One of the more awful current problems with US America's fucked up mishmash of healthcare systems -- beyond the fact that it leaves nearly 28 million Americans without any health coverage at all -- is the phenomenon of "surprise medical billing," which can occur when someone with insurance uses services they think would be covered, but then later gets a big whopping bill for a doctor or lab that assisted -- and was out of network for their insurance. It's an especially serious problem when people go to the emergency room, but it can also happen when someone has surgery: They might make sure the hospital and surgeon are in-network, but then they get a huge bill because the anesthesiologist or some other staff is out of network, and there's nothing they can do to ensure an in-network anesthesiologist in the first place.

The House and Senate, in one of those rare moments where members work together to address a serious issue, managed to actually come up with a bipartisan bill to end surprise billing. The compromise was approved by the House Energy and Commerce Committee and the Senate Health Committee, and it looked likely to be included in the big must-pass spending package needed to keep the government running. It left both hospitals and insurers grumpy, which is what compromises do. Even the White House had endorsed the proposal.

But then House Ways and Means Committee Chair Richard Neal, a Democrat of Massachusetts, threw everything into confusion by putting forward an alternate bill that would preserve doctors' ability to soak patients for those unexpected out-of network services. And wouldn't you know it, Neal has received hefty campaign donations from a private equity group that would prefer not to see hospitals make smaller profits.

God damn it, Richie. This is what the angry kids are talking about when they call Democrats "corporatists" or worse. In this case, they couldn't be more right.


As New York Times healthcare columnist Margot Sanger-Katz points out, this little episode is a cautionary tale for anyone who thinks passing a major healthcare reform will be easy, whether you're talking Medicare for All or even a good strong public option. Damn near all the stars were aligned for the joint House-Senate proposal, but then a top committee chair tossed in a bomb, apparently to keep some powerful interests happy. As Sanger-Katz notes,

The kinds of big plans that Democratic presidential candidates are pitching combine consumer protections — lower premiums, lower deductibles, more benefits — with lower pay to medical professionals. The surprise billing legislative package has this mix, too. It would protect patients from receiving surprise bills from doctors, but it would most likely result in pay cuts for certain doctors.

Doctors and investment groups would rather not have pay cuts, and they have a lobby:

When the legislative process heated up this summer, so did a fierce lobbying effort from doctors and hospitals. Doctor Patient Unity, a dark money group funded by two large private- equity-funded physician staffing companies, spent tens of millions on television advertisements and direct mail, urging lawmakers to oppose the bill. Lobbyists for doctors, hospitals, air ambulance companies and private equity funds also began making the rounds. Doctors have argued for a different solution to the surprise billing problem that would not cut their pay.

Mind you, it's not even a majority of doctors who worry about losing money here. But it's a business model for some outfits, which make a killing on out-of-network billing. And as Sanger-Katz notes, surprise bills tend to be "clustered in a handful of specialties where patients cannot choose their own doctor, including emergency medicine and anesthesiology."

Moreover, research published this week found that just four specialties -- anesthesiologists, pathologists, radiologists, and assistant surgeons -- generated the highest amount of out-of-network charges at in-network hospitals, and that the "ability to bill out of network allows these specialists to negotiate artificially high in-network rates" -- resulting in higher costs even for covered services. And just how much is that adding to hospital bills? In technical terms, an assload.

Our estimates show that if these specialists were not able to bill out of network, it would lower physician payments for privately insured patients by 13.4 percent and reduce health care spending for people with employer-sponsored insurance by 3.4 percent (approximately $40 billion annually).

The bipartisan bill that had been on track to approval would have banned hospitals and doctors from billing patients for the full balance of an out-of-network service, and would limit the charges to a local benchmark for similar services, which the Congressional Budget Office estimated would reduce payments to specialists by 15 to 20 percent. It would also send bills totaling over $750 to arbitration, which some insurers weren't crazy about since arbitration could increase their costs. But it would have reduced overall costs and limited surprise billing, so the compromise looked likely to be included in the year-end budget package.

The Ways and Means proposal put forward by Neal and ranking member Kevin Brady (R-Texas), while still not fully fleshed out, would instead make greater use of arbitration, which would tend to be far more friendly to doctors and hospitals. Plus, it put the kibosh on any hopes of including the bipartisan proposal in the upcoming spending package, which seems to be the point. Now any action on surprise medical billing will be pushed into 2020, and the very satisfactory status quo for companies that rely on those big out-of-network payments can continue.

That would include companies like the private equity firm Blackstone Group, which

owns the physician staffing organization TeamHealth [and] donated $29,000 to Neal's 2020 reelection campaign this year, according to the Center for Responsive Politics.

And it's not just Neal who seems content to slow-walk action on surprise medical bills either, as the Times notes:

In a final meeting last week, leaders in the House and the Senate met to decide what legislation would end up in the year-end spending bill. Surprise medical billing didn't make the cut. Several people close to the negotiations said it did not have strong enough support from the Democratic leadership.

The repeal of taxes that hit the medical device and health insurance industries, on the other hand, were included.

If a relatively small chunk of medical reform like clamping down on surprise billing can be stalled by industry lobbyists, that doesn't inspire a hell of a lot of confidence for far bigger changes that would upset far more powerful interests like the insurance industry and the medical-industrial complex. Which is all the more reason to push for getting corporate money out of politics through aggressive lobbying reform and undoing Citizens United and ... as a great man once said, nobody knew health care could be so complicated. Which isn't any excuse to not take it on, because people are being bled dry. One big part of the task will be telling our own leaders to knock it off with the favors to industry groups, yeesh.

It's a bad look, or what the kids call "some fucking bullshit." It's not okay.

[NYT / Fierce Healthcare / NPR / Common Dreams / The Hill / NYT]

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Doktor Zoom

Doktor Zoom's real name is Marty Kelley, and he lives in the wilds of Boise, Idaho. He is not a medical doctor, but does have a real PhD in Rhetoric. You should definitely donate some money to this little mommyblog where he has finally found acceptance and cat pictures. He is on maternity leave until 2033. Here is his Twitter, also. His quest to avoid prolixity is not going so great.

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