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U.S. Medical Panel Thinks Twice About Pushing Cognitive Screening For Dementia

A leading group of medical experts on Tuesday declined to endorse cognitive screening for older adults, fueling a debate that has simmered for years.

The U.S. Preventive Services Task Force said it could neither recommend nor oppose cognitive screening, citing insufficient scientific evidence of the practice’s benefits and harms and calling for further studies.

The task force’s work informs policies set by Medicare and private insurers. Its recommendations, an accompanying scientific statement and two editorials were published Tuesday in the Journal of the American Medical Association.

The task force’s new position comes as concern mounts over a rising tide of older adults with Alzheimer’s disease and other dementias and treatments remain elusive. Nearly 6 million Americans have Alzheimer’s disease; that population is expected to swell to nearly 14 million by 2050.

Because seniors are at higher risk of cognitive impairment, proponents say screening ― testing people without any symptoms — is an important strategy to identify people with unrecognized difficulties and potentially lead to better care.

“This can start a discussion with your doctor: ‘You know, you’re having problems with your cognition, let’s follow this up,’” said Stephen Rao of Cleveland Clinic’s Lou Ruvo Center for Brain Health.

Opponents say the benefits of screening are unproven and the potential for harm is worrisome. “Getting a positive result can make someone wary about their cognition and memory for the rest of their life,” said Benjamin Bensadon, an associate professor of geriatric medicine at the University of Florida College of Medicine.

The task force’s stance is controversial, given how poorly the health care system serves seniors with memory and thinking problems. Physicians routinely overlook cognitive impairment and dementia in older patients, failing to recognize these conditions at least 50% of the time, according to several studies.

When the Alzheimer’s Association surveyed 1,954 seniors in December 2018, 82% said they thought it was important to have their thinking or memory checked. But only 16% said physicians regularly checked their cognition.

What’s more, Medicare policies appear to affirm the value of screening. Since 2011, Medicare has required that physicians assess a patient’s cognition during an annual wellness visit if the patient asks for a checkup of this kind. But only 19% of seniors took advantage of this benefit in 2016, the most recent year for which data is available.

Dr. Ronald Petersen, co-author of an editorial accompanying the recommendations, cautioned that they shouldn’t discourage physicians from evaluating older patients’ memory and thinking.

“There is increased awareness, both on the part of patients and physicians, of the importance of cognitive impairment,” said Petersen, director of the Mayo Clinic’s Alzheimer’s Disease Research Center. “It would be a mistake if physicians didn’t pay more attention to cognition and consider screening on a case-by-case basis.”

Similarly, seniors shouldn’t avoid addressing worrisome symptoms.

“If someone has concerns or a family member has concerns about their memory or cognitive abilities, they should certainly discuss that with their clinician,” said Dr. Douglas Owens, chair of the task force and a professor at Stanford University School of Medicine.

In more than a dozen interviews, experts teased out complexities surrounding this topic. Here’s what they told me:

Screening basics. Cognitive screening involves administering short tests (usually five minutes or less) to people without any symptoms of cognitive decline. It’s an effort to bring to light problems with thinking and memory that otherwise might escape attention.

Depending on the test, people may be asked to recall words, draw a clock face, name the date, spell a word backward, relate a recent news event or sort items into different categories, among other tasks. Common tests include the Mini-Cog, the Memory Impairment Screen, the General Practitioner Assessment of Cognition and the Mini-Mental Status Examination.

The task force’s evaluation focuses on “universal screening”: whether all adults age 65 and older without symptoms should be given tests to assess their cognition. It found a lack of high-quality scientific evidence that this practice would improve older adults’ quality of life, ensure that they get better care or positively affect other outcomes such as caregivers’ efficacy and well-being.

A disappointing study. High hopes had rested on a study by researchers at Indiana University, published in December. In that trial, 1,723 older adults were screened for cognitive impairment, while 1,693 were not.

