It’s About Time: No Surprises Act

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.”

It appears that improvement in this area is on the horizon. KR Chhabra et al. NEJM 2021; 384:1381-1383. No More Surprises — New Legislation on Out-of-Network Billing

Key points:

  • “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.

Related blog posts:

Be Kind & the 21st Century Cures Act

I remember when I was first taught to dictate consultations. I was a resident doing a genetics rotation. My mentor, Peter Dignan, made several suggestions. One was to try to always include something nice about the patient. Many of my current colleagues are amused how many of my patients are ‘delightful.’ While there are a lot reasons for putting some kind information in the medical record, Dr. Dignan emphasized that patients and families can get hold of their records and undoubtedly they would appreciate a friendly word. Now with the 21st Century Cures Act Final Rule, access to records and notes will expand considerably and Dr. Dignan’s advice is probably even more important.

A good source of information on this new law, which is in effect Nov 2nd, 2020, is from the 33charts blogCures Act Final Rule – How It Will Change Medicine: “The ONC Cures Act Final Rule (Cures Rule) is the biggest health care law you’ve never heard of. But it’s a law that’s going to fundamentally shift the way we see patients and their information. It will change how physicians talk to patients about information. It will shift the way health professionals connect patients to their information.” This blog post details how this change is going to affect both healthcare providers and families. The two key changes are

  • Access to clinical notes (ie, ‘open notes’)
  • Immediate release of tests and studies.

The key point: “The Cures Rule will force health systems to be better stewards of information on behalf of our patients. I think this is going to force health professionals to help patients think about information and what they do with it. It will force patients to recognize the difference between information and knowledge and wisdom. I suspect that the most critical ultimate change will be transparent conversations and more timely physician follow-up on high stakes studies.”

Another take on the 21st Century Cures Act: C Blease et al. Annals of Internal Medicine; 2020: New U.S. Law Mandates Access to Clinical Notes: Implications for Patients and Clinicians

Some additional information (from EPIC training) — there are limited exceptions for note sharing:

Another reference:

My take: When this rolls out, a lot of physicians (myself included) will need to make some adjustments; since it is the law, don’t expect to avoid these changes. I expect early on this will generate a lot of additional questions and phone calls. In the long run, this is likely to improve communication, transparency, and availability of patient information. For example, it is more likely that needed lab results from referring physicians will be more available after this law is in effect.

Doctor Scorecards: Affecting Care (but not in the way you think)

A recent perspective article (L Rosenbaum. NEJM 2015; 373: 1385-8) explains how the use of physician scorecards are negatively affecting patients and the pitfalls in their interpretation. Her article describes a situation, that is ‘not uncommon,’ in which a higher risk cardiology patient will not have a surgical consult for a few days because most surgeons “wouldn’t touch our patient with a 10-foot pole.”  In several states, the increase reports of cardiac surgery outcomes has resulted in surgeons avoiding the sickest patients. The author notes that transparency/public reporting needs to be balanced against the potential harms. Other key points:

  • The public reporting thus far has been deeply flawed, based on insurance claims that are “notoriously inaccurate.”  The reports have poor reliability, in part, due to too few surgeries to make accurate conclusions.
  • The public reports amount to “fear mongering” rather than the “professed commitment to protecting patients.”
  • “The key question, then, is less about transparency with regard to quality than it is about what constitutes quality in the first place.”
  • “The irony in hailing the scorecard as a victory for transparency is that its purported objectivity obscures its methodologic limitations.”

My take: While you are looking a surgeon’s scorecard, keep in mind, he/she may decide to not operate on you when he/she looks at your scorecard (of illness). Related blog posts: