By Rachel
Bluth JUNE 20, 2019
About 1
in 6 Americans were surprised by a medical bill after treatment in a hospital
in 2017 despite having insurance, according to a study published
Thursday.
On
average, 16% of inpatient stays and 18% of emergency visits left a patient with
at least one out-of-network charge. Most of those came from doctors offering
treatment at the hospital, even when the patients chose an in-network hospital,
according to researchers from the Kaiser Family Foundation. Its study was based
on large employer insurance claims. (Kaiser Health News is an editorially
independent program of the foundation.)
The
research also found that when a patient is admitted to the hospital from the
emergency room, there’s a higher likelihood of an out-of-network charge. As
many as 26% of admissions from the emergency room resulted in a surprise
medical bill.
“Millions
of emergency visits and hospital stays left people with large employer coverage
at risk of a surprise bill in 2017,” the authors wrote.
The
researchers got their data by analyzing large-employer claims from IBM’s
MarketScan Research Databases, which include claims for almost 19 million
individuals.
Surprise medical bills are top of mind
for American patients, with 38% reporting they
were “very worried” about unexpected medical bills.
Surprise
bills don’t just come from the emergency room. Often, patients will pick an
in-network facility and see a provider who works there but isn’t employed by
the hospital. These doctors, from outside staffing firms, can charge
out-of-network prices.
“It’s
kind of a built-in problem,” said Karen Pollitz, a senior fellow at the Kaiser
Family Foundation and an author of the study. She said most private health
insurance plans are built on networks, where patients get the highest value for
choosing a doctor in the network. But patients often don’t know whether they
are being treated by an out-of-network doctor while in a hospital.
“By
definition, there are these circumstances where they cannot choose their
provider, whether it’s an emergency or it’s [a doctor] who gets brought in and
they don’t even meet them face-to-face.”
The
issue is ripe for a federal solution. Some states have surprise-bill
protections in place, but those laws don’t apply to most large-employer plans
because the federal government regulates them.
“New
York and California have very high rates of surprise bills even though they
have some of the strongest state statutes,” Pollitz said. “These data show why
federal legislation would matter.”
Consumers
in Texas, New York, Florida, New Jersey and Kansas were the most likely to see
a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and
Mississippi saw fewer, according to the study.
Legislative
solutions are being discussed in the White House and Congress. The leaders of
the Senate Health, Education, Labor and Pensions Committee introduced a package
Wednesday that included a provision to
address it. The legislation from HELP sets a benchmark for what out-of-network
physicians will be paid, which would be an amount comparable to what the plan
is paying other doctors for that service.
That
bill is set for a committee markup next week.
Other remedies are
also being offered by different groups of lawmakers.
Rachel
Bluth: rbluth@kff.org,
@RachelHBluth
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