“Reference pricing” is yet another intrusive diversion from real reform

Posted by on Friday, Oct 10, 2014

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Reference Pricing: A Small Piece of the Health Care Price and Quality Puzzle

By Chapin White, Megan Eguchi
National Institute for Health Care Reform, NIHCR Research Brief No. 18, October 2014

As purchasers seek strategies to reduce high health care provider prices, interest in reference pricing—or capping payment for a particular medical service—has grown significantly. However, potential savings to health plans and purchasers from reference pricing for medical services are modest, according to a new analysis by researchers at the former Center for Studying Health System Change (HSC) using 2011 private insurance claims data for about 528,000 active and retired nonelderly autoworkers and their dependents. In 2011, the California Public Employees’ Retirement System (CalPERS) adopted reference pricing for inpatient knee and hip replacements. Using quality and price information, CalPERS set an upper limit of $30,000—the reference price—for hospital facility services for a knee or hip replacement. CalPERS designated certain in-network hospitals as meeting the reference price, and patients using designated hospitals are responsible only for the health plan’s usual cost-sharing amounts. However, if patients use a non-designated hospital, they are responsible for both usual cost sharing and any amount beyond the $30,000 reference price. While reference pricing for inpatient services has some potential to steer patients to hospitals with better quality metrics, only limited savings—a few tenths of a percent of total spending—are possible from applying a similarly narrow reference pricing to other privately insured populations. The potential savings from reference pricing are modest for two reasons: Shoppable services only account for about a third of total spending, and reference pricing only directly affects prices at the high end of the price distribution. When considering reference pricing, employers and health plans need to weigh potential savings against increased plan complexity and financial risk to enrollees, along with the analytical and financial resources needed to create and manage the program.

From the Implications

The CalPERS reference pricing experience tells two different but equally true stories—a dramatic percentage decline in prices and spending on knee and hip replacements and an extremely small percentage decline in total spending. To significantly impact spending among the privately insured, reference pricing would have to be applied quite broadly. And, even using a very inclusive list of shoppable services, the potential savings are relatively modest.

Both conventional network-based plans—preferred provider organizations and health maintenance organizations—and reference pricing suffer some of the same limitations. Both types of plans rely on patient cost-sharing differentials to steer patients to certain providers, but the higher cost sharing cannot reasonably be applied in emergencies when patients can’t choose their provider. Also, both types of plans are vulnerable to the demands of dominant “must-have” providers, either to be in network or to be both in network and designated.

Compared to a limited-network plan, reference pricing faces at least three additional logistical hurdles. First, the health plan must have reliable price data for specific providers for specific services so that it can set the reference price and designate providers. Even very large plans will lack the historical data to accurately measure the prices they typically pay to smaller hospitals. Second, the plan would ideally have provider-specific quality metrics on hand that can be used to assure patients that they are not being steered to low-quality providers. Although hospital quality metrics and rankings abound, the methodologies behind those rankings are still under development. Third, reference pricing requires new customer-service tools to support shopping by patients and to deal with inevitable member complaints. Implementation would require commitment of significant resources by the plan, potentially offsetting some or all of the savings from reductions in payments to high-price providers.

The main disadvantage of reference pricing is that it adds a new layer of complexity for plan administrators and enrollees. Rather than facilities simply either being in or out of the network, there are now three types of facilities: in-network designated, in-network non-designated and out of network. Even more confusingly, a single facility might be designated for one type of service—for example, an inpatient hospital providing a knee replacement—but not designated for another—that same hospital providing a colonoscopy in an outpatient department. Additional complexity raises significant concerns, given that the basic elements of conventional benefit design are already beyond the grasp of many consumers.

One question is whether a reference pricing program can steer patients to lower-price, adequate-quality providers. The answer, based on the CalPERS experience, appears to be yes. But, that may not be the right question. A better question may be why private health plans would ever pay negotiated prices over $30,000 for inpatient knee and hip replacements. The CalPERS reference pricing program seemingly took a hard line against hospitals charging unreasonably high prices—$30,000 or more—for knee and hip replacements. But, is $30,000 really a reasonable price for an inpatient knee or hip replacement? To put that amount in perspective, the Medicare program on average paid $14,324 for inpatient knee and hip replacements in 2011.

http://www.nihcr.org/Reference-Pricing2

Our policy wonks continue to look for methods of controlling health care costs that will protect the role of private insurers, and, above all, prevent us from drawing the inevitable conclusion that we desperately need a single payer national health program. Reference pricing is one more supposed cost-saving tool that has garnered much interest. What is it and will it work?

Reference pricing is a process in which a maximum price is set for a given medical service. The patient then either goes to a designated provider who has agreed to accept that amount, along with contracted patient cost sharing, as payment in full, or, if the patient chooses a provider with higher prices, the patient must pay the full difference.

California Public Employees’ Retirement System (CalPERS) experimented with reference pricing by establishing $30,000 as a reference price for the hospital services for a knee or hip replacement. The experiment was considered to be a success based on the fact that 15 to 30 percent of patients who would have gone to a non-designated hospital switched and went to a designated hospital instead. But how do you define success?

The package fee that the private market was able to negotiate was $30,000. Medicare on average paid $14,324 for the same services. Is it a success when private insurers are paying double the fees set by a public insurer?

Some might consider it to be a success when the patient did not have to pay the difference between the reference price and the price that would have been charged in a non-designated hospital, though what is the patient giving up?

Consider how a decision is usually made to have a joint replacement. The patient typically goes to his or her primary care professional where initial evaluation indicates that a joint replacement may be indicated. A referral is made to a specialist qualified to do joint replacements. If the decision is made to go ahead with the procedure, arrangements are made with the hospital the specialist is associated with. But then the insurer intervenes and threatens the patient with severe financial penalties (all costs above the reference price) unless the patient agrees to give up the specialist and hospital that is part of the team of her primary care professional, either as a formal integrated health system or as an informal team of community professionals working together. To escape the financial penalty, the patient pays the penalty of disruption in care.

So what did this successful experiment that everyone wants to emulate actually accomplish? Care of 15 to 30 percent of patients was disrupted in exchange for establishing a cap on payment that was twice what Medicare pays, and yet netting only “an extremely small percentage decline in total spending.”

