THE PROGNOSIS

President Trump struck a conciliatory tone yesterday as he advocated protecting consumers from surprise medical bills. But differences between the White House and members of Congress over precisely how to do that are already emerging.

The difference is over whether to use a process known as “baseball-style arbitration” to settle billing disputes between insurers and health providers. Senators working on surprise-billing legislation said arbitration is a proven, effective approach, even as White House officials threw cold water on the idea.

Let’s back up for a minute. In an address at the White House (which The Health 202 previewed here), the president laid out broad areas of agreement regarding the bills incurred by many Americans when, through no fault of their own, they receive care at an emergency room outside their health plan’s network or are unexpectedly seen by an out-of-network doctor even though they’re at an in-network hospital.

Politicians and industry folks agree that patients shouldn’t be forced to pay these extra bills, which can be thousands or tens of thousands of dollars. Trump said Congress should work quickly to stop the practice, which he said is bankrupting patients by charging them for “unexpected health-care costs that are absolutely out of control.”

“No family should be blindsided by outrageous medical bills,” the president said.

Several victims of surprise medical billing were standing next to Trump and even allowed to make some of their own remarks. Health reporters have told many of their stories. Reuters reporter Chad Terhune: 

Standing next to Trump were two senators working on legislation to protect patients from surprise medical bills. Sens. Bill Cassidy (R-La.) and Maggie Hassan (D-N.H.), along with Sen. Michael Bennet (D-Colo.), are leading a bipartisan effort to craft legislation laying out exactly how insurers and providers can reach agreement on out-of-network bills without involving patients.

The group has yet to unveil legislation — they’ve promised it will be ready in the next few weeks — but both Cassidy and Hassan hinted strongly they prefer baseball-style arbitration. In this process, which Hassan has proposed separately in previous legislation, a third party collects two figures — what the doctor is charging and what the insurer is agreeing to pay — and decides which figure is fairest.

The process is similar to the way salaries for Major League Baseball players are decided. The player and the team are permitted to name the salary they feel is most appropriate, and an independent arbiter picks one. Both sides are incentivized to offer realistic salaries because they want the figure they’ve cited to win out.

The state of New York, which passed arbitration legislation in 2015, has been successful in reducing out-of-network emergency room billing. The percent of out-of-network emergency department services that were billed decreased from 20 percent in 2013 to 6 percent after the law was implemented, according to Yale University researchers.

“I’m a big believer that the states experiment and we learn from their experiment,” Cassidy said. “Arbitration has worked in New York.”

But in a news briefing earlier in the day, White House officials said they don’t favor arbitration, calling it an “unnecessary distraction.”

“We do not have a lot of enthusiasm for arbitration,” a senior administration official told reporters. “We believe that would be disruptive. And we believe … at the end of the day, a lot of potential abuses disguised in a different form would nevertheless still be inflicted against patients and Americans.”

Politico's Rachel Roubein: 

Karan Chhabra, a surgical resident at Brigham and Women's Hospital:

Insurers were pleased by that position, as they have argued arbitration leads to unnecessarily high payments to doctors. “Arbitration gives equal weight to inflated doctors’ bills . . . [and] negotiated rates,” Adam Beck, vice president for policy of America’s Health Insurance Plans, told my Washington Post colleague Amy Goldstein.

But doctors groups also pointed to New York's example, saying the federal government should try what has worked for states. “It’s encouraging that the White House agrees with patients and physicians throughout the country who are urging Congress to take action,” said Sherif Zaafran, chairman of Physicians for Fair Coverage. “The best way to ensure no patient receives a surprise bill is for Congress to pass legislation with a dispute resolution process, which has already been implemented in nine states, including years of success in New York.”

Chip Kahn, president of the Federation of American Hospitals, praised the administration's focus on the issue. “We think that patients should be held harmless for these out-of-network charges to their expected cost-sharing, so the White House’s interest focuses a light on an issue that Congress should address,” he said.

Despite his bipartisan tone, Trump couldn't resist promising yet again that Republicans would come up with another sweeping health-care bill, presumably to replace the Affordable Care Act Act. Per the Hill's Peter Sullivan: 

AHH, OOF and OUCH

AHH: Gilead Sciences, the drugmaker behind the highly effective once-a-day HIV prevention medication, announced it would donate enough pills to cover as many as 200,000 people a year for up to 11 years. Health and Human Services Secretary Alex Azar announced the donation was “a result of discussions between the Trump Administration and Gilead Sciences.”

