The Grim Lottery of Surprise Medical Bill Stories – The New Republic

An individual might get lucky and have their GoFundMe show up in a news story. They might get a call from NPR about their medical bill. For those people and their families, it makes all the difference in the world. Journalists can take pride in such reversals; it would seem that they have a high success rate in balancing the scales for people caught in these traps. But journalists are hopelessly outnumbered. You can assign a whole newsroom to this task and barely make a dent. And so, in the system at large, nothing seems to change.

Why do the stories like Hassanzais or Calvers keep happening? Largely, because of hospital pricing practices and the adjacent problem of insurance networks. Insurance networks ostensibly exist to lower prices (which explains why America spends twice what some other OECD countries spend per capita on health care). Insurers bargain on rates with providers, who then get access to that insurers patients, which is supposed to lower premiums and costs overall. If the provider is in-network, insurance will pay for more or all of the cost. If the provider is out-of-network, the insurance company might pay a bit, depending on how generous your plan is, but the patient is likely to be stuck with the balance. This is supposed to encourage patients to be sensible, shop around for care, and carefully ensure they go to only in-network providers. But this is impractical, if not impossible, for patients in dire need of emergency care.

Large medical bills like those in the NPR series often occur when a patient doesnt realize that the doctor who treated themwho might have showed up while they were unconscious, or bleeding, or in agony, when financial matters are naturally far from the front of your mindwas out-of-network; these are called surprise bills. Sometimes, people are taken in an ambulance, unconscious, to an out-of-network facility. Frequently, the ambulance itselfis out-of-network. If its an air ambulance, as in Hassanzais case, the cost can be enormous. The reason this is a common occurrence is because the out-of-network prices are purposefully inflated to aid hospitals in their negotiations with insurers. But this isnt taken into account when it comes time to bill the patient. (Unless the patient manages to get an NPR reporter on the line.) When the bill arrives, the hospital is telling you with a straight face that it absolutely costs $15,076 for four 14 millimeter screws, and theyve got all the power of the state to go after you and make you pay up.

Surprise billing has attracted a lot of federal and state-level attention, in no small part thanks to the work of journalists like those at Kaiser Health News, NPR, and Sarah Kliff, who conducted a large-scale project on emergency room bills at Vox. Pretty much everyone supports ending surprise billingexcept for those who currently profit from it, most notably the private equity companies who own physician management organizations that have taken over some emergency departments.

Research led by Zack Cooper at Yale found that when EmCare, one of the largest private equity-backed physician staffing firms, enters a hospital, they raise out-of-network rates by over 81 percentage points and increase average physician payments by 117%. Their average out-of-network billing rate was 62 percent, according to Coopers study. The research also found that these practices werent evenly distributed among hospitals: While half of hospitals billed out-of-network at a rate of less than five percent, 15 percent of hospitals billed out-of-network more than 80 percent of the time.

This practice is so lucrative for the private equity companies that own these firms that they have poured tens of millions of dollars into a shady and secretive campaign to derail the legislation Congress is considering to forge something more equitable. Last month, The New York Timesreported that TeamHealth and Envision Healthcare, two private equity-backed physician staffing companies, were behind a mysterious group called Doctor Patient Unity, which has spent more than $28 million on TV ads. This shadowy organization, along with a constellation of similar but less deep-pocketed groups, seek to defeat legislation that would set benchmarks for out-of-network prices, based on what in-network doctors are paid locally. Doctors groups prefer an approach that uses arbitration, where an independent arbitrator chooses the price. These groups successfully lobbied to get a provision added to the House surprise billing legislation that would use an arbitration backstop if the benchmark price isnt to their likingwhich it never would be.

The bigger problem with this legislation, as necessary and well-intentioned as it is, is that it is trying to bring sense and justice to a system that is fundamentally nonsensical and unjust. You cant really end surprise billing without getting rid of insurance networks, or the practice of billing patients for their care at all. You cant really banish the horrible scenario of medical debt without a single-payer system, because someone does eventually have to pay the hospital, whether its an insurance company or the patient. A system like oursin which hospitals set their prices based on what they can get away with rather than what medical care actually costs; in which insurance will pay up on these inflated costs because they can pass the pain onto consumers via premiums; in which doctors are paid off by private equity ghouls; in which the individual patient is financially liable for their bad luck to get sick if the hospital and insurance cant agree on a deal, or if they dont have insuranceis not one that can be easily brought to heel. And fixing the problem of surprise billing only scratches the surface of what needs to be done to ameliorate all of the injustices of the American health care system.

Surprise bills are just the most explicitly outrageous example of these inequities, because they arise so often through no fault of the patient, and the costs that are incurred are comedically high. For all the ardor that Republicans have poured in to making the health care system more unjust, youll never see them contending that the ridiculous charges documented by the likes of NPR are Actually Good. As the providers occasionally caught in the spotlight have learned, greeting the rarely exposed outrage with quiet acquiescence ensures that a more formidable check never gets applied to this unjust arrangement.

Thats remarkable, given what we know of other political conflicts. When the Obama administration mounted an effort to protect the DREAMerswho like the victims of surprise billing, couldnt be blamed for their circumstances, having been left out of their parents decision to bring them to the United Statesno amount of differentiating their innocence from that of other immigrants, such as the constantly railed-against gang bangers or those whose traffic violations made them worthy deportees, deterred opposition to their cause. Focusing on the most faultless, idealized individuals did not convince Republicans; Democrats only succeeded in further ostracizing immigrants who didnt fit the DREAMer mold.

In the case of surprise billing, legislation feels doomed to quietly die at the hand of massive, coordinated industry opposition and Senate Majority Leader Mitch McConnells steadfast commitment to obstruction. Even if it succeeds, it would only stem a tiny part of the bloodletting happening in American healthcare. It is no more just for a person who is completely uninsured to get saddled with tens or hundreds of thousands of dollars in medical debt than someone who got surprise billed after doing their due diligence. The medical bill itself is the problem.

People do not get into medical debt on purpose; people dont choose to be uninsured for fun, and even if they did, we should pay for their care anyway. We should pay for the care of murderers, Nazis, and people who listen to Coldplay, because health care is a human right, and it is not a choice. An unaffordable medical bill is a travesty whether its a surprise or not. Saddling a person with life-ruining debt is a cruel and inhumane system at work, even if they didnt look both ways before they got hit by that car.

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The Grim Lottery of Surprise Medical Bill Stories - The New Republic