Tagged Emergency Medicine

Texas Is Latest State To Attack Surprise Medical Bills

Texas is now among more than a dozen states that have cracked down on the practice of surprise medical billing.

Texas Gov. Greg Abbott, a Republican, signed legislation Friday shielding patients from getting a huge bill when their insurance company and medical provider can’t agree on payment.

The bipartisan legislation removes patients from the middle of price disputes between a health insurance company and a hospital or other medical provider.

“We wanted to try to take the patients — get them out of the middle of it, because really it’s not their fight,” said Republican state Sen. Kelly Hancock, the bill’s author.

Under the new law, insurance companies and medical providers can enter into arbitration to negotiate a payment — and state officials would oversee that process.

Surprise medical billing typically happens when someone with health insurance goes to a hospital during an emergency and that hospital is out-of-network. It also occurs if a patient goes to an in-network hospital and their doctors or medical providers are not in-network. Sometimes insurance companies and medical providers won’t agree on what’s a fair price for that care and patients end up with a hefty medical bill.

Consumer advocates in the state have urged lawmakers to do more to help Texans saddled with surprise medical bills.

Drew Calver is among the many Texans who have dealt with a surprise bill in the past few years. Calver, a high school history teacher in Austin, had a heart attack in 2017. He was rushed to the closest hospital by a friend that day, and doctors implanted stents to save his life.

Even though he had health insurance that paid the hospital more than $55,000 for his care, Calver ended up with a $109,000 bill. Calver and his wife, Erin, fought with the hospital and the insurance company for months with little success.

The Calvers eventually turned to the press. Last summer, he told his story to the “Bill of the Month” investigation from NPR and Kaiser Health News. “CBS This Morning” also covered the story. Shortly afterward, his bill was slashed to just $332. Erin Calver said she has seen her family’s story strike a chord.

“For whatever reason, people could relate to us — and be scared that maybe it could happen to them,” she said.

Drew Calver said he encounters many people who worry about the issue.

“The doctor that put my stents in — he either just had a baby or is about to have a baby — and he was saying that, ‘Yeah that could happen to me, too!’” Calver said.

In fact, getting a steep hospital bill is something many Americans call their biggest financial fear.

“Polling shows us that the top household pocketbook concern for consumers is a surprise medical bill,” said Stacey Pogue with the Center for Public Policy Priorities, a think tank that analyzes health and economic issues in Texas. “And that’s actually pretty shocking that consumers will say they are more worried about their ability to afford a surprise medical bill than their health insurance premiums [and] their really high deductibles.”

Last year, a Kaiser Family Foundation poll found that 67% of people worry about unexpected medical bills — a larger share than those who say they worry about prescription drug costs or basic necessities such as rent, food and gas. (KHN is an editorially independent program of the foundation.)

Pogue said that’s a big reason why lawmakers in the state took the issue seriously and passed legislation that she said is now one of the strongest state protections she has seen.

“It is as strong or stronger than any of the protections in the country,” Pogue said.

In addition to Texas, neighboring states Colorado and New Mexico also passed legislation in 2019 to address the problem of surprise out-of-network bills. The Commonwealth Fund’s most recent report on the issue found about half of states offer some legal protections from surprise bills, but only six states had laws that provide “comprehensive” consumer protections similar to those just passed in Texas.

Texas’ new surprise bill law officially takes effect Sept. 1, 2020.

Hancock said the fight over who pays disputed bills will be back where it belongs: with insurance companies, leaving the hospitals, doctors and labs to focus on providing medical care.

“It was just time to get the patient out” of the middle of disputed bills, Hancock said.

Instead, when a hospital and insurer can’t agree on a price, the two parties will have to work it out — without ever billing the patient.

“There is still the ability to negotiate,” Hancock said. “You didn’t have government determining what the price was or determining what the settlement was.”

But not all Texans will be protected by the new law. The Texas law does not apply to people who work for large employers whose plans are regulated by the federal government. In Texas, federally regulated plans account for roughly 40% of the state’s health insurance market.

In fact, Drew Calver would have been exempt from the state’s protections because until recently he had a self-funded health plan regulated by the federal government. However, Drew is now part of wife Erin’s health plan, which will be subject to these new protections.

Pogue said people who have federally regulated health plans will be protected only if Congress acts. She predicted the state’s action will spur federal lawmakers.

“Texas passing a bill will really help on that front,” she said. “There were five states, I think, in 2019 that passed bills that fully protected consumers — and every nudge like that is going to help Congress move.”

Texas lawmakers passed separate legislation that could help Texans with federally regulated plans. Senate Bill 1037 prevents a surprise medical bill from affecting someone’s credit, regardless of what health insurance plan they have.