Another important consideration discussed in this report is that reference pricing significantly increases administrative complexity – just what we need in a system that is unique in the world for all of its profound administrative waste. But very telling is the comment in this report that some of this administrative increase will be in the form of new customer-service tools “to deal with inevitable member complaints.”

Great – a disruptive program that doesn’t work very well but ticks everyone off! We’ll say it again – single payer.

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Do opinions of Medicaid patients matter?

Posted by on Thursday, Oct 9, 2014

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Low-Income Residents In Three States View Medicaid As Equal To Or Better Than Private Coverage, Support Expansion

By Arnold M. Epstein, Benjamin D. Sommers, Yelena Kuznetsov and Robert J. Blendon
Health Affairs, October 8, 2014 (online)

Abstract

Expansion of Medicaid under the Affordable Care Act to millions of low-income adults has been controversial, yet little is known about what these Americans themselves think about Medicaid. We conducted a telephone survey in late 2013 of nearly 3,000 low-income adults in three Southern states—Arkansas, Kentucky, and Texas—that have adopted different approaches to the options for expansion. Nearly 80 percent of our sample in all three states favored Medicaid expansion, and approximately two-thirds of uninsured respondents said that they planned to apply for either Medicaid or subsidized private coverage in 2014. Yet awareness of their state’s actual expansion plans was low. Most viewed having Medicaid as better than being uninsured and at least as good as private insurance in overall quality and affordability. While the debate over Medicaid expansion continues, support for expansion is strong among low-income adults, and the perceived quality of Medicaid coverage is high.

From the Discussion

In our survey of nearly 3,000 low-income adults in three states, we found strong and consistent enthusiasm—among nearly 80 percent of respondents—for expanding Medicaid under the ACA and a more nuanced picture of whether it would be preferable to gain coverage via traditional Medicaid or subsidized private insurance.

Support for expansion by the population who would most likely be eligible for it may provide further impetus for expansion, although low-income adults and the uninsured may lack the clout to bring about this policy change in many states where the ACA remains unpopular among the political leadership.

Quality and affordability of care were generally rated as better with Medicaid coverage, while private coverage was seen as offering better access to and more respect from providers. These views represent a nuanced but reasonable comparison of Medicaid versus private health insurance and are consistent with some of the empirical evidence in this area. Recent studies indicate that Medicaid provides low-income adults with better financial protection than does private coverage, while lower reimbursement rates in Medicaid have been linked to lower physician participation rates in that program compared to private coverage. Favorable views toward Medicaid were most common among racial and ethnic minorities, people with lower education and income, and those in worse health.

http://content.healthaffairs.org/content/early/2014/10/02/hlthaff.2014.0747

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Medicaid, Often Criticized, Is Quite Popular With Its Customers

By Margot Sanger-Katz
The New York Times, October 9, 2014

A study published in the journal Health Affairs found that poor residents of Arkansas, Kentucky and Texas, when asked to compare Medicaid with private coverage, said that Medicaid offered better “quality of health care” and made them better able to “afford the health care” they needed.

Medicaid, the federal-state program for poor and disabled Americans, is a frequent political target, often described as substandard because of its restricted list of doctors and the red tape — sometimes even worse than no insurance at all.

But repeated surveys show that the program is quite popular among the people who use it.

When asked to consider it alongside other big, popular government programs, Medicaid compares favorably, said Robert Blendon, a public health professor at Harvard who studies public opinion on health care issues and was a co-author on the recent study. “It’s only when you compare it to Medicare, which is so much more popular than 96 percent of what the federal government does, that it looks unimpressive,” Mr. Blendon said.

The people surveyed by the Harvard researchers didn’t prefer Medicaid to private insurance in every respect. They gave private coverage the edge when it came to seeing “doctors you want, without having to wait too long” and “to have doctors treat you with care and respect.” But Medicaid came out ahead on the question of whether it enabled them to “be able to afford the health care you need,” and on the overall question of “quality of health care.”

http://www.nytimes.com/2014/10/10/upshot/medicaid-often-criticized-is-qu…

Low-income patients strongly support the Medicaid program. It provides better financial protection than does private insurance, and they perceive the care to be of high quality. Their primary concern is that “private coverage was seen as offering better access to and more respect from providers” than does Medicaid.

When asked whether it was better to have Medicaid or to be uninsured, there was strong agreement that Medicaid patients have higher quality of care, have greater access to doctors, are treated with better respect, and, especially, are better able to afford the health care that they need, than are the uninsured.

In fact, according to Harvard’s Robert Blendon, Medicaid compares quite favorably to other popular government programs, though the support is “unimpressive” when compared to the support for Medicare.

Unfortunately, the politicians in many states do not seem to care. Even though the federal government would provide most of the funds, they would rather leave these people uninsured. Obviously, they could care less about the opinions of this low-income population that lacks political clout.

Why would Medicare be more popular than Medicaid? Medicare that is supplemented with Medigap, retiree plans, or Part C plans removes financial barriers to care, thus providing a similar level of financial protection as Medicaid – with the exception that Medicaid covers long term care as well. Medicaid does have the stigma of a welfare program whereas Medicare is considered to be an earned right available to all qualified by age or disability. The greatest reason that Medicare is preferred is that the patients have free choice of their physicians, including specialists.

Under what system would a low-income patient fare best? One in which the welfare stigma is removed, and everyone is treated equal. One in which financial barriers such as large deductibles and coinsurance are removed. One in which patients have free choice of their health care professionals and hospitals. One in which a high standard of quality is the norm for all. In other words, low-income patients would fare best is a system that would work well for all of us – a single-payer, improved Medicare for all.

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Conservatives say health costs drive income inequality

Posted by on Tuesday, Oct 7, 2014

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Income Inequality and Rising Health-Care Costs

By Mark J. Warshawsky and Andrew G. Biggs
The Wall Street Journal, October 6, 2014

A new Kaiser Family Foundation survey reports that health-insurance premiums rose by a “modest” 3% in 2013. Even more modest, however, was the 2.3% growth of workers’ earnings last year. These figures merely illustrate a long-term trend of rising health costs eating away at wages. The real story is even more dramatic: Government data show that health costs are the biggest driver of income inequality in America today.

