The Health 202: Health insurers balk at last-minute deal in Congress on surprise medical bills

Health insurers are furiously lobbying Congress to tweak a last-minute deal on protecting Americans from surprise medical bills — one that is viewed as favoring doctors over them.

But they’re up against a ticking clock, heavy influence from private-equity-backed physician groups — and the reality that the pandemic boosted their profits even as medical providers suffered.

“We do have some significant concerns about the deal that was announced,” Matt Eyles, president of America’s Health Insurance Plans, told The Health 202. “We certainly will be advocating for modifications … it’s going to be challenging, but that doesn’t mean we’re not going to try.”

The Democratic and Republican leaders of three House committees and one Senate committee said this weekend they agreed on an approach to resolving surprise medical bills, opening the door to include it in the government funding package Congress is trying to finalize this week.

“Under this agreement, the days of patients receiving devastating surprise out-of-network medical bills will be over,” House Ways and Means Chairman Richard Neal (D-Mass.), House Energy and Commerce Chairman Frank Pallone (D-N.J.) and others said in a joint statement.

Ensuring Americans don’t have to pay for out-of-network medical bills incurred through no fault of their own was expected to be a top priority for 2020. These bills, which have captured public attention in recent years, can come when a patient receives emergency care at a hospital that is outside their insurance plan’s network, or when they get care from an out-of-network provider at an in-network hospital.

Yet the pandemic overtook most priorities on Capitol Hill, reshaping the legislative to-do list. Ending surprise billing and lowering drug prices took a back seat as lawmakers worked on relief packages and ran for reelection until this weekend.

The agreement bridges a gap between two contrasting approaches — but leans heavily toward what doctors wanted.

“By and large, this is vastly better than it was a year ago,” a consultant to provider groups told me. “This is about as good as we could expect.”

Under the measure, an independent arbiter would settle disagreements between providers and insurers over how much to pay for surprise medical bills. Insurers and patient groups, who argue this would favor doctors, had instead wanted payments tied to median in-network rates, in what’s known as a “benchmarking” approach.

Yet doctors, along with some conservative organizations, know pegging payments to in-network rates (much lower than out-of-network rates) would probably translate to a major pay cut for them. So they characterized the benchmarking approach as “price fixing,” as dark-money groups that own physician staffing companies poured millions of dollars into ads to oppose the benchmarking approach.

The measure does include some concessions to insurers.

The bipartisan agreement includes some checks on the arbitration process.

After a surprise bill is resolved through arbitration, the party that brought the dispute can’t do it all over again for the same item or service for a 90-day period. And during a resolution process, the arbiter must take the median in-network rate into consideration when choosing between the offers of the insurers and the providers.

Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy:

But to insurers, those elements are far overshadowed by the fact that the measures uses the arbitration approach, which they fear will retain the power of doctors and hospitals to charge exorbitant prices for checkups, procedures and medications.

“Providers can go to dispute resolution without any sort of threshold for the amount,” Eyles said. “We think that is going to create some incentive for inappropriate practices.”

The measure also leaves open the door — albeit just a crack — for out-of-network doctors or hospitals to bill patients for whatever insurers refuse to cover, a practice known as “balance billing.” To do so, the provider would have to notify patients of their out-of-network status and provide them with an estimate of charges 72 hours before receiving out-of-network services.

Yet insurers are wrapping up a year of sizable profits.

The pandemic meant reduced payments for many doctors and hospitals, forced to cut down on elective care as more patients stayed home. But insurers continued collecting monthly premiums, even as patients used services less. The top insurers reported huge profits in the first half of 2020.

Insurers are required under the Affordable Care Act to return some of those dollars to consumers. But the background environment may have made it easier for doctors to argue this year is no time to be cutting into their revenue.

“There’s no worse time to be cutting doctors’ payments,” the consultant told me. “This didn’t square with the current politics and the state of the pandemic.”

The agreement isn’t a done deal — but there’s not much wiggle room.

