- Posted by Guest Author
- On January 8, 2020
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Be part of the Temple Israel – Greater Boston Interfaith Organization (GBIO) healthcare campaign to change a broken system that is harming people.
In-district meetings, running various times and places January 25 – February 26, are a great way for you to see GBIO in action at a convenient location, meet your representative, move the healthcare needle on reducing price of prescription drugs, eliminating out-of-network surprise billing, and improving access to mental health and substance use disorder care.
No More Nasty Surprises
By Abraham (Nick) Morse, MD, MBA and Michael Rubenstein
Imagine receiving a bill for hundreds or even thousands of dollars from a doctor you have never heard of. Even though you had an operation or visited an emergency room that was covered by your insurance, this bill is for a health care procedure that isn’t covered and you are responsible for the entire bill. And imagine you live in a state where 10,000 residents have gotten such a bill every year. Massachusetts is just such a state and for too many of us we don’t need to imagine.
The Greater Boston Interfaith Organization (GBIO) is in the midst of a campaign to bring real reform to our healthcare system and eliminating the practice of surprise medical billing is a central part of this effort. We at TI have an important role to play, as you will see below.
There are many problems in our health care system where there are at least two sides to the story. Surprise medical billing is not one of them. In emergency rooms and operating rooms, a patient has no agency to choose who is participating in their care. The hospital can hire an “out of network” provider who can charge substantially more than what a typical insurance payment might be for the service and then saddle the patient with the entire financial responsibility. This is nothing more than price-gouging – like charging $25 for a gallon of milk after a hurricane devastates your community. As MaryAnne Bombaugh, current president of the Massachusetts Medical Society, explained: “When surprise billing occurs, patients are unfairly put in the middle of a matter that should be resolved by their health plan and provider.”
Insurance companies and hospitals do have legitimate reasons to limit which providers are allowed to perform services for some specific cohort of patients. For example, hospitals and insurance companies must ensure doctors, nurses and other staff are competent and properly credentialed. They must be able to share medical information, and health care systems should incentivize individual providers to use standardized processes which improve patient safety, avoid miscommunication and decrease resource use. Sometimes, patients can understand the cost if they choose to receive care from an out-of-network provider for a non-urgent condition. In these cases, patients have a right to transparency about the financial implications of their choices.
However, a voluntary decision by a patient to choose an out-of-network provider is not possible when a patient has little or no ability to choose, either because they are in an urgent situation or they have not been informed that there is a choice to be made.
So how did surprise medical billing come about? Here are a few ways our confusing and complicated health care system can lead us down the road to surprise medical billing:
- Hospitals do not employ all of the doctors that work in their facility. Many doctors are in private practice, running their own business and contracting with nearby hospitals to care for patients. They charge a separate fee from the money that the hospital collects.
- Many hospitals are too small to afford all the specialists they need full-time.
- Emergency rooms are required to have specialists available to respond to different types of emergencies any time of day or night. For example, a patient needs an anesthesiologist for emergency surgery on the weekend, or a child comes into the emergency room with a head injury and needs to be seen by a pediatric neurosurgeon.
- Health insurance coverage is regionalized. A physician who is in-network for an insurance company in Massachusetts is not automatically in-network in New Hampshire.
Here’s the nub of the problem: some specialty physicians have discovered that they can dictate the prices for their services by purposely remaining out of network, and hospitals, especially smaller ones, struggle to retain specialists without allowing this.
What can be done?
We need legislation that removes the patient from the price and payment negotiation and creates a fair system for paying doctors for out of network services.
A number of bills have been filed in both the Massachusetts House and Senate to address out-of-network surprise billing and they include various formulas for determining how out-of-network providers should be paid. Our challenge as these bills wend their way through the legislative process is to overcome the resistance of companies and individuals that profit from out-of-network surprise bills at the expense of the people of Massachusetts.
The voices of constituents matter. So right now, Temple Israel and other GBIO congregations are organizing local meetings with our state representatives throughout Greater Boston to press for this fix. If you’ve received a surprise medical bill and want to prevent a repetition, or you want simply to stand up for an end to surprise medical billing, we invite you to join your neighbors in GBIO to meet your state representative, as we make the ask and get a commitment for change.
To find out when and where your state representative is meeting constituents and join fellow TI and GBIO neighbors in action, contact TI Healthcare Captain Anne Licciardello at email@example.com. See you there!
Want to learn why your prescription drugs cost so much? Check out Dr. Morse’s Feb 24 presentation at TI!