Most employers pay workers a combination of wages and benefits, the most important of which is health coverage. Economic theory says that when employers’ costs for benefits like health coverage rise, they will hold back on salary increases to keep total compensation costs in check. That’s exactly what seems to have happened: Bureau of Labor Statistics data show that from June 2004 to June 2014 compensation increased by 28% while employer health-insurance costs rose by 51%. Consequently, average wages grew by just 24%.

But here’s what the news headlines miss: Rising health costs don’t affect every employee the same. An average family health policy today costs employers nearly $12,000 per year, up from only $4,200 in 1999. Had employer premiums not risen, average salaries today would be around $7,800 higher. For a lower-income worker who today makes $30,000, that could have meant a 26% salary increase. By contrast, a “one percenter” making $250,000 today would have seen his earnings rise only by 3.1%. Health costs are a bigger share of total compensation for lower-wage workers, and so rising health costs hit their salaries the most. The result is higher income inequality.

These data give us a different perspective on the inequality debate. Most people think of income inequality as money “redistributed” from the poor to the rich. In reality, much of what we’re seeing is more of low-income workers’ compensation going toward their health benefits and less ending up in their pockets. That’s a different problem and points toward different solutions.

http://online.wsj.com/articles/mark-warshawsky-and-andrew-biggs-income-i…

This WSJ opinion article is from the conservative American Enterprise Institute (AEI). When they say that “health costs are the biggest driver of income inequality in America today,” this should provide us with common ground to simultaneously address both income inequality and the health care crisis.

Unfortunately, in this article the authors further define the problem as over-insurance and a need for high-deductible health plans. Reducing benefits and increasing cost sharing would make the problems even worse for low- and moderate-income individuals and families.

Nevertheless we can agree that the current inequities in health care financing – which were inadequately addressed through the Affordable Care Act – are a significant contributor to income inequality. The most effective solution to address both would be to enact a progressively-financed single payer national health program (though further public policies would be required to temper the extremes of income and wealth inequality).

There is a glimmer of hope when the opponents of single payer recognize the problems, but that hope is dashed when they revert to ideological approaches that place an even greater burden on those more vulnerable.

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George Halvorson criticizes deductibles

Posted by on Monday, Oct 6, 2014

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

An Interview With George Halvorson: The Kaiser Permanente Renaissance, And Health Reform’s Unfinished Business

By Jeff Goldsmith
Health Affairs Blog, September 30, 2014

Kaiser (Permanente) surprised the health plan community by announcing in March 2002 the selection of a non-physician, George Halvorson, as its new CEO.

During his twelve year tenure as CEO, Halvorson not only guided the plan to solid profitability, but added a million members in California, its largest market, despite a devastating recession and a national retreat of commercial HMO membership.

The Growth Of High-Deductible Health Plans

Jeff Goldsmith: If you look at the Kaiser/HRET survey, which focuses on the employer segment, the HMO wedge shrinks while the high deductible health plan wedge seem to grow in proportion. In 2013, High Deductible Health Plans (HDHPs) represented around 30 million lives.  Are HDHPs “managed care” in your view?

George Halvorson: Yes. I think they are a form of managed care.  HDHPs get involved to some degree in delivery of care.  They require care/data reporting.  They have some care protocols or some care-related elements they don’t allow. So I would classify all those plans and products under the broad category of managed care. If employers buy a $500 dollar deductible plan from Kaiser Permanente — and about 10 percent of Kaiser members are now in plans that have deductibles that are high or higher — the employees still get their care at KP.  When they pay the fee for the office visit, they pay KP as opposed to paying it outside, so that the cash flow for KP is basically the same.  It just comes down two separate channels, copays and premiums, instead of coming down one prepaid premium channel.

Goldsmith: How hard was it for your colleagues, particularly the Permanente physicians, to accept the philosophical change that required?  In the legacy Kaiser model, there was no cost to the patient.

Halvorson: Everyone at KP, including myself, strongly preferred the model where there was no cost for the patient.  However if 10 percent of our employer customers want to buy a high deductible product and we don’t sell it to them, then they leave. Kaiser has hospitals, clinics, pharmacies, lots of care-related infrastructure that would not do as well if 10 percent of the patients were gone.  It is important to point out that we made a very conscious decision to not change care in any way for those patients. That was a critical issue. It is easier to maintain the old approach for all patients because 90 percent of the KP’s members are still in the older benefit model.

Goldsmith: Of the million people that were added to Kaiser in California during your time as CEO in California, how many of them came because of this change in your benefits strategy?

Halvorson: Now about 10 percent of Kaiser’s members are in plans with deductibles of some kind. I personally went to California’s managed care regulators and worked to persuade them to allow us to offer the product.  I had to give them assurances that we would not be changing the delivery of care for those members in any way. Those members would not be there if we had not offered a product with personal financial exposure in it.

Goldsmith: Did the high deductibles make your job as a care system easier or harder?

Halvorson: Harder.

Goldsmith: Why?

Halvorson: Because we had to bill the patient.

Goldsmith: What else besides the billing?

Halvorson: The billing was the major issue.

Goldsmith: It didn’t make it more difficult for you to get them to do things that were in their own health interest, even if it cost them money?

Halvorson: Because we are who we are and because we ask people to do what we ask them to do in a very consistent and reasonable way, members tend to follow. We didn’t see a lot of people refusing to get needed care based on the fact that they had deductibles. That was largely because we are so committed to a particular set of care concepts and protocols that the credibility of the individual caregiver for the patient triumphed over the financial exposure.

http://healthaffairs.org/blog/2014/09/30/an-interview-with-george-halvor…

Former Kaiser Permanente CEO George Halvorson said, “Everyone at KP, including myself, strongly preferred the model where there was no cost for the patient.” So why did they start selling plans with deductibles?

Simply stated, it was because many employers demanded deductibles and other forms of cost sharing. Deductibles have become a standard throughout the insurance industry, and most employers like them because the premiums paid are lower since up front costs of health care are being shifted to their employees’ pockets.

Yet Halvorson said that deductibles made their job as a health care system harder, mainly because of the administrative inefficiencies of having to bill each patient for these charges. Kaiser received the same total amount but they had to establish “two separate channels, copays and premiums, instead of coming down one prepaid premium channel.”