Congress has a Dec. 18 deadline to agree on a plan to fund federal agencies. But severe gridlock over both the spending bill and another coronavirus relief package is threatening to keep lawmakers in Washington for much longer.

“Many lawmakers now expect Congress to not just blow past their new deadline of Dec. 18 but also past the once sacrosanct Christmas holiday, which would set up the first substantive legislative sessions in the days leading up to New Year’s Eve since 2012,” Paul Kane and Mike DeBonis report.

If the surprise billing agreement threatened a potential deal, it could easily be tossed by the wayside. House Speaker Nancy Pelosi has said she wants the agreement in a spending bill, but Senate Majority Leader Mitch McConnell hasn’t said anything about it – and his office didn’t respond to a query yesterday.

Vaccine latest

The first coronavirus vaccinations could start today.

The Food and Drug Administration on Friday approved Pfizer and BioNTech’s vaccine for emergency use in people 16 and older. Health-care workers and residents of long-term care facilities will be first in line to get the vaccine.

A small crowd of people on Sunday cheered as trucks carrying the first shipments of the vaccine rolled out of a manufacturing plant in Michigan on Sunday. The shipments, carrying nearly 3 million vaccine doses, are expected to arrive today at 145 sites, mostly large hospital systems, with another 491 sites receiving doses tomorrow and Wednesday.

Howard Mortman, communications director for C-SPAN:

Trump overturned a plan for White House staffers to be among the first wave of people to receive a vaccine.

Meanwhile, Operation Warp Speed announced that it planned to purchase an additional 100 million doses of Moderna’s vaccine candidate, which, like Pfizer’s vaccine, requires two doses per person. The purchase comes on in addition to 800 million doses the government has purchased from six vaccine makers, including Pfizer and Moderna. So far, Pfizer’s vaccine is the only one that has received authorization, although the Moderna vaccine is expected to receive the go ahead from the FDA shortly after an advisory panel meets to discuss it this week.

Still, it could be months before enough people are vaccinated to slow the spread of the virus. Moncef Slaoui, the head of Operation Warp Speed, the federal government’s vaccine effort, said that officials hope to reach herd immunity between May and June.

While the Pfizer and Moderna vaccines have exceeded expectations in terms of their efficacy, others have met with delays. Sanofi and its partner GlaxoSmithKline announced on Friday that a plan to start Phase 3 of its vaccine trial this month would be put on hold after results in earlier trials suggested inadequate response in older adults. Meanwhile, Australia stopped its vaccine trial after trial subjects returned false positives for HIV. The effect was the harmless result of a protein from HIV, which was used to stabilize the vaccine, but public health experts worried it would undermine trust in vaccines.

Ahh, oof and ouch

AHH: Even as the vaccines provide reason for hope, the nation is approaching nearly 300,000 recorded deaths from the virus.

“It took 2½ months for the virus to claim its first 50,000 Americans, then just one month for the death toll to climb to 100,000,” Marc Fisher, Scott Wilson and Arelis R. Hernández report. “Between late September and mid-November, the death tally climbed from 200,000 to 250,000. Now it has nearly reached the 300,000 marker in less than half that time — even though treatment of the most severe cases has improved.”

The reports of overwhelmed hospitals and thousands of deaths each day echo the early weeks of the pandemic when ambulance sirens could be heard at all hours in New York City and hospitals turned to refrigerator trucks to hold bodies. The difference is that now the virus has spread across the country, with almost nowhere spared.

“At the center of that storm, there is a gutting yet unfathomable fact: Nearly 1 of every 1,000 Americans already has died of covid-19 — the equivalent of losing the entire population of cities such as Orlando, Pittsburgh or St. Louis,” Marc, Scott and Arelis write. “There have been more than twice as many American deaths as those killed in World War I. Five times as many as in the Vietnam War. One hundred times as many as in the 9/11 terrorist attacks.”

