*OP-ED by Dr. Jay Epstein of Clearwater*
By Dr. Jay Epstein
Congress is rightly focused on fixing surprise medical bills, which arise from inadequate coverage, opaque and skinny insurance policies, and narrow carrier networks. These combine to create often insurmountable financial hardships for patients. As they close in on a policy answer, our elected officials in Washington must be sure they are legislating a solution that does not impose additional barriers to accessible and quality health care.
Unfortunately, some of the proposed solutions currently being considered could have that undesired effect. Under an especially risky approach known as government benchmarking, the law would allow insurance companies to unilaterally set physician rates for out-of-network care, using standards chosen solely by the carriers. Furthermore, doctors would be left without a legitimate appeals process.
By allowing multi-billion-dollar insurance companies to set doctors’ rates, median-in-network benchmarking would transfer significant financial losses onto local hospitals and emergency rooms, significantly eroding their ability to provide crucial care to vulnerable segments of the population, including the poor and elderly. Since many of these facilities, particularly in rural parts of the country, are already operating on thin margins, this could lead to hospital closures and decreased access to physicians. Translated: patients will end up paying more to have fewer options.
A vastly superior approach, known as Independent Dispute Resolution (IDR), can be found in the “STOP Surprise Medical Bills Act”, a bill from Louisiana Senator Bill Cassidy. IDR would enable physicians and insurers to equitably negotiate payments for out-of-network care on a case-by-case basis. The IDR process would be overseen by an independent arbitrator who would make a final decision on payment amounts. Until then, interim payments would help keep America’s rural hospitals and emergency rooms financially viable.
While Senator Cassidy’s version of IDR would provide the right balance to solve this problem, not all the bills in Congress purporting to use this process would have the same impact. Currently, a House bill called the “No Surprises Act” attempts to blend the IDR and benchmarking approaches. However, IDR would only be used when disputed payments are higher than $1,250 – the case less than 1% of the time. This appeals process is essentially meaningless.
For the 99 percent of the physician claims that fall below that amount, the inferior and insurer-determined approach would still be used. This means that all the flaws and shortcomings of benchmarking would persist under the House solution. Members of Congress, including our own Senator Rick Scott, should not be fooled.
Instead, Senator Scott should help support the true IDR framework as outlined in Senator Cassidy’s bill. I urge the Senator to work with his colleagues to ensure that the Federal government’s solution to the surprise medical bills problem does not devolve into a huge win for insurance companies and a costly loss for American healthcare consumers, like your family and mine.
Jay Epstein, M.D, FASA, is an Anesthesiologist who lives and practices medicine in Clearwater, Florida.