surprise billing

This blog is more of an FYI about a huge problem in our health care system, “surprise billing” (see https://edition.pagesuite.com/popovers/dynamic_article_popover.aspx?artguid=31669217-2e22-4bf2-a9f0-1cbbe5c3e42d&appid=1165 ). This editorial was written by Ashish J. Jha, a professor of health policy at the Harvard T.H. Chan School of Public Health and director of the Harvard Global Health Institute

Details:
-- “surprise billing” is when a patient who has health insurance opens their mail to find an exorbitant bill from a clinician that they do not know. In general, the patient may go to a hospital or provider in their insurance network, but unbeknownst to them they are seen by a provider not in their network and then receives a large bill from them
-- most commonly, surprise billing comes from emergency rooms. Though the emergency room may will be part of the patient’s network, the ER physician who happens to see the patient may well be from an ER group that is not part of the that network.
     -- The ER group may elect not to be part of insurance networks so that they can bill patients whatever amount they choose, with no constraints. And, of course, the patient has no idea whether the individuals whom they are seeing are part of their network or not, nor do they necessarily have much choice.
-- some anesthesiologist groups are also problematic. The example in this editorial was a patient who had knee surgery by a surgeon at a hospital within their network. In this case the anesthesiologists were not in the network, and the patient received a bill for $28,000 for a couple of hours of anesthesia care
-- the editorialist argues that hospitals employ these physician groups for a good reason: these specialty groups are willing to staff the hospital without pay, with the caveat that they will do direct patient billing. And, these groups may indeed prefer not have any relationship with the insurers, thereby allowing them to bill whatever they want
-- the numbers are pretty staggering:
    -- 20% of patients going to an in-network hospital are seen by out-of-network ER doctors
    -- there are clear differences in different states: 38% of ER visits in Texas but only 3% in Minnesota have these out-of-network charges
    -- 15% of hospitals account for over 80% of total out-of-network billing
    -- this editorialist notes: “by some estimates, [surprise billing] has affected over half of all American adults”
-- 13 states have enacted laws to address this problem, though one potential solution of an arbitration process enacted in New York seems to make things worse. Since the charges are so inflated, the state’s guideline to settle at 80% of the billed charges is still a ridiculously huge amount of money. Other options include capping the rate at up to twice the Medicare rate, though the Medicare rate itself is relatively generous (per the editorialist)

So, this really is a big issue. It reflects an over-the-top greed among some physician groups (though it involves only a small minority of physicians) that ultimately can undermine the oh-so-important clinician-patient relationship for many of the rest of us by undercutting patient trust. And it may dissuade patients from utilizing necessary medical services. It is also so fundamentally repulsive/immoral that a patient can actually follow the rules by going to an ED or having surgery in a hospital approved by their insurance company, then get a huge extra bill because the anesthesiologist who happened to be there that day was in a group that was out-of-network. Or someone has an accident and gets an outrageous bill from the ED staff person above and beyond their usual copay/deductibles. As the editorialist notes, the oath of “do no harm” should include the potential for financial ruin of patients.

A recent blog noted that a large % of people do not have the savings to pay for even their expected deductibles from their insurance plan: see http://gmodestmedblogs.blogspot.com/2019/05/health-insurance-deductibles.html

On that cheery note, have a wonderful holiday season…..

geoff

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