- Bipartisan members of Congress condemned the healthcare industry's failure to address surprise billing at a House Energy & Commerce Subcommittee on Health hearing Wednesday, warning that if the private sector doesn't take action, the government will intervene.
- "If you don't solve the problem, then we will solve the problem and none of you will like it," ranking member Michael Burgess, R-Texas, said.
- Payer and provider representatives sparred over the best way to stop surprise bills, with America's Health Insurance Plans and the ERISA Industry Committee stumping for rate setting and the American Hospital Association, American College of Emergency Physicians and Physicians for Fair Coverage advocating for a third-party arbitration process.
As Congress wrestles with how to resolve payment disputes between out-of-network providers and health plans, industry has grown more polarized in the debate. But policymakers at Wednesday's hearing said they were fed up with the squabbling.
"Let me be clear: I'm interested in fixing this problem for consumers, not for the stakeholders who've allowed this problem to persist for decades while consumers continually paid the price," committee chairman Rep. Frank Pallone, D-N.J., said.
Lawmakers aren't the only ones at the end of their leash. Families USA Director of Campaigns and Partnerships Claire McAndrew expressed frustration with perverse financial incentives that have allowed the practice of surprise billing to continue for decades.
"We want to ensure this discussion is not consumed by what makes powerful industries happy, and that the pace of this regulation is not slowed to meet the needs of these powerful industries," she said.
Currently, a slew of federal and state lawmakers have introduced legislation to tamp down on patients receiving surprise out-of-network medical bills, which can be prohibitively expensive.
Late last month, the leaders of the Senate HELP Committee proposed a wide-ranging set of bills, including one on surprise billing. However, the draft legislation doesn't settle on a single solution, instead including three options the committee is considering: an in-network guarantee, independent dispute resolution and a benchmark payment.
Payers and employer groups support legislation that includes a set rate for out-of-network services. These "rate setting" or "benchmarking" models include the "No Surprises Act," a bill set forward by Reps. Pallone and Greg Walden, R-Ore.
The No Surprises Act would set rates at 100% of current median in-network rates for that geographic area, ensuring some payment for provider services. The Council for Affordable Health Coverage, a business group, estimates the draft legislation would be budget neutral if enacted.
"The No Surprises Act nails it," ERISA Industry Committee EVP James Gelfand said Wednesday. "It takes the patient out of the middle."
However, provider interests came out strongly against the bill in Wednesday's hearing, arguing rate setting will actually increase healthcare prices across the board while lowering reimbursement for cash-strapped physicians and hospitals.
"If you keep everyone at a median number, everyone goes down to that median number," Sherif Zaafran, chairman of Physicians for Fair Coverage, said, warning it would de-incentivize payers from creating broad, comprehensive networks.
Providers instead advocated for some form of an independent dispute resolution process, such as so-called "baseball-style" arbitration where both providers and payers put forward their best offer and a third-party mediator selects one.
"Innovation would be really hindered by a one-size-fits-all approach," American Hospital Association EVP Tom Nickels said. "If Congress is going to do anything, we think a baseball-style arbitration is the best approach."
Twelve states including Washington, Nevada, Colorado and Texas, have adopted measures involving baseball-style independent dispute resolution, with some initial success, according to The Commonwealth Fund.
However, Sonji Wilkes, an Englewood, Colorado-based patient advocate who was hit with a $50,000 surprise bill when her son ended up in an out-of-network NICU in an in-network hospital, said none of the details would matter to patients — as long as it's fixed.
"I pay my insurance premiums, I do my part," she said. "I just want my bill to be paid."