L Norsa et al JPGN 2021; 73: 48-53. Scoring Endoscopy in Pediatric Inflammatory Bowel Disease: A Way to Improve Quality This study showed very poor agreement between 11 pediatric GIs in evaluating videos of 15 endoscopies (see below). Key finding: Intraclass correlation was 0.298 (95% confidence interval [CI]: 0.13–0.55) for ulcerative colitis (UC) and 0.266 (0.11–0.52) for Crohn disease (CD). My take: This study indicates either a need for rigorous training of endoscopists and/or need for AI review of endoscopy.
NY Times 7/2/21: Full text: For Surprise Medical Bills, It’s the Beginning of the End Key issues for regulators: define a standard price for out-of-network care, determine what hospitals and doctors will need to do to notify patients they are not in their insurance network, and establish a complaint system for consumers who believe they were illegally billed.
Pleasant surprises often don’t work out. Case in point: a colleague sent me an email to our joint email account letting me know that he would not be able to come to my wife’s surprise party (she probably knew anyway).
When it comes to medical billing, surprises are never intended to be pleasant. “As many as one in five patients visiting an emergency department or undergoing elective surgery receives an out-of-network bill from a clinician whom they had no ability to choose.”
“Effective January 1, 2022, patients receiving an out-of-network emergency services, air-ambulance transportation, or out-of-network nonemergency services at in-network facilities may be billed only the amount they would owe for an in-network provider.”
“Out-of-network providers and insurers will have 30 days to agree on payment and then may invoke a binding arbitration process.”
“Three days before scheduled procedures, clinicians and insurers must inform patients of their expected out-of-pocket costs and clinicians’ network status and consenting to out-of-network bills can patients be balance-billed.
“This notice-and-consent doesn’t apply to emergency services [and] situations in which there are no in-network alternatives…patients cannot be balance billed in these cases…, even if they provide consent.”
“The Congressional Budget Office estimates that the law will reduce payments for some clinicians, reduce insurance premiums by up to 1%, and save the federal government nearly $17 billion over 10 years.”
“The law’s transparency provisions–particularly the requirements to provide advance price and network-participation information –may have a larger effect on day-to-day practice than its balance-billing provisions.”
Omission in law: ground-ambulance surprise bills
Potential effect: insurers may leverage the law to drop high-priced providers and potentially the law may lead to low-price providers to drop out of network
My take: This is a huge advance for patients/families; it is likely to reduce financial harm to patients and improve trust in the health care system.
Background: “Federal law eliminates consumer cost sharing for multiple methods of colorectal cancer screening, including colonoscopy when done by an in-network provider. However, some patients having screening incur considerable out-of-pocket costs because out-of-network bills are not included in federal mandates. “Surprise billing” articles are widespread in the research literature and lay press . To date, the frequency of unexpected patient costs for screening colonoscopy have yet to be rigorously quantified.”
This study with ~983,000 procedures, which was conducted between 2012-2017, shows that it is common to get additional charges from a screening colonoscopy (which is supposed to be covered). Despite using an in-network physician, these charges can be due to “out-of-network” costs from anesthesia or pathology. This can also occur when anesthesia bills the colonoscopy as a diagnostic procedure rather than as a screening procedure.
This blog does not receive any sponsorships. That being said, my wife made a batch of these cookies and they are delicious! My advice is to freeze half the batch and cook some later to avoid overconsumption.
A recent commentary (ECF Brown. NEJM 2020; 382: 1189-91) helps explain why surprise billing still exists despite bipartisan contempt.
“An estimated 20% of U.S. emergency-department visits, 9% of inpatient admissions, and more than half of ambulance or air-ambulance transports involve an out-of-network provider.”
“Surprise medical billing…is more prevalent …in groups owned by certain private-equity investment companies.”
There are generally two approaches to solving the problem of surprise medical billing, either arbitration or using a payment benchmark, the former generally favors providers and the latter generally favors payers.
“Deep-pocketed private equity firms continue to oppose any legislation that cuts into their profits, as they increase their investments in physician practices…Nearly everyone else agrees that patients should be protected from surprise medical bills.”
My take (borrowed from the author): The outcome of the surprise medical billing issue “raises questions about both the role of private equity in health care and the ability of Congress to pass meaningful health care legislation.”
This article describes how “surprise bills are just the latest in a decades-long war between players in the health care industry over who gets to keep the fortunes generated each year from patient illness — $3.6 trillion in 2018.”
“Forty years a go, …billed rates were far lower…and insurer mostly just paid them…That’s when a more entrepreneurial streak kicked in…If someone is paying you whatever you ask, why not ask for more?”
“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; 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.”
Members of Congress can address this problem and “tackle the obvious injustice. Will they listen to hospitals, doctors, insurers? Or, in this election year, will they finally heed their voter-patients?”
My take: When physicians/hospitals and insurance companies are at odds, patients/families are the ones paying the price.
A recent study has shown how pervasive surprise billing has become. This is another area in medicine in which deceptive billing practices undermine the relationship between families and health care providers.