Share Share Congress wants to stop surprise medical bills. But they have one big problem left to solve. tweet share Reddit Pocket Flipboard Email Sens. Patty Murray (D-WA) and Lamar Alexander (R-TN) are working on legislation to stop surprise medical bills. Tom Williams/CQ Roll Call President Trump and Democrats want to fix an important health care problem, but lawmakers still have one very difficult question to figure out before they can move forward.
Congress suddenly has a bunch of bills to stop surprise medical bills, which can leave even some insured people with tens of thousands of dollars in medical bills for a simple trip to the emergency room, but how much providers actually get — and by what means — is still a very open question.
Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA), the top Republican and Democrat on the Senate health committee, introduced a health care costs bill on Thursday but it did not come up with a way for out-of-network health care providers to get paid by health insurers. Instead, it offers three options for determining those payments, and they will decide later which one to actually include in the final version. Its a pretty big hole left to fill in otherwise quite ambitious legislation.
Provider payments are the thorniest issue to figure out for any plan to prevent surprise medical bills. It affects the bottom lines for doctors, hospitals, and insurers, so they care a lot about those provisions and lobby hard on them. Different House and Senate bills would set up different systems for how those payments would be determined.
Trump has pledged to sign a bill blocking surprise medical bills. For now, the lawmakers working on surprise billing sound diplomatic about the differences between their plans. But solving the provider payments issue is a substantial hurdle to doing something.
My No. 1 goal is clear: Lets protect patients by ending surprise medical bills. The path to achieving this goal has multiple roads, Walden told Vox. I believe its fair to base the compensation mechanism off of private-market rates and that any solution should not raise federal health care costs. This is one solution. Arbitration is another.
The Alexander-Murray proposal joins several others that have already been introduced: a recently released House bill from Reps. Frank Pallone (D-NJ) and Greg Walden (R-OR); another Senate bill by Sens. Bill Cassidy (R-LA) and Maggie Hassan (D-NH) released last week; yet another House proposal from Rep. Raul Ruiz (D-CA) and Phil Roe (R-TN) that came out on Thursday. Rep. Lloyd Doggett (D-TX) also introduced a bill back in January. Congress really is serious about doing something on surprise bills.
Broadly speaking, the various House and Senate bills to prevent surprise medical bills would have the same consequences for patients: They would be obligated to pay only in-network costs for out-of-network emergency care.
Under the proposal legislation, if somebody ends up in the emergency room or they get surgery, and the facility or one of their providers is not in their health insurers network, they cant be asked to pay the full cost for their medical care. The practice known as balance billing — when a provider bills a patient the balance between what the patients insurer paid for a service and the price the provider wants to charge for that service — is prohibited.
The legislation from Alexander and Murray dictates that patients cant be charged extra money for any emergency care, ancillary care (anesthesia, radiology, etc.), or diagnostic care they receive from an out-of-network provider. They can only be billed for whatever co-pays, co-insurance or other cost-sharing they would have been required to pay for an in-network provider under their health insurance plan. If somebody is moved from the emergency room to a general hospital setting, they must be notified in advance about any potential out-of-network care and its costs. They must also be informed of the in-network options available to them.
The new Alexander-Murray bill also includes a bunch of other provisions beyond surprise billing to reduce health care costs for patients. Given the Tennessee senators pending retirement, he might be trying to group together some other cost-controlling provisions into an omnibus health care costs package, using the popularity of doing something about surprise billing as an incentive. Some of the other provisions in the Senate bill include:
Surprise bills seem like the surest bet for action at the moment. But there is one other big piece to this puzzle.
If a patients bill will be limited to what it would be for an in-network provider, but the health care provider and insurance company dont have a preexisting contract, then Congress has to come up with some way to figure out how much the insurer pays the provider for the out-of-network care. That is the real money at stake in this legislation, so the lobbyists for the health insurers and the doctors care a lot about these provisions.
The Alexander-Murray bill punts on this question; they instead lay out three options and plan to pick one after soliciting feedback from the interested parties representing health insurers, doctors, and patients. The three options are:
Doctors and health plans really prefer some kind of arbitration. They want to have the opportunity to appeal and seek a better price, rather than being wholly bound by what is effectively a government-set price. Cassidy and Hassan, who have been working on a surprise bills proposal for a year, certainly found that to be true while they drafted their plan. The Cassidy-Hassan bill would allow for arbitration, with the median in-network price acting as the default payment if neither side seeks arbitration within 30 days.
I continue to believe that the bipartisan STOP Surprise Medical Bills Act – given its support from stakeholders on all sides of this issue – is the most viable option to become law and end the absurd practice of surprise medical bills, Hassan told Vox in a statement. Every day, patients continue to receive these outrageous bills in the mail, and I will keep working with my colleagues on both sides of the aisle to pass bipartisan legislation without delay.
Some experts believe having a regulated price or network matching, rather than allowing for arbitration, is better policy because arbitration could end up leading to higher prices than the other two options, mitigating the cost-saving potential for these plans. The House bill from Pallone and Walden notably goes with price-setting. The White House has signaled it would prefer something other than arbitration as well.
But the politics are trickier: Doctors, hospitals and insurers could mobilize against such a bill, whereas they have sounded supportive of the provisions in the legislation from Cassidy and Hassan that allow for arbitration within certain limits.
The pure payment standard approach tied to median in-network rates … would much more clearly reduce health care costs, as the median rate for specialties most commonly involved in surprise billing is notably below the mean, said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy. The price-setting approach is pretty clearly preferable to arbitration from a policy perspective, but its certainly possible that the politics are easier on arbitration.