The company will donate up to 2.4 million bottles of the drug Truvada to the Centers for Disease Control and Prevention, and the agency will distribute the medication to people who are uninsured and at a high risk of contracting HIV, our Post colleague Lenny Bernstein reports. 

Gilead’s donation is part of the president’s pledge to stop the spread of HIV in the country by 90 percent by 2030. “The government strategy to curb the spread of HIV focuses on the small number of places where the virus is concentrated: the District of Columbia; Puerto Rico; 48 hot-spot counties across the country and in the rural parts of seven Southern states,” Lenny writes. “In 2017, the South had about 20,000 new HIV diagnoses, more than the rest of the country combined.”

A one year supply of the drug, known as PrEP, costs more than $20,000. “The majority of Americans who are at risk and who could protect themselves with PrEP are still not receiving the medication,” Azar said in a statement. “This agreement will help close that gap substantially.”

OOF: The Alabama Senate postponed until next week a vote on a controversial abortion bill after chaos broke out in the chamber over a procedural vote.
 
The bill would be the most restrictive in the country, effectively imposing a ban on abortions by making performing the procedure a felony punishable by up to 99 years in prison. Shouting erupted after an abrupt move to strip an exception for rape and incest from the bill without calling for a roll-call vote.
 
From local CBS reporter Reshad Hudson:

The bill, which is still expected to be passed by the conservative majority, is one of many measures introduced around the country making abortion illegal within the first few weeks of pregnancy. “Alabama Rep. Terri Collins (R), who sponsored the bill, said its purpose is to spark litigation that would force the conservative majority on the U.S. Supreme Court to reconsider Roe v. Wade, the landmark 1973 decision that guarantees a woman’s right to abortion,” our Post colleagues Emily Wax-Thibodeaux and Ariana Eunjung Cha report.

OUCH: The Kentucky teenager who sued a local health department after he was banned from school for not having the chickenpox vaccine contracted chickenpox last month.

His father believes that’s a good thing, our Post colleague Michael Brice-Saddler reports. Chris Wiest, an attorney for the family, said the newfound immunity 18-year-old Jerome Kunkel has after contracting the disease is proof there was no need for a ban.

In March, the Northern Kentucky Health Department barred students who did not have proof they had received the chickenpox vaccine or were immune. Kunkel’s family is against the vaccination because of religious beliefs, and sued the health department to end the ban.

“This is a stupid ban that’s never going to work, ” the family’s attorney said. “We are not at all surprised. This is exactly what we told the court would happen. Over half my clients contracted chickenpox and had no complications, and now they have a lifetime immunity.”

In a statement, the Northern Kentucky Health Department criticized Wiest’s suggestion that people should contract the disease to become immune.

“While the tactic Wiest suggests may provide an individual with future immunity from chickenpox, this infected person can easily spread the virus to other, unsuspecting people, including those particularly vulnerable to this potentially life-threatening infection,” the statement read. “Encouraging the spread of an acute infectious disease in a community demonstrates a callous disregard for the health and safety of friends, family, neighbors, and unsuspecting members of the general public.”

HEALTH ON THE HILL

— Rep. Ayanna Pressley (D-Mass.) and Democratic presidential contender Sen. Cory Booker (D-N.J.) have introduced a bill to address high maternal mortality rates, specifically pointing to the particularly high death rates for black women.

The Healthy MOMMIES Act looks to expand Medicaid to make sure pregnant women are covered across the pregnancy, labor and postpartum periods, increasing coverage from 60 to 365 days after giving birth. The bill ensures coverage beyond services only related to pregnancy.

The bill, introduced days before Mother’s Day, also comes as a recent report from the CDC found that in the United States, there are 40 pregnancy-related deaths among black women for every 100,000 births. Black women are three times as likely as white women to die of pregnancy-related condition, the report found. 

“The lived experiences of Black women demonstrate how racism and trauma directly impact the health and wellbeing of marginalized communities for generations,” Pressley said in a statement. “Maternal justice is about ensuring that every mom-to-be is listened to and treated with dignity and respect during and after childbirth. The Healthy MOMMIES Act would do just that by promoting a community-based, holistic approach to maternal care that recognizes current disparities in healthcare and critical environmental factors impacting communities.”

