THE PROGNOSIS

Partisan divisions could stymie hopes of improving Obamacare or cracking down on high prescription drug prices. But there is a bipartisan effort underway in Congress to protect Americans who get surprise medical bills after an emergency department visit or a hospital stay.

Democratic and Republican senators plan to propose legislation this month that would extend protections to ensure patients with health insurance don’t face surprise, often sizable medical bills after going to the hospital. These types of charges originate when a patient unexpectedly receives care from a doctor who is outside their plan’s network — typically in an emergency department or over the course of an in-network hospital stay.

The legislation — spearheaded by Sen. Bill Cassidy (R-La.) — represents the culmination of two efforts last fall to seek ways to mitigate surprise medical bills for people with coverage through their employers. Cassidy, along with Sens. Michael Bennet (D-Colo.), Tom Carper (D-Del.), Chuck Grassley (R-Iowa), Claire McCaskill (D-Mo.) and Todd Young (R-Ind.), released draft legislation in September. In October, Sen. Maggie Hassan (D-N.H.) introduced similar legislation.

Even when patients carefully select a hospital that is in network with their insurance plan — to pay lower in-network rates — they may still end up receiving care over a hospital stay from a radiologist, anesthesiologist or pathologist who isn't part of their insurance's coverage network. As a result, they’ll receive higher bills reflecting out-of-network rates — charges that can amount to thousands or even tens of thousands of dollars.

This is also a problem when patients are receiving emergency care and can’t choose their physician. In a study by Yale University researchers, of more than 99 percent of emergency department visits that occurred at in-network facilities, 22 percent involved out-of-network doctors.

The legislative proposals would ban insurers from charging patients higher costs after they unexpectedly see an out-of-network provider and lay out a standard for determining how much insurers would owe providers in those situations.

“Our guiding principle is how do you hold the patient harmless,” Cassidy told reporters last week. “Under the current system, the patient is an excuse for a business model … and the patient should be the center point.”

Cassidy and Bennet said they’ve received more than two dozen letters from providers, insurers and other stakeholders, who they’d invited to weigh in. They’re working with Hassan to combine the two proposals into a single bill they hope to release by the end of March.

“I am pleased that we are all working together across party lines to draft a bill that will help end the absurd practice of surprise medical bills and take the patient out of the middle of these disputes,” Hassan said in a statement.

The effort reflects a growing recognition that surprise medical bills are yet another consumer challenge when it comes to navigating the often-befuddling world of health insurance. In a recent Kaiser Family Foundation poll, four in 10 respondents said they had a surprise bill from a doctor, hospital or lab in the past year.

A number of states — including Arizona, Missouri, New Hampshire, New Jersey and Oregon — have passed measures to protect consumers from these types of bills. But states can’t regulate many health plans offered by large employers (called self-insured plans), so federal legislation would be needed to broadly apply the protections to the approximately 160 million Americans with employer-sponsored coverage.

Unexpected medical costs top the list of concerns people have about things they might not be able to afford. Sixty-seven percent of respondents to the Kaiser poll said they were “very” or “somewhat” worried about surprise medical bills, compared to just 41 percent who said they worried about affording their rent or mortgage.

Stories about patients facing shockingly huge, unexpected medical bills have gone viral. In one case, a Texas man with an Aetna insurance plan was billed $108,951 for a four-day stay at an out-of-network hospital following a heart attack. In another case, a woman was charged $17,850 for a urine test because it was evaluated at a lab outside her insurance network.

President Trump recently addressed the situation at a January roundtable on health-care costs. “Patients should know . . . the real price and what’s going on with the real prices of procedures. Because they don’t know,” the president said. “They go in, they have a procedure, and then all of a sudden, they can’t afford it. They had no idea it was so bad.”

It’s important to understand that the legislation being worked on by Cassidy and others won’t ensure patients never receive medical bills that might catch them unawares. Insurance plans often carry high deductibles people may not realize they must meet before their coverage fully kicks in. And if patients electively choose to visit a hospital or clinic that is out of network, insurers are fully within their right to charge higher cost-sharing for that care.

