The No Surprises Act went into effect on January 1, but it hasn't fully put a stop to unexpected medical bills.
Surprises bills continue to be sprung on patients, even with a federal ban in place, with one in five adults receiving an unexpected medical charge this year, according to a survey by Morning Consult.
The No Surprises Act, which went into effect on January 1, is meant to protect patients from receiving unforeseen bills for out-of-network and emergency services after receiving treatment.
Yet 20% of respondents in the Morning Consult survey say they or their family have been charged unexpectedly, with another one in five billed after being treated by an out-of-network provider at an in-network facility.
The bills have been especially costly in some cases, as 22% of respondents say their charges were over $1,000.
Unexpected charges haven't just been an issue after the fact. The survey found about one in four adults delayed or skipped medical care because they were concerned with receiving a surprise bill. Emergency room care suffered the most in this facet, with 14% of respondents saying they did not seek care, while another 14% say they hesitated but ended up receiving care.
Emergency room bills are also what respondents feel they would be least confident in knowing up front, with 45% of adults expressing suspicion. Meanwhile, 71% say they are confident in knowing primary care costs.
When it comes to addressing an unlawful surprise bill with a provider or insurer, 63% of respondents—including 61% of those who have previously received an unexpected charge—express confidence.
Those who answered they are less sure about resolving a surprise bill pointed to distrust in both healthcare companies and the system to make it right.
Finally, only 16% of adults say they've either seen, read or heard about the No Surprises Act.
While not completely stopping surprising billing, the law is reportedly alleviating the problem somewhat.
In the first two months after going into effect, the ban prevented more than two million surprise bills, according to a survey from AHIP and Blue Cross Blue Shield Association.
The Predatory Debt Collection Act, which would put a cap on interest rates for medical debt, collected over 500,000 signatures in its quest to reach the ballot.
Healthcare Rising Arizona, with the support of the Fairness Project, cleared a significant hurdle in the pursuit of placing a measure on the November ballot to curb harmful medical debt collection practices in the state.
The Predatory Debt Collection Act cleared 500,000 signatures, easily surpassing the requirement of 237,645 signatures needed to qualify for the election, giving the campaign serious legs in its aim to protect patients and oppose abusive creditors.
The signatures for the Predatory Debt Collection Act must now be validated by the Arizona secretary of state and county recorders to reach the ballot.
Along with placing a cap on interest rates for medical debt, the proposed measure would shield individuals' assets from creditors.
The Fairness Project and its partners have previously led successful initiatives to fight predatory lending, with ballot campaigns won in Nebraska in 2020 and in Colorado in 2018. In addition to Healthcare Rising Arizona, the Fairness Project is also striving to pass a measure in Michigan this year.
"No one should have to declare bankruptcy, be harassed by debt collectors, or lose their home because
they sought treatment for an illness or injury. This is a matter of basic economic justice," Fairness Project executive director Kelly Hall said in a statement. "If passed, this ballot measure will provide direct relief to Arizona families whose lives are upended by medical debt. It will also help to ensure people don’t avoid getting care they need out of fear of going into debt — something that is essential while we are still in a pandemic.
"Fairness Project has a record of supporting successful ballot measures in several states to protect borrowers from predatory lending, increase people’s access to health care, and put more money in people’s pockets — and Arizona is next."
A survey finds that 70% of large employers are planning health and benefit enhancements for 2023.
Over two-thirds of employers are planning to improve their health and benefit offerings in 2023 to attract and retain workers amid a competitive labor market, according to a study by Mercer.
The survey polled 708 organizations ranging in size, from fewer than 500 employees to 5,000 or more workers. Among large employers, 70% said they are planning on health and benefit enhancements in 2023, while 61% of all employers are conducting surveys on employee benefit preferences.
"In today's competitive labor market, employees are able to leave jobs for others offering only slightly higher pay," said Tracy Watts, senior partner and national leader for US Health Policy at Mercer. "Employers are looking to create a stronger bond with this workforce by offering health and well-being benefits and resources that their employees will value."
With health benefits being a priority for many workers, employers are revamping their health plans to appeal to talent.
The survey found 41% of employers will provide a health plan option with a low deductible or no deductible, such as a copay-based plan, while 11% are considering it.
Additionally, 11% offer free employee-only coverage for at least one plan option, and another 11% are considering it.
Over half of large employers (52%) said they will offer virtual behavioral healthcare, with 40% offering a virtual primary care physician network service.
When it comes to fertility treatment coverage, nearly a third of large employers will offer benefits such as adoption and surrogacy, while another third are considering it.
Family-friendly benefits are also a priority, with 70% of respondents currently offering or planning to offer paid parental leave and 53% providing or planning to provide paid adoption leave.
"Employers need to be really thoughtful and specific about their benefits enhancements to ensure they will get a return on their investment," said Watts. "This requires an understanding of the values and needs of their unique workforce."
