Podcasts about usc brookings schaeffer initiative

Medicare could soon pay hospitals much less for common outpatient services like x-rays and checkups.This week, we explain an old policy gathering new steam in Washington, how it could save Medicare and patients billions of dollars a year, and why it has hospitals worried.Guests: Loren Adler, MS, Fellow and Associate Director, USC-Brookings Schaeffer Initiative for Health PolicyJoe Antos, PhD, Senior Fellow, American Enterprise InstituteAmol Navathe, MD, PhD, Associate Professor of Health Policy and Medicine, University of PennsylvaniaHannah Neprash, PhD, Assistant Professor, University of Minnesota School of Public Health Ashley Thompson, MHA, Senior Vice President, American Hospital AssociationLearn more and read a full transcript on our website.Want more Tradeoffs? Sign up for our free weekly newsletter featuring the latest health policy research and news.Support this type of journalism today, with a gift. Hosted on Acast. See acast.com/privacy for more information.

Health Affairs Editor-in-Chief Alan Weil interview Loren Adler from the USC-Brookings Schaeffer Initiative for Health Policy on his recently published paper in Health Affairs, which will appear in the February 2023 issue. He and colleagues examined pricing and billing for ground ambulance transportation with a particular focus on who owns the transportation service.The researchers found higher prices and higher potential surprise bills for private sector emergency ground ambulance transportation than for public sector ambulances. Join Us for the Considering Health Spending event on February 3.Order the February 2023 issue of Health Affairs.Currently, more than 70 percent of our content is freely available - and we'd like to keep it that way. With your support, we can continue to keep our digital publication Forefront and podcasts free for everyone.Subscribe: RSS | Apple Podcasts | Spotify | Stitcher | Google Podcasts

On Monday, January 10, the USC-Brookings Schaeffer Initiative for Health Policy brought together a panel of experts to discuss policy initiatives that can more effectively and humanely address behavioral health crises. Subscribe to Brookings Events on iTunes, send feedback email to events@brookings.edu, and follow us and tweet us at @policypodcasts on Twitter. To learn more about upcoming events, visit our website. Brookings Events is part of the Brookings Podcast Network.

This week our host Rich Ehisen is joined by Professor Maanasa Kona of the Georgetown University Health Policy Institute's Center on Health Insurance Reforms (CHIR) in Washington D.C. and Loren Adler, Associate Director of the USC-Brookings Schaeffer Initiative for Health Policy, a partnership between Economic Studies at Brookings and the University of Southern California Schaeffer Center for Health Policy & Economics for an interesting discussion of an intersection of state and federal health insurance billing policies.

¿Un test de covid más caro que un Tesla? Cuando covid 19 golpeó el año pasado, la compañía de Travis Warner se puso más ocupada que nunca. Instala sistemas de video e Internet, y con la gente repentinamente trabajando desde casa, las llamadas solicitando servicios aumentaron. Warner y sus empleados tomaron precauciones como usar máscaras y distanciarse físicamente, pero ir a las casas de los clientes a diario significaba un alto riesgo de exposición a covid. “Era como esquivar balas todas las semanas”, dijo Warner. En junio de 2020, un empleado dio positivo. Eso decidió a Warner y a su esposa a hacerse la prueba. Debido a la disponibilidad limitada de pruebas en ese momento, condujeron 30 minutos desde su casa en Dallas hasta una sala de emergencias independiente en Lewisville, Texas. Recibieron pruebas de diagnóstico por PCR y pruebas rápidas de antígenos. Fue un gran alivio cuando todos los resultados dieron negativo, dijo Warner. Volvió entusiasmado al trabajo. Hasta que llegó la factura. El paciente: Travis Warner, de 36 años, quien trabaja por cuenta propia y compró la cobertura de Molina Healthcare fuera del mercado de seguros. Servicio médico: dos pruebas de covid, una prueba de PCR de diagnóstico, que suele tardar unos días en procesarse y es bastante precisa, y una prueba rápida de antígenos, que es menos precisa pero produce resultados en minutos. Factura total: $56,384, incluidos $54,000 por la prueba de PCR y el saldo de la prueba de antígeno y una tarifa de servicio de urgencias. La tarifa negociada de Molina para ambas pruebas y la tarifa de la instalación ascendió a $16,915.20, que la aseguradora pagó en su totalidad. Proveedor de servicios: SignatureCare Emergency Center en Lewisville, una de las más de una docena de salas de emergencia independientes la empresa tiene en Texas. Contexto: A lo largo de la pandemia, abundaron las historias de precios sorprendentemente altos para las pruebas de covid. Un informe reciente de una asociación comercial de seguros indicó que “el aumento excesivo de precios por parte de ciertos proveedores sigue siendo un problema generalizado”. Pero la factura de PCR de Warner de $54,000 es casi ocho veces más alto que el cargo que hasta ahora se había reportado, de $7,000. Los expertos en políticas de salud que KHN entrevistó calificaron la factura de Warner de “astronómica” y “uno de los más tremendos” que habían visto. Sin embargo, es perfectamente legal. Para las pruebas de covid, como muchas otras cosas en la atención médica estadounidense, no hay límite para lo que los proveedores pueden cobrar, explicó Loren Adler, directora asociada de la USC Brookings Schaeffer Initiative for Health Policy. Las pruebas para Covid han estado en una categoría especial. Cuando golpeó la pandemia, a los legisladores les preocupaba que la gente decidiera no hacerse las pruebas por temor a los costos. Por aprobaron normas que requerían que las aseguradoras pagaran las pruebas de covid sin copagos ni costos compartidos para el paciente. Para los proveedores dentro de la red, las aseguradoras pueden negociar los precios de las pruebas, y para los proveedores fuera de la red, generalmente están obligados a pagar cualquier precio que los proveedores indiquen públicamente en sus sitios web. La sala de emergencias independiente estaba fuera de la red para el plan de Warner. Expertos en salud dicen que, si bien la política estaba destinada a ayudar a los pacientes, sin querer les ha dado a los proveedores margen para cobrar precios arbitrarios, a veces absurdos, sabiendo que las aseguradoras deben pagar y que es poco probable que los pacientes, a quienes no se les facturará, se quejen.

On Friday, April 9, the USC-Brookings Schaeffer Initiative for Health Policy hosted the 25th Wall Street Comes to Washington Health Care Roundtable as a webinar. Designed to bridge the worlds of Wall Street and Washington health policy, an expert panel of equity analysts, moderated by Initiative Director Paul B. Ginsburg, discussed market trends shaping the health care system and the impact of federal policies on health care companies. https://www.brookings.edu/events/wall-street-comes-to-washington-health-care-roundtable-2/ Subscribe to Brookings Events on iTunes, send feedback email to events@brookings.edu, and follow us and tweet us at @policypodcasts on Twitter. To learn more about upcoming events, visit our website. Brookings Events is part of the Brookings Podcast Network.