A year later, seniors in the screening group were not more depressed or anxious — important evidence of the lack of harm from the assessment. But the study failed to find evidence that people screened had a better health-related quality of life or lower rates of hospitalizations or emergency department visits.

Two-thirds of seniors who tested positive for cognitive impairment in her study declined to undergo further evaluation. That’s consistent with findings from other studies, and it testifies to “how many people are terrified of dementia,” said Dr. Timothy Holden, an assistant professor at Washington University School of Medicine in St. Louis.

“What seems clear is that screening in and of itself doesn’t yield benefits unless it’s accompanied by appropriate diagnostic follow-up and care,” said Nicole Foster, associate director of the Center for Aging Research at Indiana University’s Regenstrief Institute.

Selective screening. “Selective screening” for cognitive impairment is an alternative to universal screening and has gained support.

In a statement published last fall, the American Academy of Neurology recommended that all patients 65 and older seen by neurologists get yearly cognitive health assessments. Also, the American Diabetes Association  recommends that all adults with diabetes age 65 and older be screened for cognitive impairment at an initial visit and annually thereafter “as appropriate.” And the American College of Surgeons now recommends screening older adults for cognitive impairment before surgery.

Why test select groups? Many patients with diabetes or neurological conditions have overlapping cognitive symptoms and “it’s important to know if a patient is having trouble remembering what the doctor said,” said Dr. Norman Foster, chair of the workgroup that developed the neurology statement and a professor of neurology at the University of Utah.

Physicians may need to alter treatment regimens for older adults with cognitive impairment or work more closely with family members. “If someone needs to manage their own care, it’s important to know if they can do that reliably,” Foster said.

With surgery, older patients who have preexisting cognitive impairments are at higher risk of developing delirium, an acute, sudden-onset brain disorder. Identifying these patients can alert medical staff to this risk, which can be prevented or mitigated with appropriate medical attention.

Also, people who learn they have early-stage cognitive impairment can be connected with community resources and take steps to plan for their future, medically and financially. The hope is that, one day, medical treatments will be able to halt or slow the progression of dementia. But treatments currently available don’t fulfill that promise.

Steps after screening. Screening shouldn’t be confused with diagnosis: All these short tests can do is signal potential problems.

If results indicate reason for concern, a physician should ask knowledgeable family members or friends what’s going on with an older patient. “Are they depressed? Having problems taking care of themselves? Asking the same question repeatedly?” said Dr. David Reuben, chief of geriatrics at UCLA’s David Geffen School of Medicine and director of UCLA’s Alzheimer’s and Dementia Care program.

A comprehensive history and physical examination should then be undertaken to rule out potential reversible causes of cognitive difficulties, implicated in about 10% of cases. These include sleep apnea, depression, hearing or vision loss, vitamin B12 or folic acid deficiencies, alcohol abuse and side effects from anticholinergic drugs or other medications, among other conditions.

Once other causes are ruled out, neuropsychological tests can help establish a diagnosis.

“If I detect mild cognitive impairment, the first thing I’ll do is tell a patient I don’t have any drugs for that but I can help you compensate for deficits,” Reuben said. The good news, he said: A substantial number of patients with MCI ― about 50% — don’t develop dementia within five years of being diagnosed.

The bottom line. “If you’re concerned about your memory or thinking, ask your physician for an assessment,” said Dr. David Knopman, a neurologist at the Mayo Clinic. If that test indicates reason for concern, make sure you get appropriate follow-up.

That’s easier said than done if you want to see a dementia specialist, noted Dr. Soo Borson, a professor emerita of psychiatry at the University of Washington. “Everyone I know who’s doing clinical dementia care says they have wait lists of four to six months,” she said.

With shortages of geriatric psychiatrists, geriatricians, neuropsychologists and neurologists, there aren’t enough specialists to handle demands that would arise if universal screening for cognitive impairment were implemented, Borson warned.

If you’re a family member of an older adult who’s resisting getting tested, “reach out privately to your primary care physician and express your concerns,” said Holden of Washington University. “And let your doctor know if the person isn’t seeing these changes or is resistant to talk about it.”

