For Surprise Medical Bills, It’s the Beginning of the End
Last winter, Congress banned a much-hated practice. Now regulators have to figure out exactly how to make the law work.
by Sarah Kliff and Margot Sanger-Katz - NYT - July 1, 2021
After years of being stymied by
well-funded interests, Congress has agreed to ban one of the most costly
and exasperating practices in medicine: surprise medical bills.
Surprise bills happen when an out-of-network provider is unexpectedly involved in a patient’s care. Patients go to a hospital that accepts their insurance, for example, but get treated there by an emergency room physician who doesn’t. Such doctors often bill those patients for large fees, far higher than what health plans typically pay.
Language included in the $900 billion spending deal that passed both chambers Monday will
make those bills illegal. Instead of charging patients, health
providers will now have to work with insurers to settle on a fair price.
The new changes will take effect in 2022, and will apply to doctors,
hospitals and air ambulances, though not ground ambulances.
Academic researchers have found that millions of Americans receive these types of surprise bills each year, with as many as one in five emergency room visits resulting in such a charge. The bills most commonly come from health providers that patients are not able to select, such as emergency room physicians, anesthesiologists and ambulances. The average surprise charge for an emergency room visit is just above $600, but patients have received bills larger than $100,000 from out-of-network providers they did not select.
Some private-equity firms have turned this kind of billing into a robust business model, buying emergency room doctor groups and moving the providers out of network so they could bill larger fees.
Among the major consumer problems in the fiendishly complex health system, surprise billing was the rare Washington issue that both parties could get behind. Health committee leaders have been engaged on the issue for years, as has the White House. President-elect Joe Biden included the proposal in his campaign health care agenda. It had the backing of many prominent and powerful legislators, including Senator Lamar Alexander, Republican of Tennessee and the retiring chairman of the Senate health committee.
A survey published Friday by the Kaiser Family Foundation found that 80 percent of adults want the practice banned. More than a dozen states, including Texas and California, have passed bans of their own on surprise billing.
Even so, the issue struggled to move through Congress as each policy proposal faced an outcry from some faction of the health care industry.
“There were a lot of things working in the legislation’s favor — it’s a relatively targeted problem, it resonates very well with voters, and it’s not a hyperpartisan issue among voters or Congress — and it was still tough,” said Benedic Ippolito, a resident scholar at the American Enterprise Institute, who helped explain the issue to lawmakers early in the process. “It has almost everything going for it, and yet it was still this complete slog.”
Hospitals and doctors, who tend to benefit from the current system, fought to defeat solutions that would lower their pay. Insurance companies and large employer groups, on the other hand, have wanted a stronger ability to negotiate lower payments to the types of medical providers who can currently send patients surprise bills.
Legislation nearly passed last December, but was scuttled at the 11th hour after health providers lobbied aggressively against the deal. Private-equity firms, which own many of the medical providers that deliver surprise bills, poured tens of millions into advertisements opposing the plan. Committee chairs squabbled over jurisdictional issues and postponed the issue.
This year, many of the same legislators behind last year’s failed effort tried again, softening several provisions that had been most objectionable to influential doctor and hospital lobbies. The current version will probably not do as much to lower health care spending as the previous version, but will still protect patients.
After years of defeats, consumer advocacy groups cheered the new legislation.
“This was a real victory for American people against moneyed interests,” said Frederick Isasi, executive director of Families USA. “This really was about Congress recognizing in a bipartisan way the obscenity of families who were paying insurance still having financial bombs going off.”
The final compromise requires insurers and medical providers who cannot agree on a payment rate to use an outside arbiter to decide. The arbiter would determine a fair amount based, in part, on what other doctors and hospitals are typically paid for similar services. Patients could be charged the kind of cost sharing they would pay for in-network services, but nothing more.
This type of policy is generally seen as more advantageous to health care providers than the other proposal Congress considered, which would have minimized the role of arbiters and instead set benchmark reimbursement rates. Several states have set up their own arbitration systems, and have found that most price disputes are negotiated before an arbiter is involved.
“If this bill will force them to come to the table and negotiate a solution, it will be a definite win for everybody,” said Christopher Garmon, an assistant professor of health administration at the University of Missouri, Kansas City, who has measured the scope of the problem.
The new law will bar air ambulances from giving patients surprise bills. These bills are infrequent but, when they do happen, tend to be very large. This summer, a Pennsylvania coronavirus patient received a surprise air ambulance bill that was over $52,000 for a flight between two hospitals that happened while she was unconscious. States that ban surprise bills have been prevented from tackling these cases because federal law bars them from regulating air transit fees.
