By Jane Anderson
Legislation to protect patients against surprise medical bills is once again gaining momentum in Congress, with two key House committees voting to advance proposals. However, passage of competing bills by the House Education and Labor Committee and the House Ways and Means Committee also emphasized the policy divide between lawmakers and stakeholders on the main sticking point: how to decide rates for out-of-network providers.
Education and Labor, which approved its bill on Feb. 11 with a bipartisan majority, would set payments for providers by basing them on regional benchmarks, while still giving providers the option of going to arbitration for bills higher than $750. Ways and Means, meanwhile, backed mediation between insurers and providers to set rates, again on a bipartisan vote. That panel also threw in a new twist: a provision designed to rein in private equity firms that have purchased physician practices.
Some policy analysts say the two camps are not as far apart as they might appear, and could rally to negotiate a compromise, particularly since this issue is on the radar of many election-year voters. “Maybe I’m being overly optimistic, but I still think there’s a good chance something gets done before the late May deadline they set for themselves,” says Loren Adler, an associate director of the USC-Brookings Schaeffer Initiative for Health Policy who has studied surprise billing.
Most surprise billing proposals would hold consumers harmless by prohibiting balance billing — when an out-of-network provider sends a patient an invoice for the difference between what they’re charging and what an insurer will pay, according to an issue brief from the American Academy of Actuaries. The proposals also would base patients’ out-of-pocket costs on in-network cost-sharing requirements for services provided at an in-network facility. But the point of contention is how to determine what providers get paid in those situations.
The Ways and Means Committee’s mediation/arbitration approach won some praise from provider groups, including the American Medical Association. Provider groups have been heavily lobbying Congress for such an approach. Meanwhile, the Coalition Against Surprise Medical Billing, which represents major health insurers and business groups, favors a benchmark approach “based on local, competitive market-based rates.”
“I don’t know whether providers or insurers will prevail on this issue, since both have very strong stances,” Caroline Pearson, a senior fellow at NORC at the University of Chicago, tells AIS Health. “The most likely scenario could be a middle-ground approach that sets payment rates for some threshold of services and uses arbitration more selectively.”