‘A lot of money on the table’: Fight brews over surprise medical bills

“The law, which takes effect Jan. 1, protects patients from receiving expensive bills for unexpected out-of-network care but doctors, hospitals and insurers are still at odds over which factors an independent arbitrator should rely on to decide who picks up the tab.

The outcome could swing billions of dollars in payments, significantly influence how doctors and hospitals negotiate prices with insurers and possibly affect premiums for millions of Americans.

“This is probably one of the most significant overhauls in the health system since the [Affordable Care Act] ACA,” said a spokesperson for the Coalition Against Surprise Medical Billing, which represents insurers, employer and union groups, and works with patient groups. “We certainly don’t see any end in sight in terms of the battle in making sure that these regs are implemented.”

The coalition supports the Biden administration’s interim final rule that instructs arbitrators to rely primarily on a single factor — the median in-network rate in a geographic area — when settling disputes between providers and payers. It has sponsored multiple six-figure digital ad-buys, including one that runs through Christmas, urging regulators to stay the course.”

“Hospitals and doctors allege the Biden administration’s decision to emphasize the median in-network rate, a figure the insurance companies calculate, gives large insurers a huge advantage when negotiating how much a service should cost.

Insurers would have an incentive to keep the in-network rates lower to avoid paying more to out-of-network doctors. And they say payers would know doctors and hospitals have little recourse if they choose to remain outside an insurer’s network.

“Being out of network is really the physicians’ only control over how their contracts look,” said Randall Clark, the president of the American Society of Anesthesiologists. “If the insurance companies can treat us the same whether we’re in network or out of network, there is no impetus on the part of the insurance companies to negotiate fair contracts.”

Trade groups representing providers say the law lists several other factors that should be equally weighted when calculating how much a service costs, such as the doctor’s experience and the complexity of the procedure. While these metrics can still be introduced during the dispute resolution process, the Biden administration’s rules don’t give them as much weight as the median in-network rate metric, which providers say puts them at a disadvantage before the process even begins.”

Covid-19 surges spark chain reactions that strain US hospitals everywhere

“One hospital being overwhelmed isn’t a one-hospital problem, it’s an every-hospital problem. Even if your community is not awash with Covid-19 or if most people are vaccinated, a major outbreak in your broader region, plus all the other patients hospitals are treating in normal times, could easily fill your hospital, too. That makes it harder for the health system to treat you if you come to the ER with heart attack symptoms or appendicitis or any acute medical emergency.”

The US is about to make the same pandemic preparedness mistakes — again

“Outside experts have estimated that as much as $75 billion should be spent over 10 years on public health infrastructure, preparedness, and prevention.

The revised Build Back Better legislation totals roughly $10 billion in public health infrastructure and pandemic preparedness funding over the next few years — a down payment on better readiness, in Democrats’ view, but one without assurance of future installations.

“All too often, when there’s a crisis, the reaction is to put money into public health. Once the crisis subsides, the funding tends to dry up,” Ron Bialek, president of the Public Health Foundation, told me. “This is not a recipe for success.””

Can Health Regulation Move Beyond Markets?

“I document a large and mounting body of empirical research that shows that key market-based policies in health care have failed. Even if well intended, these policies have often not helped people make meaningful choices of medical care or insurance plans. And neither have they controlled spending, as experts promised.

In fact, they are doing exactly the opposite. They are setting people up to make poor choices and are scaffolding a massive, ineffective market bureaucracy.

One-third of people said they would rather file their taxes than read the terms of a health plan. And reams of studies summarized in my article affirm that people do not choose well among health insurance plan options, and these errors are hard to remedy with anything short of a strong default plan—in which case, one must ask whether “choice” even matters.

Likewise, even when people have to pay a large share of their own medical care and have easy access to price information, they still do not compare prices or choose the lowest-price options, even for services with little variation in quality. One partial explanation is that health care patients look to doctors—not price lists—to steer their care. Patients lack the desire, time, knowledge, and skills to navigate medical decisions as “consumers.”

The focus of the last several decades of health regulation has been to try to fix broken markets and flawed consumers through constant regulatory, technocratic tinkering—either to spur competition or to nudge consumers toward better choices. This tinkering has fallen short, and it has produced a massive market-based bureaucracy.

Thick layers of government regulations and regulators attempt to scaffold failing market-based policies. Plus, this scaffolding has deeply embedded private health care enterprises—with high profits and salaries—into the bureaucracy. As one example, the 2018 salary for the CEO of Blue Cross and Blue Shield of Michigan was recently reported to be $19 million, which is not an unusual sum among health care executives.

Because markets do not meaningfully enhance choice, do not avoid bureaucracy, and have certainly not solved cost problems, it is time to stop tinkering and to seek a better foundation for the next era of health policy and regulation.”

“It is time to give up the false hope that health care markets and individual purchase decisions will produce a health care system that Americans want and, in the process, drive down spending. Policymakers have spent a half-century avoiding the hard questions about what values, objectives, and tradeoffs should guide health policy, by hoping that markets would magically answer these questions.

The reality is that the only way to build effective health policy—and, in turn, health regulation—is by engaging deeply in these hard questions and the challenging political battles they necessarily provoke.”

Do high deductibles lower healthcare prices? Price Controls VS Managed Market Healthcare.

Video Sources: Do high deductibles lower healthcare prices? Price Controls VS Managed Market Healthcare.

High-Deductible Health Plans Reduce Health Care Cost And Utilization, Including Use Of Needed Preventive Services Rajender Agarwal et al. 10 2017. HealthAffairs. https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0610 Does High Cost-Sharing Slow the Long-term Growth Rate of Health Spending? Evidence from the States Molly Frean and Mark