This happens frequently because people with cognitive impairments are often unaware of their problems. “But there are ways that we, as physicians, can work around that,” Holden said. “If a physician handles the situation with sensitivity and takes things one step at a time, you can build trust and that can make things much easier.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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Aging Insurance Medicare Navigating Aging

Needy Patients ‘Caught In The Middle’ As Insurance Titan Drops Doctors

BAYONNE, N.J. — For five years, Rasha Salama has taken her two children to Dr. Inas Wassef, a pediatrician a few blocks from her home in this blue-collar town across the bay from New York City.

Salama likes the doctor because Wassef speaks her native language — Arabic — and has office hours at convenient times for children.

“She knows my kids, answers the phone, is open on Saturdays and is everything for me,” she said.

But UnitedHealthcare is dropping Wassef — and hundreds of other doctors in its central and northern New Jersey Medicaid physician network. The move is forcing thousands of low-income patients such as Salama to forsake longtime physicians.

Across the nation, business and contractual disputes are separating patients from longtime doctors. This often occurs when doctors don’t want to accept the rates insurers are willing to pay. It sometimes occurs when insurers’ business plans require having a narrower network of doctors — doctors whose practice patterns may be easier to control.

But in this case, the cause of the exclusion goes to even deeper business connections: Wassef and other doctors say the insurer appears to be trying to shift patients to Riverside Medical Group, a 20-office physicians’ practice owned by Optum, a sister company of UnitedHealthcare, both of which are subsidiaries of UnitedHealth Group.  UnitedHealthcare is essentially forcing patients to transfer to doctors it controls, the doctors allege.

Indeed, several patients said the health plan directed them to Riverside when informing them their doctors were being dropped.

Lawrence Downs, CEO of the Medical Society of New Jersey, said he estimates UnitedHealthcare is trying to remove hundreds of doctors in central and northern New Jersey from its network. That is the same area where Riverside Medical operates, he noted.

“It seems like they are steering patients away from small, community-based doctors to large groups that they own,” he said.

Good For Profits

That raises questions about whether this type of “vertical consolidation” — the term for a practice occurring across the country — is a strategy that is good for profits but bad for patients.

UnitedHealthcare said the changes are not part of a campaign to get as many patients as possible to the Riverside practice. It points out that it is retaining the community-based doctors, like Wassef, in its networks to treat its Medicare Advantage and commercial plan members.

But, experts say, traumatic disruptions in doctor-patient relationships are an inevitable result of ongoing shifts in the complicated business of U.S. health care.

Salerno’s main office is in a three-story, 19th-century house in East Orange that his father used for his medical practice in the 1960s. About 40% of his patients are on Medicaid.(Phil Galewitz/KHN)

Facing a rapid consolidation of doctors’ practices and hospital systems — which have hefty negotiating power to demand high fees — insurers have limited options to control costs and maintain a positive balance sheet, said Jacob Wallace, an assistant professor of public health at Yale University. Medicaid plans are especially affected because, unlike commercial plans or even Medicare, they can’t increase premiums or demand copayments.

“Plans face a challenging landscape to keep costs down,” Wallace said. As a result, health plans have taken other approaches, including narrowing provider networks and buying their own physician practices, he said.

But further complicating matters, many Medicaid and Medicare managed-care programs are contracted out to private, for-profit insurers such as UnitedHealthcare. They are looking to create returns for shareholders. With surging enrollment in government programs, UnitedHealthcare has enjoyed rising profits and a stock price that has soared tenfold since 2010.

Wassef and about two dozen other physicians filed a federal lawsuit in September to get reinstated. Wassef, whose termination is scheduled in May, said the move could seriously affect her practice because 80% of her patients are insured by UnitedHealthcare.

UnitedHealthcare gained millions of new customers after the Affordable Care Act led New Jersey and 35 other states and the District of Columbia to expand Medicaid and states turned to private insurers to handle the business. Salama and some other UnitedHealthcare customers said they like their insurance plan because it offers richer benefits than other Medicaid options and covers the medications they use.