It’s not only coronavirus that is exacting a devastating toll this year. Roughly 356,000 more people have died than usual during the coronavirus, with more than a quarter of these deaths attributed to other causes, including diabetes, Alzheimer’s disease, high blood pressure and pneumonia, the New York Times’s Denise Lu reports.

Some of the deaths attributed to these other causes may have, in fact, been due to undiagnosed covid-19. For instance, New York City, an early epicenter of the virus, has seen deaths attributed to pneumonia that are 50 percent higher than normal. This is probably because early covid-19 deaths were not recognized as such.

Other deaths are likely to be the result of disruptions caused by the virus, including strains on the health-care system and people avoiding hospitals out of fear that they could be exposed. Deaths from Alzheimer’s are 12 percent higher than normal this year, which could be a symptom of strain in the nation’s nursing home system and isolation among residents of long-term care.

OUCH: More Americans are shoplifting food and hygiene products as coronavirus aid runs out.

“The coronavirus recession has been a relentless churn of high unemployment and economic uncertainty. The government stimulus that kept millions of Americans from falling into poverty earlier in the pandemic is long gone, and new aid is still a dot on the horizon after months of congressional inaction. Hunger is chronic, at levels not seen in decades,” Abha Bhattarai and Hannah Denham report.

Retailers, police departments and security experts are reporting an uptick in shoplifting of staples, like bread, pasta and baby formula.

“We’re seeing an increase in low-impact crimes,” Jeff Zisner, chief executive of workplace security firm Aegis, told The Post. “It’s not a whole lot of people going in, grabbing TVs and running out the front door. It’s a very different kind of crime — it’s people stealing consumables and items associated with children and babies.”

Roughly 12 million Americans are set to run out of benefits the day after Christmas if Congress does not pass new coronavirus relief measures. Programs to provide support to local food banks are also set to expire at the end of the year, despite the fact that the country has seen a 45 percent increase since 2019 in Americans struggling with hunger.

Elsewhere in healthcare

Hospital associations are suing over 340B enforcement.

Five national organizations representing hospitals, as well as an organization representing hospital pharmacists, filed a lawsuit against the Department of Health and Human Services alleging that the agency has failed to enforce laws related to the 340B program, which requires drug companies to offer discounts on outpatient drugs to hospitals and other providers that serve poor or underserved patients.

Pharmaceutical companies have long criticized the program, arguing that many of the hospitals that qualify provide little charity care. Instead of passing on drug savings to poor patients, hospitals are plowing the savings back into their profits, they say. Several drug companies, including Novartis and AstraZeneca, have made moves to restrict 340B payments by limiting payments to contract pharmacies.

It’s just one of a series of setbacks to the program: In late July, an appeals court upheld a Trump administration rule that cut the discount program by nearly 30 percent.

But now hospitals, hit hard by the virus already, are pushing back with the lawsuit, which aims to compel HHS to require drug companies provide the discounts.

“The 340B program plays a critical role in helping eligible hospitals provide a wide range of comprehensive services and low-cost drugs to vulnerable patients and communities, many of which have been the hardest hit by the COVID-19 pandemic,” Rick Pollack, the president of the American Hospital Association, said in a statement.

Advocates urge for an extension in open enrollment for health insurance.

Open enrollment for health insurance is scheduled to close in 80 percent of marketplaces across the nation on Tuesday, but some groups are pushing for an extension amid the coronavirus pandemic, which they say has disrupted enrollment efforts even as millions of Americans find themselves without insurance due to job losses.

Covered California, a service aimed at connecting residents of California with health insurance under the Affordable Care Act, announced plans to extend its open enrollment period through Dec. 30 and sent a letter to federal health officials urging them to do the same.

“Keeping the doors open as long as possible during the worst health care crisis in more than a century is neither new or extraordinary, rather it is the right policy for Americans during this critical time,” Peter V. Lee, the director of Covered California, wrote in a letter to CMS Administrator Seema Verma.

By |2020-12-14T08:18:35-05:00December 14th, 2020|insurance, insurance executives, Legislation, News|