The 116th Congress finished their reign by passing every section of government funding into law with COVID relief attached. In this episode, learn about the new COVID relief law after you hear about a surprise dingleberry that promises to end surprise medical billing in the United States. That's right! Something good happened! Find out in this episode how the new provisions will positively affect you. Please Support Congressional Dish – Quick Links Click here to contribute monthly or a lump sum via PayPal Click here to support Congressional Dish via Patreon (donations per episode) Send Zelle payments to: Donation@congressionaldish.com Send Venmo payments to: @Jennifer-Briney Send Cash App payments to: $CongressionalDish or Donation@congressionaldish.com Use your bank’s online bill pay function to mail contributions to: 5753 Hwy 85 North, Number 4576, Crestview, FL 32536 Please make checks payable to Congressional Dish Thank you for supporting truly independent media! Recommended Episodes CD219: Oversights of CAREs CD213: CARES Act - The Trillions for COVID-19 Law CD199: Surprise Medical Bills Coronabus Outline CBO Score of COVID provisions (Division N) CBO Score of COVID provisions (Division M) CBO Score of the omnibus H.R.133: Consolidated Appropriations Act, 2021 "Coronabus" Congress.gov Text Explanatory Statement 1 Explanatory Statement 2 DIVISION M: CORONAVIRUS RESPONSE AND RELIEF SUPPLEMENTAL APPROPRIATIONS ACT Sec. 201: General Provisions The Federal government will pay 100% of the cost of funeral expenses that the Governor of a state chooses to pay for expenses through 12/31/2020. Child Care and Development Block Grant: Provides $10 billion and expand eligibility by waiving eligibility restrictions tied to income. It specifically mentions health care sector employees, emergency responders, sanitation workers, farm workers, and other "workers deemed essential during the response to coronavirus by public officials". The money can be used to pay for co-payments and tuition payments for families. Public Health and Social Services Fund: Provides $22,945,000,000 for vaccines and $22,400,000,000 for testing and contract tracing. Education Stabilization Fund: Provides almost $82 billion available through September 2022 to “prevent, prepare for, and respond to coronavirus domestically or internationally”. $2.75 billion will go to "non-public schools". Non-public schools can not also take PPP money if they apply for this money. Federal Aviation Administration: Provides $2 billion for airports, and requires them to retain at least 90 percent of their workforce as of March 27, 2020 (minus retirements and employees who quit) until February 15th DIVISION N - ADDITIONAL CORONAVIRUS RESPONSE AND RELIEF TITLE I - HEALTHCARE Sec. 101: Supporting Physicians and Other Professionals in Adjusting to Medicare Payment Changes During 2021 Medicare fee schedules will be increased by 3.75% from January 1, 2021 through January 1, 2022. Prohibits judicial review of the fee schedules that determine payment amounts. Funds it with $3 billion plus "necessary" amounts from the Supplementary Medical Insurance Trust Fund. TITLE II - ASSISTANCE TO INDIVIDUALS, FAMILIES, AND BUSINESSES Subtitle A - Unemployment Insurance Sec. 201: Extension and Benefit Phaseout Rule For Pandemic Unemployment Assistance Extends the eligibility period for COVID-19 unemployment payments through March 14, 2021. People who haven't used their benefit eligibility of 50 weeks can get payments through April 5, 2021. Gives individuals the right to appeal denials of their unemployment benefits, but any denials issued before the end of 2020 will stand. Sec. 203: Extension of Federal Pandemic Unemployment Compensation Adds $300 in federal tax money to the weekly unemployment benefits we receive from our states from December 26, 2020 through March 14, 2021. Sec. 241: Requirement To Substantiate Employment or Self-Employment and Wages Earned or Paid to Confirm Eligibility for Pandemic Unemployment Assistance Requires people filing for COVID unemployment benefits who aren't usually eligible (such as self-employed people, people who can't work because they are sick with COVID or caring for a COVID, etc.) to provide documentation to prove they are employed or self employed. The law is not specific about what kind of documentation is required. Sec. 263: Continuing Eligibility for Certain Recipients of Pandemic Unemployment Assistance Starting in February 2021, people in this category have to submit documents every week proving they are still, caring for someone who is sick, or can't work for another eligible reason. Sec. 242: Requirement for States to Verify Identity of Applicants for Pandemic Unemployment Assistance Requires the states to verify the identity of any approved to receive COVID unemployment payments. States need to start doing this by February 1. Sec. 251: Return to Work Reporting For CARES Agreement By February 1, states have to set up a snitching hotline or website for employers to use to rat on employees who refuse to return to work "without good cause." The definition of good cause is left up to the states. Subtitle B - COVID-related Tax Relief Act of 2020 Sec. 272: Additional 2020 Recovery Rebates For Individuals Individuals making up to $75,000 - based on 2019 taxes - will receive a $600 "tax credit", in addition to $600 per dependent Sec. 276: Clarification of Tax Treatment of Forgiveness of Covered Loans A business that receives a PPP loan that is forgiven does not have to count that money as income and expenses paid with the PPP money can be deducted. Sec. 277: Emergency Financial Aid Grants Students who receive emergency financial aid grants don’t have to count the money as income Sec. 286: Extension of Credits For Paid Sick and Family Leave Extended a tax credit for employers which would cover 100% of the costs of paid sick and family leave they offer to their employees and the tax credit for self-employed people for the days they can’t work because of COVID until March 31, 2021. TITLE III - CONTINUING THE PAYCHECK PROTECTION PROGRAM AND OTHER SMALL BUSINESS SUPPORT Sec. 304: Additional Eligible Expenses Expands the list of expenses that can be paid using PPP funds to include operations expenditures, property damage caused by the BLM protests in summer 2020 that were not covered by insurance, supplier costs, and worker protection measures related to COVID safety. Sec. 305: Hold Harmless Exempts the banks that administer the PPP program from lawsuits related to loan origination or forgiveness for a second draw of PPP loans as long as they collect required paperwork "in good faith". Sec. 307: Simplified Forgiveness Application Creates a simplified application process for PPP loan forgiveness for loans less than $150,000. Those loans "shall be forgiven" if the person submits a 1 page document describing how many employees were retained thanks to the loan, how much of the loan was spent on payroll, and the total loan amount. The recipient will have to retain employment records for 4 years after submitting the application. The banks are not allowed to require any other documents for loan forgiveness. This is effective from the signing of the CARES Act. Sec. 308: Specific Group Insurance Payments as Payroll Costs Clarifies that "group life, disability, vision, or dental insurance" counts as payroll costs, which can be paid using PPP loan money. Sec. 311: Paycheck Protection Program Second Draw Loans Allows people to get a second round of forgivable PPP loans with the amount based on their payroll expenses for the last year or 2019 with a maximum loan amount of $2 million. Limits the size of the business to one with fewer than 300 employees per location, instead of 500 employees per location. Sec. 318: Eligibility of 501(c)(6) and Destination Marketing Organizations For Loans Under the Paycheck Protection Program Allows PPP funds to be given to tax exempt business organizations, including organizations that engage in lobbying Congress. Sec. 319: Prohibition on Use of Loan Proceeds For Lobbying Activities Prohibits PPP funds from being used on lobbying expenses. Sec. 322: Conflicts of Interest A business that is more than 20% owned or controlled by the President, Vice President, the head of an Executive department or a member of Congress or their spouses is not eligible to receive PPP loans. Sec. 324: Grants for Shuttered Venue Operations Live performance venues, except ones that "present live performances of a prurient sexual nature", that have taken in 30% or less of their 2019 revenues can get grants to help make up for 45% of their lost revenue during the pandemic. $2 billion is set aside for businesses with fewer than 50 employees. Sec. 342: Prohibition of Eligibility For Publicly-Traded Companies Prohibits publicly traded companies from receiving PPP loans. TITLE IV - TRANSPORTATION Subtitle A - Airline Worker Support Extension Sec. 402: Pandemic Relief for Aviation Workers Provides $15 billion to pay the salaries and benefits of passenger airlines and $1 billion for contractors. Sec. 404: Required Assurances Conditions the money on the promise from the airlines and contractors that they won't lay anyone off or reduce their pay until March 31, 2021 and that the money won't be used to buy the companies stock or pay out dividends until March 31, 2022. Airlines or contractors that accept this money will have 72 hours from the time they accept the agreement with government to recall any employees they laid off. The employees who return will receive back pay from December 1, 2020 (minus any severance they received). Sec. 406: Limitation of Certain Employee Compensation Freezes the pay of anyone in the airlines accepting our tax money funded bailout who made more than $425,000/year in 2019 to their 2019 pay levels until October 1, 2022. No one in the company will be allowed to collect more than $3 million plus 50% of the amount over $3 million that they earned in 2019. Sec. 407: Minimum Air Service Guarantees Authorizes the Secretary of Transportation (Pete Buttigeg) to require an airline to maintain service to any destination that airline served on March 20, 2020, if the airline accepts the COVID bailout money. This authority automatically expires on March 1, 2022. Subtitle B - Coronavirus Economic Relief for Transportation Services Act Sec. 421: Assistance For Providers of Transportation Services Affected by COVID-19 Provides $2 billion to transportation service companies that have lost at least 25% of their revenue due to COVID-19 that has fewer than 500 employees or a company with over 500 employees that hasn't received a bailout yet. The companies have to use at least 60% of the money to pay up to $100,000/yr per employee in salary as long as they don't furlough any more workers (they can spend the money on other things if all their workers are back and making their 2019 pay levels already). TITLE V - BANKING Subtitle A - Emergency Rental Assistance Sec. 501: Emergency Rental Assistance Provides $25 billion for rental assistance . The money will be given to the states and 90% of it needs to be used to pay rent, utilities, home energy costs, and other costs as determined by the Treasury Secretary. Under no circumstance can any household get payments for more than 15 months. The money will flow from the government directly to the landlord or utility provider (unless the landlord or utility provider refuses to accept the payment, which is the only circumstance during which the household will get the money). To be eligible you either have to have income below 50% of the area median income or one or more individuals in the home have been unemployed for at least 90 days. Landlords are allowed to apply on behalf of their tenants, with their permission and signature on the application. The funding expires December 31, 2021. Sec. 502: Extension of Eviction Moratorium Extends the eviction moratorium through January 31, 2021. Subtitle B - Community Development Investment Sec. 522: Capital Investments For Neighborhoods Disproportionately Impacted By The COVID-19 Pandemic Creates a new fund with $9 billion to give money to banks - by purchasing their stock - to lend out in low income and minority communities. The administration of these purchases can be outsourced to "any bank, savings association, trust company, security broker or dealer, asset manager, or investment advisor as a financial agent of the Federal Government." The law sets no limits on executive compensation, share buybacks, or dividend payments for the recipients of the bank's lending (the Secretary of the Treasury gets to make those rules). The authority for using this $9 billion is valid until 6 months after the emergency declared on March 13, 2020 is terminated. Subtitle C - Miscellaneous Sec. 540: Extension of Temporary Relief and Emergency Authorities Extends the provision from the CARES Act that exempted banks from relatively new reporting requirements on their credit losses until the end of the emergency or January 1, 2022, an extra year. Sec. 541: Extension of Temporary Relief From Troubled Debt Restructurings And Insurer Clarification Extends the provision from the CARES Act that allows banks to avoid counting troubled loans as troubled on their balance sheets until 60 days after the emergency declared on March 13th ends or January 1, 2022, an extra year. This law also expands the eligibility to include insurance companies. TITLE VI - LABOR PROVISIONS Sec. 601: Job Corp Flexibilities Temporarily allows people who have already turned 25 to qualify for the Jobs Corps. TITLE VII - NUTRITION AND AGRICULTURE RELIEF Subtitle A - Nutrition Sec. 702: Supplemental Nutrition Assistance Program From January 1, 2021 through June 30, 2021, food stamp beneficiaries will get 115% of the amount they received in June 2020. Money received from Federal unemployment payments - the money provided on top of state payments - will not be counted as income for the month the money was received or for the 9 months that follow for the purpose of determining food stamp eligibility. Subtitle B - Agriculture Sec. 751: Office of the Secretary Provides over $11 billion for farmers and those that provide for local food systems such as farmers markers, restaurants, and schools. $1.5 billion will be used to purchase food for hungry Americans. $1 billion of this money can be used to pay up to 80% of the revenue losses of contract growers of livestock and poultry for the period beginning on January 1, 2020 (two months before COVID) through January 1, 2021. TITLE VIII - UNITED STATES POSTAL SERVICE Sec. 801: COVID-19 Funding For The United States Postal Service Allows the postal service to keep the money it was loaned by the CARES Act TITLE IX - BROADBAND INTERNET ACCESS SERVICE Sec. 904: Benefit For Broadband Service During Emergency Period Relating to COVID-19 Creates the "Emergency Broadband Benefit Program" funded with $3.2 billion, which allows households that qualify for some other COVID relief benefits can also get a monthly $50 discount on their internet service, or $100 if they are renting equipment, but only if their internet service provide elects to participate in the program. The FCC will reimburse the internet companies directly for the discounts. Companies that accept the money are not allowed to require an early termination fee of new customers who get service due to this benefit who then decide to cancel later. This is valid until 6 months after the end of the emergency is declared. TITLE X - MISCELLANEOUS Sec. 1003: Rescissions Rescinds $429 billion out of the $500 billion that was provided the CARES Act to provide loans and invest in corporate bonds by the Federal Reserve. Sec. 1005: Termination of Authority Terminates the authority created by the CARES Act for the Federal Reserve to make loans or purchase securities using the Main Street Lending Program, or the authorities granted to loan money to state and local governments. They can still make loans using the Term Asset-Back Securities Loan Facility. They are allowed to restructure and extend existing loans. Sec. 1006: Rule of Construction Clarifies that the Federal Reserve is not in any way restricted from using authorities it already had before enactment of the CARES Act. DIVISION BB - PRIVATE HEALTH INSURANCE AND PUBLIC HEALTH PROVISIONS TITLE I - NO SURPRISES ACT Sec. 102: Health Insurance Requirements Regarding Surprise Medical Billing Starting on January 1, 2022, any health insurance company that provides "any benefits" in an emergency department can not require pre-authorization of those services or deny coverage because the emergency department is out of their network. If emergency services are provided out-of-network, there can not be any limits on coverage any more restrictive than what would be covered by an in-network emergency department and the out-of-pocket costs can't be more than they would be in-network. Out-of-pocket payments at an out-of-network emergency room must count towards in-network deductibles and out-of-pocket maximums. Emergency services include any care that happens in connection to the emergency visit, regardless of what department of the hospital provides the services. After the patient is stabilized, inpatient or outpatient stays in connection to that event are also covered. Loophole: Services are not covered if the patient is able to travel without medical transportation, is able to provide informed consent, and "other conditions" that will be determined by regulation. The prices to be paid by insurers will be based on the median price paid in the geographic area for similar services, and it will increase along with the consumer price index. In the case of a out-of-network doctor who works at an in-network hospital, if that doctor doesn't notify the patient that he/she is out-of-network, the health insurance company can't require the patient to pay any more out of pocket than they would pay if the doctor were in-network. Any cost-sharing payments must be applied to the in-network deductible and annual maximum out of pocket limits. This also applies to air ambulance providers. Health insurance companies are no longer allowed to require referrals for women to go to the gynecologist. Health insurance plans are still allowed to require gynecologists to notify the plan and/or the primary care doctor of their treatment decisions. Sec. 103: Determination of Out-of-Network Rates to Be Paid By Health Plan; Independent Dispute Resolution Process To determine how much an insurance company will directly pay to an out-of-network provider, the provider has 30 days from receiving a payment or a denial of payment to start a negotiation process. If the negotiation fails, within four days, the provider or health insurance company can elect to start an independent dispute resolution. The Secretaries of Health and Human Services, Labor, and Treasury have until the end of 2021 to create this process by regulation. The regulation process will determine who will be certified to act as the dispute resolution judge, but it is not allowed to be an affiliate, subsidiary or trade group that represents a health insurance company or health care provider. The independent disputer settler will have 30 days to make the payment determination. The payment amounts can consider the comparable rates in the geographic region, the market share that provider controls in the region, the complexity of the patients case, and if either side made any effort to be in each other's network. They payment amounts can not consider the amount the provider usually chooses to charge or the rates usually paid by Medicare and Medicaid. The decisions will be binding and not subject to judicial review, unless there is evidence of fraud. The insurance company will have 30 days from the decision date to pay the bill. A lot of information about who uses this process and its results will be made public. Sec. 104: Health Care Provider Requirements Regarding Surprise Medical Billing The emergency departments and doctors can't send patients bills for anything more than their co-pay amounts. Out-of-network doctors working at in-network facilities are also prohibited from sending bills that are greater than the co-pay amounts. Out of network doctors at in-network facilities that provide services such as anesthesiology, radiology, and lab services can send bills to patients if the the patient makes an appointment to see them 72 hours or more in advance of their treatment and if the patient signs a written notice or email. The notice has to inform the patient that getting treated by the out-of-network doctor is optional and that they have the option to get treated by an in-network doctor, along with a list of in-network doctors available to provide the service. The notice also has to inform the patient that the amount they pay may not apply to their out-of-pocket limits or in-network deductible. The notice has to be dated and signed by the patient before they receive the services. Loophole: The notice has to have a "good faith estimated amount" that the provider "may" charge, but that