The company operates New Jersey’s second-largest Medicaid health plan, with 418,000 members. (The state Department of Human Services has blocked UnitedHealthcare from enrolling any additional Medicaid members, a severe and rare penalty. That move — which is not related to the termination of doctors’ contracts — stems from complaints related to care management and discharge planning, the health plan’s call center and other issues.)

A company spokesperson acknowledged the health plan is dropping 2% of its Medicaid doctors, saying the move was designed to help control costs.

“As health care costs continue to rise, we are working to mitigate the impact on the customers, states and members we serve by negotiating with care providers on their behalf to keep reimbursement rates affordable,” the company said in a statement. “We understand that our members have personal relationships with their doctors and that network changes can be difficult.”

A Practice Destroyed

New Jersey Medicaid officials refused to comment on whether they are concerned about UnitedHealthcare’s actions. But patients caught up in the standoff have reason to worry, said Linda Schwimmer, CEO of the New Jersey Health Care Quality Institute, a coalition of health plans, providers and a variety of health trade groups.

“Once you have a trusted relationship with a provider, it means a lot and it goes to the quality [of your care] because if you are seeing the same providers and you trust them, you are more likely to take your medication and adhere to whatever care plan you have,” she said.

Velylia McIver switched to a new Medicaid health plan after Salerno was initially dropped by UnitedHealthcare in order to keep seeing him.(Phil Galewitz/KHN)

Dr. Alexander Salerno, an internist who runs a 17-doctor multispecialty practice in East Orange, New Jersey, another plaintiff in the lawsuit, is helping lead the court fight. Salerno’s main office is in a three-story, 19th-century house that his father used for his medical practice in the 1960s. About 40% of his patients are on Medicaid.

Until the dispute began last year, Salerno advised his patients to sign up for UnitedHealthcare because of its broad array of benefits, including vision and dental care, and because of the ease in referring to specialists.

And UnitedHealthcare never complained about this group’s skill. In fact, the group received a $130,000 bonus last year for its good care to patients. Salerno said Riverside Medical offered to buy his group practice in 2018, but he declined.

Since UnitedHealthcare announced it would drop his group from the network, more than 500 of his practices’ patients have already changed doctors to stay with the UnitedHealthcare plan, Salerno said.

“It’s not a bad insurance company. It just seems like they have become greedy trying to control both ends of the pendulum — wanting to be the payer and provider,” Salerno said.

A federal judge ordered the case to be heard by a neutral arbitrator, which in late November granted an emergency injunction that will keep Salerno from being removed from UnitedHealthcare’s network until an arbitrator makes a decision on a permanent injunction, which is expected in March.

But that leaves patients in limbo.

Glorida Rivera, 68, said UnitedHealthcare’s decision to drop Salerno was upsetting because she relied on him to care for her diabetes, thyroid and heart conditions. She credits Salerno for referring her to a cardiologist, who put stents in her heart to clear a blockage.

“He knows my whole story, so why do I have to change?” wondered Rivera. Nonetheless, she is sticking with UnitedHealthcare.

Velylia McIver, 83, decided in November to search for another plan so she could stay with Salerno. But it took her more than a month to get coverage for some medications.

“I feel caught in the middle of all this, and it’s the pits,” McIver said.

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Health Industry Insurance Medicaid

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! The gloves came off and the knives came out at the debate this week, so let’s jump right into the fray.

Sen. Elizabeth Warren (D-Mass.) came out swinging on Wednesday night in an all-around livelier debate than most we’ve seen this primary season. When it came to health care, few were safe from Warren’s jabs — South Bend, Indiana, Mayor Pete Buttigieg’s plan was deemed “paper-thin,” Minnesota Sen. Amy Klobuchar’s was so short it could fit on a Post-it note. Even Vermont Sen. Bernie Sanders (whose plan Warren supports) was criticized as not being realistic or a team player.