It’s the truly surprise medical bills that the lawmakers are going after — the bills patients can’t avoid even after doing their due diligence. Cassidy said one of the tricky problems in writing the legislation is making sure it’s fair to both insurers and doctors. That requires limiting how much physicians can charge for out-of-network care delivered under the circumstances the bill is trying to address, but also seeks to ensure insurers provide more generous coverage so patients don’t get these kind of bills.

“We’re trying to come up with something which holds the patient harmless but is fair to both parties,” Cassidy said.

AHH, OOF and OUCH

AHH: An 18-year-old who got vaccinated against the wishes of his anti-vaxx mother has been invited to speak before lawmakers who are examining what is causing outbreaks of preventable disease.

Ethan Lindenberger from Ohio is set to testify Tuesday in front of the Senate Health, Education, Labor and Pensions Committee alongside experts in the field.

“I’m looking forward to speaking in Washington, D.C.,” Lindenberger said in a YouTube video over the weekend announcing his scheduled appearance. He also shared the news on Twitter:

“Lindenberger’s story has caught on amid a measles outbreak that has affected dozens of people in the United States, prompting increasing scrutiny of parents who do not get their children vaccinated,” our Post colleague Kayla Epstein writes. “The teenager said he lived for years without being vaccinated because of his mother’s belief in vaccine conspiracies. So Lindenberger began to do his own homework, consulting scientific research and the Centers for Disease Control and Prevention.”

In the Pacific Northwest, 68 people have contracted measles amid the ongoing outbreak, according to the Associated Press. Meanwhile in the state of Washington, lawmakers want to pass a bill that would limit exemptions people could seek for vaccination requirements, but they face opposition from members of the anti-vaxx movement who believe vaccines lead to health conditions such as autism, Kayla writes.

OOF: Centers for Disease Control director Robert Redfield is planning to travel to the Democratic Republic of Congo this week, Stat News’s Helen Branswell reports, as the ongoing Ebola outbreak is now the second-largest ever recorded.

There have been 888 people infected by the outbreak as of last week, and 557 who have died.

CDC spokeswoman Kate Grusich did not confirm the plans to Stat, saying the agency doesn’t confirm specific travel locations to “protect the safety of CDC staff, including leadership.” The director-general of the World Health Organization Tedros Adhanom Ghebreyesus is set to travel with Redfield, Helen reports.

Last year, the agency withdrew workers from the region affected by the outbreak because of security concerns, and those concerns have continued, she adds, as “two medical groups that were running the operations in the area decided to withdraw their personnel following attacks on Ebola treatment centers.”

“Since this outbreak began, 168 CDC employees have been deployed to DRC, neighboring countries or to WHO headquarters, Grusich said,” Helen writes. “And other U.S.-based personnel have been working with the Congolese health ministry, providing guidance on matters such as case investigation, contact tracing, and community engagement.”

OUCH: It’s been more than two months since D.C. Mayor Muriel Bowser announced a plan to reduce by half opioid overdose-related deaths in the District by late 2020. But our Post colleague Peter Jamison writes key programs from the plan aren't yet deployed. The efforts the mayor detailed included an expanded availability of the overdose antidote naloxone and new treatment programs for overdose survivors in emergency rooms, but both of those programs are still in the planning stages, according to city officials and service providers.

“City officials said Friday that the mayor’s plans for reducing overdose deaths are on track,” Peter writes. “Within two weeks, the Bowser administration will be issuing a revised, more detailed plan that lays out specific goals and timelines, said Department of Health Director LaQuandra Nesbitt.”

Still, the slow start has troubled some critics who argue the city is wastimg time in responding to D.C.’s opioid crisis. D.C. Council member Vincent C. Gray (D-Ward 7), chairman of the council’s health committee, told Peter he did not see much progress.

