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This May Be The Best Solution To Health Care's Worst Nightmare

Surprise billing needs to go away.

Surprise billing is probably the most terrifying medical development to come down the pike in a long while. It landed faster than you can say “single-payer” and the solution ― outlined quite brilliantly recently in a joint paper by the Center for Health Policy at Brookings and the USC Schaeffer Center for Health Policy and Economics ― will require even more political determination than it would for Donald Trump to keep his hands to himself.

For the healthy among you who have not yet run up against the practice known as “surprise billing,” here’s a primer: Some doctors, hospitals and labs sign contracts with health insurers agreeing to accept a pre-determined fee for caring for patients. This means they are in-network and aren’t suppose to hit the patient up for another penny. When a health care provider doesn’t have such a contract with your insurance company, they are considered out-of-network and have the right to bill you, the patient, whatever they want to be paid for their services. 

Surprise billing occurs when you go to an in-network hospital or emergency room but are seen by out-of-network doctors and later are sent whooping big bills ― surprise! You are guilty of foolishly assuming that the doctor in the in-network emergency room ― the one with the paddles on your chest ― was indeed in-network. Further, since you didn’t stop him from treating you while you were having a heart attack and/or were unconscious at the time, you will pay mightily for your oversight.  

In the white paper jointly produced by Brookings and USC, the solution starts with these things:

1. Stop holding patients responsible for something that is clearly outside their control.

Certainly, anything that goes on in an emergency room situation gets a pass. But don’t stop there, says the report.

That should be extended to getting you to the ER as well. (In real life practice, it is the ambulance driver who decides which hospital you are going to ― and it’s based on proximity, urgency, and the facility’s ability to provide you with quick and appropriate care. Frankly, much of the time, those ambulance rides themselves aren’t even in-network.)

Beyond that, solutions need to cover all out-of-network billing at in-network facilities, along with all care resulting from emergency room screening and patient transfers (including ambulance transport) at out-of-network facilities. Doing this avoids the need to draw arbitrary distinctions among different types of hospital services or urgent care situations.

Patients also need protection from surprise billing in outpatient settings, such as ambulatory surgery facilities and laboratory testing. Why do you have to pay when your in-network doctor uses an out-of-network lab to process your blood tests? 

2. States’ efforts are great and all, but the solution needs to be at the federal level.

States have a front-row seat to what’s happening in their local markets. But the feds need to dip their toes in the murky waters too. It’s necessary to protect the half of the privately insured market that is in self-funded employer plans. States have sufficient authority over people in self-funded plans if the remedies are directed only to providers. But if health plans are included, either a federal remedy is needed, or a federal enactment that provides states the necessary authority. Without a congressional enactment, the Department of Labor lacks full authority on its own to impose a comprehensive solution, the report said. 

3. Demand greater transparency. 

Sure, patients can check their insurer’s online information to see if a prospective doctor is in-network. But that’s no guarantee of anything. Even if you do land in the safe financial zone of an in-network doctor, he has no obligation to check if the specialist he refers you to is also in-network. That could be changed.

The reality, of course, is that surprise billing situations don’t typically arise in a calm atmosphere. When patients are sick, they rely on their primary doctor or in-network hospital to provide the best care possible. So, do you want the best doctor in the field to treat your brain tumor or the one who takes your insurance?

So sure, patients should have good access to current, accurate information about network membership. But that alone won’t solve most surprise billing situations, the report says. Notifying patients sometimes makes it feasible to freely consent to out-of-network billing. However, for that notice to be helpful ― the report says “adequate,” ―  it must include a case-specific estimate of the extra costs, and information about feasible in-network alternatives. 

There’s another reality at play here too. Sometimes there are no in-network providers in a particular specialty or sub-specialty at your in-network hospital. This is becoming increasingly more prevalent as networks shrink. We’ve heard of cases where an in-network hospital has no ― not a one ―  anesthesiologist on staff who accepts insurance. 

4. The patient doesn’t have to pay for surprises.

While this one isn’t likely to sit well with the medical community, that potential controversy should “not deter lawmakers from crafting a solution that holds patients financially harmless when they take reasonable steps, or have no reasonable opportunity, to avoid out-of-network billing,” says the report.

Holding patients harmless means that health plans charge them only in-network deductibles and cost-sharing and that providers not “balance bill” patients for the portion of their charges not paid. Holding our breath on that one.

5. Get the hospitals to show more love.

As anyone who has gotten bills from strange doctors  ― hospitalists ― who do those 90-second drive-by visits when you are a patient knows: The hospital doesn’t much care when you complain about the out-of-network bills that descend on your mailbox after you are discharged. Many hospitalists form groups and work under contract at the hospital. They are not on staff. And many of them are out-of-network.

The report says that when hospitals contract with specialists for hospital-based services (emergency, pathology, radiology), the “preferred policy approach” would be to have hospitals require participating physicians to join at least the primary health plan networks that the hospital joins. They could also require network participation as a condition of medical staff membership, for these and other key hospital-based specialists such as anesthesiologists.

Health plans could require hospitals to do so, in order to join their networks. Need more of a push?  Regulators could challenge whether health plan subscribers have adequate access at hospitals that lack sufficient network participation by key hospital-based specialists. Regulators should also use antitrust authority more actively to determine whether market power is being used inappropriately when most hospital specialists refuse to join networks.

At some point, patients may simply need to say “I’m mad as hell and not going to take it anymore.” That, or mouth the words “single payer.” 

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