Healthcare Consumer Priorities Key for Surprise Medical Bill Laws

A letter from patient advocates asserted that any legislation addressing surprise medical bills must account for the patient perspective.

By Sara Heath

April 09, 2019 - Legislation crafted to address surprise medical bills must take into account the priorities of patients and healthcare consumers, says a group of patient advocacy groups.

In a recent letter to Congressional leaders, the groups, which included the likes of Families USA and organizations from 17 states, stated that the patient perspective will be critical when creating laws that tackle the issue of surprise medical bills.

Surprise medical bills are unexpected healthcare costs that patients did not think they would receive or did not expect to be so high. These charges usually occur when a patient receives treatment at an in-network facility from an out-of-network provider, or when the patient is incapacitated and transported to an out-of-network facility. These situations typically arise when patients need emergency care.

Surprise medical bills have come to the forefront as a growing healthcare industry problem. Sixty-seven percent of patients have said they worry about receiving a surprise medical bill, according to the Kaiser Family Foundation.

Thirty-eight percent of respondents reported that they are very concerned and 29 percent saying they are somewhat concerned about surprise medical bills. Only 16 percent of patients said they are not at all worried about surprise medical bills.

Industry leaders are working to address the issue, foremost through bipartisan legislation. Such legislative efforts are tapping the expertise of healthcare industry experts as well as information from health payer data sets.

And now, patient advocates are bringing the patient perspective to the forefront, the signatories, led by Families USA, said.

Surprise medical billing legislation should foremost protect patients from any harm, the signatories asserted. Patients should not receive a surprise medical bill in the first place, they explained, but in the event that a patient does receive a surprise bill, he or she should not be responsible for mitigating it.

“In a surprise billing situation, insured consumers should never have to pay more than their normal in-network cost-sharing requirement for a service,” the letter authors said. “Legislation should also be explicit that costs accrue to in-network deductibles and out-of-pocket caps in surprise bill situations.”

Additionally, any measures to quell surprise medical billing should protect patients from rising healthcare costs in other realms. Industry experts have warned that some proposals to address surprise medical bills would result in increased premiums or higher health insurance costs. This would occur when a health plan felt the need to compensate for any high costs they incur when covering a patient’s out-of-network care encounter.

The signatories agreed that whatever method for setting healthcare costs should protect patients from those resulting price increases. While the cohort did not specify which type of price benchmarking they preferred, they did say price benchmarking should prevent any price gouging along the line.

Surprise medical bill legislation must also apply to all insurance plans and all care settings, the signatories agreed. Current statewide efforts to address surprise medical bills have not addressed the issue with self-insured plans, despite the fact that many healthcare consumers receive coverage through those plans. Future legislation should protect all consumers with any plan in any care setting.

Finally, measures to address surprise medical bills should go beyond creating more healthcare transparency. Healthcare policymakers have offered requirements to disclose when a provider is out-of-network as a solution to the surprise medical billing issue.

But the problem runs deeper than that, the signatories stated.

“In the vast majority of surprise billing cases, the affected patient has little-to-no ability to seek an alternative in-network provider, even if given more information,” they explained. “While we would not oppose greater transparency requirements for plans and providers, such requirements are clearly insufficient to meaningfully protect consumers.”

This letter comes a week after Congress held a special hearing on surprise medical bills, listening to testimony from various healthcare experts. But the patient perspective is also essential as policymakers work to address this issue, the Families USA coalition said.

“While stakeholders may disagree on the details, members of Congress must demonstrate leadership on behalf of their constituents. This may require tough choices – choices that may not be uniformly popular among special interest groups,” they concluded.

“The public has identified health care costs as a top priority for action this Congress, and addressing surprise billing is a chance to demonstrate real leadership to the people. We urge you to swiftly take advantage of this opportunity, and our organizations stand ready to help as you move forward on these important protections for consumers.”

The Families USA coalition offered several of the same strategies that healthcare stakeholders did at the House hearing last week. For example, the healthcare experts agreed that any legislation must apply to all health plans and all healthcare facilities.

Additionally, experts across the care continuum agreed that legislation must go beyond mandating more healthcare transparency.

“Protections, at least in nonemergency situations, only apply if the required disclosure does not occur,” testified Jack Hoadley, PhD, a healthcare policy researcher. “Disclosure can be helpful to consumers but making protection contingent on this disclosure seems inadequate given the challenges that consumers face in understanding the many disclosures handed to them when receiving medical services.”

The healthcare industry leaders testifying at the House hearing did offer a few recommendations that did not come up in the Families USA coalition letter. For example, the medical industry must create incentives that would compel ancillary providers – anesthesiologists, or emergency department doctors, to whom many surprise medical bills may be attributed – to join insurance networks.

“For most types of physicians in most geographic areas, joining insurance company networks is standard because many patients are not willing to bear higher out-of-network costs,” explained Young, who is a fellow at the USC-Brookings Schaeffer Initiative on Health Policy.

“But for types of physicians that patients do not choose, this logic does not apply,” he continued. “Emergency physicians, anesthesiologists, and other ancillary physicians receive a flow of patients based on individuals receiving care at the hospital in which they practice, and that volume will be largely the same regardless of whether they join an insurance company network.”

Legislative efforts to address surprise medical billing is only in its nascency. But as healthcare professionals continue to work on such laws, they must take into account all perspectives, including those from industry researchers and healthcare consumers.

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