“I don’t think anybody can truthfully tell you that a lot has occurred,” Gray said.

HEALTH ON THE HILL

— A bipartisan group of senators sent a letter to the Food and Drug Administration calling for a faster process for the approval of cheaper, generic insulin to help patients affected by the high cost of the life-saving treatment.

“To help expedite approval in the short term of desperately needed lower-cost biosimilar or ‘generic’ insulin products, we urge FDA to quickly amend its recent guidance documents that pose unreasonable approval delays for insulin products that could help patients with diabetes,” Sens. Dick Durbin (D-Ill.), Tina Smith (D-Minn.), Kevin Cramer (R-N.D.) and Bill Cassidy (R-La.) wrote.

“We recognize there are myriad reason for the significant insulin price increases, including limited competition, exploitation of the patent system, the opaque role of pharmacy benefit manager rebates, product improvements and variance over time, and lack of transparency,” they write. “However, it remains unacceptable that — nearly a century after insulin was first discovered — there are no approved, lower-cost insulin products that can be substituted at the pharmacy level.”

The lawmakers wrote the current regulatory process for approving biosimilar versions “introduces perverse incentives that could delay the introduction of low-cost insulin products into the market in the short-term, when they are needed most.”

MEDICAL MISSIVES

—The flu is still spreading throughout the United States this season.

At the end of February, high rates of the flu were reported in 33 states and in New York City, Bloomberg News’s Michelle Cortez reports.

“At this point a year ago, doctors’ visits for the flu were in the middle of a free fall after patients inundated hospitals and medical facilities for weeks. This season, it seems to be hitting a plateau,” Michelle writes. “In all, about one in every 20 doctor visits nationwide was because of flu-like symptoms, including fever, cough and a sore throat, according to a CDC weekly report known as the FluView. That’s higher for this time of year than in any recent season except last year’s epidemic, which killed almost 80,000 Americans.”

The head of the CDC’s domestic influence surveillance team told Michelle the flu season could still continue for several weeks or months more. The CDC has found that people in the country have been going to the doctor at higher than normal rates starting in mid-November.

— And here are a few more good reads: 

Economic Policy
It seems pretty clear that our 20th-century institutions are failing our 21st-century families.
Matt O'Brien
As financial pressures have forced scores of small-town nursing homes to shut down, their residents often must relocate far from their families to find care.
New York Times
Women and girls will be offered free tampons and other sanitary products, officials said, calling the move “a big step forward” in the effort to end period poverty.
New York Times
'We still get messages that say these diseases are good for you,' says one Oregon lawmaker who opposes efforts to let more parents opt out.
Politico
TRUMP TEMPERATURE
Politics
Sheldon Adelson and his wife, Miriam, are among President Trump’s most prolific backers.
Michelle Ye Hee Lee
OPIOID OPTICS
Health & Science
Dentists are overprescribing these painkillers. Recent studies show youths are at risk of addiction.
Ronnie Cohen
Limiting prescriptions seems logical, but a simulation study shows it would actually increase deaths, not decrease them, in the initial years.
New York Times
INDUSTRY RX
Daniel Loepp, president and CEO of Blue Cross Blue Shield of Michigan, earned total compensation of $19.2 million in 2018, a 43 percent increase from $13.42 million in 2017.
Crain's Detroit Business
DAYBOOK

 

Coming Up

  • The Senate Health, Education, Labor and Pensions Committee holds a hearing on vaccines and what’s driving preventable disease outbreaks on Tuesday.
  • The House Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies holds a hearing on electronic health record modernization on Wednesday.
  • The Food and Drug Administration holds a vaccines and related biological products advisory committee meeting Wednesday and Thursday.
  • The Senate Special Committee on Aging holds a hearing on prescription drug prices on Thursday.
  • The House Judiciary Subcommittee on Antitrust, Commercial and Administrative Law holds a hearing on the effects of consolidation and anticompetitive conduct in health care markets on Thursday.  
SUGAR RUSH

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