— Sens. Mitt Romney (R-Utah) and Mike Braun (R-Ind.) introduced a bill meant to address skyrocketing out-of-pocket costs for consumers and increase transparency about the costs of medications they pick up at the pharmacy.

The Prescription Drug Rebate Reform Act of 2019 will mandate that coinsurance for patients be based on a percentage of net price, which is the price of a drug after rebates, discounts and fees. Patients currently pay coinsurance based on the drug’s list price, which does not include those discounts. “Drug prices—and out of pocket expenses paid by consumers—seem to continually be on the rise,” Braun said in a statement.

“What is not talked about enough, however, is the inherent conflict of interest arising from negotiated rebates that affect the actual cost of drugs, which are paid by drug makers to pharmacy benefit managers (PBMs) in exchange for preferred status on insurers’ health plan formularies … These rebates are often hidden from consumers, contribute to high list prices for prescription drugs, and leave consumers with all, or a big part of the tab.”

OPIOID OPTICS

— There are signs the deadly opioid crisis is starting to slow in Maryland.

According to preliminary data released from a state organization in Maryland, there were 2,114 opioid-related deaths last year in the state, which is an increase of 5.2 percent from the year prior. While still an uptick, it’s the slowest single-year increase since 2011, according to the data released by Maryland’s Opioid Operational Command Center in a first-of-its-kind report, our Post colleague Erin Cox reports.

The rise in annual fentanyl deaths was not as sharp last year as it was before, with a 17.1 percent increase in 2018 compared with a 42.5 percent jump the year before that. Still, more people were killed by fentanyl and fentanyl mixed with cocaine, while deaths from heroin and prescription painkillers declined last year, Erin reports.

Steven R. Schuh, executive director of the state organization that tracks the government’s response to the opioid crisis, said: “We are encouraged that the epidemic is starting to plateau.”

MEDICAL MISSIVES

— A group of diabetes advocates traveled from Minnesota to Canada over the weekend in part to make a point about the cost of insulin.

“Can you explain to me why I would stay in the U.S. and continue to be price-gouged for $320 a vial when I can drive five hours and get it for $30?” one of the participants in the mission told Stat’s Nicholas Florko. “The only difference between us and Canada is politicians here in America have not created any solutions to lower the price of insulin. … The federal government, they talk about all these laws, but they can’t get them passed.”

That participant, Quinn Nystrom, has diabetes and said she spends more than $7,000 in out-of-pocket expenses a year. Others on the trip, such as Nicole Smith-Holt, whose son Alec died after rationing his insulin, made the trip as a symbolic effort. 

After a five-hour car ride, the group walked into a pharmacy and came out with the medication they wanted — many bought Novo Nordisks’s NovoLog, labeled in Canada as NovoRapid, at $30, compared to the $289.36 list price in the United States, Nicholas writes.

— And here are a few more good reads: 

The court has also put off taking action in cases involving abortion, same-sex wedding cakes and transgender bathroom access.
Bloomberg
As violence makes it harder to reach stricken villages in Congo, experts plan to stretch supplies and to give the vaccine to everyone, not just contacts of victims.
New York Times
Health
Researchers in Australia found that kissing with tongue could be a way to transmit throat gonorrhea, or oropharyngeal gonorrhea, particularly among gay and bisexual men.
Lindsey Bever
AGENCY ALERT
WASHINGTON (AP) — The Republican and Democratic leaders of the Senate Finance Committee are questioning whether the Trump administration is neglecting its duty to protect unaccompanied immigrant...
Associated Press
INDUSTRY RX
WASHINGTON (AP) — The young models and the candy-colored graphics that helped propel Juul to the top of the e-cigarette market are gone. In their place are people like Carolyn, a 54-year-old...
Associated Press
STATE SCAN
More Republicans, at the statehouse level, are saying research and results support their endorsement of a once-controversial plan to limit disease among drug users.
Kaiser Health News
DAYBOOK

Coming Up

  • The Washington Post Live will host actress and mental health advocate Glenn Close and Sens. Debbie Stabenow (D-Mich.) and Roy Blunt (R-Mo.) for an event on mental health and addiction on May 16.
SUGAR RUSH

The Fix’s Amber Phillips on the standoff between congressional Democrats and the Trump administration and whether it could lead to impeachment proceedings: