Tagged Health Care Costs

Senate Panel Makes Surprisingly Fast Work Of ‘Surprise Medical Bills’ Package

It may seem as if the Senate, or at least certain key senators, have decided on a way forward to fix the nation’s “surprise medical bill” problem. But make no mistake: The door is still open to try another solution.

Members of the Health, Education, Labor and Pensions (HELP) Committee approved a sweeping measure Wednesday that tackles a range of big-ticket health care concerns. The 196-page bill touches nearly every aspect of the health care industry, from lowering the price of prescription drugs and creating a national database of health care costs, to increasing vaccine rates and preventing youth tobacco use.

One thing the bill specifically does not deal with: the insurance market and the Affordable Care Act, which could be why the massive package was voted out of the committee in just over two hours with little debate. The Lower Health Care Costs Act of 2019, sponsored by HELP Committee Chairman Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the top Democrat on the panel, sailed through with a bipartisan 20-3 vote.

“You don’t have to preach the whole Bible in one sermon,” said Alexander as he described his panel’s action. “We picked out one important thing: reducing health care costs.”

Still, just because the first hurdle has been cleared doesn’t mean there’s room for speculation about what could happen between now and when it reaches the Senate floor. Alexander said he’s hoping the bill will be voted on before the Senate leaves Aug. 2 for a monthlong recess.

The smooth hearing capped a busy few weeks, as senators debated the mechanism that would be used to stop surprise medical bills — the unexpected and often costly charges patients face when they get care from a doctor or hospital not in their insurance network.

An earlier draft of the bill outlined three options to solve disputes between payers and providers. There was an in-network guarantee, where all of the health care providers at a hospital — whether the anesthesiologist or lab — must accept in-network insurance rates.

Another option, often referred to as baseball-style arbitration, would have the health plan and the doctor — if they couldn’t reach an agreement on reimbursement — present to an independent arbitrator their best offers for how much a patient’s out-of-network care should cost. The arbitrator would choose between the two.

But another approach — benchmarking — ultimately made it into the formal draft. Here’s how it works: When patients are seen by doctors who aren’t in their network, the insurer would pay the providers the “median in-network rate,” meaning the rate would be similar to what the plan pays other doctors in the area for the same procedure.

At the markup hearing Wednesday, Alexander said he initially preferred one of the other approaches, the in-network guarantee, but changed his mind when the Congressional Budget Office said benchmarking would save more money.

A group of senators on the panel led by Sens. Bill Cassidy (R-La.), Maggie Hassan (D-N.H.) and Lisa Murkowski (R-Alaska) voted for the chairman’s choice, even though they had advocated for arbitration. Cassidy made clear he continues to have reservations.

“This is entirely for the insurance companies,” he said of benchmarking. “I’m surprised that my colleagues on the other side of the aisle running for president are OK with this.”

Neither of the two Democratic senators on the committee running for president, Sens. Elizabeth Warren (Mass.) and Bernie Sanders (Vermont), were present but both voted no by proxy.

But it is also not an entirely settled issue.

Cassidy and Alexander indicated that the door was still open to including independent arbitration before the package gets to the floor.

“We’re going to keep working on that the next three or four weeks. There are clearly opportunities to improve the bill and move in the direction Sen. Cassidy wants to go,” Alexander told reporters after the hearing.

At the markup hearing Wednesday, the committee took a step toward Cassidy’s preferred vision for fixing surprise bills. It passed an amendment from Cassidy that would require insurance companies to post accurate lists of who is in-network, so patients have a better chance of avoiding surprise bills.

“This bill is not as good as it should be,” Cassidy said. “And I thank the chairman because he has offered to work between now and floor consideration on the surprise bills.”

The only other amendment approved by the panel, offered by Sen. Tammy Baldwin (D-Wis.), would require drug companies to report price increases.

And despite Alexander saying early on that he didn’t want to talk about the individual insurance market or the ACA, some Democrats couldn’t let the opportunity pass without mentioning Republican efforts to undermine it.

“Repairing the train can only get you so far if you are pulling up the track at the same time — and that’s unfortunately exactly what this administration is doing,” Murray said in her opening statement. “The biggest threat to families’ health care continues to be sabotage from President Trump.”

‘An Arm And A Leg’: Why Are Drug Prices So Random? Meet Mr. PBM


Can’t see the audio player? Click here to listen.


Surely, an old-time, generic drug can’t cost $720 — for a three-month supply?

After a close call with an outrageous Rx tab, host Dan Weissmann tackles the health care cost puzzle he’s been avoiding: figuring out prescription drug prices.

Here’s what he found: Your insurance company is probably in cahoots with a pharmacy benefit manager — and the negotiations that go on between them are trade secrets. No wonder it’s so hard to know what you’ll pay at the drugstore counter!

On Episode 4 of “An Arm and a Leg,” meet the behind-the-scenes negotiator that helps decide how much you pay at the pharmacy counter.


Season 2 is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

Fuzzy Math Fuels Sanders’ Claim That Cost Barriers To Health Care Kill 30,000 A Year

“Medicare for All” — or single-payer health care — is a flagship issue for Democratic presidential candidate and Vermont Sen. Bernie Sanders. So when a conservative group launched an ad campaign claiming such a policy would drive up wait times for medical care, the 2020 candidate responded aggressively.

His point: Some people may wait a bit for care under a new system. But under the current one, many people do not have access to affordable care and the results are sometimes dire.

Still, Sanders’ precision gave us pause.

Namely, he tweeted, “30,000 Americans a year die waiting for health care because of the cost.”

Where did that 30,000 figure come from? How could Sanders — or for that matter, anyone — know how many people died “waiting for health care” specifically “because of the cost”?

We reached out to the Sanders campaign but never heard back.

But multiple experts suggested that the 30,000 figure, while not conjured out of thin air, relies on math that is shaky at best. There isn’t enough evidence, either way, to entirely validate or repudiate this claim.

The Math

Sanders’ 30,000 statistic appears to come from a figure used by Physicians for a National Health Program, a doctor-driven nonprofit group that has advocated for years for single-payer health care.

But how did it compute that number? We asked Dr. David Himmelstein, a physician and part-time lecturer at Harvard Medical School, and one of PNHP’s founders.

He said the group looked at the Oregon Health Insurance Experiment, a landmark study in which some state residents had been assigned Medicaid coverage by lottery, and others remained uninsured. One year into that study, researchers found the death rate differed by 0.13 percentage points between those who received insurance and those who did not.

But, per the researchers’ analysis, that difference was not statistically significant. (That’s important and something we’ll come back to.)