that amount is not a contractual obligation. The states are given the authority to enforce these laws. If the state refuses to enforce them, the Secretary of Health and Human Services has the ability to enforce them, and issue fines to doctors (and specifically air ambulance operators) up to $10,000 per violation. There will be a process for submitting complaints to the Secretary of Health and Human Services, and the department has 60 days to respond. The doctor or air ambulance operator can avoid the fine by withdrawing the bill, reimbursing the patient for the difference between what they were charged and what they should have been charged, plus interest, within 30 days. Loophole: The law does give the Secretary of HHS the permission to create a "hardship exemption" to the fines. Sec. 105: Ending Surprise Air Ambulance Bills Establishes similar laws for air ambulance operators as are enacted for emergency rooms and out-of-network doctors working at in-network facilities. Patients with health insurance who receive air ambulance services can only be charged the in-network rate for a copay. Air ambulance companies are not allowed to bill patients with health insurance more than their co-pay amount. Sec. 107: Transparency Regarding In-Network and Out-of Network Deductibles and Out-of-Pocket Limitations By January 1, 2022, health insurances have to issue new insurance identification cards which include "any deductible", "any out-of-pocket limit", and a telephone number and internet website that patients can use to find out who is in-network. Sec. 111: Consumer Protections Through Health Plan Requirement for Fair and Honest Advance Cost Estimate Starting on January 1, 2022, before a patient receives a scheduled service, the health insurance company has to send them a physical notice or email - patient's choice - about whether they are schedule to see an in-network or out-of-network doctor. If they are scheduled for an in-network appointment, they have to tell the patients the contracted rate for the service. If they are scheduled for an out-of-network appointment, they have to tell the patient how to find an in-network doctor. The notice also has to include cost estimates, including an estimate submitted by the doctor, how much the health insurance company will probably pay, the cost of any co-pays, and how close the patient is to reaching any out-of-pocket limits. The notice must also include a disclaimer that these are only estimates. Sec. 112: Patient Protections Through Transparency and Patient-Provider Dispute Resolution Starting on January 1, 2022, before a patient receives a scheduled service, the doctor needs to ask the patient if they have insurance, are covered bypass a government plan, or have no insurance. If the patient has insurance, they have to provide the health insurance company or the government with a "good faith estimate" of the expected charges with the billing codes for the expected services. If the person does not have insurance, the estimate has to be given directly to the patient. The Secretary of Health and Human Services will have to create a process by January 1, 2022 for uninsured patients who are charged more than their estimates to have their bill determined by an independent dispute resolution authority. Sec. 113: Ensuring Continuity of Care If a health insurance plan ends its contract with a patient's doctor, the health insurance company has to notify the patient and give the patient the opportunity to request and be granted 90 days of keeping the co-payment structure they had while the doctor was in-network. Sec. 114: Maintenance of Price Comparison Tool Health insurance companies will have to offer patients - via telephone and internet - a tool that allows them to compare the co-pays they would be responsible for if they received a service from each of their in-network providers. Sec. 116: Protecting Patients and Improving the Accuracy of Provider Director Information Requires health insurance companies to accurately maintain their in-network provider database. If the patient gets information about a doctor from an outdated database, or if the patient's requests for information go unanswered, the insurance company must charge the patient in-network copays, but the deductible will be applied to the out-of-network maximum limit. TITLE II - TRANSPARENCY Sec. 201: Increasing Transparency By Removing Gag Clauses on Price and Quality Information Health insurance companies will be prohibited from contractually preventing doctors from revealing their pricing agreements to referring doctors, the patient, the patient's employer, or people eligible to be a part of that health insurance plan. Restrictions can be placed upon what information is made public. Sec. 204: Reporting on Pharmacy Benefits and Drug Costs Starting at the beginning of 2022, health insurance companies will annually submit a report to the government about the 50 most common prescription drugs they pay for, the 50 most expensive prescription drugs, and the 50 prescription drugs with the greatest increase in price. The report also has to break down the costs of other categories of care, such as hospital visits, provider costs, and drug costs. They will also have to report on the average amount monthly premiums they receive from employers and patients. TITLE XIV - COVID-19 CONSUMER PROTECTION ACT Sec. 1401: Prohibiting Deceptive Acts or Practices In Connection with the Novel Coronavirus For the duration of the public emergency, it will be illegal for "any person, partnership, or corporation" to deceive anyone in association with a COVID-19 treatment, cure, prevention, or diagnosis or a government benefit related to COVID-19. This will be enforced by the Federal Trade Commission and violators can be fined up to $10,000 per violation. Articles/Documents Article: Want a Bigger Stimulus Check? Consider Filing Your Tax Return Early, By Anna Wilde Mathews, Tom McGinty and Melanie Evans, The Wall Street Journal, February 11, 2021 Article: Want a Bigger Stimulus Check? Consider Filing Your Tax Return Early, By Richard Rubin, The Wall Street Journal, February 6, 2021 Article: Surprise Medical Bills: New Protections for Consumers Take Effect in 2022, By KFF.org, February 4, 2021 Article: Freeloaders and the Fed: Scrutinizing the Federal Reserve’s Secondary Market Bond Purchases Under the CARES Act, By Brandon Brockmyer and Ryan Summers, Pogo, February 3, 2021 Article: Amazon’s quarterly revenue hits record $125.6 billion, By Katherine Khashimova Long, Seattle Times, February 2, 2021 Article: Delay in Extending Unemployment Aid Has Shortchanged Workers $17 Billion in January, By Ellie Kaverman and Andrew Stettner, The Century Foundation, February 2, 2021 Article: Judge mulls striking law barring pandemic relief to strip clubs&firstPage=true), By Jody Godoy, Westlaw Today, January 20, 2021 Article: Libor scandal: the bankers who fixed the world’s most important number, By Liam Vaughan and Gavin Finch, The Guardian, January 18, 2021 Article: Unlucky: Do the recent changes to the Federal Reserve’s powers under Section 13(3) of the Federal Reserve Act inhibit future action?, By White & Case LLP, Lexology, January 7, 2021 News Release: U.S. DEPARTMENT OF LABOR ANNOUNCES NEW GUIDANCE TO STATES ON UNEMPLOYMENT INSURANCE PROGRAMS, Department of Labor, December 30, 2020 Document: Estimate for Divisions O Through FF, H.R. 133, Consolidated Appropriations Act, 2021, Public Law 116-260, By Congressional Budget Office, December 27, 2020 Article: Finally Positive News for Nonprofits: $900 Billion COVID-Relief Package Has Been Approved by Congress, By Rachel Lilienthal Stark, National Law Review, December 22, 2020 Article: Congress Acts To Spare Consumers From Costly Surprise Medical Bills, By Julie Appleby, npr, December 22, 2020 Article: Senators reach deal on Fed powers, setting stage for coronavirus relief passage, By Alexander Bolton, The Hill, December 19, 2020 Article: Fight over Federal Reserve powers holding up year-end deal, By Alexander Bolton, The Hill, December 17, 2020 Article: Borrowers looking to use Fed’s Main Street lending program run into dead end, By Steve Liesman, CNBC, December 8, 2020 Article: Admiral Theatre is among a bevy of adult businesses suing to get a PPP loan. So far, the nightclubs are winning., By Robert Channick, Chicago Tribune, May 21, 2020 Article: Joe Biden: The Heartbreaking Car Accident that Killed His Wife and Daughter, By Tim Ott, Biography, September 28, 2020 Sound Clip Sources News Clip: Dr. Fauci: It will be ‘open season’ by April for everyone to receive vaccines, Today, February 11, 2021 Hearing: Safeguarding American Consumers: Fighting Fraud and Scams During the Pandemic, House Committee on Energy and Commerce: Subcommittee on Consumer Protection and Commerce, February 4, 2021 Watch on Youtube Witnesses: Bonnie Patten Executive Director of TruthInAdvertising.org Jessica Rich Distinguished Fellow at the Institute for Technology Law and Policy at Georgetown Law School Former Director of Consumer Protection at the Federal Trade Commission She served at the FTC for 26 years Transcript: 44:40 Bonnie Patten: The list of deceptively marketed products and services exploiting this pandemic is extensive. CBD products marketed to military veterans as a Coronavirus treatment, bleach advertised as a liquid cure all, Wellness Centers targeting first responders, with IV vitamin drips to protect against COVID-19. Amazon and eBay sellers falsely claiming that their PPE FDA approved. Hand sanitizer marketed is protecting for 24 hours against COVID-19. Alleged immune immunity boosting supplements targeting children. Colloidal Silver solutions advertised as having the ability to kill the virus from within. Toothpaste and teeth whitening products claiming to prevent COVID-19 and Sham wellness kits targeting seniors. Unfortunately, the deception does not stop with outrageous health claims. Many are exploiting the economic desperation wrought by this pandemic. Multi level marketing companies claiming people can earn full time pay working part time. Lending companies deceptively using the cares act to exploit college students. Investment scams claiming to have patented COVID cures and financial entities pretending to be SBA authorized lenders to lure in small businesses struggling to keep their workers employed. 46:15 Bonnie Patten: And to make matters worse, the agency primarily charged with policing these deceptive acts, the FTC, is now at risk of losing a mainstay of its enforcement authority and the ability to make victims whole under Section 13-b. Because 13-b does not specifically say anything about equitable relief when a permanent injunction is issued, the Supreme Court is now deciding the remedial scope, if any of 13-b in the case AMG vs FTC. AMG was a payday lending scheme that extracted money from people in desperate circumstances and in its appeal, the company does not dispute that it violated the law. Instead, it argues that the $1.3 billion it's stole should be it's to keep. AMG asserts that it was never Congress's intention for the FTC to return money to victims of fraud under 13-b. Quite to the contrary. AMG argues that this legislative body fully endorsed the notion that wrongdoers should pocket the money they've illegally taken when it drafted 13-b. If the Supreme Court rules in AMG's favor, and this Congress does not act to empower the FTC to seek restitution under 13-b, then the deceptive practices I have enumerated will only multiply. 1:17:40 Jessica Rich: The new law covers a huge amount of scams. It's very broad as to COVID scams. So if a company engages in any of that activity, the FTC can pursue civil penalties and so just as Miss Patton just said, it's very important for deterrence to make it painful for fraudsters to rip off consumers. 1:18:20 Rep. Frank Pallone (NJ): But now that the FTC has this authority to find companies who've committed fraud and scams related to the pandemic under this new law, why is it still important to ensure that the FTC 13 b authority is preserved? Why is that so important? Bonnie Patten: COVID scams are terrible, but they're one of many frauds that the FTC has to fight all year long in and out of a pandemic. So in many of those cases, the FTC doesn't have civil penalty authority, and its rigorous authority is under threat. So it's a much broader problem that goes beyond the COVID scams that are occurring here. And so it still needs to be fixed. 2:23:25 Rep. Darren Soto (FL): Is this being sufficiently used already by the FTC? Do you anticipate gaps in all this law realizing it just was passed? Bonnie Patten: To my knowledge, the FTC has not yet used that act. But that's the only information I know, that there's no public on their website. It does have gaps. It does. You cannot target work from home scams using this, because it's really focused primarily on government benefits, scams and healthcare scams. But what I would say is that, while it's absolutely critical to have an act like this, at this time, during the pandemic, I would warn you that it doesn't provide for coverage for the next disaster. For the next earthquake for the next fire, what have you, there are unfortunately will always be a segment of our population that is in devastating events. And so I think that legislation is necessary that covers all such events and not just focused on the pandemic. Hearing: Examination of Loans to Businesses Critical to Maintaining National Security, Congressional Oversight Commission, December 10, 2020 Witnesses: Eric Rosengren - President and Chief Executive Officer of the Federal Reserve Bank of Boston Gwen Mills - Secretary Treasurer of Unite Here Lauren Anderson - Senior Vice President & Associate General Counsel of the Bank Policy Institute Transcript: 03:20 Bharat Ramamurti: Four months ago, Congress gave the Treasury Department half a trillion dollars to stabilize the economy. The Treasury quickly pledged 75 billion of those dollars to the Federal Reserve's Main Street lending program for small and mid sized companies. After taking three months to set up the program, the Fed has now been operating it for about a month. In that time, it has supported only 18 loans for a total of $104 million. That is 0.017% of the $600 billion lending capacity that the Fed touted for the program in April. 16:07 Eric Rosengren: This facility is very different than some of the other traditional kinds of facilities that central banks operate during a time of crisis. So most of our facilities operate through markets, market securities, you can purchase them very easily through the market. They clear usually in a couple days depending on the security. So it's relatively easy to quickly purchase a large number of securities and hold those securities over time. This facility is a facility we didn't have during the financial crisis, and really tries to get to a different segment of the population, which is those businesses that are bigger than the PPP program was designed for and smaller than what the corporate facilities are designed for. Session: The Senate confirmed two nominations to the National Labor Relations Board, Senate, July 29, 2020 Session: Senate Session, Part 2:The Senate confirmed two nominations, Senate, July 28, 2020 News Clip: Senate GOP outlines next coronavirus relief bill as deadline for enhanced unemployment benefits nears, CBS News, July 28, 2020 Hearing: NO MORE SURPRISES: PROTECTING PATIENTS FROM SURPRISE MEDICAL BILLS, Committee on Energy and Commerce: Subcommittee on Health, June 12, 2019 Watch on Youtube Witnesses: Sonji Wilkes: Patient Advocate Sherif Zaafran, MD: Chair of Physicians for Fair Coverage Rick Sherlock: President and CEO of Association of Air Medical Services James Gelfand: Senior Vice President of Health Policy at The ERISA Industry Committee Thomas Nickels: Executive Vice President of the American Hospital Association Jeanette Thornton: Senior Vice President of Proiduct, Employer, and Commercial Policy at Americas’ Health Insurance Plans Claire McAndrew: Director of Campaigns and Partnerships at Families USA Vidor E. Friedman, MD: President of American College of Emergency Physicians Transcript: 51:50 CEO Rick Sherlock: $10,199 was the median cost of providing a helicopter transport. While Medicare paid $5,998, Medicaid paid $3,463 and the uninsured paid $354. This results in an ongoing imbalance between actual costs and government reimbursement and is the single biggest factor in increasing costs. 53:45 Senior VP James Gelfand: We're focused on three scenarios in which patients end up with big bills they couldn't see coming or avoid. Number one, a patient receives care at an in-network facility, but is treated by an out of network provider. Number two, a patient requires emergency care, but the provider's facility or transportation are out of network. And number three, a patient is transferred or handed off without sufficient information or alternatives. It's usually not the providers you're planning to see. It's anesthesiologists, radiologists, pathologists, or emergency providers or transport or an unexpected trip to the NICU. Many work for outsourced medical staffing firms that have adopted a scam strategy of staying out of networks, practicing at in-network facilities and surprise billing patients. It's deeply concerning, but the problem is narrowly defined and therefore we can fix it. Hearing: Safeguarding American Consumers: Fighting Fraud and Scams During the Pandemic, House Committee on Education and Labor, April 2, 2019 Watch on Youtube Witnesses: Christen Linke Young: Fellow at USC-Brookings Schaeffer Initiative on Health Policy Ilyse Schuman: Senior Vice President for Health Policy at American Benefits Council Frederick Isasi, Executive Director at Families USA Professor Jack Hoadley: Research Professor Emeritus at Georgetown University’s Health Policy Institute Transcript: 33:50 Frederick Isasi: Take for example, one significant driver of this problem. The movement of hospitals to offload sapping requirements for their emergency departments to third party management companies. These hospitals very often make no requirements of these companies to ensure the staffing of the ED fit within the insurance networks that the hospitals have agreed to. As a result, a patient who does their homework ahead of time and rightly thinks they're going to an in network hospital, received services from an out of network physician and a surprise medical bill follows. 43:30 Chairman Frederica Wilson (FL): Under current law, who is responsible for making sure that a doctor or a hospital is in-network? Is it the doctor, the insurance company or the patient themselves? Frederick Isasi: Uh, chairman Wilson, thank you for the question. To be very clear, it is the patient themselves that has a responsibility and these negotiations are very complex. These are some of the most important and intense negotiations in the healthcare sector between a payer and a provider. There is absolutely no visibility for a consumer to understand what's going on there. And so the notion that a consumer would walk into an emergency department and know, for example, that their doctor was out of network because that hospital could not reach agreement on an in-network provider for the ED is absurd, right? There's no way they would ever know that. And similarly, if you walk in and you received surgery and it turns out your anesthesiologist isn't in-network, there's no way for the consumer to know that. Um, and I would like to say there's some discussion about transparency and creating, you know, sort of provider directories. We've tried to do that in many instances. And what we know is that right now the healthcare sector has no real way to provide real actual insight to consumers about who's in-network, and who's out of network. I would-probably everybody in this room has tried at some point to figure out if a doctor's in-network and out of network and as we know that system doesn't work. So this idea that consumers can do research and find out what's happened behind the scenes in these very intensive negotiations is absurd and it doesn't work. 46:30 Professor Jack Hoadley: Provider directories can be notoriously inaccurate. One of the things that, even if they are accurate, that I've seen in my own family is you may be enrolled in Blue Cross-You ask your physician, "are they participating in Blue Cross? They say "yes", but it turns out Blue Cross has a variety of different networks. This would be true of any insurance company, and so you know, you may be in this one particular flavor of the Blue Cross plan and your provider may not participate in that particular network. 1:01:25 Rep. Phil Roe (TN): I've had my name in networks that I wasn't in. That you-that you use, and many of those unscrupulous networks, will use that too to get people to sign up because this doctor, my doctor is in there when you're really not. Cover Art Design by Only Child Imaginations Music Presented in This Episode Intro & Exit: Tired of Being Lied To by David Ippolito (found on Music Alley by mevio)

On February 3, the USC-Brookings Schaeffer Initiative for Health Policy hosted a webinar discussing ways the federal government can work with states to improve the Medicaid program.  https://www.brookings.edu/events/how-can-the-new-administration-improve-the-medicaid-program/ Subscribe to Brookings Events on iTunes, send feedback email to events@brookings.edu, and follow us and tweet us at @policypodcasts on Twitter. To learn more about upcoming events, visit our website. Brookings Events is part of the Brookings Podcast Network.

In this health care podcast, I speak with Loren Adler, who is the associate director of USC-Brookings Schaeffer Initiative for Health Policy and has a particular focus on surprise billing. I wanted to talk to Loren about the surprise billing legislation that is going into effect on 1/1/22. I will let Loren explain, but, in short, this legislation removes the patient from the mix. If a provider decides to send a surprise bill, the patient will just pay the co-pay or coinsurance they normally would have if the provider had been in network. Then, it’s up to the provider who sent the bill and the insurer to duke it out on the back end. What this back end duking out consists of is the provider sending their big surprise bill to the insurer. The insurer may reply, with regrets, “Hey, we’re only gonna pay you … whatever … a fraction of the big bill.” The provider may at that point say, “Fine … whatever. I’ll take it.” Or the provider may say, “No can do. I’ll see you in arbitration.” This arbitration that then happens is a style called baseball arbitration, and Loren gets into the “why” there. Also, a provider cannot trigger an arbitration more than once every 90 days for the same service. So, there’s a wrinkle that will slow the roll of any provider with a plan to clog up the system by arbitrating every claim. I quiz Loren mercilessly about exactly what the provisions of this legislation are and the winners and the losers. But we also talk a lot about potential ramifications. For example, making surprise bills illegal will potentially accelerate bundled payments, if you think about it, because one of the reasons why bundles have stalled is because various parties who enjoy surprise billing refuse to be a part of the bundle—and then the whole thing just flies off the track. Also, premiums will go down approximately 1%, they say, for self-insured employer plans. And Loren and I get into the “why” of that—or, more accurately, Loren gets into the “why” of that. In listening to this recording, I realized we do sort of pick on anesthesiologists a bit here. So, apologies to those anesthesiologists who have been billing fairly this whole time, which is definitely the majority. You can learn more at brookings.edu. Loren Adler is associate director of the USC-Brookings Schaeffer Initiative for Health Policy. His research focuses on a range of topics in health care economics and policy, including provider payment and consolidation, insurance markets, Medicare, the Affordable Care Act, prescription drugs, and COVID-19 testing. Previously, he served as research director for the Committee for a Responsible Federal Budget and as a senior economic policy analyst for the Bipartisan Policy Center. Adler holds a bachelor’s degree in mathematical economics from Wesleyan University and a master’s degree in applied economics from Johns Hopkins University. 03:04 What is this surprise billing legislation? 04:27 What happens when a patient is sent a huge bill from the provider? 06:15 What is “the going rate”? 09:44 “If you weren’t leveraging surprise billing beforehand, this law has no effect on you.” 11:14 Will this legislation push the industry toward one hospital bill? 12:20 What will providers have to do if they don’t like what insurance wants to pay them? 15:26 What is benchmark pricing? 17:37 “Fundamentally … it’s really consumer groups and patient groups plus your self-insured employers … on one side and then provider groups on the other.” 18:19 Is this surprise billing legislation a compromise? 19:48 “Arbitration really isn’t meant to adjudicate every single claim.” 20:11 “The idea is really to kind of push the facility … to negotiate and figure this all out.” 20:50 Are hospitals being impacted by this bill? 24:56 What happens to providers who decide to send surprise bills anyway? 26:09 What are the implications of this legislation for self-insured employers? 28:48 Why have ground ambulances been left out of this surprise billing legislation? 32:23 “At the end of the day, I think this is a net positive for consumers and should be considered a win.” You can learn more at brookings.edu.   @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is this surprise billing legislation? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If you weren’t leveraging surprise billing beforehand, this law has no effect on you.” @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Will this legislation push the industry toward one hospital bill? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What will providers have to do if they don’t like what insurance wants to pay them? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is benchmark pricing? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Fundamentally … it’s really consumer groups and patient groups plus your self-insured employers … on one side and then provider groups on the other.” @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Is this surprise billing legislation a compromise? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are hospitals being impacted by this bill? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are the implications of this legislation for self-insured employers? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why have ground ambulances been left out of this surprise billing legislation? @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth “At the end of the day, I think this is a net positive for consumers and should be considered a win.” @LorenAdler discusses #surprisebilling legislation on our #healthcarepodcast. #healthcare #podcast #digitalhealth

Scientific innovation was put to the test in the development of the COVID-19 vaccine, and it resulted in two vaccines in record time that are at least 94% effective in clinical trials. Now the task of vaccinating the population has begun with many skeptics fearing side effects, rushed science in its development, and political involvement. There is also a segment of the population who are generally vaccine skeptics. Join the USC-Brookings Schaeffer Initiative for Health Policy and the USC Behavioral Science and Well-Being Policy Initiative for an expert discussion on how to encourage vaccine adoption. Learn more about the USC Schaeffer Center at healthpolicy.usc.edu

In light of the major financial burden that health care places on many households and the limited competition in many health care markets, some policymakers and experts have called for governments to play a larger role in determining the prices of health care services, such as by regulating those prices or introducing a public option. The late Uwe Reinhardt wrote and spoke for many years in support of a larger role for the public sector in determining health care prices. On October 7, USC-Brookings Schaeffer Initiative for Health Policy and the Center on Regulation and Markets at Brookings hosted, in honor of Uwe’s work, the final webinar in a series examining whether a larger public role is appropriate. https://www.brookings.edu/events/lessons-from-international-experience-in-determining-health-care-prices/ Subscribe to Brookings Events on iTunes, send feedback email to events@brookings.edu, and follow us and tweet us at @policypodcasts on Twitter. To learn more about upcoming events, visit our website. Brookings Events is part of the Brookings Podcast Network.