Either way, the employees were paying the costs – through forgone wage increases that paid the premiums, or through direct out-of-pocket payment of the deductibles. The only reason for making this change was the pigheadedness of the employers who insisted, based primarily on misguided ideology, that they wanted to join the high deductible, consumer-directed bandwagon.

It is well known that deductibles frequently cause individuals to forgo appropriate care which can then result in adverse health outcomes. Halvorson said that they “didn’t see a lot of people refusing to get needed care.” Without the data it is hard to know, but since most of Kaiser’s patients have decent jobs with employer-sponsored plans, these are patients from a relatively healthy sector of the population, mostly with reasonable incomes, so they may be less likely to forgo appropriate care. But even amongst Kaiser’s patient population, there will be some who will find deductibles to be significant barriers to care.

There is nothing good about Kaiser’s deductibles, but there are several things that are bad. And this is in the best of circumstances.

With a single payer system there would be no deductibles, just as there were not in Kaiser’s legacy system. Perhaps the most revealing comment Halvorson made is that before and after instituting deductibles, “the cash flow for KP is basically the same.” It didn’t make a difference; it just mucked things up!

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HHS authorizes higher hypothetical cost threshold for privatized Medicaid

Posted by on Friday, Oct 3, 2014

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Medicaid Demonstrations: HHS’s Approval Process for Arkansas’s Medicaid Expansion Waiver Raises Cost Concerns

GAO, Released September 8, 2014

What GAO Found

In approving Arkansas’s Medicaid Section 1115 demonstration, the Department of Health and Human Services (HHS) gave the state the authority to test whether providing premium assistance to purchase private coverage offered on the health insurance exchange will improve access to care for individuals newly eligible for Medicaid as a result of the Patient Protection and Affordable Care Act (PPACA).

In approving the demonstration, HHS did not ensure that the demonstration would be budget- neutral — that is, that the federal government would spend no more under the state’s demonstration than it would have spent without the demonstration. Specifically, HHS approved a spending limit for the demonstration that was based, in part, on hypothetical costs — significantly higher payment amounts the state assumed it would have to make to providers if it expanded coverage under the traditional Medicaid program — without requesting any data from the state to support the state’s assumptions. GAO estimated that, by including these costs, the 3-year, nearly $4.0 billion spending limit that HHS approved for the state’s demonstration was approximately $778 million more than what the spending limit would have been if it was based on the state’s actual payment rates for services under the traditional Medicaid program. Furthermore, HHS gave Arkansas the flexibility to adjust the spending limit if actual costs under the demonstration proved higher than expected, and HHS officials told us that the Department granted the same flexibility to 11 other states implementing demonstrations that affect services for newly eligible beneficiaries. Finally, HHS, in effect, waived its cost-effectiveness requirement that providing premium assistance to purchase individual coverage prove comparable to the cost of providing direct coverage under the state’s Medicaid plan, further increasing the risk that the demonstration would not be budget-neutral.

As of June 2014, HHS has approved one additional state’s — Iowa’s — demonstration to use premium assistance to purchase exchange coverage. Iowa’s demonstration is more limited in scope in that it covers a portion of the expansion population, those with incomes of 101 percent to 133 percent of the federal poverty level. As with its approval of the Arkansas demonstration, HHS gave Iowa the flexibility to adjust its spending limit and waived the cost-effectiveness requirement. According to HHS officials, three other states as of June 2014 had indicated an interest in implementing a similar approach.

In commenting on a draft of this report, HHS disagreed with GAO’s findings that HHS’s approval process did not ensure that the Arkansas demonstration will be budget-neutral. GAO maintains the validity of these findings.

What GAO Recommends

GAO is not making recommendations in this report. GAO has had long-standing concerns with HHS’s policy, process, and criteria for reviewing and approving section 1115 demonstrations, including the lack of transparency in the basis for approved spending limits. GAO has previously reported that HHS’s budget neutrality policy and process did not provide assurances that demonstrations would be budget-neutral to the federal government. Among other concerns, GAO reported that HHS allows methods for establishing the spending limit that GAO believes are inappropriate, such as allowing states to include hypothetical costs — expenditures that the state could have made under its Medicaid program but did not — in establishing the baseline for the spending limits. As a result, GAO has made a number of recommendations in the past to improve the budget neutrality process for Medicaid demonstrations. In 2008, because HHS disagreed that changes to the budget neutrality policy and review process were needed, we suggested that Congress require the Secretary of HHS to improve the demonstration review process by, for example, better ensuring that valid methods are used to demonstrate budget neutrality.

http://www.gao.gov/products/GAO-14-689R

From the full GAO report:

HHS’s approval of $778 million dollars of hypothetical costs in the Arkansas demonstration spending limit and the department’s waiver of its cost-effectiveness requirement is further evidence of our long-standing concerns that HHS is approving demonstrations that may not be budget-neutral. HHS’s approval of the Arkansas demonstration suggests that the Secretary may continue to approve section 1115 Medicaid demonstrations that raise federal costs, inconsistent with the Department’s policy of budget neutrality. Moreover, the additional flexibility granted to Arkansas and 11 other states to increase the spending limit if costs prove higher than expected sets another precedent, further eroding the integrity of HHS’s process. If, as it did with Arkansas, HHS allows states to use an approach to expanding Medicaid that is expected to cost more than expansion under the existing Medicaid program with fewer cost controls in place, there could be significant cost implications for the federal government. Efforts to ensure cost- effectiveness and budget neutrality in Medicaid expansion demonstrations have even greater fiscal implications given that states that choose to do so will receive enhanced federal funding for the newly eligible population.

http://www.gao.gov/assets/670/665265.pdf

Our two major public programs for health care financing – Medicare and Medicaid – continue down the path of privatization, with the complicity of the Department of Health and Human Services (HHS).

We’ve reported many times that the private Medicare Advantage plans that are displacing the traditional Medicare program have been deliberately funded well in excess of that allotted for traditional Medicare, both by acts of Congress and by administrative chicanery at HHS.

Now the GAO reveals that HHS has also used the section 1115 Medicaid waiver process to allow states to not only transfer their Medicaid patients to private health plans, but to also allow them to meet the higher costs of private plans, through innovative chicanery such as “allowing states to include hypothetical costs — expenditures that the state could have made under its Medicaid program but did not — in establishing the baseline for the spending limits.”