Ground ambulances, which generate a significant number of surprise bills, are excluded from the new law.
The Congressional Budget Office found that an earlier version of the plan would cause small reductions to affected providers including emergency room doctors and anesthesiologists. This would happen to providers that both do and do not send surprise bills, because taking away the option would reduce their leverage in negotiating contracts with health insurers.
Health insurers tend to be disappointed with the new legislation, while hospitals and doctors have offered a more mixed response. Some have cited the coronavirus pandemic as a reason to delay new rules.
The American Medical Association sent a letter to congressional leaders on Tuesday saying it was “deeply concerned” about the possibility of lower reimbursement rates, “especially in light of the significant financial pressures practices have faced in the last 10 months.”
TeamHealth, a large private-equity-owned physician staffing firm that has previously engaged in surprise billing, called the agreement “a significant improvement over the catastrophic proposals advanced by major insurance companies over the past two years.”
The American Hospital Association, the country’s largest hospital group, and the Federation of American Hospitals, which represents private hospitals, supported the final bill.
https://www.nytimes.com/2020/12/20/upshot/surprise-medical-bills-congress-ban.html
Why is a 108-year-old resorting to GoFundMe to pay for home care?
A 108-year-old woman named Juliet Bernstein recently launched a GoFundMe to pay for around-the-clock home care that she could otherwise not afford. A retired schoolteacher who is physically frail but mentally sharp, Bernstein, who was born before the first world war, hopes to remain in the modest Massachusetts home where she retired, receiving help to cook, clean and bathe.
“I saw it was being done for someone whose child was very sick,” Bernstein, a longtime civic activist, told the Boston Globe. “So I said, ‘I’m not going to go to a nursing home. I’m remaining here.’”
Bernstein has raised more than $100,000 so far, an impressive figure that still may be spent down quickly, given the realities of the American healthcare system. Bernstein’s home care is not eligible for Medicare or Medicaid assistance. She cannot afford private insurance for long-term help, living on her modest pension and social security.
While it’s heartwarming that the GoFundMe has been able to raise cash for her home care, her predicament is just one more example of how America’s byzantine patchwork of public and private for-profit healthcare options fail so many people, particularly the elderly and the vulnerable.
Even if Bernstein decides to move to a nursing home, Medicare will pay for only a limited stay with such care. Medicaid provides nursing home coverage if a person’s assets do not exceed $2,000, excluding a home, car and personal belongings.
Since she has a pension along with social security, Bernstein does not meet that threshold. She wants to avoid the fate of many seniors who spend down their assets to qualify for long-term care under Medicaid. That would mean bleeding out her savings, selling her home and becoming effectively destitute.
Tragically, to receive mostly free healthcare in America, that is the decision many elderly and ill people must make. The challenge of healthcare coverage is that it will be offered with any generosity only if you are already very rich or incredibly poor. The rich can, of course, buy whatever coverage they want, accessing the best doctors.
The very poor – those without assets at all – can receive Medicaid coverage, which is helpful by the standards of stingier, expensive private care. But the trouble with Medicaid is that many poor people cannot qualify for it if they secure enough work or manage to acquire modest assets.
The working class is largely excluded from Medicaid, unless a person happens to live in a state that expanded coverage under Obamacare. Though rightwing Republicans have argued, against all available evidence, that such a system incentivizes work – the poor get less, so they must struggle to get more – it’s this approach to healthcare that actually encourages deep poverty as the only route to sustainable healthcare.
There are many Bernsteins across the US, individuals who must choose between receiving adequate coverage or liquidating their possessions. It’s an absurd predicament that should not exist in the wealthiest nation on Earth. Instead, comprehensive medical coverage – an even more generous version of Medicare and Medicaid – must be available to all Americans, regardless of income. This is the only sensible and humane way forward.
Other advanced democracies, of course, already guarantee healthcare to everyone. America is the tragic laggard. Instead of single-payer healthcare or a national health service, we have been forced to endure an expensive, predatory privatized system with a fractured safety net for the elderly and the extremely poor.
The medical and insurance lobbies, along with the politicians they control in both parties, have ensured there will be no change in the status quo for the foreseeable future. As much as Joe Biden is willing to spend on Covid aid and infrastructure, he has yet to show interest in challenging the entrenched elites that maintain such an unequal healthcare system. Instead, there will only be more GoFundMes, more pleas for generosity where the powers-that-be have failed.