Himmelstein said the margin of 0.13 percentage points suggests that for every 769 people to lack health coverage, one will die. Looking at the current American uninsured population — about 27 million lack coverage —should put you close to 30,000.

The Problem

Generally, experts said, it’s likely that cost barriers prevent thousands of Americans from accessing lifesaving medical care.

But “the particular math here seems a bit questionable” in arriving at 30,000, said Dr. Benjamin Sommers, a physician and health economist at the Harvard T.H. Chan School of Public Health.

The problem lies in extrapolating so much from the Oregon Health Insurance Experiment. While it yielded important findings, the death rate differential in particular is not statistically significant, so it cannot be applied so broadly, he said. The study wasn’t big enough to generate sufficient evidence spelling out the link between insurance coverage and mortality.

Other research makes clear that such a link exists. Sommers’ own work, for instance, looked at the impact of Massachusetts’ 2006 health reform law — the model for the Affordable Care Act, which brought the state to near-universal coverage.

That expansion was associated with a significant drop in mortality. For every 830 adults to gain coverage, one death was prevented.

But differences nationally in both population and health care generally still mean it’s difficult to apply this statistic to the rest of the country — and, namely, to the remaining 27 million uninsured.

So is 30,000 right or wrong?

We don’t know.

“My guess is that one, [Sanders] is right that thousands of people die because they remain uninsured, despite the ACA; but two, the 30,000 number may be too high,” said Stan Dorn, a senior fellow at Families USA, a left-leaning health policy advocacy group.

Going Beyond Insurance

There’s one other issue: More often than not, people are uninsured because they can’t afford to buy coverage. In turn, that often means they can’t afford health care and suffer dire consequences.

But it isn’t a one-to-one substitution.

For instance, there are healthy people who lack insurance but may not need much medical care in that particular year, or may simply choose not to buy it.

And, on the other hand, some people have coverage that isn’t robust enough to make lifesaving treatments affordable.

So, if you want to measure how many Americans do die “waiting for health care because of the cost,” you’d have to look beyond just the question of having insurance.

Our rating

On its face, Sanders’ claim speaks to an important, undisputed policy concern — thousands of Americans die because they cannot afford their health care.

But his “30,000 people” talking point relies on weak math, and it lacks meaningful support either way. It could be true. But it also could easily not be.

“The senator’s comment looks like a reasonable attempt to use prior research,” Sommers said. But “he’s overstating the precision and confidence we can have in that number.”

Sanders’ argument speaks to something more broadly true but neglects important details of the Oregon Health Insurance Experiment’s limitations. We rate it Half True.

Trump Administration Seeks More Health Care Cost Details For Consumers

Anyone who has tried to “shop” for hospital services knows one thing: It’s hard to get prices.

President Donald Trump on Monday signed an executive order he said would make it easier.

The order directs agencies to draw up rules requiring hospitals and insurers to make public more information on the negotiated prices they hammer out in contract negotiations. Also, hospitals and insurers would have to give estimates to patients on out-of-pocket costs before they go in for nonemergency medical care.

The move, which officials said will help address skyrocketing health care costs, comes amid other efforts by the administration to elicit more price transparency for medical care and initiatives by Congress to limit so-called surprise bills. These are the often-expensive bills consumers get when they unwittingly receive care that is not covered by their insurers.

“This will put American patients in control and address fundamental drivers of health care costs in a way no president has done before,” said Health and Human Services Secretary Alex Azar during a press briefing on Monday.

The proposal is likely to run into opposition from some hospitals and insurers who say disclosing negotiated rates could instead drive up costs.

Just how useful the effort will prove for consumers is unclear.

Much depends on how the administration writes the rules governing what information must be provided, such as whether it will include hospital-specific prices, regional averages or other measures. While the administration calls for a “consumer-friendly” format, it’s not clear how such a massive amount of data — potentially negotiated price information from thousands of hospitals and insurers for tens of thousands of services — will be presented to consumers.

“It’s well intended, but may grossly overestimate the ability of the average patient to decipher this information overload,” said Dan Ward, a vice president at Waystar, a health care payments service.

So, does this new development advance efforts to better arm consumers with pricing information? Some key point to consider:

Q: What does the order do?

It may expand on price information consumers receive.

The order directs agencies to develop rules to require hospitals and insurers to provide information “based on negotiated rates” to the public.

Currently, such rates are hard to get, even for patients, until after medical care is provided. That’s when insured patients get an “explanation of benefits (EOBs),” which shows how much the hospital charged, how much of a discount their insurer received and the amount a patient may owe.

In addition to consumers being unable to get price information upfront in many cases, hospital list prices and negotiated discount rates vary widely by hospital and insurer, even in a region. Uninsured patients often are charged the full amounts.

“People are sick and tired of hospitals playing these games with prices,” said George Nation, a business professor at Lehigh University who studies hospital contract law. “That’s what’s driving all of this.”

Some insurers and hospitals do provide online tools or apps that can help individual patients estimate out-of-pocket costs for a service or procedure ahead of time, but research shows few patients use such tools. Also, many medical services are needed without much notice — think of a heart attack or a broken leg — so shopping simply isn’t possible.

Administration officials say they want patients to have access to more information, including “advance EOBs” outlining anticipated costs before patients get nonemergency medical care. In theory, that would allow consumers to shop around for lower cost care.

Q: Isn’t this information already available?

Not exactly. In January, new rules took effect under the Affordable Care Act that require hospitals to post online their “list prices,” which hospitals set themselves and have little relation to actual costs or what insurers actually pay.

What resulted are often confusing spreadsheets that contain thousands of a la carte charges — ranging from the price of medicines and sutures to room costs, among other things — that patients have to piece together if they can to estimate their total bill. Also, those list charges don’t reflect the discounted rates insurers have negotiated, so they are of little use to insured patients who might want to compare prices hospital to hospital.

The information that would result from Trump’s executive order would provide more detail based on negotiated, discounted rates.

A senior administration official at the press briefing said details about whether the rates would be aggregated or relate to individual hospitals would be spelled out only when the administration puts forward proposed rules to implement the order later this year. It also is unclear how the administration would enforce the rules.

Another limitation: The order applies only to hospitals and the medical staff they employ. Many hospitals, however, are staffed by doctors who are not directly employed, or laboratories that are also separate. That means negotiated prices for services provided by such laboratories or physicians would not have to be disclosed.

Q: How could consumers use this information?

In theory, consumers could get information allowing them to compare prices for, say, a hip replacement or knee surgery in advance.

But that could prove difficult if the rates were not fairly hospital-specific, or if they were not lumped in with all the care needed for a specific procedure or surgery.

