients with “out of network” charges for services — especially when patients were in poor position to dicker. Emergency room clinicians, anesthesiologists, pathologists, surgeons, and, yes, ambulances (on streets and airborne) infuriated patients with big surprise bills. The howls reached to Washington, where armies of lobbyists representing the many special interests in medicine — doctors, hospitals, and insurers, to name a few — barraged lawmakers.

The politicians took great heat from the public, especially because news organizations, notably Vox, the New York Times, and the nonpartisan Kaiser Health News (KHN) service, have published regular, outrage-provoking articles about patients getting gouged by providers with bills, which, too often arrived late and with extreme costs.

Elisabeth Rosenthal, an editor, journalist, and onetime practicing doctor, is KHN’s editor and wrote an Op-Ed for the New York Times, her one-time employer, that succinctly described medicine’s billing mess. It’s worth repeating her core contention: “Much of what we accept as legal in medical billing would be regarded as fraud in any other sector. I have been circling around this conclusion for this past five years, as I’ve listened to patients’ stories while covering health care as a journalist and author. Now, after a summer of firsthand experience — my husband was in a bike crash in July — it’s time to call out this fact head-on …”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent health care. This has become an ordeal due to the skyrocketing costs, complexity, and uncertainty of treatments and prescription medications, too many of which turn out to be dangerous drugs.

Medical billing, especially with its surprises but also with its Byzantine, bumpf-creating back-and-forth, is an unacceptable grind on the people who should count most in our health care system — sick and injured patients and their anxious loved ones. When dealing with significant illness or injury — and we’re all a blink away from such instances — the last thing that consumers and their families need to deal with is a mountain of bankrupting bills that are so mysterious they would baffle an Ivy League MBA. This bureaucracy also costs Americans billions of dollars in wasted health care costs.

While it is a positive development that Democrats and Republicans in Congress managed at long last to legislate in a way that benefits ordinary Americans and their health needs, it took far too long for Senate Majority Leader Mitch McConnell and his GOP colleagues to start to heed the anguish of patients. This includes not only those ripped by surprise bills but also tens of millions of Americans in joblessness, hunger, poverty, and misery due to the coronavirus pandemic. Congress has sat on its hands for far too long on issues like these and health concerns like funding the states’ roll-out of the coronavirus vaccine and providing Pacific Islanders in this country unjustly denied Medicaid.  Why can lawmakers act only under calamitous deadlines and throwing everything into packages so large as to jam Capitol Hill printers and crash congressional web sites? A little justice and humanity? Political compromise to get the nation working better? What Washington is doing may be too little. Here’s hoping it’s a holiday hint of vast and needed improvements ahead.

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