Maine health care advocates cheer legislative victories
But their satisfaction at securing new MaineCare dental benefits, an insulin safety net and higher pay for direct care workers is tempered by failures to ban flavored tobacco and rein in drug prices.
by Joe Lawlor - Portland Press Herold - July 7, 2021
More than 200,000 Mainers will now be eligible for dental care under the Medicaid program. Patients can get an emergency supply of insulin that will be capped at $35 per month. Direct care workers will be paid a higher wage for the in-home services they provide to disabled people and the elderly.
But flavored tobacco products will still be legal. And bills that attempted to control the cost of prescription drugs were vetoed by Gov. Janet Mills..
These are some of the key outcomes of action on health care issues in the current session of the Maine Legislature.
One long hoped-for priority for health care advocates – the expansion of Medicaid benefits to include dental coverage for adults – was signed into law.
But despite having Democratic majorities in the House and Senate, Mills used her veto pen on two measures championed by progressives, bills that aimed to control the cost of prescription drugs.
“I am frustrated that even though we have a Democratic legislature and governor, that we are not addressing the root cause of many problems, and that is how expensive health care is,” said Mitchell Stein, a Maine-based independent health policy analyst. “They did accomplish some things. Importantly, the adult Medicaid dental benefit is huge and will actually help improve many people’s lives.”
Another measure, a potential ban on flavored tobacco products, failed when it didn’t receive funding.
DENTAL BENEFIT FOR MEDICAID
Maine was one of only 14 states that didn’t extend Medicaid coverage for dental services to adults. Children who have Medicaid also have dental coverage, but dental insurance for adults is a voluntary benefit under the Medicaid program, which is a federal program funded with a blend of federal and state dollars, but operated by the states.
The expansion will open up access to more than 200,000 Mainers, but based on usage in other states, about 70,000 Maine people will use the new benefit.
The law will cost the state $4 million per year, with the federal government chipping in an additional $12 million annually. In 2012, a study concluded that Maine spent $17 million on emergency room visits for dental care. Emergency room spending for dental services should decline sharply after the new benefit goes into effect on July 1, 2022, following a three-year effort by health care services advocates.
“It’s kind of overwhelming to think how this is going to change so many people’s lives for the better,” said Kathy Kilrain del Rio, director of campaigns and health care advocacy for Maine Equal Justice, a progressive policy group. “People will have access to things normally associated with dental care, cleanings and cavities, and if necessary root canals and other restorative work.”
Del Rio said untreated dental infections can cause worse medical problems for patients. The long runway to implementation – one year – will give the Mills administration time to set up a reimbursement system and work out other logistical issues before people with Medicaid can begin signing up for benefits.
PRESCRIPTION MEDICATION
Democratic lawmakers, including Senate President Troy Jackson – pushed for a suite of bills that attempted to rein in the cost of prescription drugs.
But Mills vetoed two of the more ambitious bills: one by Jackson that outlawed price gouging and another that tried to rein in prices by requiring drug manufacturers to justify price increases.
In her veto message, Mills said she shared the concern with lawmakers about the cost of prescription drugs, but didn’t believe the two bills were constitutional.
The bills “would not survive constitutional scrutiny, would invite costly and protracted litigation and even if unexpectedly upheld in court, would not have the intended effect of significantly lowering the price of medications for Maine citizens,” Mills wrote.
Mills did sign other prescription drug bills into law, including a measure by Sen. Cathy Breen, D-Falmouth, that mandates that those without insurance or who can demonstrate that they have trouble paying for insulin be able to purchase an emergency 30-day supply for $35.
FLAVORED TOBACCO PRODUCTS
A proposed ban on flavored tobacco products that would have cost an estimated $32 million was not funded during a meeting last week of the Joint Standing Committee on Appropriations and Financial Affairs, drawing a rebuke from Rebecca Boulos, executive director of the Maine Public Health Association.
Boulos said lawmakers “played politics with people’s lives.”
“At a time when millions of dollars were added to the rainy day fund, there was no investment in tobacco prevention and control. None. Not one additional dollar to prevent youth tobacco use,” Boulos wrote in a June 30 news release.
While public health advocates decried the failure of the flavored tobacco ban, those supporting services for adults with intellectual and developmental disabilities cheered a bill that improved reimbursement rates.