Warren wasn’t the only one on the attack. Former Vice President Joe Biden hit at new-comer and billionaire Mike Bloomberg for once upon a time labeling the Affordable Care Act “a disgrace.” But Biden left out some context in that particular attack — such as the fact that Bloomberg was commenting that the law wasn’t enough to fix the deeply flawed health system.

Meanwhile, Midwestern Nice was put to the test as tensions between Buttigieg and Klobuchar boiled over. “You voted to confirm the head of Customs and Border Protection under Trump, who was one of the architects of the family-separation policy,” Buttigieg pointed out. At one point, Klobuchar shot out: “Are you trying to say that I’m dumb? Or are you mocking me here, Pete?”

The Washington Post: A Guide to the Most Biting Brawls of the Contentious Las Vegas Presidential Debate

The Washington Post: Fact-Checking the Ninth Democratic Debate

Buttigieg also tried to get Sanders to take some responsibility for his supporters’ social media behavior. The issue was top of mind this week after a powerful culinary union in Nevada condemned the “vicious attacks” its members were receiving following the union’s criticism of Sanders’ “Medicare for All” plan.

The Wall Street Journal: Democratic Debate in Nevada: The Moments That Mattered

The incident between the union and Sanders’ supporters is the tip of the iceberg of a larger Medicare for All civil war roiling organized labor. On one side, you have liberal unions who argue a government-run plan would free them up to refocus and allow them to concentrate on other important matters. The other side of the coin says there’s no way the health care provided under such a system would be as good as the hard-earned plans they have now.

Politico: Labor’s Civil War Over ‘Medicare For All’ Threatens Its 2020 Clout


I was overly optimistic last week in everyone’s desire to adopt an official name for the coronavirus outbreak. Sorry scientists, “COVID-19” does not seem to have taken off, and, at least colloquially, you might be stuck with “coronavirus.” But no matter what it’s called, it is still demanding the world’s attention. Here’s a look at some of the more noteworthy and interesting stories from the week:

— The number of cases in China keeps dropping, in a sign that the outbreak might be stabilizing, at least in the epicenter. But that doesn’t mean anyone should be optimistic (heaven forbid!), because it’s likely cases outside China are on the cusp of blooming into a pandemic.

The New York Times: Coronavirus Epidemic Keeps Growing, But Spread in China Slows

— The Washington Post peels back the curtain on a fight between the State Department and the CDC over whether infected cruise ship passengers should be flown back to America without telling the other people on the plane. Guess who won …

The Washington Post: Diamond Princess: State Department Flew Coronavirus-Infected Americans to the US Against CDC Advice

— Who in our cast of characters holds the responsibility of steering the world through this crisis? (All I keep thinking is: “Responders…Assemble!” Anyone else? Or only your resident Marvel geek here?)

Stat: The Responders: Who Is Leading the Charge in the Coronavirus Outbreak

— Why is a hospital in Omaha, Nebraska, making news? Because in the early 2000s a group of doctors and scientists came up with the idea of creating a biocontainment unit there. Not everyone was on board at the time, calling it “overkill.” But nearly two decades of epidemics have proved the skeptics wrong.

The Associated Press: Why Treat People Exposed to Virus in Omaha? Why Not?

The New York Times: First Ebola, Now Coronavirus. Why an Omaha Hospital Gets the Toughest Cases.

— Are computers better at spotting an outbreak before humans’ puny minds can? Well, they’re quicker, certainly, but they lack our finesse. AI is more like an overly anxious car alarm, and disease fighters are still needed to come in and tease out the complexities of the situation.

The Associated Press: Can AI Flag Disease Outbreaks Faster Than Humans? Not Quite

— More men than women are falling victim to the coronavirus, and that might have something to do with smoking rates.

The New York Times: Why the Coronavirus Seems to Hit Men Harder Than Women

— The prejudice that tagged along with this outbreak is nothing new. Experts warn that there’s a long history of this kind of reaction, and that if we don’t heed warnings about the consequences of such behavior we’ll just be repeating mistakes of the past again.