Although privatization of Medicare and Medicaid has long been a Republican goal, since the neo-liberals have dominated the Democratic leadership, they have aided and abetted this effort. We are supposed to be a democracy, yet no matter how we vote, we are electing politicians who spend more of our tax and premium dollars on the administrative waste and mediocre performance of the private insurers. Any suggestions?

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The public thinks that we should have limited networks? Let’s get real!

Posted by on Thursday, Oct 2, 2014

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Reforming Medicare: What does the public think?

AEI and the Brookings Institution, September 19, 2014

Panelists: Joseph Antos (AEI), Marge Ginsburg (CHCD), Robert Moffit (Heritage), Kavita Patel (Brookings) and John Rother (NCHC)

On Friday at AEI, Marge Ginsburg of the Center for Healthcare Decisions (CHCD) opened a discussion on redesigning Medicare by presenting new findings from the CHCD’s MedCHAT study, which engaged diverse participant groups in reviewing current Medicare benefits and addressing the potential for budget reallocation.

http://www.aei.org/events/2014/09/19/reforming-medicare-what-does-the-pu…

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How To Fix Medicare? Ask The Public

By Mary Agnes Carey
Kaiser Health News, September 23, 2014

While participants did not eliminate benefits, they accepted stricter criteria or new limitations on current coverage. For example, 82 percent supported the use of defined networks of providers, but allowed the use of a provider outside the set network if approved by a primary care provider.

http://capsules.kaiserhealthnews.org/index.php/2014/09/how-to-fix-medica…

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OK to Limit Medicare Provider Choices, but Don’t Cut Benefits

American Academy of Family Physicians (AAFP), September 26, 2014

Overall, participants did not choose to cut benefits but opted instead for increased restrictions regarding how and when those benefits would be provided, said Ginsburg. Of those who participated, 82 percent said they would require Medicare enrollees to choose a provider network rather than continue the current carte blanche approach to seeing health care professionals. Most stipulated that referrals outside the network should be covered with consent from a patient’s primary care physician.

http://www.aafp.org/news/practice-professional-issues/20140926medchat.html

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Re-Designing Medicare

Findings from the California Medicare CHAT Collaborative
Center for Healthcare Decisions, September 2014

The Center for Healthcare Decisions (CHCD) in partnership with LeadingAge California developed the California Medicare CHAT Collaborative (“MedCHAT”) to encourage public input on Medicare.

MedCHAT is an interactive, computer-based simulation, in which participants create a benefits package when potential coverage options exceed current Medicare funding.

82% of participants accepted a network model when it was presented as a trade-off for new Medicare benefits.

Participants were presented with several categories where coverage could be improved or new benefits added to Original Medicare. The majority of participants opted to include all of them. (Long term care; dental, vision and hearing; mental health; transportation)

Of the 82% of participants that agreed to the network model, most included the flexibility of allowing the primary care provider to authorize out-of-network use. The remaining 17% chose to retain Medicare’s current provider model.

Participants’ views were also captured via the pre/post survey questions regarding the actions they could support to reduce the impact of Medicare on the federal budget. Before the MedCHAT discussion, “requiring Medicare users to choose a specific provider network” was an option supported by 23% of participants. After MedCHAT, 34% supported this requirement. However, 82% of participants accepted a network model when it was presented as a trade-off for new Medicare benefits. Thus it appears that requiring use of provider networks was not as acceptable when the purpose was to reduce the federal cost burden.

(As a way of reducing the federal budget, lowering the amount Medicare pays doctors was supported by 14%, the lowest of any recommendation.)

http://chcd.org/wp-content/uploads/2014/09/MedCHAT-full-report.pdf

Citing this study from the Center for Healthcare Decisions, it is being widely reported that 82 percent of the public would be willing to accept provider networks for Medicare. Conservatives particularly are touting the fact that the public is no longer demanding unlimited choice of physicians and hospitals under Medicare. Is this what the study really showed?

A few specifics:

  • In the study, 82 percent accepted a network model when it was presented as a trade-off for a significant level of new Medicare benefits: long term care, dental, vision, hearing, mental health, and transportation.
  • Most approved a network model if their primary care provider were to have the freedom to authorize out-of-network care. This basically defeats the control imposed by the closed network since it allows the primary care gatekeeper to open the gate at any time.
  • 86 percent did not approve of reducing Medicare payments to physicians. The purpose of limited networks is to extract provider agreements to accept lower payments. If there is no reduction in payment rates, then in-network providers would still receive the same established Medicare rates as the out-of-network providers, defeating the primary purpose of networks.

So the public can accept provider networks in exchange for more generous benefits as long as the networks do not limit provider choice and do not fulfill their function of reducing payments to physicians.

This study will be used to claim that Medicare beneficiaries prefer limited provider networks. They do not. The majority of seniors are still enrolled in the traditional Medicare program. Those who select the private Medicare Advantage plans (MA) do not do so in order to decrease their choices in health care providers. They do so because they pay less for premiums and cost sharing while receiving additional benefits such as the Part D drug benefits – benefits made possible by federal legislation authorizing overpayments to the MA plans, much of which is retained by the insurers.

The claim that patients do not mind losing their choice of physicians and hospitals as long as the insurance product is a better deal has almost become a meme. But patients supporting networks did not intend that that limitation be applied to their own doctors and hospitals. As that reality is now hitting home, we’re beginning to hear the rumblings.

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Interconnectivity though private market health information technology

Posted by on Wednesday, Oct 1, 2014

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Doctors Hit a Snag In the Rush to Connect

By Julie Creswell
The New York Times, September 30, 2014

Regardless of who is at fault, doctors and hospital executives across the country say they are distressed that the expensive electronic health record systems they installed in the hopes of reducing costs and improving the coordination of patient care — a major goal of the Affordable Care Act — simply do not share information with competing systems.

While most providers have installed some kind of electronic record system, two recent studies have found that fewer than half of the nation’s hospitals can transmit a patient care document, while only 14 percent of physicians can exchange patient data with outside hospitals or other providers.

Epic and its enigmatic founder, Judith R. Faulkner, are being denounced by those who say its empire has been built with towering walls, deliberately built not to share patient information with competing systems.

Where interconnectivity between systems does occur, it often happens with steep upfront connecting charges or recurring fees, creating what some see as a digital divide between large hospital systems that have the money and technical personnel and small, rural hospitals or physician practices that are overwhelmed, financially and technologically.

A research report from the RAND Corporation described Epic as a “closed” platform that made it “challenging and costly for hospitals” to interconnect with the clinical or billing software of other companies.

A sort of Microsoft of the Midwest, built on a sprawling campus on nearly 1,000 acres of farmland near Madison, Wis., the privately held Epic has emerged as a leader in the race to digitize patient medical records. Its systems hold the health records of nearly half the country.

In 2005, when it became clear to her that the government was not prepared to create a set of rules around interoperability, Ms. Faulkner said, her team began writing the code for Care Everywhere. Initially seen as a health information exchange for its own customers, Care Everywhere today connects hospitals all over the country as well as to various public health agencies and registries.

Careful in her choice of words, Ms. Faulkner offered muted criticism of regulators for, essentially, failing to create what she did — a contract to help providers connect to one another and a way to authenticate that only the correct person could view the patient information.

“I’m not sure why the government doesn’t want to do some of the things that would be required for everybody to march together,” she said.

http://www.nytimes.com/2014/10/01/business/digital-medical-records-becom…

****

The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care

By David J. Brailer, MD, PhD, National Coordinator for Health Information Technology
PNHP Quote of the Day (excerpts), July 21, 2004

While the federal government plays an important role in HIT adoption, the effective use of, and value creation from, this technology lies predominantly with the private sector. The federal government will provide a vision and a strategic direction for a national interoperable health care system, but will rely on a competitive technology industry, privately operated support services, and shared investments in HIT adoption. The private sector must develop the market institutions to deliver the products and services that can transform the paper-based health care system into an electronic, consumer-centered, and quality-based system. The private sector can best ensure that HIT products are successfully implemented in ways that meet the varying needs of American health care across settings, cultures, and geographies. The private sector can also continue constant innovation in HIT and ensure that products are delivered on an affordable basis.

Comment by Don McCanne (July 21, 2004)

What has the magic of the competitive marketplace produced in the way of an integrated IT system to this date? High costs, very poor penetration, and system failures! Competitive market theory dictates that we should be leading the world with a high quality health care IT system at a low cost. What went wrong?

First of all, a fragmented system of multiple private plans, public programs and uninsurance does not provide an infrastructure that is very conducive to an integrated IT system. A single payer system, or, at minimum, a highly regulated system of universal coverage through multiple plans, would provide a framework that would ensure adaptability of an integrated IT system. Of course, a single, publicly administered system would be much preferred for an integrated IT system.

But the greatest difficulty with private IT solutions lies in the very nature of these marketplace models. Their goals are, above all, to maximize profits and to maximize the market price of their shares.

What might the private sector do that doesn’t serve our interests well? They will produce products that command the highest prices that the market will bear. They will design the products to provide a continuing revenue stream. Once gaining a significant share of the market, they will design incompatibility with other systems in an attempt to garner the entire market. They will design obsolescence into their systems to ensure future markets for their new innovative products. They will partner with and perhaps acquire other related entities that can expand profit potentials through greater control of components of the health care system which their products can influence. Although these are good business practices, they are terrible policies for our health care system.

The health information technology report released today (July 21, 2004) should alarm us all. Although we all agree on the importance of an integrated IT system, the Bush administration is limiting the role of the government to being an enabler that encourages the private sector to develop a successful business model. Rather than higher quality at a lower cost, we’ll end up with mediocrity at a much higher cost, wasting even more of our health care dollars.

http://www.pnhp.org/news/2004/july/a_private_health_car.php

A decade ago we already had a very successful, publicly-owned health information technology system (HIT) with interconnectivity – VistA – the system in use by the Veterans Health Administration. Under the leadership of President George W. Bush, it was decided that we should move forward with interconnecting our entire health care system through HIT, but that the system should be developed in the private sector instead. What has happened since?

President Bush appointed David Brailer as his National Coordinator for Health Information Technology. On July 21, 2004 he released a 178 page report describing the framework of his proposal – The Decade of Health Information Technology (a decade just completed). Although the link to their report is no longer active, perhaps the most informative sentence in the report is the following: “The private sector must develop the market institutions to deliver the products and services that can transform the paper-based health care system into an electronic, consumer-centered, and quality-based system.” Although the federal government would provide “a vision” for HIT, it would be developed and operated exclusively in the private market.

In my Quote of the Day comment on the day the report was released 10 years ago, I wrote: “What might the private sector do that doesn’t serve our interests well? They will produce products that command the highest prices that the market will bear. They will design the products to provide a continuing revenue stream. Once gaining a significant share of the market, they will design incompatibility with other systems in an attempt to garner the entire market. They will design obsolescence into their systems to ensure future markets for their new innovative products. They will partner with and perhaps acquire other related entities that can expand profit potentials through greater control of components of the health care system which their products can influence. Although these are good business practices, they are terrible policies for our health care system.”

So what did they do? The New York Times article reveals that Epic, a privately held company, “holds the health records of nearly half the country.” Epic is “a ‘closed’ platform that made it ‘challenging and costly for hospitals’ to interconnect with the clinical or billing software of other companies.” “Where interconnectivity between systems does occur, it often happens with steep upfront connecting charges or recurring fees.” Recognizing the need for interoperability, Judith Faulkner, the founder of Epic, established “Care Everywhere” which performs well as a new profit center for Epic but performs poorly in establishing universal connectivity. How could anyone know ten years ago that this might happen? Well, it was known.

This is analogous to the decision made to rely heavily on private health insurance in our efforts to expand health care coverage to everyone, based on the idea that the market can do it better than the government. We have been predicting the adverse consequences of this, and every day we see more evidence that our predictions, based on solid health policy science, are all coming true. In health care we are facing excess costs and poor performance, just as we are with our private HIT systems.

Under a single payer system we would have a cost-effective, publicly-owned, integrated HIT system that is designed to serve patients and their health care professionals, rather than a system that is designed to serve, well, Judith Faulkner (#261 on Forbes 400, Net worth $2.3 billion).