Congressional leaders have said they are working on coming up with a fix for people across the country with federally regulated plans. President Donald Trump also recently held an event at the White House, with Drew and Erin Calver standing by his side, announcing his administration’s support for banning surprise medical billing in the country.

During a U.S. House Ways and Means Health subcommittee meeting in May, members discussed ways to ban the practice of surprise medical billing.

The committee’s chairman, Austin Democrat Lloyd Doggett, said that “federal action is essential” to addressing the issue for many Americans with federally regulated plans. He said he plans to continue to push for legislation that will “finally offer some relief to patients.” However, no legislation has been passed, yet.

During his opening statements, Doggett said there is a bipartisan desire to shield patients from surprise bills, but “conflict remains over how to resolve insurer-provider disputes.”

This story is part of a partnership that includes KUT, NPR and Kaiser Health News.

Readers And Tweeters: No Rush To Judge Patients Who Leave The ER Without OK

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.


At The ER, It’s Hurry Up And Wait

At least the patients mentioned in “As ER Wait Times Grow, More Patients Leave Against Medical Advice” (May 17) were allowed to leave. An emergency room may not be a safe place for people and they may wish to go. It is not always the patient who is being irresponsible; it is sometimes those who work in the hospital.

My significant other and I ended up in a situation at the University of New Mexico Hospital. We were there for an appointment with a doctor associated with the hospital, but while she was getting checked in, she fainted. She was out for a short time. They sent over a paramedic to take her to the ER. She did not wish to go to the ER but was not immediately able to get up and leave, even by wheelchair.

The paramedic and his assistant took elaborate measures to separate me from my significant other, for whom I am a caregiver, and they interrogated her. It seemed they wanted her to admit to drug usage. She was very frightened. Eventually, I was allowed to enter the ER, and when the paramedic saw me, he scattered like a roach.

Five hours is a long time to wait. That makes no sense. If people have to wait for five hours it means you really do not have enough staff to handle them all. In most cases, an ER is useless, anyway. They work for people who suffer a car accident, gunshot wound, broken leg or heart attack. For other things, they generally are not much help and often do not even have essential services manned, like ultrasound, MRI, etc. So, in most cases, it is basically a waste of time.

Look inward to figure out why people bolt.

— Sigmund Silber, Santa Fe, N.M.


— Dr. Ali Khan, Omaha, Neb.


There is a lot of discussion over the cost of health care, but people don’t realize how inefficient our system is. I have an 18-year-old son who was born with spina bifida and has had many other health issues. In mid-May, he had a pain in the left side of his back. Not common, and he does not complain about pain. The nurse at his school was concerned; my son looked pale, he came to her wanting to lie down — not typical. So I called his urologist’s office asking how to recognize kidney stones, which he has never experienced. The front desk personnel told me to take him to the ER.

We traveled almost an hour to Children’s Healthcare of Atlanta at Scottish Rite, where he has specialty docs. After running many tests, they told us he had a stomach virus, and we were sent home. On May 30, my son got his annual renal bladder ultrasound done in preparation for a mid-June spina bifida clinic appointment. Turns out, he had a kidney stone! It showed up on the ultrasound.

I am extremely frustrated since it is not the first time I have been told to take my son to ER only to be told “nothing is wrong” or “we can’t help him” even though there later proved to be a problem. What a BIG waste of time and money on our health care system. But you can’t get in to see doctors when you have a problem, so you almost always have to go to the ER. In my opinion, that is a waste of ER services, which I do not hear talked about in the news.

— Rebecca Joiner, Fayetteville, Ga.


— Michael Bertaut, Baton Rouge, La.


Give Midwives And Birth Centers A Chance

In your “Bill of the Month” piece about laughing gas, “Not Funny: Midwife Slapped With $4,836 Bill For Laughing Gas During Her Labor” (May 29), I wish your recommendations would have included seeking out birth centers as an alternative to hospital births. Given the embarrassing state of maternity care in the United States, it’s time to focus on the advantages of midwives and birth centers. They have proven statistically better outcomes at half the cost. As a former consultant to the American Association of Birth Centers, I was impressed when I learned that the AABC built a registry of data to track, measure and improve quality over 13 years ago. They recognized the need for a separate credentialing association, the Commission for Accreditation of Birth Centers, or CABC, and supported the development of its standards. Women need an alternative to our current standard options for low-risk maternity care.