Dr. Matthew Fiedler is a fellow at the USC-Brookings Schaeffer Initiative for Health Policy. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. M. Fiedler. Competing Visions for the Future of Health Policy. N Engl J Med 2020;383:1197-1199.

On September 9, the USC-Brookings Schaeffer Initiative for Health Policy hosted, in honor of Uwe Reinhardt’s work, the first of three webinars examining whether a larger public role in US healthcare is appropriate. https://www.brookings.edu/events/are-u-s-health-care-prices-too-high-too-low-or-some-mix-of-the-two/ Subscribe to Brookings Events on iTunes, send feedback email to events@brookings.edu, and follow us and tweet us at @policypodcasts on Twitter. To learn more about upcoming events, visit our website. Brookings Events is part of the Brookings Podcast Network.

A decade after the passage of the Affordable Care Act, the COVID-19 pandemic is testing the US health insurance system amid a public health and economic crisis. Christen Linke Young and Matthew Fielder, fellows with the USC-Brookings Schaeffer Initiative for Health Policy, join to discuss stresses, gaps, and successes in maintaining Americans’ consistent access to affordable, high-quality healthcare coverage, and how COVID-19 may inform the outlook for policy changes in the months ahead.

On May 18, the USC-Brookings Schaeffer Initiative for Health Policy, in partnership with the American Enterprise Institute, hosted a webinar discussing pathways to auto-enrollment that can help expand health insurance coverage.  https://www.brookings.edu/events/health-insurance-auto-enrollment/ Subscribe to Brookings Events on iTunes, send feedback email to events@brookings.edu, and follow us and tweet us at @policypodcasts on Twitter. To learn more about upcoming events, visit our website. Brookings Events is part of the Brookings Podcast Network.

Dr. William A. Haseltine, known for his groundbreaking work on HIV-AIDS and pioneering application of genomics to drug discovery with Human Genome Sciences, joined USC-Brookings Schaeffer Initiative for Health Policy Director Paul Ginsburg for a discussion on short- and long-term approaches to the COVID-19 pandemic. Subscribe to Brookings Events on iTunes, send feedback email to events@brookings.edu, and follow us and tweet us at @policypodcasts on Twitter. To learn more about upcoming events, visit our website. Brookings Events is part of the Brookings Podcast Network.

On Tuesday, March 31, the USC-Brookings Schaeffer Initiative for Health Policy hosted the 24th Wall Street Comes to Washington Health Care Roundtable as a webinar. Designed to bridge the worlds of Wall Street and Washington health policy, an expert panel of equity analysts, moderated by Initiative director, Paul B. Ginsburg, discussed market trends shaping the health care system and the impact of federal policies on health care companies. Subscribe to Brookings Events on iTunes, send feedback email to events@brookings.edu, and follow us and tweet us at @policypodcasts on Twitter. To learn more about upcoming events, visit our website. Brookings Events is part of the Brookings Podcast Network.  

On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act, perhaps the most significant change in health care policy since the passage of Medicare and Medicaid in 1965. But opposition to the law has been unrelenting since before its enactment, and efforts to repeal it in the courts are ongoing. In this episode, Christen Linke Young, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy, discusses where we are a decade after the law’s enactment. Her extensive experience in health policy includes working as a senior policy advisor for health reform in the White House. Also on this episode, Sarah Binder, Senior Fellow in Governance Studies, discusses what’s happening in Congress. Subscribe to Brookings podcasts  or on , send feedback email to , and follow us and tweet us at  on Twitter. The Brookings Cafeteria is part of the .

Chase is joined on the show by Loren Adler, the associate director of the USC-Brookings Schaeffer Initiative for Health Policy, Lucy Hodder, law professor and director of health law and policy at UNH Franklin Pierce School of Law and Concord Coalition Executive Director, Bob Bixby. They continue the discussion from last week's show on health care, focusing on surprise billing, pharmaceutical costs, state and federal efforts to combat systemic cost growth, as well as the government's response to the Coronavirus.

Chase is joined on the show by Loren Adler, the Associate Director of the USC-Brookings Schaeffer Initiative for Health Policy, Lucy Hodder, law professor and director of health law and policy at UNH Franklin Pierce School of Law and Concord Coalition Executive Director, Bob Bixby. They continue the discussion from last week's show on health care, focusing on surprise billing, pharmaceutical costs, state and federal efforts to combat systemic cost growth, as well as the government's response to the Coronavirus.

Polls show that health care is one of the top issues American voters care about, but ideas about controlling costs and expanding coverage are divided along partisan lines. This episode features a deep dive into health care policy and what Democratic presidential candidates and Republican Party leaders are offering as their solutions. Guests are two of Brookings’s top health policy experts: is a fellow in the USC-Brookings Schaeffer Initiative for Health policy and, among her many roles in public service, served in the White House as a senior policy advisor for health. is also a fellow with the Schaeffer Initiative and was previously chief economist of the Council of Economic Advisers in the White House, where he oversaw the council’s work on health care policy. Both Young and Fiedler have contributed a few explainer pieces on health policy as part of the here at Brookings. Also, meet , a new David M. Rubenstein Fellow in the Metropolitan Policy program at Brookings. Subscribe to Brookings podcasts  or , send feedback email to , and follow us and tweet us at  on Twitter. The Brookings Cafeteria is part of the .

The authors of a new book argue that national security “fearmongering” is causing U.S. leaders to focus more on the threats that Americans perceive—like terrorism and nuclear war—than the ones that exist at home, like gun violence and the opioid crisis. In Clear and Present Safety: The World Has Never Been Better and Why That Matters to Americans (Yale University Press), Michael Cohen and Micah Zenko argue that “The American public is being fed, by politicians and pundits alike, a steady diet of threat inflation that has made them deeply fearful of the world outside their borders.“ In this episode, Thomas Wright, director of the Center on the United States and Europe and senior fellow in the Project on International Order and Strategy at Brookings, speaks with Zenko, a columnist at Foreign Policy, about the premise of the book, the geopolitical risks that do exist, and what role foreign policy might play in the 2020 presidential election. Zenko explains why the mid-1990s were the most dangerous time to be alive, the wide array of domestically driven risks, and why these factors matter more to American security than distant threats. Also, meet Christen Linke Young, a fellow in our USC-Brookings Schaeffer Initiative for Health Policy. Find out what she’s working on and why she recommends reading both Dreamland, by Sam Quinones, about the rise of the opioid epidemic, and Infinite Jest, by David Foster Wallace.   Subscribe to Brookings podcasts  or on , send feedback email to , and follow us and tweet us at  on Twitter. The Brookings Cafeteria is part of the .