“They could take the top 20 common procedures the hospital does, for example, and put negotiated prices on them,” said Nation at Lehigh. “It makes sense to do an average for that particular hospital, so I can see how much it’s going to cost to have my knee replaced at St. Joe’s versus St. Anne’s.”

Having advance notice of out-of-pocket costs could also help patients who have high-deductible plans.

“Patients are increasingly subject to insurance deductibles and other forms of substantial cost sharing. For a subset of so-called shoppable services, patients would benefit from price estimates in advance that allow them to compare options and plan financially for their care,” said John Rother, president and CEO  at the advocacy group National Coalition on Health Care.

Q: Will this push consumers to shop for health care?

The short answer is maybe. Right now, it’s difficult, even with some of the tools available, said Lovisa Gustafsson, assistant vice president at the Commonwealth Fund, which has looked at whether patients use existing tools or the list price information hospitals must post online.

“The evidence to date shows patients aren’t necessarily the best shoppers, but we haven’t given them the best tools to be shoppers,” she said.

Posting negotiated rates might be a step forward, she said, but only if it is easily understandable.

It’s possible that insurers, physician offices, consumer groups or online businesses may find ways to help direct patients to the most cost-effective locations for surgeries, tests or other procedures based on the information.

“Institutions like Consumer Reports or Consumer Checkbook could do some kind of high-level comparison between facilities or doctors, giving some general information that might be useful for consumers,” said Tim Jost, a professor emeritus at the Washington and Lee University School of Law.

But some hospitals and insurers maintain that disclosing specific rates could backfire.

Hospitals charging lower rates, for example, might raise them if they see competitors are getting higher reimbursement from insurers, they say. Insurers say they might be hampered in their ability to negotiate if rivals all know what they each pay.

“We also agree that patients should have accurate, real-time information about costs so they can make the best, most informed decisions about their care,” said a statement from lobbying group America’s Health Insurance Plans. “But publicly disclosing competitively negotiated, proprietary rates will reduce competition and push prices higher — not lower — for consumers, patients, and taxpayers.”

KHN’s ‘What The Health’: Politics Heading Into 2020: Live From Aspen!


Can’t see the audio player? Click here to listen on SoundCloud.


The cost of health care looms as a major issue going into the 2020 campaign. But even as Democratic presidential candidates debate ways to bring down prices and expand insurance to more Americans, Democrats and Republicans in Congress are trying to pass legislation to address the price of prescription drugs and put an end to “surprise” out-of-network medical bills.

Chris Jennings and Lanhee Chen know about both. Jennings, president of Jennings Policy Strategies, has been a health adviser to Presidents Bill Clinton and Barack Obama. Lanhee Chen is a research fellow at the Hoover Institution and a director in the public policy program at Stanford University. He has advised Republican presidential candidates Mitt Romney, Marco Rubio and others.

This week’s panelists for KHN’s “What the Health?” — recorded at the Aspen Ideas: Health festival — are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • The term “health care costs” means different things to different people. For most of the public, it refers to the amount they must pay out-of-pocket for premiums, deductibles and services. For policymakers, it often means the total amount the U.S. spends on the health care system. That often creates a disconnect.
  • Even small changes to the way drugs are priced and ending surprise medical bills might end up satisfying many members of the public, although those adjustments might have a minimal effect on overall health spending.
  • Republicans are as divided as Democrats on health care. That is the main reason Republicans did not repeal the Affordable Care Act in 2017 and why there has been no major Republican replacement proposal since then.
  • Many of the Democrats running for president, meanwhile, continue to advocate for a “Medicare for All” program run by the government, although many are hedging their bets by supporting other, less sweeping proposals to expand coverage, as well.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Hundreds Camp Out Overnight At Rural Town’s First-Come, First Serve Clinic In Sign Of Just How Many People Have ‘Fallen In The Gap’

The federal government now estimates that a record 50 million rural Americans live in what it calls “health care shortage areas,” where the number of hospitals, family doctors, surgeons and paramedics has declined to 20-year lows. A look at a pop-up clinic in Tennessee shows just how bad that reality is for the people living it.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! The jury is still out whether we’re all growing horns out of the back of our heads because of how much we use smartphones, but apparently humans on the whole are somewhat decent people when it comes to finding wallets with cash in them. Now buckle up, because our cups have runneth over this week in terms of truly excellent health stories.

We’ll start, though, with what to look out for next week: President Donald Trump is expected to issue an executive order that would compel hospitals, insurers and others in the health industry to reveal closely guarded information about the true cost of procedures, according to The Wall Street Journal. This is the order that certain players in the health field have been dreading. It’s unclear how aggressive the administration will be with the rule, considering the rumblings of discontent already rippling through D.C. But a whopping 88% of people in a recent survey said they support such a policy — so the president is not exactly going out on a limb with voters.

The Wall Street Journal: Trump to Issue Executive Order on Health-Care Price Transparency


Speaking of voters, this executive order comes closely on heels of the official kickoff for Trump’s reelection campaign, which took place on Tuesday in Florida. The president has been searching for ways to win back ground against Democrats on the topic of health care — and promised to issue a plan within the next month or two that would counter the buzzy “Medicare for All.”

Many Republicans, though, kind of wish Trump would channel “Frozen” and let it go. With polls showing voters favor Democrats’ stance on health care, Republicans want the president to focus on issues where they think they have an edge, such as immigration.

The New York Times: Trump Wants to Neutralize Democrats on Health Care. Republicans Say Let It Go.

The New York Times: Trump, At Rally in Florida, Kicks Off His 2020 Re-Election Bid

Adding to the prevailing narrative that health care is a winning issue for the Dems, House Speaker Nancy Pelosi is using the topic to divert attention away from the more volatile talk of impeachment. “When we won the election in November, it was health care, health care, health care,” Pelosi said earlier in the week. She also promised that Democrats would fight relentlessly against Trump’s attempts to chip away at the health law.

In short, you can pretty much guarantee health care is going to play a central role in the 2020 races.

Bloomberg: Impeach Trump? Pelosi’s Dems Prefer Health Care Focus for 2020

Meanwhile, The New York Times interviewed many of the Democratic candidates about their stances on different issues, including health care. While they all agree something needs to be done about the country’s system, what that looks like becomes a dividing line in a crowded field.

The New York Times: 2020 Democrats on Health Care


A federal appeals court handed the Trump administration a win this week when a panel of three Republican-appointed judges ruled that new rules prohibiting federal family-planning grants to health clinics offering on-site abortions or referrals for the procedure can go into effect. The changes — which are largely thought to be targeting Planned Parenthood and are called a “gag rule” by opponents — have provoked fierce backlash among abortion rights groups that say the implementation of such restrictions will be devastating to women who rely on the clinics for health care. Although the decision isn’t the final say on the matter, the judges predicted the administration will prevail in this case.