— Linda Davis, Minneapolis


Editor’s note: This is a teachable moment. The following tweeter might have confused Kaiser Health News for Kaiser Permanente. KHN, the health care policy news source you’re currently reading, is not affiliated with the managed-care consortium, although both were named for innovative American industrialist Henry J. Kaiser. Any confusion shouldn’t diminish the strength of her argument, however.

— Allie Keeley, Richmond, Va.


— Dr. Tom Pink, Geneva, Switzerland


In fact, there are positive developments in prenatal care. Several readers weighed in on our article about what to expect when you go through pregnancy with a group of other expectant parents.

— Lauren Lee White, Los Angeles


At The Center Of Group Maternity Care

It was great to see your story on the centering model of maternity care (“The Unexpected Perk Of My Group Pregnancy Care: New Friends,” May 30), but how about some credit to Sharon Rising, the nurse who founded, tested and promotes this health-expanding approach? Nurses are rarely credited. She is an astonishing clinician-scientist who deserves being named in such stories. Thank you.

— Debbie Ward, Sacramento, Calif.


A tweeter in Portugal called her role in a group prenatal program a career highlight:

— Justine Strand de Oliveira, Algarve, Portugal


Missing Tool In The Toolbox For Treating PTSD

I was grateful to see the recent story by Caroline Covington about treatment for PTSD (“For Civilians, Finding A Therapist Skilled In PTSD Treatments Is A Tough Task,” May 22). Unfortunately, she missed a huge piece of the puzzle. A therapy called Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based treatment for post-traumatic stress disorder, having been validated by more than 36 randomized controlled studies. Endorsed by the American Psychological Association, the Substance Abuse and Mental Health Services Administration, and the Departments of Defense and Veterans Affairs, it is used throughout the world to heal PTSD efficiently. It was developed in 1987 by Francine Shapiro. Please check out EMDRIA.org for research documentation. As a licensed psychotherapist and certified EMDR therapist, I have witnessed the dramatic healing effect of EMDR with my clients suffering from PTSD for many years. I appeal to Ms. Covington to look into this area and complete the story.

—Stephen Weathersbee, a licensed marriage and family therapist, Tyler, Texas


— Harry Stark, Woodland Hills, Calif.


As a short-term veteran (1988-90) diagnosed in 2016 with complex post-traumatic stress disorder, I wanted to add a couple of thoughts. As much as my story was influenced by having been in the military, I constantly found myself comparing my experiences with other veterans. I was always giving deference to the fact that my story wasn’t theirs, and that theirs was usually far more of a “good excuse” to have the condition. In treatment, that logic extended to my individual circumstances. I was constantly comparing my experiences, minimizing at every turn.

I’ve been through both Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), about two years apart; the PE was used more recently and, in my opinion, was more effective. I wanted to mention another therapy your missed, though: Eye Movement Desensitization and Reprocessing (EMDR). I am on a waiting list with Virginia’s Salem VA Medical Center to try this cutting-edge, light-based therapeutic tool. I even wrote to Samsung and Oculus corporations to suggest they work on making EMDR programs for their VR headsets, in conjunction with VA clinicians.

As you suggested in the article, the industry is catching up to both new methodologies as well as a new client base for PTSD that includes the civilian community. The influx of money and research capacity that comes with this new client base could be well used in advancing this method, and/or combining it for use with current methods.

I know your article concentrated on PTSD experienced by civilians and overcoming the stigma that this disease is somehow reserved for veterans. People need to understand that because we’re all different in our brains that this condition is never the same exact thing … even in two veterans who served side by side. Sure, someone always has it worse than you, but that doesn’t mean your symptoms don’t deserve help.

— Neil Marsh, Moneta, Va.


Spreading The Word (Correctly) About Measles

The United States did not declare measles “eradicated” (“How Measles Detectives Work To Contain An Outbreak,” June 10). It declared the disease “eliminated.” Big difference. In medical terms, “eradicated” means gone forever, as in smallpox. “Eliminated” means no sustained transmission over the period of a year.

— Linda Hultman, Louisville, Colo.

Editor’s note: Another teachable moment. We stand corrected. Thank you!


Dignity At The End Of Life

Something useful to add to Jenny Gold’s article “Will Ties To A Catholic Hospital System Tie Doctors’ Hands?” (April 29): I believe Catholic hospitals ignore patients’ end-of-life wishes. No advance medical directives. So, if I want a do-not-resuscitate (DNR) order, they can override that and insist I live my final days in agony or zoned out.

I always learn something in your newsletters. Keep up your good work!

— Gail Jackson, Waikoloa, Hawaii


Readers everywhere rejoiced over good news, for a change.