It could be that highly regulated arbitration — like Option No. 2 in the Alexander and Murray legislation — becomes the middle ground to clear this policy obstacle. New York, when passing its own surprise medical billing plan, took such an approach, and the new plan from Ruiz and Roe is modeled on that states law.
But for now, Congress is leaving this space blank, as demonstrated by the unusual Option A, B, or C in the Alexander-Murray bill.
The safest bet is always against health care legislation passing Congress, especially in a time of divided government. But surprise medical bills might be the exception.
Alexander and Murray lead the Senates foremost health care committee, and Pallone and Walden are the top members of a powerful House panel. To have the top Democrat and Republican on those committees co-sponsoring these bills denotes a real intention to pass something — if they can first resolve this dispute over payments and arbitration.
Surprise bills are really only a symptom of the underlying disease plaguing American health care — exorbitantly high and irrationally set prices — but they are a particularly egregious example, as they can leave even patients who have insurance with medical bills that total tens of thousands of dollars. Voxs Sarah Kliff summarized her findings after collecting ER bills for a year like this:
Patients find themselves in a vulnerable position during these encounters with the health care system. The result is often high — and unpredictable — bills. Hospitals are not transparent about the cost of their services, their prices vary wildly from one ER to another, and its hard to tell which doctors are covered by insurance (even if the hospital itself is covered). In many cases, patients cant be certain what they owe until they receive a bill in the mail, sometimes weeks or months later.
States like California and New York are acting on their own to crack down on surprise bills, but Congress looks insistent on taking action nationwide. These new bills are a hopeful sign that the days of patients ending up in the emergency room with not only a broken arm but also a huge bill might be numbered.
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Two people ask to take a photo with House Judiciary Committee Chairman Jerrold Nadler, D-N.Y., center, as the Senate and the House of Representatives shut down for the week-long Memorial Day recess, at the Capitol in Washington, Thursday, May 23, 2019. Rep. Nadler, whose district covers parts of Manhattan and Brooklyn in New York, has gained notoriety by leading one of the House committees investigating President Donald Trump. (AP Photo/J. Scott Applewhite) Senior lawmakers of both parties Thursday proposed legislation to tackle “surprise medical bills” and other concerns, from prescription drug costs to uneven vaccination rates. WASHINGTON (AP) — Plunging ahead despite paralyzing partisanship in the nation’s capital, senior lawmakers of both parties Thursday proposed legislation to tackle surprise medical bills and other concerns, from prescription drug costs to uneven vaccination rates.
The draft bill from Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., echoes a time when health care issues often led to dialogue and cooperation between political parties. Alexander chairs the Health, Education, Labor and Pensions committee, while Murray is the ranking Democrat.
“We can make progress when both sides are at the table ready to put patients and families first,” Murray said in a statement. Alexander said he wants to bring the bill to the Senate floor in July and get legislation on President Donald Trump’s desk.
But with Trump threatening to halt all cooperation with Democrats unless House Democrats stop investigating him, the outlook is unclear. Alexander says his bill represents “common sense steps” — more than 30 specific ideas — that are readily achievable.
“Surprise medical bills” are the shockingly high charges insured patients can get hit with when a hospital or doctor is not in their insurers’ network. Earlier this month, Trump held a White House event to declare his eagerness to sign a fix into law.
The Alexander-Murray legislation would protect patients by limiting their financial responsibility to their own plan’s in-network rates, when they receive emergency care at an out-of-network hospital, or when an out-of-network clinician provides services at an in-network facility.
But the legislation remains a work in progress, since lawmakers still have to figure out how hospitals, doctors and insurers would settle the costs among themselves. Insurers and employers who sponsor workplace coverage favor a set formula for calculating fees, while hospitals and doctors are calling for arbitration.
Alexander and Murray have plenty of company on surprise medical bills, since lawmakers in both chambers of Congress have advanced various proposals. A lobbying war has broken out between insurers and employers on one side, and hospitals and doctors on the other, over how to determine payments once patients are no longer liable for out-of-network care.
On prescription drugs, the bill includes a smorgasbord of measures aimed at indirectly lowering drug prices. But none of the proposals would require drugmakers to lower their prices or authorize the government to negotiate better deals.
Instead, several sections of the bill would discourage industry tactics long used to delay the launch of lower-priced generic medications. For instance, branded drug manufacturers routinely file frivolous petitions with the Food and Drug Administration against potential generic competitors, often delaying their entry to the market for months. The bill would empower the FDA to ignore such petitions.
— Authorize a national campaign to promote vaccination to prevent disease and control its spread. The campaign would “combat misinformation” and circulate scientific evidence making the case for vaccinations. The recent U.S. measles outbreak has been blamed on lagging vaccination rates in parts of the country.
— Call on the Health and Human Services Department to set up a grant program for improving medical care for pregnant women, with the aim of preventing maternal deaths and complications. Another grant program would focus on improving care for infants.
— Broaden consumer access to information from their health plans, including readily accessible lists of network providers, calculators for estimating out-of-pocket costs and medical claims data.
— Take steps to promote disclosure of contracting information in the health care industry, where accurate pricing information remains hard to obtain.
Missing from the legislation are any provisions to stabilize coverage under the Affordable Care Act, or mitigate the potentially far-reaching consequences if opponents succeed in a lawsuit to strike down the law as unconstitutional. Alexander and Murray had earlier written a bipartisan bill to shore up the health law’s insurance markets, but the effort failed.
Before the political wars over the Obama-era health law, it was not uncommon to see lawmakers of both parties working side by side on health care. Federal mental health parity legislation grew out of bipartisan collaboration. The Medicare prescription drug benefit under Republican President George W. Bush had support from key Senate Democrats.