The Washington Post: Trump Administration’s Abortion ‘Gag Rule’ Can Take Effect, Court Rules

Meanwhile, a look at two abortion clinics 20 minutes apart highlights the great divide evident around the country as state-level laws stand in stark contrast to one another.

The Wall Street Journal: Two Abortion Clinics, 20 Minutes and a Legal Universe Apart


Politico lifts the curtain on the ever-deepening quarrel between White House aides and HHS Secretary Alex Azar. “Alex is outnumbered and keeps losing,” an individual familiar with the simmering tensions told reporters. With Trump’s focus on health issues as he launches his campaign, the discord threatens to derail progress on key administration agenda items like high drug prices.

Politico: ‘They’re All Fighting Him’: Trump Aides Spar With Health Secretary


Major stakeholders have been anxiously watching congressional action on surprise medical bills — an issue most lawmakers agree needs to be addressed but for which there are several approaches. Industry players each have a preferred strategy (such as independent arbitration), but powerful HELP Committee leaders Sens. Alexander Lamar and Patty Murray hadn’t yet settled on theirs. That changed this week when they announced they back a “benchmark” plan, meaning insurers would pay a provider a rate similar to what the plan pays other doctors in the area for the same procedure. Alexander had “intrinsically” supported a different plan previously but changed his mind after the Congressional Budget Office ruled that this one would garner the most federal savings.

Hospitals were not pleased with the direction this is taking, calling the tactic “unworkable.”

Politico: HELP Committee Leaders Back Benchmark for ‘Surprise’ Billing


One of my favorite stories of the week looks at how those much-hated robocalls, which are mostly just a huge nuisance for most of us, become a life-and-death situation for hospitals. While the rest of us can either block or ignore the calls, hospitals don’t have that option. And when the calls come in waves of thousands, they can jam up emergency lines.

The Washington Post: Robocalls Are Overwhelming Hospitals and Patients, Threatening a New Kind of Health Crisis

I know a lot of people are creeped out by the privacy issues of having digital ears listening in on your every move, but there could be a flipside. Researchers want to train Alexa et al. to listen for gasping that could signal someone is experiencing cardiac arrest.

Stat: ‘Alexa, Are You Listening?’ A Research Tool Warns of Cardiac Arrest


Arkansas’ implementation of a Medicaid work requirement was closely watched by other conservative states eager to follow its lead. Advocates were appalled by the tens of thousands of people dropped from coverage, while state leaders and the Trump administration insisted that an improving economy was the reason behind the declining enrollment.

But a new study adds another layer to the debate: The work mandate has done nothing to affect the number of people who are unemployed in the state. So, after all of that, fewer people have insurance and fewer people have jobs.

Modern Healthcare: More Arkansans Uninsured, Unemployed Post-Medicaid Work Requirement


In news that surprised zero people, but should be noted anyway: Drugmakers made official their opposition to the new rules requiring them to include prices in TV ads. They say the requirements violate their freedom of speech rights and will be confusing to patients, since the prices aren’t what most people end up paying for the drugs.

Reuters: U.S. Drugmakers File Lawsuit Against Requiring Drug Prices in TV Ads


In the miscellaneous file this week:

• It often seems as if the anti-vaccination movement is this grassroots thing that has bubbled up through social media. But the tried-and-true “follow the money” method paints a more interesting picture, starting with a wealthy Manhattan couple who pumped millions into the cause over the past several years.

The Washington Post: Meet the New York Couple Donating Millions to the Anti-Vax Movement

• Immigrant children in U.S. custody give bleak accounts to lawyers of their experiences — including reports of toddlers without diapers being cared for by 10-year-old girls. The lawyers involved say that during their interviews the “little kids are so tired they have been falling asleep on chairs and at the conference table.”

The Associated Press: Migrant Children Describe Neglect at Texas Border Facility

• The youth suicide rate appears to have reached the highest since the government began collecting such statistics in 1960 — driven, in part, by a sharp increase among older teenage boys.

Los Angeles Times: Suicide Rates for U.S. Teens and Young Adults Are the Highest on Record

• Firefighters who die of cancer outnumber firefighters who die responding to an emergency “at least ten, 20, 30 to one.” Yet the very cities they risk their lives protecting are turning their backs on them once they become sick. “My city’s workers’ comp carrier initially flat-out said, ‘We don’t cover cancer,’” one firefighter recalled.

CBS News: Firefighters Battle Occupational Cancer: Many Sickened First Responders Are Being Denied Workers’ Comp Benefits


That was a fairly grim file to end The Friday Breeze with, so make sure to check out Stat’s list of 23 of the best health and science books to read this summer to give yourself a little boost to finish off your week. And have a great weekend!

Small Colorado Ski Towns Banded Together To Drive Down Health Costs. But Can That Model Work Statewide … Or Even Nationwide?

Residents who were sick of paying astronomical health care costs figured out a way to come together so that they had negotiating power over the health groups in their area. But will other cities in the state be able to replicate the group’s success in areas where there’s less fat to trim? In other news on insurers and the health industry: medical prices continue to swell; AHIP focuses on social determinants; the importance of dental care gets lost in cost debate; and more.

Curing Cancer: Easy Politics, Difficult Science

President Donald Trump made a new promise if voters grant him a second term: “We will come up with the cures to many, many problems, to many, many diseases, including cancer.”

Trump’s statement was part of his 2020 campaign kickoff in Orlando, Fla., on Tuesday. It echoed remarks by former vice president and Democratic candidate Joe Biden on the stump last week in Iowa: “I promise you, if I’m elected president, you’re going to see the single most important thing that changes America: We’re going to cure cancer.”

“Let’s cure cancer” is hardly a new political ambition. Go back to 1971, when then-President Richard Nixon launched “The War on Cancer” by signing the National Cancer Act, which directed $1.6 billion to research and established the National Cancer Institute.

Or take a famous fictional White House: On “The West Wing,” a TV drama that first aired from 1999 to 2006, President Jed Bartlet pushes to include in his State of the Union a pledge to “cure cancer in 10 years.”

In 2016, President Barack Obama tapped Biden to run the White House’s “cancer moonshot” soon after Biden’s son Beau died of brain cancer.

It’s a compelling promise. After all, who could be against curing the nation’s second-leading cause of death?

If only it were that simple. Here are three reasons “let’s cure cancer” is very easy for politicians to say but very hard to accomplish.

Neither the Trump campaign nor the Biden campaign responded to requests for comment.

With Cancer, The Biology Is Especially Tricky

Cancer is multifaceted and uniquely complex — it is not so much one disease as a class of related diseases.