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MedPAC continues to ignore ACO overhead

Posted by on Wednesday, Oct 1, 2014

Public meeting of the Medicare Payment Advisory Commission (MedPAC)

September 11, 2014

From the transcript:

MR. [GLENN] HACKBARTH [MEDPAC CHAIR]: It is time to begin our afternoon session. We have three topics … this afternoon, the first being ACOs …. [p. 118]

MR. [DAVID] GLASS [MEDPAC STAFF]: Good afternoon. … I will … look at recent developments in the two Medicare ACO programs: the Medicare shared savings program, or MSSP, and the Pioneer demonstration [p. 118]. … In summary, the ACOs in the MSSP program had aggregate savings of about 0.3 percent [p. 121]. … Turning now to the Pioneer ACO model … CMS reports the program saved about 0.5 percent [p. 122]. …

DR. [DAVID] NERENZ: [Y]ou used the phrase “low overhead.” … Is it low overhead in practice? Do we know anything about that?

DR. [JEFF] STENSLAND [STAFF]: [P]eople we talk to and the data we have seen, it looks like maybe 1 to 2 percent of your spend, that that’s what they’re spending on their ACO to operate it. … [p. 133].

DR. NERENZ: [I]f I could go back to the overhead cost issue, I just want to … see if I’m thinking about this correctly. If, say, Jeff, as you said, two percent of overall spend might be administrative – you said one to two, but let’s just use two – in order, then, for the ACO to make money net, it would have to achieve four percent savings if the shared savings ratio is about 50 percent. … I’m just trying to figure out, in the data you’ve seen, are there ACOs who have actually made money net of overhead cost? Do we know that yet?

DR. STENSLAND: [I]f you averaged everybody [all Medicare ACOs] so far … the share of savings, on average, that they get is going to be less than their administrative costs. … [p. 144].

DR. [MARY] NAYLOR: Do we have a sense of the overhead cost for the Medicare program as we’re doing this model development? It’s just something that I think is really important. … [p. 165].
I would say that in assessing [savings or losses] we have to look at the total program costs . … [p. 168].

http://www.medpac.gov/documents/092014-medpac_transcript.pdf?sfvrsn=0

In a comment I posted on this blog last December, I noted that the Medicare Payment Advisory Commission (MedPAC) refuses to ask a very obvious question about the two Medicare ACO programs authorized by the Affordable Care Act: Do the administrative costs of running an ACO exceed the savings ACOs allegedly achieve for Medicare?

Specifically, I noted that a MedPAC employee by the name of Kate Smalley told the commissioners at their November 7, 2013, meeting that the Pioneer ACO program (the smaller of the two programs) was saving Medicare 0.5 percent of total spending but that the ACOs were spending 1 to 2 percent of their revenues on administrative costs. Then I leveled what appears to me to be an extremely obvious criticism: “Neither Ms. Smalley nor any commission member pointed out the obvious: While Medicare may have saved a half percent, the health care system as a whole suffered an increase in total spending on the order of half to one-and-a-half percent.”

I’m happy to report that at MedPAC’s last meeting (September 11, 2014) at least two commissioners (out of 17 who sit on the MedPAC commission) finally got around to raising that obvious question. I’m unhappy to report, though, that the two commissioners, Nerenz and Naylor, got only the vaguest of answers from MedPAC’s staff and absolutely no expression of interest in this issue from the other 15 commissioners.

The exchange between the two commissioners and staff began when Commissioner Nerenz inquired of staff member Jeff Stensland whether “we know anything about” the overhead costs of ACOs. The accurate answer would have been, “We know next to nothing about ACO overhead costs because we have ignored the issue over the seven years we’ve been recommending ACOs to Congress.” Instead, Stensland said “it looks like maybe 1 to 2 percent.” That is the same estimate Ms. Smalley reported at the November 2013 meeting.

Neither Stensland nor other commissioners pursued Nerenz’s question. Nerenz bided his time, and came back to the overhead issue 11 pages later in the transcript. This time he asked the obvious question: Do we know whether any ACOs are making money AFTER taking their overhead costs into account?

Stensland’s answer was vague. “There would be some,” he replied. He didn’t name any. Then he went on to state that the average ACO is losing money.

Only one other commissioner, Mary Naylor, expressed interest in Nerenz’s question. She said it was important to know not only the ACO’s overhead costs but the overhead costs to CMS of running the ACO experiment.

But that was it. No other commissioners expressed interest in Nerenz’s and Naylor’s questions. The only impact Nerenz’s question had was to generate a discussion among the commissioners about whether to reduce the number of “quality” measures ACOs have to report on and whether to give ACOs more money, either in the form of a higher share of any savings or in the form of outright subsidies. Naylor’s question had no impact at all. Chairman Hackbarth closed the discussion within seconds after Naylor made her statement.

MedPAC’s assiduous avoidance of the issue of ACO overhead is consistent with its assiduous avoidance of the overhead costs of the Medicare Advantage (MA) insurers. To its everlasting credit, MedPAC has consistently called on Congress to stop overpaying MA plans. But MedPAC has never acknowledged the obvious consequences of doing that, namely, the mass withdrawal from the program by private insurers. That would happen because the traditional fee-for-service Medicare program is more efficient than the private insurance industry, in large part because the traditional program’s administrative costs are so low (1 to 2 percent) compared with those of the insurance industry (they average 15 to 20 percent).

But MedPAC commissioners and staff would rather crawl over broken glass than admit a fee-for-service program could be more efficient than the MA program where insurers allegedly “manage care.” Ditto for the ACO programs. The fee-for-service method of payment is MedPAC’s Great White Whale. Conceding that fee-for-service Medicare is more efficient than either the MA or ACO programs, after all these years of promoting the managed care fads MA and ACO programs are supposed to use, would make MedPAC look foolish.

MedPAC’s avoidance of administrative costs is, of course, characteristic of the health policy establishment. One-third of U.S. health care spending is devoted to administrative costs. We could cut that fraction in half with a single-payer system and use the savings to finance universal coverage.

But we mustn’t think about that. We must continue to flog the conventional wisdom that our health care costs are high because MEDICAL spending, not administrative spending, is high. And, in our relentless focus on medical spending as opposed to administrative spending, we must fixate on the VOLUME of medical spending, not the price at which medical goods and services are sold. And we must fixate on volume rather than price because that is consistent with our undocumented theory that fee-for-service is the root cause of the U.S. health care crisis.

