Health Policy in Nursing Essay Paper

Identification of the problem/background

Surprise medical bills are a concern in the USA. Out of network charges expose medical service users to higher cost sharing when they seek medical services. This leads to a situation in which health care providers directly bill patients at unexpectedly higher rates to cover the billing difference that insurance fails to pay. In fact, 20% of insured adult Americans pay unexpected medical bills from out of network providers at every encounter. In addition, 67% of adult Americans are worried that surprise medical bills are making healthcare unaffordable for themselves and their families. This is especially a concern in emergency care delivery where 18% of visits result in at least one surprise bill with the rates varying between states (Pollitz et al., 2020). In this respect, surprise medical bills present a concern for health care delivery and access in the USA.

Surprise medical bills refer to unexpected costs that patients are expected to pay for receiving treatment from an out of network provider at an in network facility. They many presented as costs for services partially covered or not covered at all, depending on the type of insurance and benefit design. Within the USA, health plans contract with medical providers to reduce care costs and keep premiums low for consumers. The primary concern of the plans is costs with quality being a secondary concern. In this case, the insurers seek out providers who accept lower payments per patient in return for handling a larger number of patients. In this process, the plan ends up creating networks that exclude higher priced providers thus creating a narrow network of available health care providers. When patients who are covered by the plan receive medical care from out of network providers, they are likely to make higher out of pocket payments if a narrow network plan is used that does not cover any or all the costs. This gives rise to surprise medical bills that health plans reject to pay and are then forwarded to the patient (Kliff, 2019).

The presence of surprise medical bills is indicative of a mismatch and distortions in the US health care industry. The health plan offers patients access to an adequate network. However, there may be a mismatch of providers at critical moments, such as in medical emergencies. In addition, it results in the providers with lower prices enjoying monopolies in certain areas so that providers with higher prices lack negotiating leverage and remain unable to reach agreements with the plan and remain out of network. Local monopolies are especially common in areas experiencing scarcity of medical personnel, such as rural areas. This becomes a concern when providers who offer higher quality and higher prices medical services band together and refuse to be included in health plans contracts presented by insurers unless they meet their higher reimbursement cost demands (Lynch et al., 2019). It is not surprising that patients do not accept the narrow networks presented in the health plans, especially in emergency and potentially lifesaving situations where quality becomes a primary concern while cost turns into a secondary concern. In such cases, patients are likely to go for health services that may not be affordable or available in the health plan. For instance, when a patient requires emergency transport by an air ambulance that is not covered in the plan so that insurers balk at pay for the air ambulance costs. This results in surprise billing for the out of network essential services so that patients struggle to pay high medical costs out of pocket even with health insurance (Lynch et al., 2019).

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Introduction and discussion of the bill

The bill under consideration is Lower Health Care Costs Act (S.1895) that is sponsored by Sen. Lamar Alexander (R-TN) and was introduced into the Senate on 19th June 2019. The bill is currently before the Senate Committee on Health, Education, Labor and Pension. It seeks to makes changes related to health care services costs and coverage. Of particular interest to the present analysis are the provisions related to ending surprise medical bills. Firstly, the bill proposes that in-network cost sharing requirements be applied to cover certain non-emergency and emergency medical services that are provided out of network. In addition, the bill prohibits medical practitioners and facilities from billing patients above the applicable in-network cost sharing rates set for such medical services. Secondly, the bill includes a requirement for health care practitioners and facilities to present patients with a list of the services they provided. The list must be provided upon discharge and billed within 45 days so that patients are aware of what they are paying for and are better protected from surprise charges. Health Policy in Nursing Essay Paper Thirdly, the prices that pharmacy benefit managers charge for prescription drugs are limited. Finally, estimated out of pocket costs are presented by insurers and accessible to patients through specified technologies, such as mobile applications (Congress.Gov, 2020; GovTrack, 2020). Overall, the bill helps to protect patients from surprise bills and goes on to reduce payments.

Relation of the proposed legislation to an objective from Healthy People 2020

The proposed legislation (S.1895 – Lower Health Care Costs Act) is related to the second objective of Healthy People 2020. The identified objective seeks to achieve health equity, eliminate disparities and improve the health of all groups. Surprise medical bills are burdensome to patients, and they contribute to health inequity and disparities. That is because patients end up receiving bills for medical services that are supposed to have been covered by health insurance. These unexpected bills leave many patients in medical debt and make them wary of using medical services for fear of the associated financial burden. In addition, the unexpected bills are charged at significantly higher rates than the services provided in negotiated networks. The concern is further highlighted by the fact that medical debt among patients remains a leading cause of bankruptcy filings in the USA (Cunningham, 2019).

The situation that leads to surprise billing is deliberately created by health insurance plans that narrow the network of health care providers available to patients with insurance coverage. This is a situation that shrinks the network of providers thereby increasing the probability that a patient would receive care from an out of network provider, especially in emergency situations. In addition, surprise billing shifts costs to patients as they are exposed to higher out of pocket costs through higher copays and larger deductibles (Robeznieks, 2019). This has been the case for 57% of patients with the common sources of surprise billing being prescription drugs at 29%, imaging at 35%, facility charges at 43%, laboratory tests at 51% and physician services at 53%. These surprise medical billings occur for a range of reasons to include prescription drugs and medical services not being covered by the health plan (NORC at the University of Chicago, 2018).

