Medicine: An unwelcome surprise from the doctor
One in five surgery patients can expect a “jaw-dropping” surprise on their bill, said Elisabeth Buchwald in MarketWatch.com, even when the procedure wasn’t an emergency. That’s according to a study of nearly 350,000 people published in February in the Journal of the American Medical Association, which looked into what happened to patients “after having one of seven common elective operations” between 2012 and 2017. That these were elective surgeries is notable because patients “can usually choose in-network surgeons and facilities.” Still, 20 percent of respondents “ended up owing $2,011 more, on average,” in addition to their out-of-pocket health-care costs, with bills often coming from out-of-network clinicians—assistants, anesthesiologists, pathologists, etc.—whom the patient never chose.
“These practices are an obvious outrage,” said Elisabeth Rosenthal in The New York Times, “but no one in the health-care sectors wants to make the big concessions that would change them.” It took decades for us to get to this point. Once, hospitals didn’t think they could charge whatever the market would bear. Then they got entrepreneurial, adding “facility fees and infusion charges.” In response, insurers raised co-pays and deductibles and shrank their networks of providers. And now, when doctors decide that insurers aren’t paying them enough, they simply “stop participating in the network”—and stick patients with the bill. That’s how “a patient having a heart attack is taken by ambulance to the nearest hospital and gets hit with a bill of over $100,000 because that hospital wasn’t in his insurance network.”
Surprise billing has turned into “a hotbutton issue for voters,” but there’s one big obstacle to change, said Rachana Pradhan in KaiserHealthNews.org: doctors. Four major lobbying groups that support physicians gave roughly $1.1 million to lobby Congress on surprise-billing legislation. Capitalizing on the respect accorded to the profession, doctors “have waged an extraordinary on-the-ground stealth campaign to win over members of Congress.” Doctors want arbitrators to determine the rate insurance companies pay them when they have no deal. They like a New York state law designed to handle such cases; that law tells mediators “to base their decisions on the 80th percentile of the prices set by the hospital or physician.” Research suggests that this approach spares some patients the pain of surprise medical bills, but ratchets up medical costs across the board. Federal lawmakers “punted on this in December,” said Caitlin Owens in Axios.com, and “now they are faced with the same hard problem.” The doctors like mediation, while insurance industry groups have pushed for another system, benchmarking, that ties reimbursement to typical bills. Patients are caught in the middle of a dispute that “splits lawmakers not by party but by which industry group they sympathize with more.”