“‘One cure’ is not a tenable concept,” said Edward Giovannucci, an associate professor at Harvard Medical School. “An analogy I think of is ‘curing infectious disease.’ No one would ever say this.”

For one thing, individual cancers mutate differently. And those different mutations don’t always respond to the same medicines. That means the best therapy for one person’s lymphoma might not work for someone else’s. And there is consistently potential for new cancer mutations to develop — meaning that, in some ways, there is also a consistent need for new treatments.

“One cannot rightfully say, ‘In the next five years, we’re going to cure cancer,’ because cancer is so many different diseases,” said Dr. Philip Kantoff, the chairman of medicine at Memorial Sloan Kettering Cancer Center in New York.

Some suggested literalism isn’t the point. And, to be fair, statements and pledges like these can yield advances in cancer treatment in research when accompanied by substantial increases in research funding or efforts to encourage interdisciplinary scientific endeavors.

“One of the things Biden has done is generate a much larger public awareness that cancer is a set of problems that, if we direct both science and policy in the right way to it, we can actually transform,” said Paula Hammond, a chemical engineering professor at the Massachusetts Institute of Technology, who has worked with the nonprofit Biden Cancer Initiative.

We Already Have Treatments. But There’s An Affordability Problem.

Many cancers — certain types of breast or colon cancer, for instance — are already curable. But they need to be promptly diagnosed and treated. Meanwhile, 27.4 million Americans don’t have health insurance.

Universal prevention, treatment and curing of cancer means anyone with a chance of developing the disease needs health insurance, experts said. And the coverage needs to be robust enough that patients will go for preventive screenings and follow-up care, without being deterred by the cost.

“If you’re going to find it early, treat it early and completely, which would be the ‘cure it’ option, that’s something where insurance is going to be required, whether it’s ‘Medicare for All,’ or some variant of that,” said Amy Davidoff, a health economist at Yale who studies how cancer costs affect people.

Focusing on treatments without expanding meaningful access to coverage, she said, is “problematic.”

Already, that link is clear. For instance, research Davidoff worked on found that when states expanded eligibility for Medicaid coverage — optional under the Affordable Care Act — gaps between white and black adults closed when it came to timely treatment of advanced cancer.

Health insurance — and universal health care, in particular — has already emerged as an election issue.

Trump, for his part, has not rolled out a health care agenda. But his administration’s work thus far has exacerbated insurance barriers. Some 700,000 more Americans were uninsured in 2018 under Trump. The White House’s stance on a pending Obamacare lawsuit would dismantle the law, leaving millions more Americans without coverage and upending its protections for people with preexisting conditions — including, crucially, cancer.

Biden has not formally released a health care platform, and he has favored policies to expand coverage. This week, he suggested making a “Medicare-like public option” generally available, and available at no premium for uninsured people who live in states that did not expand Medicaid.

That sort of proposal could go a long way toward addressing the issues of uninsured people. But it also could leave holes.

Currently, even if people have coverage, Davidoff said, the price tag for many newer cancer treatments and immunotherapies can put them well out of reach.

That means the generosity of any public option, and indeed of any existing health plans, matters a great deal, too.

The Importance Of Healthy Habits

And when it comes to advancing cancer treatment, experts stressed the importance of disease prevention.

In practice, that means developing strategies to bring down smoking rates and obesity, or improving access to nutritious food. Those require funding, political will and a robust public health infrastructure — none of which is easy to come by. But the potential payoff is far bigger.

“If we are to make very significant inroads on cancer mortality rates over the next several decades, we need to focus on prevention and early detection,” Giovannucci said. “We know the majority of cancers are, in principle, preventable.”

Amazon Wants To Cut PBMs Out Of Drug Sales Pipeline By Contracting Directly With Health Plans, Employers

By contracting directly with health plans and employers, Amazon-PillPack would essentially become its own pharmacy benefit manager, which, given Amazon’s distribution capabilities, could quickly shake up the nation’s prescription drug market. Court documents in a case about personnel revealed the strategy that many in the industry fear. In other pharmaceutical news: a drug-price watchdog group with ties to pharma; Merck’s expansion into cancer treatments; and more.

Stem Cell Company Persuades Employers To Steer Workers Toward Controversial Therapy

A Midwestern grocery chain, Hy-Vee, is taking an unusual — and highly controversial — approach to reducing health care costs.

Before employees in certain cities can undergo knee replacement, they first must visit a stem cell provider. Hy-Vee has contracted with one of the United States’ leading stem cell companies — Regenexx, based in Des Moines, Iowa — that claims injections of concentrated bone marrow or platelets can help patients avoid expensive joint surgery.

Regenexx has persuaded over 100 employers to include its services in their health insurance plans. In a marketing booklet, Regenexx, whose injections range in price from $1,500 to $9,000, notes that its treatments cost a fraction of major surgery. A single knee replacement, for example, ranges from $19,000 to $30,000 in the U.S.

The benefits of stem cells are hotly debated in the medical community, and federal regulators have warned the public to beware of clinics that peddle unapproved injections as a cure-all. Many doctors and ethicists say they fear the public is being misled about how well stem cells work — and whether the procedures save their money or waste it.

“This definitely is not a high-quality, proven treatment,” said Dr. Freddie Fu, chairman of orthopedic surgery at the University of Pittsburgh Medical Center.

Knee Pain and the Bottom Line

Health insurance typically doesn’t cover stem cell injections, with the exception of certain accepted treatments, such as bone-marrow transplants for cancer and aplastic anemia. Aetna, the United States’ third-largest health insurer, dismisses stem cells and platelet injections as experimental; Anthem, the country’s second-biggest health insurance provider, classifies the injections as “not medically necessary.” Without insurance coverage, patients are forced to pay out-of-pocket or forgo treatment.

So instead of dealing with disapproving insurance executives, Regenexx appeals directly to employers large enough to fund their own health plans. These businesses have the freedom to customize their plans, covering services that aren’t part of a standard insurance package. Over half of U.S. workers insured through their jobs belong to such plans, according to the Employee Benefit Research Institute, a D.C.-based nonprofit.

Perhaps Regenexx’s best-known corporate client is Des Moines-based Meredith Corp., which owns multiple TV and radio stations, as well as magazines such as Better Homes & Gardens. (Meredith owned Time magazine until September 2018.)

In a statement, Regenexx said its goal is to “replace more invasive surgical orthopedics” with nonsurgical options, noting that recent research has found many joint operations are ineffective. On its website, Regenexx claims its procedures “repair and regenerate damaged or degenerated bone, cartilage, muscle, tendons, and ligaments.” In a bone marrow stem cell procedure, for example, a doctor withdraws bone marrow cells from a patient’s hip, concentrates them, then reinjects them into a problem area, such as an arthritic knee. Doctors target the exact location in the joint using ultrasound. For a “platelet-rich plasma” treatment, doctors draw blood, concentrate the platelets, then inject them into the target area.

