- - Monday, November 18, 2019

The high cost of health care is putting the squeeze on all American families — and tightening that grip is an unfair practice known as surprise medical billing. Patients should not be held responsible for the costs associated with receiving out-of-network care, especially in emergency situations where they have little or no control over where or from whom they receive care.

Fortunately, Congress seems to be taking this issue seriously, with several legislative measures having been introduced to address this issue at the national level. However, some of the proposals currently on the table could come with some serious, negative consequences for patient access and affordability, especially in rural communities where these are already major causes for concern.

One particularly dangerous proposal is called “benchmarking,” and it would essentially put the government in charge of setting rates for physicians. To determine out-of-network rates, this method would rely on insurers’ in-network averages — which include significant discounts that arise during the contract-negotiation process with physicians. That means benchmarking would give insurers the power to drastically reduce reimbursements for physicians, passing enormous financial losses onto local hospitals and emergency rooms.


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In rural parts of the country, where our nation’s doctor shortage is most pronounced, such an approach could be devastating. It could result in many struggling health care facilities being forced to make cutbacks, consolidate or even close down altogether — thereby limiting patient choice, undermining access and pushing costs even higher. With rural Americans already facing such high barriers to care, benchmarking would only make things considerably worse.

For that reason, Congress should concentrate on another proposed solution — Independent Dispute Resolution (IDR). Through the IDR process, providers and insurers would be able to negotiate out-of-network payments through an online portal. The entire process would be overseen by an unbiased, third-party mediator who would take into consideration payment offers from each party as well as a number of other factors and independent data.



Within 30 days or less, this mediator would determine a fair, reasonable payment that ensures doctors are being reimbursed for the true value of their services and that health care facilities are able to continue providing high-quality care for the patients they serve. Moreover, under the IDR process, providers would receive interim payments that would be especially beneficial for struggling or at-risk hospitals and emergency rooms operating in America’s hard-to-reach, rural communities.

The IDR process has worked exceedingly well in New York, where it was passed into a law that went into effect in 2015. In that time, network participation has improved while out-of-network billing rates and emergency care costs have declined by 34 percent and 9 percent, respectively. Altogether, IDR has protected patients while saving New Yorkers some $400 million in emergency service alone. It is a solution that is working for all parties, with even the New York Health Plan Association endorsing the process because it ensures emergency services “are fair and reasonable while holding individuals harmless.”

As a former director of Emergency Services as a small regional hospital in New Hampshire, I know the last thing patients are thinking about when they need emergency care is which doctors are in which network. The same is true for the physicians and specialists that are charged with providing care for anyone who walks through their doors.

That is why Congress must find a smart solution to end surprise medical billing in a way that ensures patients are only responsible for their normal, in-network cost sharing amounts while at the same time preserving the strength and stability of local hospitals and emergency rooms, especially in rural communities where lack of access and high costs already prevent many from getting the care they need.

The only solution that will achieve these goals is one that incorporates the proven-effective IDR framework. Anything less would be a disservice to providers, to patients and to our entire health care system. Congress must pass strong, IDR-focused legislation without delay.

• Jennifer Nunez served as the director of Emergency Services at Lakes Region General Hospital in Laconia, New Hampshire.

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