Surprise Medical Bills Give Both Parties an Unexpected Opportunity to Agree – The New York Times

Surprise Medical Bills Give Both Parties an Unexpected Opportunity to Agree - The New York Times

Sens. Lamar Alexander, Patty Murray Introduce Bill To Reduce Health Care Costs : Shots – Health News

ImageAt a White House policy event this month, Dr. Paul Davis of Findlay, Ohio, showed President Trump a surprise $17,000 medical bill his daughter received for a routine test.CreditJonathan Ernst/ReutersPresident Trump and House Democrats are fighting over the Affordable Care Act as hard as ever, with Mr. Trump still vowing to repeal it and House Democrats passing bills to bolster it. And yet both parties have found a health issue they can agree to fight together: surprise medical bills.

Washington finds itself having a genuine policy debate that isnt driven by party line. The president gave a speech this month about the need for action, standing in front of patients whod received huge surprise bills. Various lawmakers from the House and the Senate have introduced bills with solutions — all bipartisan. Some of them include elements that might seem unusual for Republican proposals: setting prices, if only in limited circumstances.

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.

Surprise bills — which occur when a hospitalized patient is treated by a doctor who is not in the same insurance network as the hospital, and is billed for the difference — arent tied to any of the political controversies about Obamacare.

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.

Loren Adler, an associate director at U.S.C.-Brookings Schaeffer Initiative for Health Policy, said that lawmakers he talks to immediately understand. Its facially absurd that certain doctors can spring large, surprise bills onto patients who carefully choose their hospital. Compared with most issues he discusses with legislators, he said, its just a lot more intuitive of a problem.

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.

But just because everyone agrees that the problem should be solved doesnt mean theres broad agreement about the right solution.

Currently, there are four public pieces of legislation on the issue. And legislators expect more hearings, debate and revision. The bills authors have been holding sessions with professors and policy experts — and with lobbyists for insurers, hospitals and doctors, all of whom would be affected by such a law and have strong preferences about how it should be written.

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.

The real fight is between industries, not Republicans and Democrats, said Shawn Gremminger, the senior director of federal relations at the consumer advocacy group Families USA.

Several studies have found that about 20 percent of patients seen in an emergency room or admitted to a hospital are treated by an out-of-network doctor. Although fairly common, research has also shown that the practice is not random: It appears that a very small number of hospitals use doctors who routinely go out of network. Surprise billing has emerged as a major voter concern, and is showing up in public opinion surveys.

What should happen when an insurer and a doctor cant agree on a price? For most health care services, there is pressure to make a deal because both sides benefit. But because people generally dont pick their own emergency room doctor or anesthesiologist, these types of doctors can walk away from the bargaining table without losing any patients.

Left: U.S. Senator Lamar Alexander (R-TN) and Senator Patty Murray (D-WA) shake hands to celebrate the Every Student Succeeds Act in Washington, on December 10, 2015. The senators have once again teamed up to address surprise medical bills. Photo by Jonathan Ernst/Reuters

But there are various ways to resolve disagreements between a doctor and an insurance company over the right payment.

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One solution is to pay out-of-network doctors a set price, based on amounts that other doctors have negotiated with insurance companies. Thats the approach embraced in recent draft legislation written by the bipartisan leadership from the House Energy and Commerce Committee. Under that bill, if doctors and insurers cant agree on a price, the doctor will get the median price paid to in-network doctors in that area.

Two bills, one from a bipartisan group of senators including the Republican Bill Cassidy of Louisiana and the Democrat Maggie Hassan of New Hampshire, and another from a bipartisan group of House legislators, would let doctors and insurers who disagree bring their dispute to a professional arbiter. Each would offer the arbitrator a price, and the arbitrator would pick one.

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.

A last option, which the White House appears to favor, would require doctors who work in hospitals to sign contracts with the same set of health insurers.

In general, the insurance companies like the price-setting approach, and the medical providers like arbitration. The constituency for the contract approach is mostly professors.

The most recent bill, from Lamar Alexander of Tennessee and Patty Murray of Washington, the leaders of the Senate Committee on Health, Education, Labor and Pensions, has yet to commit to a solution. Their draft bill asks for comments on all three options.

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.

Which will Congress pick? The answer probably depends a bit on how comfortable legislators are with the idea of price setting. If Congress dictates how much out-of-network doctors should be paid, it will affect negotiations between doctors and insurance companies. Currently, a doctor who doesnt like an insurance companys offer can walk away from the negotiating table and just charge higher prices to patients directly.

Those dynamics tend to drive up the negotiated prices for their work, said Ben Ippolito, an economist at the American Enterprise Institute, who has spoken with legislators about the issue. Over time, he said, it is likely that more doctors would come to be paid something similar to the benchmark, as insurers know that they wont have to pay more if they fail to make a deal.

But experts note that arbitration could lead to a similar clustering of prices. In choosing between bids, arbiters will need to decide their own benchmarks for what a reasonable price looks like, and they will tend to pick prices close to that number.

Another portion of the bill deals with the rise in measles cases in the U.S. The proposal would have the Department of Health and Human Services launch an education campaign to tell people about the importance and safety of vaccines. The department would send grants to states so that health departments can update health data systems that track infectious disease cases in various communities and to help them more effectively provide parents in those communities with information about the safety of vaccines.

In New York, which set up an arbitration system five years ago, very few claims make it to arbitration. The theory goes that, as players come to understand the preferences of the arbitrators, they will settle the bill themselves at a similar rate. Those who like the approach say it is less heavy-handed than setting a standard price. Critics say that arbitration is simply a more complicated way to set prices.

In an effort to further reduce prescription drug costs, apart from regulating pharmacy benefit managers, the Food and Drug Administration would have the authority to deny citizens petitions, which are requests to the FDA arguing for a monopoly over one drug by one manufacturer, often on behalf of the drug manufacturer, rather than allowing approval of generic alternatives and biosimilars. The idea would be to help generics enter the market faster and offer lower-cost alternatives to brand-name drugs.

The third approach, requiring doctors who work in a hospital to accept all the same insurance as the hospital itself, would eliminate the possibility of a surprise bill, rather than establishing a process for resolving the dispute later. Advocates of this approach say, in practice, that it will probably mean hospitals will do much of the negotiating on behalf of doctors who work with them.

The draft would have providers and insurers disclose to patients exactly what services would cost before they receive procedures. Insurers would not be permitted to direct patients to use specific providers in contract with the insurers and thereby pushing patients to seek higher-priced care. Additionally, insurers would not be able to engage in an all or nothing approach to contract with all providers in a practice or no provider at all.

Though theres a lot to be figured out before Congresss flurry of bill releases leads to a law, the breadth of the consensus has made optimism high among all the major players.

Another idea would be to have practitioners and insurers, in cases where a surprise bill is above $750, resolve the cost of services by working with a third-party arbitrator to figure out what a fair price is. Through this measure, which does not have White House support, the patient would be removed from the complicated processes of fixing the dispute.

I cant think of another single issue that has been getting this level of attention, that has this level of bipartisan support, and where across the health care spectrum you do, at the very least, have consensus we need to address this, said Adam Beck, vice president for employer health policy and initiatives at the health insurance trade group Americas Health Insurance Plans.

Margot Sanger-Katz is a domestic correspondent and writes about health care for The Upshot. She was previously a reporter at National Journal and The Concord Monitor and an editor at Legal Affairs and the Yale Alumni Magazine. @sangerkatz • Facebook

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.

The portion addressing prescription drugs suggests barring pharmacy benefit managers such as CVS Health from charging a patient or insurer any more for the drug than what it paid. Pharmacy benefit managers would give rebates directly to employer-provided plans or plans on the exchanges.

“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.

It came as part of a highly anticipated health care package from Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the duo that helms the Senate health committee that is widely respected for bipartisan health-policy work.

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.


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