Regenexx, previously known as Regenerative Sciences, is one of the oldest stem cell companies in the U.S. When it opened its doors in 2005, it had only a handful of competitors. Today, there are more than 1,000 stem clinics in the U.S., said Leigh Turner, an associate professor at the University of Minnesota’s Center for Bioethics, who has published a series of articles describing the stem cell market.

At times, Regenexx has clashed with the Food and Drug Administration. In 2010, for example, Regenexx sued the FDA, claiming the agency lacked the authority to regulate its procedures, which involved culturing stem cells before reinjecting them into patients. Regenexx lost its case and was countersued by the FDA, which charged that Regenexx was marketing an unapproved drug. In 2014, the U.S. Court of Appeals in Washington sided with the FDA, forcing Regenexx to stop performing the controversial procedures. Today, Regenexx performs this procedure only in the Cayman Islands, where the government allows it. The Cayman Islands, where there is less government regulation of health care, has become known as a medical tourism destination, Turner said.

Regenexx says that the treatments offered at its U.S. clinics comply with FDA regulations, which require that cells injected into patients undergo no more than “minimal manipulation.”

On its website, Regenexx lists more than two dozen studies led by its doctors. For example, its chief medical officer, Dr. Chris Centeno, published a small study last year that found patients with knee arthritis who received bone marrow and platelets fared better than those randomly assigned to exercise therapy. Regenexx says it tries to be transparent about its results, noting that it posts data on patient results. In a statement, the company said most patients it treats for knee pain have good functioning five years later.

A Regenexx marketing booklet says 70% of orthopedic surgeries “can be completely avoided with a Regenexx procedure” — a claim Fu called “silly.”

“There is zero evidence that you can replace 70% of surgeries with stem cells,” he said.

Recent research suggests stem cells and platelets may work no better than placebos, Fu added. In a recent analysis, over 80% of patients with knee arthritis experienced a noticeable improvement in pain after receiving simple saltwater injections, writes Dr. Benjamin Rothrauff, a postdoctoral fellow who works with Fu at the University of Pittsburgh.

There’s also no definitive evidence stem cells and platelets can regrow lost cartilage, Fu said. A 2018 review concluded platelets have “marginal effectiveness,” and experts note that most published studies are so small or poorly designed that their results aren’t reliable.

Is Regenexx Actually Saving Employers Money?

If Regenexx treatments worked as well as the company claims, insurance companies would rush to cover them, Turner said. But the notion that Regenexx will save employers money hasn’t been proven and is “a boastful claim with no clinical merit,” said Henry Garlich, director of health care value solutions and enhanced clinical programs at Blue Shield of California, who has reviewed Regenexx’s publications.

“The problem is that we don’t have enough data. When a company does not have this type of evidence, then they will go direct to the consumer market,” Garlich said. “Some vulnerable individuals, including companies that want to reduce their health care costs, may buy what they’re selling.” If Regenexx procedures don’t work, Garlich said, an employer could end up paying twice — once for stem cells and once for knee replacement.

Some employers are, in fact, skeptical. The Des Moines Public Schools has opted not to add Regenexx to its employee health plan, said Catherine McKay, director of employee services for the school system. She said a salesman for a local stem cell clinic, which has since merged with Regenexx, told her the treatments could save the school system lots of money. McKay wasn’t sold.

“My experience with them has not been great, in terms of marketing and sales. They’re very, very pushy,” McKay said. “They claim they can get people back to work earlier” than surgery. “But if I still need knee surgery a year down the road, that doesn’t cut my costs.”

The Des Moines school system has agreed to consider covering Regenexx procedures as part of its workers’ compensation program on a case-by-case basis, McKay said. The school system has not signed a contract with Regenexx, however, and hasn’t included Regenexx in its health plan.

McKay said she knows of two school employees who have tried Regenexx. While one employee was satisfied with the results, McKay said, another “went through a couple procedures and ended up needing surgery anyway.”

Corporate executives have become some of Regenexx’s biggest boosters. Hy-Vee’s former chairman and CEO, Ric Jurgens, appears in a Regenexx marketing brochure and says that he turned to Regenexx because of heel pain. The brochure, which was removed from a Regenexx website after Kaiser Health News began reporting this story, quotes Jurgens as saying, “I knew that giving our employees the chance to explore options besides surgery was in their best interest.”

Hy-Vee did not make Jurgens or other employees available to interview.

Steve Lacy, Meredith’s former CEO and current board chairman, said he underwent a Regenexx procedure two years after his company began covering stem cell treatments. He had been facing knee surgery and thought stem cells were worth a try. The procedure got him back to doing everything he wants to do, Lacy said, even running several days a week. He also has done daily physical therapy for over two years. “The rehab and recovery is far less onerous” with the Regenexx procedure than with surgery, Lacy said. “If the procedure doesn’t work for an individual, there’s no harm.”

Meredith has spent about $400,000 in four years on 85 employees who have had Regenexx treatments, or about $4,700 a patient, said Meredith spokesman Art Slusark. That’s a small share of the roughly $75 million a year that Meredith spends on its medical plan, he said.

At its headquarters, Meredith has promoted Regenexx procedures through email, posters and “lunch-and-learn” sessions in the office, said Jenny McCoy, Meredith’s corporate communications director.

McCoy herself has become a poster child for Regenexx’s benefits. She and two other Meredith employees appear with Lacy in a marketing video on the Regenexx site. Although McCoy had begun to experience knee and hip pain during exercise, she said in an interview that her pain was not severe enough to need surgery. McCoy underwent platelet injections two years ago and is pain-free today, she said.

“I thought, ‘If Meredith is covering it, I might as well have it done early before [the pain] causes me too many problems,’” said McCoy, 52. Given the price tag, she said, “I would not have done it otherwise. I wouldn’t have even known about it.” In the Regenexx marketing video, Lacy is shown saying stem cells saved Meredith roughly $700,000 in one year. Lacy said he estimated that number by comparing what Meredith spent on Regenexx with what it would have spent on hip and knee replacements.

But Slusark said Meredith hasn’t examined employee medical records to determine how many were eligible for surgery or how many needed joint surgery after trying Regenexx. “We don’t spend a lot of time calculating savings,” Slusark said.

Without that medical information, Meredith can’t accurately estimate how much money it saved, if any, Fu said. He noted that relatively few people with joint pain undergo surgery, which doctors typically view as a last resort for patients who have exhausted all other treatment options. Although 14 million Americans have knee arthritis, the Arthritis Foundation estimates that doctors perform only about 757,000 knee replacements each year.

