This week, two committees of the US House of Representatives. UU. They presented their arguments in favor of different approaches to prevent surprise medical bills: the unexpected costs that patients receive with the result of services provided by doctors or companies outside the network.
The House of Representatives Media and Arbitration Committee on Wednesday approved its bipartisan bill by voice vote. The measure seeks to establish greater use of third-party negotiators, or arbitration, to resolve certain disputes about paying for out-of-network care. The bill is supported by the American Hospital Association and the American College of Emergency Physicians, according to press releases. In a prepared statement, the American Medical Association also praised the committee's dependence on mediation for disputes over bills.
On Tuesday, the House of Representatives Education and Labor Committee presented a more hybrid proposal that seeks to use the prices established in local markets to resolve many disputes over out-of-network bills. In cases where the bills exceed $ 750 or, in the case of air ambulance services, $ 25,000, doctors and insurers could resort to arbitration, described by the Education and Labor Committee as an independent dispute resolution.
The Chamber of Education and Labor approved this bill in a vote of 32-13. Support and dissent mixed between Democrats and Republicans. Although most Americans may never receive a surprise medical bill, the fear of receiving it can be "crippling" and lead people to avoid visits to doctors and hospitals, said Rep. Virginia Foxx of North Carolina, the Republican of higher rank of the committee.
"We, as elected representatives, cannot stand idly by while American families give up the care they need for fear that they will end up being responsible for an unexpected and unaffordable surprise medical bill," he said.
Leaders from both sides have talked about the use of a May deadline as the target date for surprise medical billing legislation.
In December 2019, Congress passed an important 2021 tax expense bill that brought a short-term solution to the community health center program and some other smaller federal medical initiatives. The short term patch ends on May 22. Senate leader Mitch McConnell (R-KY) set the deadline this week by answering a question about surprise medical billing during a press conference.
"We will have the expiration in May of several popular health care arrangements, for example, community health centers that will generate another discussion, and we will continue trying to do so," McConnell said.
Last year, the Congressional Budget Office (CBO) priced $ 22.2 billion at the cost of a proposed extension of three federal programs: community health centers, the National Health Services Corps and certain health centers Teachers
To address these three federal programs in a May bill, legislators will likely want to offset the cost of extensions with savings from another measure. The CBO estimate of $ 22.2 billion comes from its July 2019 review of a package of legislative proposals from the Senate of Health, Education, Labor and Pensions (HELP), which also addressed surprise medical billing. CBO estimated that nearly $ 25 billion could be saved in a decade if Congress enacted HELP proposals on surprise medical billing.
The HELP bill called for insurers to reimburse costs outside the network based on their own average rates for in-network providers. Although CBO has not published a score of the surprise billing legislation of the Chamber of Education and Labor, the committee staff had indicated that the measure would probably save about $ 24 billion.
CBO has estimated that Ways and Means surprise billing legislation would save almost $ 18 billion in a decade.
A key step in curbing surprise billing would be for insurers to better update their directories of doctors in the network, according to AARP, which advocates for Americans over 50.
In a letter dated February 11, Megan O & # 39; Reilly, vice president of government affairs for AARP, said her organization was pleased that the legislation of the Chamber of Education and Labor on surprise medical billing includes mandates in the directories. There have been reports about directories that are not available and about confusing and outdated information that can be accessed.
The legislation requires real-time updates and periodic audits, seeks to standardize directories in all health plans in individual and group markets, and forces insurers to notify consumers if a doctor they have visited has left the network, wrote O & # 39; Reilly.
O & # 39; Reilly also emphasized the need for doctors to consider insurance networks when making decisions about patient care.
Consumers who spend time researching their insurers' offers and seeking in-network care "should not receive a bill from a separate provider or laboratory for which they had no other option," said O & # 39; Reilly.
"Once at the facility or in the doctor's office, the discretion is with the provider, not with the consumer, to consult specialists, order tests and process images," he wrote.
JAMA editors made a similar argument this week in a note that accompanies a new report on surprise medical billing.
More than 1 in 5 elective procedures result in liability for out-of-network costs. The average surprise bill is just over $ 2011, according to an analysis of insurance data published in the magazine. Surprise medical bills are often derived from services provided by anesthesiologists, surgical assistants, pathologists, medical consultants and radiologists.