Besides that, surprise billing denies care access through utilization management. Insurers make use of surprise billing alongside prior authorization to make patients pay for medically necessary treatments and procedures, as is the case for emergency situation, thus making patients more reliant on out of network care. This is the case even if the severity of the symptoms at the time of seeking treatment makes it prudent to visit the nearest emergency department that could be an out of network provider (Robeznieks, 2019).

Additionally, surprise billing helps to create disparities, especially in mental health coverage. Despite efforts to improve mental health parity, substance use and mental health treatments have been largely squeezed out of health plans so that they are now reliant on out of network care that are costly to access/receive the required medical services. To receive substance use and mental health treatments from out of network providers without paying the high surprise bills, patients are required to receive prior authorization even when time is of the essence to get the patient into treatment. The result is that patients who are unable to pay for out of network care have to do without care as they wait for prior authorization, even if the wait has devastating consequences. These sets of circumstances essentially create health inequity as care options become limited for persons with insurance and restricting access to treatment that is necessary to stabilize medical conditions. In passing the bill, the network of providers would be increases so that patients are not faced with surprise billing even in emergency situations (Robeznieks, 2019).

Desired outcomes and identification of stakeholders

Surprise medical bills contribute to higher health care costs, and this places a burden on patients. The bill seeks to lower health care costs. This is expected to result in four outcomes. Firstly, lower out of pocket payments for patients as health insurers will cover the previous unexpected medical bills. Secondly, increased access to health care as there will be no cost distinction between in network and out of network providers so that patients are not restricted on where to receive medical services. Thirdly, improved health care quality as there will be greater competition on quality and not just competition on cost as is the present case. Insurers are looking to improve their profits by selecting providers charging lower costs, and this tends to be associated with lower quality. Fourthly, improved health care access and equity since there would be more providers to choose from without necessarily paying higher costs (Lynch et al., 2019).

The major stakeholders in addressing health care costs are the insurance industry, pharmaceutical companies, physicians, patients and the government. Firstly, the insurance industry remains profit driven and efforts to eliminate surprise medical bills would cause their profits to dip as they take on the costs. They must be involved in seeking a balance between their responsibilities to patients and shareholders. Secondly, pharmaceutical companies play a key role on costs since patients rely on their products. High drug prices would cause patients to pay more while low drug prices would cause patients to pay less. Thirdly, physicians play a key role in health care costs through the prices they charge for their services. They must balance between their advocacy role for patients and gatekeeper role for insurance companies. Fourthly, patients are important stakeholders as they have a responsibility to control costs. They are interested in having lower health care costs and use their options to make cost-effective and reasonable choices. Finally, the government has a responsibility to deliver on the right to equality and right to liberty, which includes making care accessible at fair costs. Health care is a right that the government must seek to provide to its citizens, and this is possible through lowering costs (Truglio-Londrigan & Lewenson, 2018).

Conclusion

One must accept that surprise medical bills are a concern because they expose patients to higher cost sharing from the billing differences that insurance fails to pay with the need for higher out of pocket payments. In addition, one must acknowledge that Lower Health Care Costs Act seeks to address concerns about surprise medical bills by presenting in network sharing requirements, list of services and bills, limited pricing, and presentation of out of pocket costs. The proposed legislation has implications for achieving health equity, eliminating disparities and improving health as an objective of Healthy People 2020. The desired outcomes of the legislation are to lower out of pocket payments for patients, increase access to health care, improve health care quality, and improve health care access and equity. The major stakeholders who would be involved in developing the legislation addressing health care costs include the insurance industry, pharmaceutical companies, physicians, patients and the government.

References

Congress.Gov (2020). S.1895 – Lower Health Care Costs Act. https://www.congress.gov/bill/116th-congress/senate-bill/1895

Cunningham, P. (2019). The Health 202: Congress is probing secretive groups opposing medical billing reforms. https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2019/09/17/the-health-202-congress-is-probing-secretive-groups-opposing-medical-billing-reforms/5d7fd3e2602ff171a5d735fd/

GovTrack (2020). S. 1895 – 116th Congress: Lower Health Care Costs Act. https://www.govtrack.us/congress/bills/116/s1895

Kliff, S. (2019). Surprise Medical Bills, the High Cost of Emergency Department Care, and the Effects on Patients. JAMA Intern Med., 179(11), 1457-1458. https://doi.org/10.1001/jamainternmed.2019.3448

Lynch, H., Cohen, G., Shachar, C., & Evans, B. (Eds.) (2019). Transparency in Health and Health Care in the United States: Law and Ethics. Cambridge University Press.

NORC at the University of Chicago (2018). New survey reveals 57 percent of Americans have been surprised by a medical bill. https://www.sciencedaily.com/releases/2018/08/180830143045.htm

Pollitz, K., Lopes, L., Kearney, A., Rae, M., Cox, C., Fehr, R., & Rousseau, D. (2020). US Statistics on Surprise Medical Billing. JAMA Inforgraphic, 323(6), 498. https://doi.org/10.1001/jama.2020.0065

Robeznieks, A. (2019). 6 ways insurers drive the surprise-billing phenomenon. https://www.ama-assn.org/delivering-care/patient-support-advocacy/6-ways-insurers-drive-surprise-billing-phenomenon

Truglio-Londrigan, M., & Lewenson, S. (Eds.) (2018). Public Health Nursing: Practicing Population-Based Care (3^rd ed.). Jones & Bartlett Learning, LLC.  Health Policy in Nursing Essay Paper