Kip Sullivan, J.D., is a member of the steering committee of the Minnesota chapter of Physicians for a National Health Program. His writing has appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.

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Auto-renewal of health plans is a problem we don’t need

Posted by on Tuesday, Sep 30, 2014

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Auto-Renewing Your Health Plan May Be Bad for You, and for Competition

By Austin Frakt
The New York Times, September 29, 2014

Overwhelmed with increasing choice in the new exchanges, returning consumers may not relish the idea of selecting a new plan. A feature built into the exchanges practically invites them not to do so: auto-renewal. Consumers insured by an exchange plan this year who do not actively choose a new one for next year will be automatically re-enrolled in their current plan or automatically enrolled in a similar one if their plan is discontinued. This auto-renewal is meant to help increase and maintain the size of the insured population and to promote continuous coverage. But if people rely on auto-renewal without evaluating all available options, some may end up in plans that aren’t ideal for them.

Next year, the premiums of the currently cheapest silver-rated plans are going up by an average of 8.4 percent. Because of that, many of those plans will no longer be the cheapest. The customers who switch to the silver plans that are the cheapest in 2015 will see their premiums rise by only 1 percent on average.

Auto-renewal also offers insurers a way to retain customers without vigorously competing for them, counting on the fact that some consumers will stick with their plans even when, rationally, they should not.

Here, basic economic theory is in conflict with the finding from behavioral economics that when choices become too numerous and complex, consumers resort to heuristics (or shortcuts), leading to suboptimal decisions. For instance, when we can’t fully evaluate all options, we tend to default to familiar brands. And, because it takes time and effort to re-evaluate options, we tend to stick with our initial choice of brand when making a new purchase.

If we want more competition, we need to induce fewer people to default to auto-renewal.

Auto-renewal exists for a reason, but if consumers rely on it too much, the results will include higher premiums and greater market power for insurers.

http://www.nytimes.com/2014/09/30/upshot/auto-renewing-your-health-plan-…

Under a well designed single payer national health program there would be no need to choose networks since the entire health care delivery system is covered, and there would be no need to shop deductibles since they would be eliminated.

The problem of auto-renewal would disappear since enrollment would be for life.

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When your emergency physician is out of your network

Posted by on Monday, Sep 29, 2014

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not

By Elisabeth Rosenthal
The New York Times, September 28, 2014

Patients have no choice about which physician they see when they go to an emergency room, even if they have the presence of mind to visit a hospital that is in their insurance network. In the piles of forms that patients sign in those chaotic first moments is often an acknowledgment that they understand some providers may be out of network.

But even the most basic visits with emergency room physicians and other doctors called in to consult are increasingly leaving patients with hefty bills: More and more, doctors who work in emergency rooms are private contractors who are out of network or do not accept any insurance plans.

When legislators in Texas demanded some data from insurers last year, they learned that up to half of the hospitals that participated with UnitedHealthcare, Humana and Blue Cross-Blue Shield — Texas’s three biggest insurers — had no in-network emergency room doctors. Out-of-network payments to emergency room physicians accounted for 40 to 70 percent of the money spent on emergency care at in-network hospitals, researchers with the Center for Public Policy Priorities in Austin found.

“It’s very common and there’s little consumers can do to prevent it and protect themselves — it’s a roll of the dice,” said Stacey Pogue, a senior policy analyst with the nonpartisan center and an author of the study.

When emergency medicine emerged as a specialty in the 1980s, almost all E.R. doctors were hospital employees who typically did not bill separately for their services. Today, 65 percent of hospitals contract out that function. And some emergency medicine staffing groups — many serve a large number of hospitals, either nationally or locally — opt out of all insurance plans.

Regulations created by the Affordable Care Act specify that insurers must use the best-paying among three methods for reimbursing out-of-network physicians dispensing emergency care: pay the Medicare rate; pay the median in-network amount for the service; or apply the usual formula they use to determine out-of-network reimbursement, which often depends on “usual and customary rates” in the area.

But in most states, doctors can then bill patients for the difference between their charge and what the insurer paid.

http://www.nytimes.com/2014/09/29/us/costs-can-go-up-fast-when-er-is-in-…

Center for Public Policy Priorities study of out-of-network emergency room doctors:http://forabettertexas.org/images/HC_2014_09_PP_BalanceBilling.pdf

KFF on state balance billing restrictions: http://kff.org/private-insurance/state-indicator/state-restriction-again…

A consequence of allowing health insurers to contract selectively with health care professionals (physicians) and institutions (hospitals) is that patients not only are financially penalized should they elect to obtain their care outside of the contracted networks, they may unavoidably face such penalties when they have sought care only within networks.

One of the more egregious examples is when they obtain emergency services at a contracted emergency room only to find out after the fact that the physicians staffing the emergency room are not in the network. The patient then is billed not only for deductibles and copayments applied to allowed charges, but also for the balance of the charges in excess of the allowed charges – a process known as balance billing.

“The Affordable Care Act provides some protections for enrollees in need of emergency services, but does not prohibit balance billing by out-of-network providers” (KFF). For further information on state restrictions on balance billing, use the KFF link above.

When something is not right, as it clearly isn’t here, it is important to define the problem before crafting a solution. State regulators and legislators are defining this as a problem of balance billing “abuse” and are looking at mechanisms to prohibit balance billing. But is that really the problem?

Insurers, with the complicity of state and federal legislators, have established limited networks of providers to leverage more favorable payment rates for health care services. But these rates neglect the health care delivery system outside of the networks. Now states are considering making out-of-network physicians comply with contracts to which they never agreed. That is as unreasonable as making insurers pay out-of-network fees in full simply because the insurers did not have a contract with the physicians. Do you have a contract or not? You can’t have it both ways.

The problem here needs to be redefined. Balance billing is not the primary defect. It is the nature of our complex, dysfunctional financing infrastructure that leads to a multitude of perverse consequences such as balance billing – an infrastructure that was perpetuated and expanded by the Affordable Care Act. We need to rebuild the infrastructure. We need a single payer national health program. Balance billing would not exist under such a system.

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