An equitable end to surprise medical billing

Published August 29, 2019

By Howard N. Lee

Health care costs are too high in this country—that’s one thing both political parties can agree upon. Further compounding the issue is the pervasive problem of surprise medical billing. Families already struggle to meet co-pays and deductibles; getting hit by high, unexpected medical costs only makes it that much harder for them to access the critical health care services they need. Something has got to give.
A few states have successfully passed legislation to protect patients from surprise billing; however, this isn’t an issue that should be addressed on a state-by-state basis. No, this requires congressional action so we can nip this problem in the bud at the national level. That is why it is past time for Congress to find a workable solution that helps provide relief to vulnerable patients and their families.
Surprise billing usually happens one of two ways. Either a patient seeks treatment at an emergency room or hospital that is not in their network—or they are treated by an out-of-network doctor at a facility that is in their network. Obviously, most patients don’t have the time or foresight to quiz every health care provider they see so they can determine their network status—nor should they be required to do so.
This issue impacts some 57 percent of Americans—but it has a profoundly disproportionate impact on minorities. For many underserved communities of color, the emergency room is the primary provider for medical care. However, by visiting an emergency room, minorities are more likely to be treated by a physician who is not in their network, leading to surprise bills that place more financial hardships on the backs of patients and families who can least afford it.
As Congress works to address this issue, lawmakers must ensure that whatever solution they enact is one that will not only eliminate surprise billing, but also maintain patient access to affordable, quality health care. Currently, not all the options on the table would guarantee that.
Some in Congress have proposed a government-mandated benchmark to set rates paid to physicians in the case of out-of-network payments that cannot be agreed upon between insurers and providers. Such an approach would, theoretically, help to prevent some patients from being impacted by surprise billing. However, benchmarking would also expose a vastly larger amount of patients to a lower standard of care, higher costs, and decreased access. These are not acceptable trade-offs.
Using insurers’ in-network averages—which are hardly transparent figures as it is—to set artificially low rates for physicians would result in many of our vital hospitals and emergency rooms incurring massive financial losses. For those facilities serving traditionally underserved, disenfranchised neighborhoods, these losses would likely be too great to bear and would force many of them to either cut staff, eliminate offerings, or even close down altogether. Any of these outcomes would only undermine patient access to care and threaten affordability in some for some of our most at-risk, vulnerable patient groups.
However, there is a better solution under consideration, and it is called Independent Dispute Resolution, or simply IDR. As outlined in other legislation, IDR would facilitate an open, transparent negotiation process between insurance companies and health care providers, enabling them to resolve payment disputes among themselves by submitting their best offers through an online portal. An impartial, third-party mediator would determine a final payment within 30 days and providers would receive temporary payments for services rendered based on the fair market value. This is the key part for hospitals serving our at-risk communities as these payments will help ensure financial stability so there is no disruption to patient care.
IDR is the only solution in Congress that has been proven to work. New York passed a state law in 2015 using IDR to protect patients from surprise billing. Since then, in-network participation has increased, out-of-network bills are down 34 percent, and emergency room care costs have declined. In California, where a benchmark solution was recently implemented, doctors are already sounding the alarm as insurers have been emboldened to cut long-standing contracts, thereby diminishing patient access to in-network care.
It’s time for Congress to end surprise billing—and to do so in a fair, equitable, and balanced way that protects health care for everyone. Our congressional delegation should throw their full, unabashed support behind IDR and Representative G.K. Butterfield along with Senators Richard Burr and Thom Tillis should make sure that any bill that passes through Congress includes this proven-effective process instead of the potentially disastrous benchmarking approach.
Howard Lee is a former four-term North Carolina state senator and was the first African-American mayor elected in North Carolina. He also served as Secretary of Environment & Natural Resources and is the former chairman of the North Carolina State Board of Education.