Almost 40% of Americans WITH health insurance reported they had received a surprise medical bill in the past year from a doctor or hospital for a service they thought was covered by their insurance plan. Why is this happening? And what can we do about it?  Please Support Congressional Dish – Quick Links Click here to contribute monthly or a lump sum via PayPal Click here to support Congressional Dish for each episode via Patreon Send Zelle payments to: Donation@congressionaldish.com Send Venmo payments to: @Jennifer-Briney Send Cash App payments to: $CongressionalDish or Donation@congressionaldish.com Use your bank's online bill pay function to mail contributions to: 5753 Hwy 85 North, Number 4576, Crestview, FL 32536 Please make checks payable to Congressional Dish Thank you for supporting truly independent media! Additional Reading Article: Went to the ER? You may be hit with a surprise medical bill by Tami Luhby, CNN, June 20, 2019. Press Release: House Supports Porter Amendment to Improve Affordable Care Act Enrollment by Representative Katie Porter, Porter House News, June 13, 2019. Article: Alexander-Murrary Bill, by Tammy Luhby, CNN, May 23, 2019. Bill: Bill S. 1531 Stopping The Outrageous Practice of Surprise Medical Bills Act of 2019 by Senator Bill Cassidy, Govtrack.us, May 16, 2019. Press Release: Trauma Coalition Press Release, by Trauma Association of America, May 16, 2019. Article: Trump calls for an end to surprise medical bills by Tami Luhby, CNN, May 9, 2019. Article: UnitedHealth's David Wichmann buys record $4.6 million worth of UNH stock by Alex Wittenberg, Biz Journals, May 7, 2019. Article: After Vox reporting, California moves forward on plan to end surprise ER bills by Sarah Kliff, Vox, April 24, 2019. Article: How to fight an outrageous medical bill, explained by Sarah Kliff, Vox, April 1, 2019 Bill: Bill S. 1266 Protecting Patients from Surprise Medical Bills Act 116th Congress, March 1, 2019. Bill: Bill H.R. 861 End Surprise Billing Act of 2019  116th Congress, January 30, 2019. Article: A $20,243 bike crash: Zuckerberg hospital’s aggressive tactics leave patients with big bills by Sarah Kliff, Vox, January 24, 2019.  Article: After Vox story, Zuckerberg hospital rolls back  by Sarah Kliff, Vox, January 24, 2019. Document: NBER Working Paper No. 23623 Surprise! Out-of-Network Billing for Emergency Care in the United States by Zach Cooper, Fiona Scott Morton and Nathan Shekita, NBER, January 2019 Article: LifePoint merges with RCCH, goes private by Ayla Ellison, Becker Hospital Review, November 16, 2018. Article: “It’s unacceptable”: Sen. Maggie Hassan explains her plan to end surprise ER bills by Sarah Kliff, Vox, October 29, 2018. Article: Gov. Rick Scott took responsibility? No, he took $300 million | Randy Schultz by Randy Schultz, Sun Sentinel News, October 2, 2018. Article: UnitedHealthcare issues warning to hospitals about out-of-network coverage for ER physicians by Susan Morse, Healthcare Finance News, September 25, 2018. Article: Three Ways Self-Insured Plans Can Leverage State Laws to Protect their Members from Balance Billing  by Matthew Albright, The Self-Insurer, September 2018. Article: The Last Company You Would Expect Is Reinventing Health Benefits  by Reed Abelson, NY Times, August 31, 2018. Article: As Health and Financial Challenges Grow, More Older Adults File for Bankruptcy by Lindsey Copeland, Medicare Rights Center, August 9, 2018. Article: A baby was treated with a nap and a bottle of formula. His parents received an $18,000 bill by Jenny Gold, Kaiser Health News and Sarah Kliff, Vox, July 20, 2018. Article: Air Ambulances Are Flying More Patients Than Ever, and Leaving Massive Bills Behind  by  John Tozzi, Bloomberg News, June, 11 2018. Case Docket: Case Proceeding Air Medical Group, KKR North America, and AMR Holdco, In the Matter of Federal Trade Commission, May 3, 2018. Article: Are Physician Staffing Companies Killing the Patient Experience and Bottom Line? by Berta Bustamante, InsideArm, April 10, 2018. Press Release: Ambulance Companies Air Medical Group Holdings, Inc. and AMR Holdco, Inc. Agree to Divest Air Ambulance Services in Hawaii as a Condition of Merger  Federal Trade Commission, March 7, 2018. Document: Letter to Christopher Holden-President and Executive Officer for Envision Healthcare US Senate, September 20, 2017 Bill: California Assembly Bill 72 by Ann Whitehead,JD,RN.,CAP Physicians, August 30, 2017. Report: AIR AMBULANCE Data Collection and Transparency Needed to Enhance DOT Oversight  Government Accountability Office, July 2017. Article: The Company Behind Many Surprise Emergency Room Bills by Julie Creswell,Reed Abelson and Margot Sangor-Katz, NY Times, July 24, 2017. Article: AB 72: No More Balance Billing for Out-of-Network Care In-Network by Staff, Word&Brown, July 14, 2017. Report: Health Policy Report Up in the Air: Inadequate Regulation for Emergency Air Ambulance Transportation Consumer Reports, March 2017. Article: One In Five Inpatient Emergency Department Cases May Lead To Surprise Bills by Christopher Garmon and Benjamin Chartock, Health Affairs, January 2017. Article: Trauma fees growing across the nation at 'absurd' rate by Alexander Zayas and Kris Hunley, Tampa Bay Times, November 21, 2014. Article: 10 Things to Know About HCA Becker's Hospital Review, April 16, 2014. Article: HCA to Eliminate Trauma Fees for Uninsured Patients Becker's Hospital Review, April 10, 2014.   Resources Profile Link: Connie Potter Profile, RN, BSN, MBA-HCA Link  Linkedin. Profile Link: Sherif Zaafran Profile, MD, FASA  Linkedin. Contact Us: Physicans for Fair Coverage  End of the Insurance Gap.org About Us: Independence Company (IBX)  IBX.com Document: License Agreement: Use of Current Procedural Terminology, Fourth Edition ("CPT®")  Centers for Medicare and Medicaid Services 2013-2018 Contributor List: Sen. Rick Scott Election Contributor List   Opensecrets.org Campaign Money Data Table: David Wichmann Political Campaign Contributions 2016 Election Cycle  Campaign Money.com Online Review Score: Regence Health Plan Company Profile Review  BestCompany.com False Claims Act: Nation’s Largest Healthcare Fraud Settlement Doesn’t Stop Medical Behemoth, WhistleBlowerJustice.net Visual Resources   Sound Clip Sources Hearing: NO MORE SURPRISES: PROTECTING PATIENTS FROM SURPRISE MEDICAL BILLS, Not on C-Span, Committee on Energy and Commerce, June 12, 2019. Watch on Youtube Witnesses: Sonji Wilkes: Patient Advocate Sherif Zaafran, MD: Chair of Physicians for Fair Coverage Rick Sherlock: President and CEO of Association of Air Medical Services James Gelfand: Senior Vice President of Health Policy at The ERISA Industry Committee Thomas Nickels: Executive Vice President of the American Hospital Association Jeanette Thornton: Senior Vice President of Product, Employer, and Commercial Policy at Americas’ Health Insurance Plans Claire McAndrew: Director of Campaigns and Partnerships at Families USA Vidor E. Friedman, MD: President of American College of Emergency Physicians Transcript 47:54 CEO Rick Sherlock: Emergency air medical services are highly effective medical interventions appropriate in cases where getting a patient directly to the closest most appropriate medical facility can make a significant difference in their survival in recovery. Today, because of air medical services, 90% of Americans can reach a level one or level two trauma center within an hour. However, since 2010, 90 hospitals have closed in rural areas and an estimated 20% more are at risk of closing. Our members fill the gap created by closures, but this lifeline is fraying as 31 air medical bases have also closed in 2019. 48:31 CEO Rick Sherlock: Emergency or medical providers never make the decision on who to transport. That decision is always made by a requesting physician or medically trained first responder. Air medical crews then respond within minutes, 24 hours a day, seven days a week without any knowledge of a patient’s ability to pay for their services. 48:45 CEO Rick Sherlock: Our members are unique in the healthcare system. The services heavily regulated by the states for the purposes of healthcare, as ambulances and the federal government for aviation safety and services as air carriers. It is their status as air carriers that allow rapid transport of patients over significant distances. Over 33% of our flights cross state lines every day. For that reason, the Airline Deregulation act uniform authority over the national airspace is essential to the provision of this lifesaving service. Exempting air medical services from the ADA would allow states to regulate aviation services, including where and when they’re able to fly, limiting access to healthcare for patients in crisis. 49:54 CEO Rick Sherlock: To prevent balance billing, our members are actively negotiating with insurance companies to secure in-network agreements. One member alone has increased their participation from 5% to almost 43% in the last three years. Despite that, some insurers have refused to discuss in-network agreements. That hurts both patients and caregivers. 50:30 CEO Rick Sherlock: Uh, covering air medical services in full, represents about a $1.70 of the average monthly premium. 51:50 CEO Rick Sherlock: $10,199 was the median cost of providing a helicopter transport. While Medicare paid $5,998, Medicaid paid $3,463 and the uninsured paid $354. This results in an ongoing imbalance between actual costs and government reimbursement and is the single biggest factor in increasing costs. 53:45 Senior VP James Gelfand: We’re focused on three scenarios in which patients end up with big bills they couldn’t see coming or avoid. Number one, a patient receives care at an in-network facility, but is treated by an out of network provider. Number two, a patient requires emergency care, but the provider’s facility or transportation are out of network. And number three, a patient is transferred or handed off without sufficient information or alternatives. It’s usually not the providers you’re planning to see. It’s anesthesiologists, radiologists, pathologists, or emergency providers or transport or an unexpected trip to the NICU. Many work for outsourced medical staffing firms that have adopted a scam strategy of staying out of networks, practicing at in-network facilities and surprise billing patients. It’s deeply concerning, but the problem is narrowly defined and therefore we can fix it. 54:40 Senior VP James Gelfand: The No Surprises Act nails it. It takes patients out of the middle and creates a market based benchmark rate to pay providers fairly. The benchmark is not developed by government and it is not price setting. The committee might also consider network matching. It’s simple. If a provider practices at an in-network facility, they take the in-network rate or they go work somewhere else. Or base the benchmark on Medicare, you could set the rate higher, say 125% of Medicare and still make the system more affordable, sustainable and simpler. These approaches will eliminate the surprise bills. That’s a huge win for patients. 54:50 ** Senior VP James Gelfand: But not everyone wants to stop the surprise bills. Some provider specialties are saying, “let us keep doing what we’re doing, just use binding arbitration to make someone else pay these bills”. They’re asking for a non- transparent process that could force plans and employers to pay massive and fake medical list prices. It’s essentially setting money on fire. Funds that would have been used to pay for healthcare will instead be spent on administrative costs such as lawyers, arbitrators, facility fees, and on reasonable settlement amounts. Make no mistake, patients will pay these costs. 55:20 Senior VP James Gelfand: The ground and air ambulance companies are asking Congress to let them keep surprise billing too. Do nothing, wait for another study, another report, and there have already been four. They know patients cannot shop for them and many participate in no networks. State insurance commissioners are begging for help with air ambulances, but Congress has tied their hands. Employers think Congress should end this. Treat medical transport the same as emergency care. We should end surprise billing in the ER and on the way there. 56:30 Senior VP James Gelfand: Other providers figure they’re willing to stop surprise billing, but only if they can increase in-network rates. They’re calling for network adequacy rules to force insurers and employers to add more providers to their networks, even if those providers demand astronomical payments. Does anyone here actually believe that these hospital based doctors who services cannot be shopped for, who are guaranteed to see our patients, are begging to be included in our networks, but nobody will return their calls? That they have no choice but to go and join these out of network Wall Street owned firms? It doesn’t make sense. 57:00 Senior VP James Gelfand: Employers design health benefits to help our beneficiaries. We don’t sell insurance. We want networks that meet our patients’ needs. Why would we want to cover an operation, but leave out the anesthesia? We want our employees to be able to afford their health insurance too, and that means we must be able to say no when providers are gaming the system. 1:08:10 Dr. Vidor Friedman: Unlike most physicians, emergency physicians are prohibited by federal law from discussing with a patient any potential costs of care or insurance details until they are screened and stabilized. This important patient protection known as Emtala, ensures physicians focus on the immediate medical needs of patients. However, it also means that patients cannot fully understand the potential cost of their care or the limitations of their insurance coverage until they receive the bill. 1:10:40 Dr. Vidor Friedman: The goal should be a system in which everyone is in-network, or essentially that. That requires a level playing field between providers and insurers. Insurers are concerned that benchmarking the even median charges, favors providers. Providers are concerned that benchmarking the median in-network rates, favors insurer’s. What’s Congress to do? ACEP supports a system that has already proven to be balanced between insurers and providers. That is a baseball style independent dispute resolution process similar to that used in New York and noted in the legislative proposal put forth by Doctors, Ruiz Rowe and Busan. 2:02:30 Rep. Brett Guthrie: If there does become a federal arbitration system, what do you think congressional oversight should be? And I don’t know if that should be something that I’m supposed to talk about or…Sonji Wilkes: Well, I’ve been sitting here listening, thinking I pay my insurance premiums, I do my part and I expect the bill to be paid. I mean, there’s only so much I can do to control that and I don’t really care how the reimbursement works. And quite frankly, I think the insurance industry is doing probably better in their bottom line than my bottom line. Um, I want to go to the best provider possible and I want the best care possible. I don’t really care how the payment works. 2:34:50 Dr. Sherif Zaafran: Well, I can tell you that from the physician’s standpoint, for emergency room physicians for example; the average weighted cost of every visit is about $155. 