Undark: Coronavirus Spurs Prejudice. History Suggests That’s No Surprise.

— The vast majority of coronavirus cases are mild. But in 2% of cases, it’s brutally lethal. So what’s happening?

The Washington Post: How the New Coronavirus Can Kill People or Sicken Them

— Is COVID-19 here to stay or will it disappear like its coronavirus brethren?

Los Angeles Times: SARS Killed Hundreds and Then Disappeared. Could This Coronavirus Die Out?

— And, something I had not considered, but with the Olympics coming up, experts say the world needs to have a better grip on the virus before countries should think about attending.

The Associated Press: Virologist: Tokyo Olympics Probably Couldn’t Be Held Now


As the Trump administration pushes to increase patients’ access to their electronic health records, tech companies wait hungrily in the wings for the data to slip out from under the protection of HIPAA. Supporters of the administration’s moves say that Big Tech will be mindful of their own brands and reputations and treat the potential of (lucrative, sweeping) health data responsibly. Critics are a little less sure about that rose-colored-glasses view of an industry mired in data-privacy scandals.

Politico: Trump’s Next Health Care Move: Giving Silicon Valley Your Medical Data


Covered California enrollment numbers gave health law supporters something to be smug about this week: Thanks to a state-level individual mandate and more subsidies, the marketplace saw a 41% jump in new sign-ups. Covered California officials were pretty much, like, “See what can be done when you support this model?”

Sacramento Bee: Covered California Health Insurance Sign-Ups Rise in 2020

Speaking of California, Gov. Gavin Newsom made a big statement by devoting the entirety of his State of the State address to the homelessness crisis. “Let’s call it what it is. It’s a disgrace,” he said. A main focus for Newsom was the intersection of mental health and homelessness, and what the state can be doing to better help those who need it.

Los Angeles Times: California Homelessness Crisis ‘A Disgrace,’ Newsom Says in State of the State


In the miscellaneous file for the week:

— Pharma used to rule the roost on Capitol Hill. But those days are looking more and more like a thing of the past. The WSJ dissects the once-ironclad relationship between the industry and Republicans, and what went wrong for the drugmakers.

The Wall Street Journal: How the Drug Lobby Lost Its Mojo in Washington

— These days we’re used to courts demanding scientific evidence, to jurors being presented with experts in the field when having to make a decision about the medical ramifications of something like a pesticide or other chemical. But that wasn’t always the case. Undark looks back on when that changed, and the family that’s cited so often in court cases their name has become a verb.

Undark: For Science in the Courts, the Daubert Name Looms Large

— Ever wonder why things are priced to the 99 cents? That’s because of the way people perceive numbers and the greater likelihood you’ll buy something priced at $4.99 versus $5.00. When it comes to pennies, that might seem inconsequential. But it turns out the same kind of thinking can be applied to age — and, thus, decisions about where the cutoff should be on procedures like open-heart surgery.

Stat: How Psychology of a $4.99 Price Tag May Affect Doctors’ Decisions

— Everyone went into the opioid lawsuits with high hopes, buzzing about the possibility of the reckoning (and settlement) being akin to that of Big Tobacco’s in the 1990s. But the reality is likely to be a letdown.

The New York Times: Payout From a National Opioids Settlement Won’t Be As Big As Hoped


And that’s it from me! Have a great weekend.

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Elections

Analysis: Who Profits From Steep Medical Bills? The People Tasked With Fixing Them.

Every politician condemns the phenomenon of “surprise” medical bills.

Last week, two committees in the House were marking up new surprise billing legislation. One of the few policy proposals President Donald Trump brought up in this year’s State of the Union address was his 2019 executive order targeting “balance bills.” In the Democratic debates, candidates have railed against such medical bills, and during commercial breaks, back-to-back ads from groups representing doctors and insurers proclaimed how much the health care sector also abhors this uniquely American form of patient extortion.