Before recommending joint replacement, doctors often tell patients to try exercise, physical therapy, weight loss, supportive shoe inserts or steroid injections, Garlich said. Physical therapy, in particular, helps many patients, said Fu; it’s possible that PT, and not the stem cell injections, should get the credit for Lacy’s recovery.

How the Patients Feel

Regenexx has posted video interviews of dozens of satisfied customers on its website, including a refinery worker treated for a non-healing wrist fracture, a snowboarder who had stem cell therapy in his knees and an avid weightlifter with multiple shoulder problems. All say Regenexx helped them.

Other Regenexx patients say the treatments wasted their time and money. Several patients who posted online reviews of the company agreed to be interviewed for this article.

One is Amanda Lynch, a 42-year-old Australian trapeze artist who lives in Montreal. Lynch said she spent $7,700 last year to treat an injured ligament at a Regenexx clinic in Colorado. Doctors administered a series of injections in her knee over several days, including platelets and her bone marrow, Lynch said. She shared copies of the emails she exchanged with the clinic, a bill from Regenexx and a document in which doctors evaluated her candidacy for treatment.

But within a few months, Lynch had to undergo surgery in Montreal for both knees, she said, paying an additional $16,100, according to her medical bill. Because Lynch is Australian, she was not eligible for free care in the Canadian health system and had to pay out-of-pocket.

Roland Jersevic, a 67-year-old lawyer living in Saginaw, Mich., said he needed knee replacement after his stem cell treatments failed to relieve his arthritis. Jersevic said he went to a Regenexx clinic in Toledo, Ohio, in 2015 to get help with severe arthritis in his knees, which had caused his legs to bow. “The pain was horrendous all the time,” he said. Jersevic’s medical bills, obtained for this article, show that he paid the clinic $7,500 out-of-pocket because his insurance wouldn’t cover stem cell therapy. “They told me they were going to regrow my cartilage,” he said, referring to Regenexx. “I wanted it to work.”

Although the fat and bone marrow injections may have given Jersevic a “little bit” of temporary relief, his pain soon returned, he said. Regenexx offered to administer more injections, at an additional cost, Jersevic said. “At that point, I had lost all faith in what they were doing. To spend more money on a booster — what for? It wasn’t working.”

Jersevic had both knees replaced in summer 2016, his medical records show, and his insurance paid most of the bill. His knee pain is gone, and Jersevic said he felt well enough to return to track-and-field competitions — including hurdles and pole vaulting — in 2017.

“When your knees are that bad, it’s not going to work for you,” Jersevic said. “They should tell you it’s not going to work for you. But they want the cash.”

In response, Regenexx noted that many patients who undergo knee surgery are also unhappy with the results. Research suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while one-fifth report that they are dissatisfied with the results of their surgery.

“We are disappointed to learn of any patients who didn’t have a positive outcome,” Regenexx said in a statement. “Our goal at Regenexx is to achieve the best possible clinical efficacy, and we are actively researching to find out why some patients respond better than others.”

1 In 6 Insured Hospital Patients Get A Surprise Bill For Out-Of-Network Care

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there’s a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

“Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017,” the authors wrote.

The researchers got their data by analyzing large-employer claims from IBM’s MarketScan Research Databases, which include claims for almost 19 million individuals.

Surprise medical bills are top of mind for American patients, with 38% reporting they were “very worried” about unexpected medical bills.

Surprise bills don’t just come from the emergency room. Often, patients will pick an in-network facility and see a provider who works there but isn’t employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices.

“It’s kind of a built-in problem,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don’t know whether they are being treated by an out-of-network doctor while in a hospital.

“By definition, there are these circumstances where they cannot choose their provider, whether it’s an emergency or it’s [a doctor] who gets brought in and they don’t even meet them face-to-face.”

The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don’t apply to most large-employer plans because the federal government regulates them.

“New York and California have very high rates of surprise bills even though they have some of the strongest state statutes,” Pollitz said. “These data show why federal legislation would matter.”

Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study.

Legislative solutions are being discussed in the White House and Congress. The leaders of the Senate Health, Education, Labor and Pensions Committee introduced a package Wednesday that included a provision to address it. The legislation from HELP sets a benchmark for what out-of-network physicians will be paid, which would be an amount comparable to what the plan is paying other doctors for that service.

That bill is set for a committee markup next week.

Other remedies are also being offered by different groups of lawmakers.

Sen. Alexander Details His Plan To Fix Surprise Medical Bills

Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), who are pushing a major legislative package to lower health costs, announced their favored solution to handle disputes about surprise medical bills.

Those unexpected and often high charges patients face when they get care from a doctor or hospital that isn’t in their insurance network are a perpetual complaint from consumers.

Alexander and Murray formally introduced their wide-ranging bill Wednesday, but they had offered a broad outline before without taking a stand on how to mediate between health care providers and patients on the surprise bills.

When a patient is seen by a doctor who isn’t in their network, the Alexander-Murray bill says insurance would pay them the “median in-network rate,” meaning the rate would be similar to what the plan charges other doctors in the area for the same procedure. If there aren’t enough other doctors covered by the plan to compute a median in-network, the plan would use a database of local charges that is “free of conflicts of interest.”

Alexander said in a written statement that his decision was swayed by an assessment by the Congressional Budget Office, which “indicated that the benchmark solution is the most effective at lowering health care costs.”

According to early numbers from a CBO report, benchmarking could save $25 billion over the next 10 years. Loren Adler, associate director of USC-Brookings Schaeffer Initiative for Health Policy, said that means commercial insurance premiums would be reduced by about a half-percent.

“That’s pretty significant for federal policy,” Adler said.

The formula is similar to what a different group of bipartisan senators, led by Sen. Bill Cassidy (R-La.), proposed earlier this year. The critical difference is that in the Cassidy bill if the insurer and doctor can’t agree on a median-in-network rate, they can take their case to an independent arbitrator.

The provider community has pushed back on any attempt to set a “benchmark” for physician pay, like the one in Alexander and Murray’s bill.

At a hearing Tuesday before the Health, Education, Labor and Pensions Committee — of which Alexander and Murray are the chairman and ranking member, respectively — Tom Nickels, executive vice president of the American Hospital Association, said benchmarking would hurt efforts to set up broad insurance networks because providers and insurers would already know what they would be paid for surprise bills and it would be hard to recruit physicians to adequately staff hospitals.

“Health plans and hospitals have a long-standing history of resolving out-of-network emergency service claims, and this process should not be disrupted,” he said in written testimony.