3:49:00 CEO Rick Sherlock: The median cost of a helicopter air transport is $10,199 according to a study conducted in 2017. If you look at the cost of uncompensated care, because Medicare pays less than $.60 on the dollar of that 10,199. About $5,998, Medicaid pays significantly less than that. Less than $3,500 on average, and the uninsured pay about $350. Those make up…those three groups make up 70% of air medical transports. So when you take that cost of uncompensated care and you add it to the median cost of $10,200, that’s the average charge of $36,000 that the representative from New Mexico referenced earlier. When you…when those kinds of situations happen, no one in our industry wants to see a patient or their family placed in jeopardy because they’ve just had a health emergency. Our members will sit down with each individual and their families and work out a solution tailored for them. 3:54:30 Dr. Sherif Zaafran: Again, there is no such thing as an out of network provider. There is a provider who may happen to be out of network with that specific product. So the only one who knows what the product is, is of course the patient and the insurance carrier and they’re the only ones who really have the information as to whether they’re in-network or out of network. Hearing: The Need to Reauthorize the September 11th Victim Compensation Fund, June 11, 2019 Hearing: Hearing on September 11 Victims Compensation Fund, June 11, 2019 Hearing: Watch on CSPAN-Surprise Medical Bills House Ways and Means Subcommittee on Health-May 21, 2019 Committee website Watch on YouTube Witnesses: Rep. Katie Porter (CA) James Patrick Gelfand: Senior Vice President, Health Policy, ERISA Industry Committee Dr. Bobby Mukkamala: Board of Trustees, American Medical Association Tom Nickels: Executive Vice President, Government Relations and Public Policy, American Hospital Association Jeannette Thornton: Senior Vice President for Product, Employer, and Commercial Policy at America’s Health Insurance Plans (AHIP) Transcript *7:15 Chairman Lloyd Doggett (TX): Fortunately, there now appears to be a growing consensus. Most recently joined by president Trump that holding the patient harmless should form the foundation for any surprise billing proposal. Under the legislation that I advanced, patients would only be charged in network cost sharing rates in emergency situations and non-emergency situations out of network charges would be permitted only when the patient has agreed in advance after receiving effective notice regarding any providers and services together with estimated charges. No other bill addressing this issue has yet been filed here in the house, but there is a very useful discussion draft proposal that is being circulated on a bipartisan basis by the House Energy and Commerce Committee and there’s several proposals that have service in the Senate. While every proposal currently begins with the basic premise of the enterprise billing act, conflict remains over how to resolve insurer provider disputes. *13:40 Rep. Katie Porter (CA): I’m concerned about surprise billing, as someone who’s dedicated my life to protecting consumers, but also because I have had to fight my own battle with surprise billing. On August 3rd last year when I was on the campaign trail, I started to feel pain in my abdomen. At 1:00 PM I could not continue and I went home. At 4:31, I texted my campaign manager that I needed to go to the emergency room. I couldn’t safely drive through the pain and I remember sitting on my front porch, so if I lost consciousness, somebody might find me and I wouldn’t be home alone. I didn’t call an ambulance because I was concerned about the cost. I could not drive and I asked my manager to please take me to Hoag hospital. I chose that hospital even though it was farther away from other providers, because I knew Hoag was an in-network facility. When I got to the hospital, I waited six hours alone in the emergency exam room without treatment. When I finally went to surgery, my doctor told me it was nothing to worry about, just a routine appendectomy. I was given anesthesia and when I awoke, the team around me was panicking. They couldn’t get my temperature to drop and they couldn’t get my blood pressure to rise. My appendix had ruptured hours before causing an infection that was making my whole body very sick. I spent the next five days in the hospital receiving powerful IV antibiotics. A few weeks later, I received the bill from my insurance company. The idea of an astronomical hospital bill had weighed heavily on me and I was happy to see that the cost of my emergency room treatment and assessment and hospital charges, and nearly all of my inpatient services, were covered. I remember sitting at my kitchen table and taking a deep breath filled with relief, but a few days later I received another bill. This one from my surgeon. While the hospital I had gone to was in-network, the insurance company now claimed the surgeon was not, even though they had sent me a notification telling me that my surgeon was in-network . Enclosed in that bill for nearly $3,000, was a handout from my surgeon detailing the steps I would have to take while recovering in order to fight to have my insurance company cover the care. So many of his patients had been put in this situation, that this medical doctor had used his staff to address patient billing problems. That’s not what he trained for in medical school. Your so-called explanation of benefits and the surgeon’s handout explained that he was being treated as an out of network provider even though he was employed by and worked at an in-network hospital. As someone in an emergency situation, I had no ability to assess whether he was in or out of network, and in those cases insurers are supposed to cover the costs, but I got that bill because my insurer put profits before patients. I called insurance company to request an appeal. The benefits manager kept asking me questions to guide me and coach me towards saying that it was my surgeon’s fault to blame him for overcharging me. She asked me to call the surgeon and attack my doctor for his bill. Apparently, to Anthem Blue Cross, $3,000 was too high a price for saving my life. The tens of thousands in premiums I’d paid to that company over the years were not enough to have them, cause them to cover the lifesaving care. Nearly five months after I was hospitalized, the surgeon simply requested payment, and at that point I reached out to my employer of the University of California Irvine. That’s when I learned that U.C. Irvine has a designated patient advocate, a medical doctor, whose sole job is to help university employees get the health insurance that the university and the employees pay for. Can we just reflect on that for a moment? The university is paying a medical doctor to do nothing but navigate insurance. Finally, the patient advocate, invoking the fact that I had just been just elected to Congress, was able to get the insurance company to agree to pay my surgeon’s bill. But here’s what I learned from getting sick. I am well educated. I had an employer prepared to help me. I have professional experience fighting for consumer rights, but there are thousands of Americans with fewer resources than me who are surprised with bills far more devastating than mine. I’m here today because they refuse to accept this as the status quo. I refuse to stand idly by while families go bankrupt because of surprise medical bills. Any solution to this issue must rely, must not rely, excuse me, on the patient’s ability to go to war with the insurer or with their provider. That is not the solution. It’s time we start putting patients first. 31:00 Jeanette Thornton: We ask that federal legislation focus on four things. First, balanced billing should be banned in situations where inpatients are involuntarily treated by an out of network provider. This includes emergency health services at any hospital, any health healthcare services or treatment performed at an in-network facility by an out of network provider, not selected by the patient and ambulance transportation in an emergency. Second, health insurance providers should be required to reimburse out of network providers inappropriate and reasonable amount in those above scenarios. Third, state should be required to establish an independent dispute resolution process that works in tandem with the established benchmark. Fourth hospitals or other healthcare providers should be required to provide advanced notice to patients of the network status of the treating providers. We appreciate the health sub-committee chairman Lloyd Doggett has introduced legislation to end surprise billing act or HR 861, which would establish a role for hospitals in providing such notices, along with banning balanced billing. AHIP supports this bill. 46:00 Chairman Lloyd Doggett (TX): What I’m referring to is the difference… Dr. Bobby Mukkamala: Right. Chairman Lloyd Doggett (TX): …in charges and why one one price for those who are in network and another for those that are out. Dr. Bobby Mukkamala: Right. So there is a benefit for me to be in network with Blue Cross Blue Shield of Michigan for example. I get something from that. They sit with me, they show me their data. We had…we worked together on incentive programs to sort of curb costs. If there’s an insurance company that’s in town that does none of that activity to improve the care of the population in my town, but yet wants to benefit from the same rate of compensation to me, they’re doing nothing to earn that discount. Blue Cross sits across from me on a weekly or monthly basis to improve the care of my population. But Golden Rule insurance, that’s new in town for example, doesn’t do any of that work and yet wants to benefit from having the same provider rates. No, I mean, I take a discounted rate from Blue Cross because of all this other robust activity. But if you’re not offering me anything to participate in your network, then naturally, you should be expected to pay more for my services. Right? I get something from Blue Cross. I get nothing from Golden Rule. 53:05 Dr. Bobby Mukkamala: Medicare is usually sort of the foundation upon which all the other insurance companies tend to set their rates. So when I participate in network, like with Blue Cross Blue Shield of Michigan, it’s usually about 110/ 115% of Medicare rates. So that’s one step higher. If I don’t participate with Blue Cross Blue Shield of Michigan, then that rate is so I can get the assigned rate from them and then I have a choice about what to do with the balance. And usually in my practice, I write that off. I don’t balance bill the patient. Uh, but Blue Cross Blue Shield sort of sets their rate and that’s it. My point is that, if-in Blue Cross Blue Shield, I have a great relationship with, we do a lot of constructive work together. But if a new insurance company comes into town and puts up billboards and markets their product and says, here, come, come buy our policy, and then they get 15,000 patients to sign up, but has never come to my door to say, you know, when they have an ear, nose and throat problem, we’d like you to be in-network and provide their care. Why should they get the benefit of the in-network price that Blue Cross Blue Shield gets? So, my point, is that that out of network price for this new insurance company that wants me to take care of their patient, but never came to sit down with me to sign a contract, ought to be something that I negotiate with them, not something that’s dictated to me. 55:50 Rep. Mike Thompson (CA): A staff person of mine went to the emergency room. He has insurance. His insurance covered nearly everything, including a cat scan. But a few weeks later, he got two separate bills from physicians he never saw and didn’t ask to see. They reviewed some of his test results and the bill for those two physicians was larger than the bill for his total ER visit. 56:15 Rep. Mike Thompson (CA): It’s also alarming that, uh, according to one study, 20% of hospital visits, one of every five of those visits, uh, that began in the ER, resulted in a surprise bill. 58:30 Dr. Bobby Mukkamala: Uh, yes, sir. So, in answer to your question, there are multiple already cases documented of insurance companies shrinking their network in California because they can get the same service at that rate with physicians that are out of their network. And so, contracts are already not being renewed for physicians that have had contracts for 20 years, and then they go to renew it and they’re dropped from the network. 1:03:00 Dr. Bobby Mukkamala: My wife and I, we contract with probably about 30 insurance companies. When I take a kid’s tonsils out, one insurance company may be $200- may pay me $200, one pays me about $450 and everything in between. I can’t have a different fee in my fee schedule for each of those. So my fee for tonsillectomy is about $475, so that when I do it, I know that the highest paying payer, I’m still-they’re still within that threshold, right? Because if I charge $400, they’re not going to send me $450. They’re going to send me $400. 1:07:00 Jeanette Thornton: So it’s very interesting what we’ve seen and when it comes from a hospital perspective. It’s maybe only 15% of the hospitals nationwide that are causing this issue that results in, you know, 80% of the visits. One of the statistics had cited a lot that result in a surprise medical bill. So this is not every doctor. This is not every hospital that are resulting in these surprise medical bills. It’s really more of a targeted problem. 1:09:15 Tom Nickels: In terms of how much of this is really going on, I think there is a certain level of frustration. I don’t know that we all know with certainty. The only federal study that I’ve seen, that we’ve seen, is from the Federal Trade Commission, which basically said that they studied ambulances going to hospital emergency departments. 99% of hospital emergency departments in that study were in-network. So it’s not the hospital itself that is out of network. it is people, physicians who practice in our institution. 1:22:20 Tom Nickels: The federal government-state government need to acknowledge that they underpay. I mean, Medpack and others acknowledges that this isn’t just industries talking about ourselves. AMA has said the same thing on the physician side, but I think that the federal government and state governments have a responsibility to pay more adequately. The truth of the matter is, and we haven’t even talked about this, is the cost shift is that private insurers pay more than costs and the government pays less. That should end. The government should take responsibility. 1:38:00 Tom Nickels: We cannot force by law, physicians who are not employed by us to take in-network rates. That is-if we did that, um, we would be sued. It would be restraint of trade. Um, however, what we’re trying to suggest here and I think what the other panelists are trying to suggest, is we have a way to protect the patient from that surprise bill. To your question about who are these physicians that you don’t even know about who are treating you, if you come in in an emergency, you don’t know what’s going on. And you need to be taking care of it, who’s ever there is going to take care of you. The other situation which we’ve talked about is when you knowingly come into an inpatient in-network facility. You did all the right things, but an out of network physician, (anesthesiologists, perhaps radiologists, pathologists) takes care of you. And that’s where the, uh, the bill is generated from. So we cannot make people do that. We try to get physicians to be in our networks-in the same networks. But again, this is an issue of private contracting. 