Surgeons have the "ethical responsibility to speak against surprise billing," write the editors of JAMA, Karen E. Joynt Maddox, MD, MPH, and Edward Livingston, MD. Otherwise, they run the risk of losing the trust of patients who then receive unexpected bills for their care.
"When possible, surgeons should ensure that all personnel involved in the care team they lead accept the same insurance plans and should consider refusing to work in facilities that allow surprise billing," write Joynt Maddox and Livingston.
JAMA editors also urged lawmakers to address surprise billing.
"There have been rejections of medical groups, particularly those backed by private equity firms, who argue that such legislation will have potentially negative consequences for doctors by reducing their influence to negotiate a fair reimbursement," write Joynt Maddox and Livingston. "While it is important that the legislation takes these issues into account, it is crucial that the interests of the patients remain fundamental."
It is not clear if there is enough public pressure for Congress to act in 2020 on surprise medical billing. There is still a clear division of opinion among powerful groups on the best way to address this problem.
Critics of the reference approach argue that it gives insurers too much power at the expense of the medical community.
"We already know that insurers are looking for any way to pay as little as possible," House Ways and Means president Richard Neal (D-MA) said Wednesday. "They will work to reduce those rates, regardless of what it means for community providers such as doctors, hospitals and our constituents who they employ."
Congress should examine the effects of insurers that sign agreements with very few doctors, a condition known as narrow networks, Neal said. "Surprise bills would be much less common if insurance networks were stronger," he said.
Critics of the arbitration approach say it benefits private equity firms, which are linked to medical personnel firms, at the expense of consumers.
The Ways and Means bill would create "a new system that is noticeably worse than the current law for patients and families," said James Gelfand, senior vice president of health policy at the ERISA Industry Committee, which represents large employers, in a statement of February 10. .
Gelfand blames those involved in the medical profession of surprise medical billing that avoid insurance networks and then charge unreasonable rates in emergencies.
"An arbitration regime ordered by the government will waste billions of dollars and countless hours and will only reward players with greater financial motivation in the health care system: air ambulance companies, medical personnel firms belonging to investors and hospitals that Companies have been financially intertwined with private equity, "Gelfand said in the statement.
Lawmakers finally criticized this issue last year when faced with this difficult choice of choosing sides among powerful interest groups.
The serious debate in Congress about surprise billing began in 2019 with the HELP Committee's health care package. It included a provision that sought to use established prices for medical services to resolve disputes over surprise medical bills.
That was very unpopular with many groups of doctors, especially those often involved with cases outside the network. Four organizations opposed to the reference approach: the American College of Emergency Physicians, Envision Healthcare, US Acute Care Solutions and US Anesthesia Partners, last year donated approximately $ 1.1 million to members of Congress, according to a recent analysis by Kaiser Health News. (The private equity firm KKR, which owns the medical personnel firm Envision Healthcare, a medical personnel firm, also owns Internet Brands, the parent company of Medscape).
Then, the House of Representatives Energy and Commerce Committee followed with a hybrid model to handle surprise medical billing, as reported by Medscape Medical News. Something similar to the new bill of the Chamber's Education and Labor Committee, the 2019 Energy and Commerce proposal allows both benchmarks and arbitration.
A December effort to advance a compromise bill of the Senate House failed, and lawmakers criticized the issue of surprise medical billing until at least this year.
The two margins of the House of Representatives this week seem to have left many advocates of different approaches to surprise medical billing in their positions.
Representative Phil Roe, MD (R-TN), was among the detractors in Tuesday's vote on the hybrid measure of the Chamber of Education and Labor. Roe has been a leader for many months in efforts for Congress to use the arbitration model.
The House of Representatives Education and Labor bill "will empower insurers to establish low reimbursement rates and narrow networks, hurting patients by reducing the fixed price for services as low as possible," Roe said in a release.
Instead, he urged his colleagues to continue with the Forms and Media approach to surprise billing.
But Egan Kemp, a health policy advocate with the Public Citizen nonprofit surveillance group, argues that the Forms and Media approach is "the atypical case in the process and continues to delay crucial protections for patients."
"The influence of private capital, one of the worst abusers of surprise bills, is evident in its legislation," he said in a statement to Medscape Medical News, in which he urged the rapid approval of legislation on this matter.
"The time has come for Congress to act to protect patients from surprise medical bills," Kemp said. He noted that patient advocates, consumer groups and unions have supported the reference approach.
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