Patients, of course, hate surprise bills most of all. Typical scenarios: A patient having a heart attack is taken by ambulance to the nearest hospital and gets hit with a bill of over $100,000 because that hospital wasn’t in his insurance network. A patient selects an in-network provider for a minor procedure, like a colonoscopy, only to be billed thousands for the out-of-network anesthesiologist and pathologist who participated.

And yet, no one with authority in Washington has done much of anything about it.

Here’s why: Major sectors of the health industry have helped to invent this toxic phenomenon, and none of them want to solve it if it means their particular income stream takes a hit. And they have allies in the capital.

That explains why Trump’s executive order, issued last year, hasn’t resulted in real change. Why bipartisan congressional legislation supported by both the House Energy and Commerce Committee and the Senate Health Committee to shield Americans from surprise medical bills has gone nowhere. And why surprise billing provisions were left out of the end-of-year spending bill in December, which did include major tax relief for many parts of the health care industry.

Surprise bills are just the latest weapons in a decades-long war among the players in the health care industry over who gets to keep the fortunes generated each year from patient illness: $3.6 trillion in 2018.

Here’s how they came to be:

Forty years ago, when many insurers were nonprofit entities and being a doctor wasn’t seen as a particularly good entree into society’s top 1%, billed rates were far lower than they are today, and insurers mostly just paid them. Premiums were low or paid by an employer. Patients paid little or nothing in copayments or deductibles.

That’s when a more entrepreneurial streak kicked in. Think about the opportunities: If someone is paying you whatever you ask, why not ask for more?

Commercial insurers as well as Blue Cross Blue Shield plans, some of which had converted to for-profit status by 2000, began to push back on escalating fees from providers, demanding discounts.

Hospitals and doctors argued about who got to keep different streams of revenue they were paid. Doctors began to form their own companies and built their own outpatient surgery centers to capture payments for themselves.

So today your hospital and doctor and insurer — all claiming to coordinate care for your health — are often in a three-way competition for your money.

As the battle for revenue has heated up, each side has added weapons to capture more: Hospitals added facility fees and infusion charges. Insurers levied ever-rising copayments and deductibles. Most important, they limited the networks of providers to those that would accept the rates they were willing to pay.

Surprise bills are the latest tactic: When providers decided that an insurer’s contracted payment offerings were too meager, they stopped participating in the insurer’s network; either they walked away or the insurer left them out. In some cases, physicians decided not to participate in any networks at all. That way, they could charge whatever they wanted when they got involved in patient care and bill the patient directly. For their part, insurers didn’t really care if those practitioners demanding more money left.

And, for a time, all sides were basically fine with this arrangement.

But as the scope and the scale of surprise bills have grown in the past five years, more people have experienced these costly, unpleasant surprises. With accumulating bad publicity, they have become impossible to ignore. It was hard to defend a patient stuck with over $500,000 in surprise bills for 14 weeks of dialysis. Or the $10,000 bill from the out-of-network pediatrician who tends to newborns in intensive care. How about the counties where no ambulance companies participate in insurance, so every ambulance ride costs hundreds or even thousands of dollars?

These practices are an obvious outrage. But no one in the health care sector wants to unilaterally make the type of big concessions that would change them. Insurers want to pay a fixed rate. Doctors and hospitals prefer what they call “baseball-style arbitration,” where a reasonable charge is determined by mediation. Both camps have lined up sympathetic politicians for their point of view.

So, nothing has changed at the federal level, even though it’s hard to imagine another issue for which there is such widespread consensus. Two-thirds of Americans say they are worried about being able to afford an unexpected medical bill — more than any other household expense. Nearly 8 in 10 Americans say they want federal legislation to protect patients against surprise bills.

States are passing their own surprise billing laws, though they lack power since much of insurance is regulated at a national level.

Now members of Congress have yet another chance to tackle this obvious injustice. Will they listen to hospitals, doctors, insurers? Or, in this election year, will they finally heed their voter-patients?

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Cost and Quality Health Care Costs Health Industry Insurance Uninsured