For the first time, reimbursement rates for direct care workers – such as those who work in group homes or provide home-based health care services – are slated to be higher than the minimum wage and remain higher, even if the minimum wage is increased in future years. The law, which goes into effect in January, states that the reimbursement rate must be at least 125 percent of the minimum wage for services.
Ray Nagel, executive director of the Independence Association in Brunswick, which operates 10 group homes that serve 38 people, said the rate increases “will help tremendously” although there are many reasons for the workforce shortage, so nonprofits that operate group homes will likely still struggle to attract workers.
“People can still get jobs that pay much more elsewhere, but this still really helps with our staffing,” Nagel said. “We will take our victory.”
Another bill that passed extended Medicaid coverage for pregnant women for 12 months after birth. Currently, services are cut off 60 days after the child is born, but postpartum coverage will increase to six months starting in January, nine months starting July 1 and move to 12 months starting in 2023.
https://www.pressherald.com/2021/07/07/health-care-advocates-reap-victories-from-maine-legislature/
The US health system was already falling short. Then Covid-19 happened.
Covid-19 put American health care even further behind other wealthy nations.
Take a long enough lens — say, 25 years — and it seems as though health care in America is inarguably getting better.
People are living longer than they did a quarter century ago. The burden of disease, a metric that includes premature deaths and disability, has dropped. The number of avoidable hospitalizations and hospital errors is lower.
But below those rosy numbers is the truth: American health care has been falling behind other countries in the developed world for decades.
Life expectancy has increased, but by less in the US than in the wealthy nations of Europe and Asia. The improvement in disease burden has likewise been less impressive than that of comparable countries. Meanwhile, to achieve those mediocre results, the United States continues to spend more money on medical care than any other country in the world; while health spending in the US isn’t going up faster than in other countries, it was higher to begin with and continues to increase. We’ve maintained a sizable lead in health care spending while getting outcomes that are worse than countries that spend less.
And all of that was true even before the United States experienced one of the worst Covid-19 outbreaks in the world.
Kaiser Family Foundation researchers recently warned of a “further widening of the gap” between the US and other countries as a result of the pandemic. Life expectancy in the US had already stagnated in the last few years, driven by a rise in drug overdoses and suicides; now Covid-19 will shorten it further. Disease burden had been trending upward in the US while dropping elsewhere; the Covid-19 pandemic is likely to widen that disparity too.
You could say the trajectory of American health care before, during, and after the pandemic is like that of an individual vulnerable patient: It was sicker to begin with, hit hard by Covid-19, and will be dealing with the lingering effects for a long time.
The US was already falling behind the rest of the world on health care
When it comes to getting value for money in health care, America slowly but perceptibly fell behind other developed countries over the last 25 years.
It starts with life expectancy, the bluntest measure of how well people are served by their health system. Life expectancy in the developed world has steadily improved over the past few decades, driven primarily by major breakthroughs in the treatment of heart disease and other cardiovascular problems, which rank near the top among causes of deaths in wealthy nations.
But not as much in the United States as in other countries. According to a KFF analysis of health care trends from 1991 to 2016, Americans saw their life expectancy rise by 3.1 years during that period — a meaningful improvement, to be sure, but substantially less than the 5.2 years gained in comparable countries.
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And in the US specifically, that progress has stagnated in recent years. With tens of thousands of people dying of opioid overdoses every year and a sustained increase in the number of suicides, American life expectancy actually started tailing off in 2014, according to a 2019 analysis published in JAMA. The gap between the US and other wealthy countries was already growing before Covid-19 struck.
Likewise, disease burden had steadily improved until a recent downturn separated the US from other countries. The reasons for the improvement were the same: better medical treatment for chronic diseases. But once again, America did not improve to the degree that comparable countries did, seeing a 12 percent improvement versus an average of 22 percent elsewhere. In the United States, the burdens from disease of the heart, lung, kidney, and liver — as well as from diabetes — remain stubbornly high compared with the rest of the developed world.
And the reasons for America’s recent stagnation are the same, too: Suicides and drug overdoses, plus a rise in the number of young people with chronic health conditions, are robbing people of years of healthy living.
The same pattern holds for medical errors. They have been declining in the US over the last 25 years but are still more common in America than in comparable countries. Avoidable hospitalizations and adverse drug events are down, but not as much as in wealthy European or Asian nations. Americans are roughly twice as likely to experience an error in their medical care as their counterparts the world over.
One metric — known as mortality amenable to health care — combines all of these characteristics and grades a country’s health system on how well it prevents deaths from conditions that should be treatable with timely access to health care. The US ranked behind the biggest countries in Europe, as well as Japan, as of 2016.