— Oral Hazell, St. Thomas, U.S. Virgin Islands


Good Work Restoring Faith In Humanity

The article “Churches Wipe Out Millions In Medical Debt For Others” (June 3) was one of the most uplifting and inspirational stories I have read in such a long time. Kudos to the author and your publication. This is a creative solution that not only stretches donation dollars but sets an example that other religious organizations could easily follow. Thank you.

Philip Heigl, New Cumberland, Pa.


— Chase McGee, Durham, N.C.


— Don Purser, Marietta, Ga.


Helping Those With Developmental Disabilities Navigate Health Care

I have a 17-year-old son with cerebral palsy, so the article “For Those With Developmental Disabilities, Dental Needs Are Great, Good Care Elusive” (May 3) hits home. I would like to see more stories that shed light on the challenges of navigating the health care system for individuals with developmental disabilities. Along with a small share of the U.S. population, my son receives long-term services and supports (LTSS) through Arizona’s Medicaid program. According to a report from Truven Health Analytics, “The Growth of Managed Care Long-Term Services and Supports Program: 2017 Update,” approximately 1.78 million individuals are enrolled in the MLTSS program. Our health care system should do a better job easing the burden in navigating the system for this vulnerable population. I hope that by bringing more attention to these issues will result in policy changes.

— Son Yong Pak, Tempe, Ariz.


In response to the article by David Tuller on dental care for the disabled: I wanted him to know that Special Olympics Virginia provides free dental care (including treatment and procedures) for hundreds of special needs athletes at their Summer Games. Dozens of dentists donate their time for this free clinic. Special Olympics Virginia is able to do this with the support from the Virginia Dental Foundation, Virginia Commonwealth University and Missions of Mercy (MOM Project).

— Donnie Knowlson, Special Olympics Virginia board member, Chesterfield, Va.


The Other Side Of The Opioid Story

Your article “Opioid Prescriptions Drop Sharply Among State Workers” (May 20) draws from biased and highly inaccurate opinion. Here’s a contradicting view.

Massive reductions in opioid prescribing are not a measure of success but instead signal failures of pain medicine under a draconian and unjustified program of persecution of doctors by Drug Enforcement Administration and state regulatory agencies. Tens of thousands of patients have been deserted by physicians afraid of losing their licenses if they treat pain with the only therapies that work for the majority of those with severe pain.

In the article, Beth McGinty is quoted as follows: “These reductions … signal a reduction in the overprescribing practices that have driven the opioid epidemic in the U.S.” This assertion is false. Overprescribing has never substantially “driven” the opioid crisis in the U.S. Statistics on opioid deaths are grossly inflated, representing deaths where a prescription-type opioid is among several factors detected in postmortem “tox screens.” No less a figure than Dr. Nora Volkow, director of the National Institute on Drug Abuse, informs us that addiction is not a predictable outcome of prescribing, and is rare even in at-risk patients.

The article states “One major factor is that many health insurers have imposed limits on prescriptions, as recommended by the CDC in 2016.” The Centers for Disease Control and Prevention recently issued a clarification that the guideline was never intended to justify mandatory tapering of legacy patients. The American Medical Association also repudiated the fundamental logic of the guidelines in Resolution 235 of the November 2018 House of Delegates meeting. Practicing physicians do not consider the equivalent of 50 morphine milligrams (MME) a high dose. Minimum effective dosages can range from ~20 MME to over 1000 MME, depending on metabolism.

Kathy Donneson, chief of CalPERS’ Health Plan Administration Division, says the surest sign of success will be when patients with chronic pain are “kept pain-free in other ways.” However, the literature for such therapies is abysmal, offering weak evidence and no direct comparisons of “alternatives” to properly titrated opioids.

CalPERS is on a course of action that is deeply damaging to patients. The agenda is cost control, not patient care. The other side of the story involves deserted patients who are committing suicide every day.

— Richard Lawhern, Fort Mill, S.C.


— Ben Miller, Denver


Not News To Me

As someone who has worked as a health actuary and executive for major insurers, I am surprised that Rand Corp. or anyone else thought a study needed to be done on what private insurers pay compared with Medicare (“Market Muscle: Study Uncovers Differences Between Medicare And Private Insurers,” May 9). This is OLD, OLD news. Hospitals and other health providers have been demanding more from private payers for the past 30 years! No study needed to be done. Just ask any actuary or health executive who works on contracting with providers. Despite the protestations of health economists who don’t work for insurers, providers demand more from private payers to make up for insufficient payments from Medicare and Medicaid. I can’t believe that this is a surprise to KHN or anyone who is knowledgeable about how medical insurance works in this country.

— Roy Goldman, Jacksonville Beach, Fla.