OPINION

A Patient-First Solution to Surprise Medical Bills

Health care is a top-of-mind concern for Americans. The current system is difficult to navigate, fragmented and expensive.

Systemic weaknesses are unacceptable for a nation blessed with the greatest medical talent and resources on earth. Patients are rightfully demanding change.

Solving surprise medical billing is a priority for the health care system and policymakers. Envision, a medical group of 25,000 physicians and clinicians, is advocating for a solution.

Surprise bills occur when insurers and providers cannot agree on a fair price for care delivered. It should not be the patient’s responsibility to sort out these disputes. Therein lies the heart of the problem.

Insurers are incentivized to drive down the cost and utilization of care. In contrast, physicians are bound by a professional oath to make sure patient care comes first.

In a perfect world, both sides would find a balance that promotes access to quality patient care. The system is unbalanced.

A recent U.S. Government Accountability Office report revealed that in 43 states, three or fewer insurance companies control more than 80 percent of the large group insurance market. This includes seven states that offer only one or two insurance carrier options.

In stark contrast, physicians are organized into thousands of small independent groups. Insurance companies have become so large and concentrated that physicians are now treated as a commodity, and their role as the patient advocate is under attack.

Hospital-based physicians are particularly easy targets as they are bound by law to treat every patient regardless of their health coverage. For years, many insurers did not bother to contract with emergency physicians because they knew their beneficiaries would receive care. 

Insurers increasingly pay arbitrarily low rates on out-of-network claims, forcing physicians to take legal action to seek proper payment. Most physicians cannot afford litigation, and many capitulate to the more powerful insurance company or exit the market. Again, the system is unbalanced.

In February 2017, Envision highlighted the confusion related to out-of-network care, high deductible plans and narrowing insurance networks — particularly for emergency services — and took a bold step to be part of the solution. We publicly announced our commitment to an in-network strategy.

Today, more than 90 percent of our business is from in-network patient encounters. Envision was acquired by private equity firm KKR last year. Our partners at KKR have been fully supportive of our in-network strategy.

Together, we are making investments in leadership talent, technology and training to innovate and drive positive change. We continue to lead and remain optimistic that someday soon all insurance companies and providers will share our vision for solving this issue.

Envision physicians have been unwavering in their support for a comprehensive independent dispute resolution process, such as those implemented in New York and Texas, which protects patients and physicians without raising premiums. This is a proven solution.

IDR establishes a process for out-of-network claims to be adjudicated by an independent third party to determine a fair price when insurers and physicians cannot. A study on the New York law found arbitration to be balanced and fair, and another recent report found that the IDR solution has saved consumers $400 million from the time the law was implemented in March 2015 through the end of 2018 for emergency services alone.

IDR allows for a broad range of factors to be considered rather than a one-size-fits-all approach. Several physicians in Congress have put forward draft legislation with some type of arbitration or mediation.

Our physicians, who are on the front line of patient care every day, do not view government rate setting as a viable solution. The Congressional Budget Office projects a nationwide 20 percent cut in physician reimbursements should Congress pass legislation tying payments to the “median in-network” rate. This approach risks physician shortages and hospital closures — particularly in rural communities.

There are only 50,000 emergency physicians serving 150 million patients per year. Any policy that jeopardizes the current physician supply — or the prospects for attracting the next generation of physicians — is fundamentally dangerous.

Our current safety net of hospitals and emergency services is very fragile. In my home state of Tennessee, 12 hospitals have closed since 2013. The risks and unintended consequences of rate setting offset any limited benefit. There are better solutions that don’t put the nation’s health care safety net or patients’ access to care at risk.

Physicians bring an important perspective to the table. Their input should be heard and carefully considered. I urge policymakers to listen to the collective voice of those closest to the patient: Support a comprehensive IDR process and keep patients first.

On behalf of our outstanding team of clinicians, we welcome the current national debate. It is healthy and long overdue. 

 

Chris Holden is the president & CEO of Envision Healthcare, an American health care company and national hospital-based physician group.

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