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A country like Taiwan, which performed much worse than the US on the same metric 30 years ago, is now nearly its equal.
And for those middling outcomes, the US still spends more on health care than other countries: nearly 18 percent of its GDP versus about 11 percent, on average, in comparable nations. Health spending has been rising at the same rate in the US and its peers over the last few decades, and yet those other countries have seen more improvement in their health outcomes.
They are, in other words, getting more value out of their health systems than the US.
“One could conclude that the comparable ... countries’ value improvement was greater,” the KFF researchers wrote in 2018, “even though they started at a higher threshold in terms of better outcomes and a lower percentage of GDP consumed to achieve it.”
One possible explanation for America’s poor performance: We underinvest in social spending and overspend on medical care compared with other developed countries. If you combine social services spending and health spending, the US and its peers actually spend about the same amount of money, a little more than 30 percent of their GDPs. But spending in those other countries is more slanted toward social services, while America spends more on medical care.
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America’s underinvestment exacerbates disparities between haves and have-nots: 18 percent of Americans live in poverty versus 10 percent in other wealthy countries. We know that people with lower incomes have structural challenges — access to healthy food, clean water, and fresh air, for starters — that lead to worse health outcomes. When they get sick, they have a harder time finding a doctor and affording their medical care.
“Economic inequality is increasingly linked to disparities in life expectancy across the income distribution, and these disparities seem to be growing over time,” wrote the authors of a 2018 review of relevant research in Health Affairs. Poor health also tends to lead to lower incomes, creating a feedback loop known as the “health-poverty trap.”
And those disparities — between rich and poor, white and Black — only worsened during the Covid-19 pandemic.
Covid-19 will have long-term consequences for American health
The gap between the US and other wealthy nations is expected to grow because of the pandemic. America has lost more than 600,000 people to Covid-19, the highest confirmed death toll in the world. Adjusting for population, the US has lost more people on a per-capita basis than most of the European and Asian countries to which it is compared.
Official death counts can be somewhat arbitrary because they depend on testing to identify cases. Excess deaths — the number of deaths from all causes above what would be expected in an ordinary year — are considered by experts to be a more reliable gauge. On that metric, too, and adjusting for population, the United States is one of the worst performers among wealthy nations.
“The outsized effect of the pandemic on the U.S. will likely widen the existing gap in mortality rates between the U.S. and peer countries,” wrote the authors of an October 2020 analysis on Covid-19 death rates and life expectancy.
America is also likely to experience a higher disease burden (that’s the years of quality life lost to premature death and disability) as a result of its pandemic failures. People under 65 in the US have died from Covid-19 at higher rates than their peers elsewhere.
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A prolonged mental health crisis may linger after a year of disrupted social lives and isolation. More than 4 in 10 Americans reported experiencing symptoms of anxiety or depression in 2020, according to US census surveys.
Health spending actually slowed down in 2020, a historic aberration, as people postponed medical care during the pandemic. But medical spending did not slow down as much as the rest of the economy: As of October 2020, it had fallen 0.5 percent versus a 1.8 percent contraction overall. So even as spending dropped, health care likely consumed an even greater share of America’s GDP than in years prior.
And the short-term drop in spending could have long-term consequences. Last year, 24 percent of Americans said in a census survey that they did not get needed medical care during the pandemic, with 33 percent saying they delayed care. To give one example, cervical cancer screenings dropped about 80 percent from normal levels in spring 2020, and while they rebounded later in the year, they were still 25 percent down by the end of September.
While patient volume generally has recovered, we still don’t know what the long-term effects of people missing care or receiving belated diagnoses will be. And there are tens of millions of people recovering from a Covid-19 infection; as many as 15 million of them may struggle with “long Covid” for the foreseeable future, according to a new analysis in the New England Journal of Medicine that called long Covid-19 “our next public health disaster in the making.” Those direct health aftershocks from the pandemic will be yet another burden on the US health system long after the coronavirus itself starts to subside.
Long-term spending trends were already prompting health plans to push more of the cost of health care onto patients. Deductibles and worker premiums have been increasing for years.
Post-Covid-19, at least as a relative share of the economy, health care is eating up even more of the country’s resources. America’s health outcomes have been set back by the pandemic, and the spending crunch is intensifying.
https://www.vox.com/policy-and-politics/22555949/us-health-care-system-ranking-covid-19-pandemic