Alexander also pointed out that Rep. Frank Pallone (D-N.J.), chairman of the House Energy and Commerce Committee, and Rep. Greg Walden (R-Ore.), the ranking member of that committee, have also recommended this proposal.

Although it isn’t the most aggressive solution the committee could have picked, according to Adler, it’s still a positive step, and he said it was promising that an influential health committee in the Senate and an influential health committee in the House are on the same page.

“There’s some logic to moving trains in the same direction,” Adler said.

The Alexander-Murray legislation says that any care the patient receives would count toward their in-network cost sharing, like their deductible, coinsurance or copay.

Once they are stable and lucid after an emergency, patients must be given written notice that they are going to be seen by an out-of-network doctor, an estimate of how much that could cost, and a list of in-network doctors or facilities where they could seek care.

The bill specifies that the notice must be short, easy to read and that consent to see an out-of-network doctor is clearly optional. If the patient doesn’t get this document, they can only be billed at an in-network rate.

In Debate Over What To Do About Surprise Medical Bills, Alexander Hints At Support For In-Network Guarantee

Although many lawmakers agree that patients need to be protected from surprise medical bills, there are different ways that could go and many stakeholders who have strong opinions on what the solution should be. At a hearing on Wednesday, Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander said that requiring hospitals to guarantee that any doctor a patient sees is in-network is the strategy he “intrinsically liked the best.” But the future of any legislation is still unclear.

State Highlights: New York Lawmakers Expected To Ban ‘Gay Panic’ Defenses In Murder Cases; Texas, Florida Cut Back On Charging Students In School Shooting Threats

Media outlets report on news from New York, Florida, California, Iowa, New Hampshire, District of Columbia, Minnesota, New Jersey, Pennsylvania, Rhode Island, Massachusetts, North Carolina, Illinois, Ohio, Georgia, Oregon and Wyoming.

‘An Arm And A Leg’: Can You Shop Around For A Lower-Priced MRI?


Can’t see the audio player? Click here to listen.


An MRI is one of those standard tests that doctors order routinely. But the price you’ll pay can be unpredictable.

Sometimes the price tag depends on where you live: It could reach $10,000 in San Francisco. Or be as low as $1,000 in St. Louis — if you’re willing to haggle. And the kind of imaging center you choose often makes a difference: Was it a fancy specialty hospital linked to a university or a standalone facility at the mall?

Liz Salmi — of Sacramento, Calif. — has been living with brain cancer for more than 10 years and gets an MRI every six months to make sure the cancer’s not growing. On her old insurance plan, she paid $50 for a brain scan. Then her job changed, her health insurance changed, and she was billed $1,600.

Not everyone has the time or patient know-how, but Salmi shopped around and found a deal that saves her hundreds of dollars every year.

On Episode 3 of “An Arm and a Leg,” find out how she did it.


Season 2 is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

Senators Agree Surprise Medical Bills Must Go. But How?

Two years, 16 hearings and one massive bipartisan package of legislation later, a key Senate committee says it is ready to start marking up a bill next week designed to contain health care costs. But it might not be easy since lawmakers and stakeholders at a final hearing Tuesday showed they are still far apart on one simple aspect of the proposal.

That sticking point: a formula for paying for surprise medical bills, those unexpected and often high charges patients face when they get care from a doctor or hospital that isn’t in their insurance network.

“People get health insurance precisely so they won’t be surprised by health care bills,” said Sen. Maggie Hassan (D-N.H.), the co-author of a separate proposal to tamp down surprise bills. “So it is completely unacceptable that people do everything that they’re supposed to do to ensure that their care is in their insurance network and then still end up with large, unexpected bills from an out-of-network provider.”

It’s a cause that has been taken up by President Donald Trump and various bipartisan groups of lawmakers on Capitol Hill.

The wide-ranging legislative package on curbing health care costs is sponsored by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.), the chairman and ranking member of the Health, Education, Labor and Pensions (HELP) Committee. Given the committee’s influence, and because this legislation has bipartisan support in the Senate where not many bills are moving, industry observers are taking the HELP panel’s proposal very seriously.

Alexander and Murray’s bill lays out three options for paying surprise medical bills but does not specify which path the final legislation should take. Advocates for each of the choices were among the five witnesses Tuesday.

Their positions fell along familiar fault lines. Everyone acknowledged that patients who stumble into a surprise bill because their emergency care was handled at a facility not in their insurance network or because a doctor at their in-network hospital doesn’t take the patient’s plan should not have to pay more than they would for an in-patient service. But they differ on how much doctors, hospitals and other providers should be compensated and how the disputes should be resolved.

Tom Nickels, an executive vice president of the American Hospital Association, cautioned against using benchmarks to set pay levels, such as local customary averages or a price set in relation to Medicare. He said such a plan might underpay providers and hospitals could lose their leverage to negotiate with insurers.

Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health — a group that represents employers, including some who are self-insured who pay their workers’ health costs— said doctors should be paid 125% of what Medicare pays. She told senators that an independent arbitration process like the one Nickels advocates would add unnecessary costs to the system.

Benedic Ippolito, a researcher with the American Enterprise Institute, said requiring all providers in a hospital to be in-network was the cleanest solution.

“On surprise billing, all three approaches are equal in that first and foremost they protect the consumer,” said Sean Cavanaugh, chief administrative officer for Aledade, a company that matches primary care physicians with accountable care organizations.

There was also broad support among the witnesses for some of the legislation’s transparency measures, especially the creation of a nongovernmental nonprofit organization to collect claims data from private health plans, Medicare and some states to create what’s called an all-payer claims database. That could help policymakers better understand the true cost of care, these experts told the committee.

Sen. Susan Collins (R-Maine) expressed trepidation about the all-payer claims database, noting that increased transparency could hurt rural hospitals, which typically charge higher prices than those in cities because their patient base is small and they need to bring in enough revenue to cover fixed costs.

The witnesses also offered support for eliminating “gag clauses” between doctors and health plans. These stipulations often prevent providers from telling patients the cost of a procedure or service.

“Patients and families absolutely have skin in the game … but they are in a completely untenable and unfair situation. They have no information,” said Mitchell, from the Pacific Business Group on Health. “We’re talking about providers not being allowed to share information. … Transparency is necessary so people can have active involvement.”

If one thing is clear, it’s that Alexander doesn’t want this summer to be a rehash of last year, when it appeared he had a bipartisan deal to address problems in the federal health law’s marketplaces before the effort fell apart.

“For the last decade, Congress had been locked in an argument about the individual health care market,” said Alexander at Tuesday’s hearing. “That is not this discussion. This is a different discussion. We’ll never lower the cost of health insurance until we lower the cost of health care.”

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.