1:42:05 Rep. Mike Kelly (PA): I do agree with you. If there’s limited talent there to take care of that specific problem, there has to be a way of compensating for it. Because at the end of the day, it is a business. Dr. Bobby Mukkamala: Right. So the solution is if an insurance company is going to come into Flint, Michigan and sell insurance, they know that eventually they’re going to need a hand surgeon, right? How do they sell insurance to a town that’s an industrial based town, where there’s a lot of hand injuries and not have any hand surgeons in their network? When they put up the billboard saying, “we’re selling insurance here”, they should have at the same time look at their provider list and say, “you know what”?, we’re missing an orthopedic hand surgeon. "Let’s go find one and figure out how to get him in-network or get her in-network. Right? And that’s a step that’s skipped routinely, right? They’ll sell the product for years and then fill in this way with lack of a good provider network by trying to negotiate out of network rates that are the same as in-network because they’d skip that first step, right? Maintain a network adequacy-establish a network adequacy before you sell your product. 1:48:30 James Gelfand: Many of the hospitals are not doing what Zuckerberg hospital was doing. The hospital will be in-network, but they will have outsourced their emergency room to a Wall Street owned private company and that company won’t take insurance. And those guys are definitely making enough profits that Wall Street is suggesting that people should invest in those companies because of these relationships they have with the in-network hospitals and the out of network emergency rooms. Trump remarks on medical billing-Watch on C-SPAN, May 9, 2019 13:00 President Donald Trump: Today I’m announcing principles that should guide Congress in developing bipartisan legislation to end surprise medical billing. And these senators and congressmen and women that are with us today are really leading the charge. And I appreciate that they’re all here. Thank you all. Thank you all for being here. This is fantastic. And I think it’s going to be a successful charge. From what I understand, we have bipartisan support, which is rather shocking. That means it’s very important. That means it’s very good. But that’s great. First, in emergency care situations, patients should never have to bear the burden of out-of-network costs they didn’t agree to pay. So-called balance billing should be prohibited for emergency care. Pretty simple. Second, when patients receive scheduled, non-emergency care, they should be given a clear and honest bill upfront. That means they must be given prices for all services and out-of-pocket payments for which they will be responsible. This will not just protect Americans from surprise charges; it will empower them to choose the best option at the lowest possible price. Third, patients should not receive surprise bills from out-of-network providers that they did not choose themselves. Very unfair. Fourth, legislation should protect patients without increasing federal healthcare expenditures. Additionally, any legislation should lead to greater competition, more choice — very important — and more healthcare freedom. We want patients to be in charge and in total control. And finally, in an effort to address surprise billing, what we do is, all kinds of health insurance — large groups, small group, individual markets, everything. We want everything included. No one in America should be bankrupted and unexpectedly by healthcare costs that are absolutely out of control. No family should be blindsided by outrageous medical bills. And we’ve gone a long way to stop that. Examining Surprise Billing: Protecting Patients from Financial Pain-Not on C-SPAN, House Committee on Education and Labor, April 2, 2019 Watch on YouTube Witnesses: Christen Linke Young: Fellow at USC-Brookings Schaeffer Initiative on Health Policy Ilyse Schuman: Senior Vice President for Health Policy at American Benefits Council Frederick Isasi, Executive Director at Families USA Professor Jack Hoadley: Research Professor Emeritus at Georgetown University’s Health Policy Institute Transcript 7:15 Chairman Frederica Wilson (FL): This is the first hearing the United States Congress has held on surprise billing. 7:30 Chairman Frederica Wilson (FL): Surprise medical bills occur when patients covered by health insurance are subject to higher than expected out of pocket costs for care, received from a provider who is outside of their plan’s network. The victims of surprised medical billing often have no control over whether they’re medical provider is in or out of network. 8:15 Chairman Frederica Wilson (FL): A young San Francisco woman named Nina Dang suffered a severe bike accident. She was barely lucid when a bystander called an ambulance and took her to an emergency room at a nearby hospital. Before she knew it, doctors had done x-rays and scans and put her broken arm in a splint and then sent her on her way. A few months later, Nina was hit with a $20,000 medical bill because the hospital, which she did not choose, was an out of network facility. 8:30 Chairman Frederica Wilson (FL): But even patients who are able to take precautions to avoid out of network costs during a medical emergency, are not immune from surprise bills. Scott Cohan suffered a violent attack one night in Austin, Texas. He woke up in an emergency room with a broken jaw, a throbbing headache, and staples in his head. Despite his shock and immense pain, Scott took out his phone and searched through his insurer’s website to make sure he was laying in an in-network hospital bed. When he found out it was, he proceeded with unnecessary jaw surgery. Imagine Scott’s frustration and devastation when he received a surprise medical bill for nearly $8,000. It turned out that the emergency room was in his insurance network, but the oral surgeon who worked in the ER was not. 16:00 Rep. Tim Walberg (MI): 39% of insured working age adults reported they had received a surprise medical bill in the past year from a doctor, hospital, or lab that they thought was covered by their insurance. Of the 39% of individuals who received surprise medical bills, 50% owed more than $500. 27:05 Ilyse Schuman: While a number of states have sought to address this problem or risk that exempts self insured plans from State Insurance Regulations to ensure that national employers can offer uniform health benefits to employees residing in different states. Accordingly, the problem of surprise billing cannot be left to the states to solve. 33:20 Frederick Isasi: So what’s most important to remember about this issue? We are talking about situations in which families, despite enrolling in health insurance, paying their premiums, doing their homework and trying to work within the system, are being left with completely unanticipated and sometimes financially devastating healthcare bills. And this is happening in part, and I want to say this really clearly because hospitals, doctors and insurers are washing their hands of their patient’s interest. 33:50 Frederick Isasi: Take for example, one significant driver of this problem. The movement of hospitals to offload sapping requirements for their emergency departments to third party management companies. These hospitals very often make no requirements of these companies to ensure the staffing of the ED fit within the insurance networks that the hospitals have agreed to. As a result, a patient who does their homework ahead of time and rightly thinks they’re going to an in network hospital, received services from an out of network physician and a surprise medical bill follows. 34:20 Frederick Isasi: Let me give you one real world example. Nicole Briggs from Morrison, Colorado outside of Denver. Nicole woke up in the middle of the night with intense stomach pain. She went to a freestanding ER. She was told she needed an emergency appendectomy. She went to a local hospital. She did her due diligence. Confirmed repeatedly that the hospital and its providers were in network. However, months later she received a surprise bill from the surgeon who ended up, was out of network. The bill to Nicole was $5,000. Nicole tried to work it out with her insurance company, but within two years, a collection agency representing the surgeon took her to court and won the full amount, including interest. As a result, a lien was placed on her home and the collection agency garnished her wages each month. This came right before Nicole was about to deliver a baby and go on maternity leave. And by the way, this investigation found that there were over 170 liens placed on people’s homes in the Denver area by emergency department physicians. 38:05 Professor Jack Hoadley: Our research shows that today, 25 states have acted to protect consumers from surprise bills in at least some circumstances. Nine of these 25 meet our standards as offering what we consider to be comprehensive protection. For protections to be comprehensive, we look to number one, whether they apply in both emergency situations and an in-network hospital setting, such as electing an in-network surgeon, but being treated by another clinician who’s out of network. Second, that these laws apply to both HMO’s, PPO’s and all other types of insurance. Third, that the law does address both insurers by requiring them to hold consumer’s harmless from balanced bills and providers by barring them from sending balanced bills. And fourth, that the laws adopt some kind of a payment standard. Uh, either a rule to determine payment from insurance provider or an arbitration process to resolve payment disputes. Although these four conditions don’t guarantee complete protection for consumers, they combine to protect consumers in most emergency and network hospital settings that the states can address. But as you’ve already heard, state protections are limited by federal law, ERISA, which exempt states from state regulation’s, self insured, employer sponsored plans. 43:30 Chairman Frederica Wilson (FL): Under current law, who is responsible for making sure that a doctor or a hospital is in-network? Is it the doctor, the insurance company or the patient themselves? Frederick Isasi: Uh, chairman Wilson, thank you for the question. To be very clear, it is the patient themselves that has a responsibility and these negotiations are very complex. These are some of the most important and intense negotiations in the healthcare sector between a payer and a provider. There is absolutely no visibility for a consumer to understand what’s going on there. And so the notion that a consumer would walk into an emergency department and know, for example, that their doctor was out of network because that hospital could not reach agreement on an in-network provider for the ED is absurd, right? There’s no way they would ever know that. And similarly, if you walk in and you received surgery and it turns out your anesthesiologist isn’t in-network, there’s no way for the consumer to know that. Um, and I would like to say there’s some discussion about transparency and creating, you know, sort of provider directories. We’ve tried to do that in many instances. And what we know is that right now the healthcare sector has no real way to provide real actual insight to consumers about who’s in-network, and who’s out of network. I would-probably everybody in this room has tried at some point to figure out if a doctor’s in-network and out of network and as we know that system doesn’t work. So this idea that consumers can do research and find out what’s happened behind the scenes in these very intensive negotiations is absurd and it doesn’t work. 46:30 Professor Jack Hoadley: Provider directories can be notoriously inaccurate. One of the things that, even if they are accurate, that I’ve seen in my own family is you may be enrolled in Blue Cross-You ask your physician, "are they participating in Blue Cross? They say “yes”, but it turns out Blue Cross has a variety of different networks. This would be true of any insurance company, and so you know, you may be in this one particular flavor of the Blue Cross plan and your provider may not participate in that particular network. 47:30 Christen Linke Young: Notice isn’t enough here. Even if a consumer had perfect information, which is not a reasonable expectation, but even if they did have perfect information, they can’t do anything with that information. They can’t go across town to get their anesthesia and then come back to the hospital. Um, their-even with perfect information, they may be treated by out of network providers. And so we need to set a standard that limits how much providers can be paid in these out of network scenarios that makes it sort of less attractive for providers to remain out of network. And so instead, they are subject to more normal market conditions. 1:01:25 Rep. Phil Roe (TN): I’ve had my name in networks that I wasn’t in. That you-that you use, and many of those unscrupulous networks, will use that too to get people to sign up because this doctor, my doctor is in there when you’re really not. 1:10:25 Frederick Isasi: Um, there is a concept here, which is, what does in network mean, right? When you sit down with your husband or your partner and decide what kind of insurance do we want for our kids, right? We want to make sure that they can go to the ED if they’re playing soccer, they get hurt, all those sorts of things. The question is when you make that decision and you say, "Oh, look, this hospital is in-network, right? But what does that mean? If you can go to that hospital and all the services they’re providing are out of network, right? And I think as you’ve said, and as we’ve heard from other folks, the patient is not the person who should be responsible for that. It’s the folks who are negotiating. It’s the hospital, it’s the doc’s and the payers that should bear that responsibility. So let’s start by clarifying what does in-network mean, so that we have some way of making educated decisions about the insurance that we’re purchasing and putting our trust in. 1:29:30 Professor Jack Hoadley: There may be instances where consumers get bills sent to them, aren’t aware that they don’t need to pay them, so don’t start the process. And that goes to this sort of point of how do you really make sure it’s not the consumer’s responsibility to figure out that, oh, I don’t, by law, I don’t actually have to pay this bill. Now what do I do to make sure that happens? If you don’t know that, uh, that doesn’t really help you. And so what some other states like California has done, is to include a provision that says the provider really can’t send a bill and if they do end up sending a bill and the consumer pays it, there’s an obligation on that provider to refund the amount that was paid back to the consumer. And that’s something we haven’t seen in some of the other states. 1:39:15 Rep. Joe Courtney (CT): ERISA really has to be dealt with if we’re going to really have a comprehensive solution for America’s patients. Is that correct? Ilyse Schuman: That’s exactly right. Um, for the self funded plan too 60% of employer based plans that are not subject to these state laws, like in Connecticut or other states, we have to have a federal solution that addresses ERISA, so that we deal with this problem in a uniform nationwide way. Documentary: This is a clip from the documentary: 911, Toxic Legacy which aired on Canadian CBC 9/10.2006, September 10, 2006 Community Suggestions See Community Suggestions HERE. Cover Art Design by Only Child Imaginations Music Presented in This Episode Intro & Exit: Tired of Being Lied To by David Ippolito (found on Music Alley by mevio)