Physician groups are upset by the proposed change in the Medicare Physician Fee Schedule, which includes a $1.53 decrease in the conversion factor for 2023.
Providers face costly cuts to Medicare reimbursements in the 2023 Physician Fee Schedule proposed rule by CMS.
The newly released proposed rulefeatures a decrease of $1.53 to the calendar year (CY) 2022 conversion factor of $34.61, resulting in a conversion factor of $33.08 for CY 2023.
CMS states that the change reflects the expiration of the 3% increase in Physician Fee Schedule payments for CY 2022 as required by the Protecting Medicare and American Farmers From Sequester Cuts Act, along with a 0% conversion factor update and a budget-neutrality adjustment. The 3% bump was put in place by Congress to help providers offset the expenses of the COVID-19 pandemic.
Physician groups have expressed their displeasure and frustration with the proposed rule, suggesting that the cuts not only damage providers, but patients as well.
"It is immediately apparent that the rule not only fails to account for inflation in practice costs and COVID-related challenges to practice sustainability, but also includes a significant and damaging across-the-board reduction in payment rates," Jack Resneck Jr., MD, president of the American Medical Association, said in a statement. " Such a move would create long-term financial instability in the Medicare physician payment system and threaten patient access to Medicare-participating physicians."
The Medical Group Management Association (MGMA), meanwhile, pointed to the additional 4% in cuts coming under Congress' Pay-As-You-Go (PAYGO) law, which calls for cuts to counterbalance an increase in federal spending.
"These proposed cuts, coupled with the 4% PAYGO sequestration scheduled to take effect on Jan. 1, 2023, will have a detrimental impact on group practices, with 58% of recently surveyed groups indicating they are considering limiting the number of new Medicare beneficiaries served should the cuts take effect," said Anders Gilberg, senior vice president of government affairs at MGMA.
The Surgical Care Coalition, which consists of 14 surgical professional associations representing more than 180,000 surgeons across the U.S., also blasted the proposed rule.
"The current Medicare Physician Fee Schedule is broken. It fails to incentivize collaboration and pits doctor against doctor every year," said Joseph C. Cleveland Jr., MD, chair of The Society of Thoracic Surgeons Council on Health Policy and Relationships. "It's crucial that Congress work to address these cuts and create a more sustainable payment system. Failure to do so presents a serious risk to patients during a time of declining access to surgical care and rising prices for services and treatments."
Comments on the proposed rule are due September 6.
The analysis, which examines 230.9 million in-network claims across 144 major insurers for that year, finds that the average in-network claim denial rate was 18.3% (42.3 million). Denial rates ranged from 1% to 80% depending on the payer.
Additionally, researchers of the study found that individuals rarely appealed denied claims, at a rate of just one-tenth of 1%, and when they did insurers upheld their original decision 63% of the time.
Under the Affordable Care Act, marketplace plans are required to report transparency data, which includes claim denials, claims payment policies and practices, and more. The researchers, however, point to the data not being audited or used to develop other tools to help individuals compare plans, while also omitting information that could better protect consumers.
"Twelve years after enactment of the ACA, limited transparency in coverage data collected by the federal government is notable for what it doesn’t show, perhaps even more than for what it does reveal," the authors write.
The analysis found that of the 144 studied insurers, 28 had a denial rate of less than 10%, 52 died between 10% and 19%, 36 denied 20-30%, and 28 denied more than 30%.
Insurers that denied over one-third of claims included Celtic in five states (Arizona, Indiana, Missouri, Tennessee, and Texas), Molina in six states (Missouri, Mississippi, Ohio, South Carolina, Utah, and Wisconsin), and QualChoice in Arkansas and Ambetter in North Carolina, Oscar in seven states (Arizona, Florida, Mississippi, Missouri, Tennessee, Texas, and Virginia), and Meridian in Michigan.
Reasons for denying claims varied, with about 16% denied because the claim was for an excluded service, 10% due to lack of preauthorization or referral, and about 2% based on medical necessity. Among 2% of claims identified as medical necessity denials, while one in five were for behavioral health services. The majority of denials (72%) were for 'all other reasons.'
With the insurer marketplace running on competition between plans, the authors state, it's important individuals can access all of an insurer's features, including how reliable plays pay claims.
"More robust transparency data reporting, while potentially more burdensome to insurers, could provide data useful to both regulators and consumers," the researchers write.
With its unanimous decision, the Supreme Court sided with AHA and deemed the cuts illegal because HHS did not first survey the hospitals' drug acquisition costs. Though SCOTUS did not offer a remedy to the dispute, the ruling allows the hospitals to fight for the $1.6 billion owed to them annually.
AHA now wants 340B hospitals to be repaid the withheld funds without delay, as well as paid for the past four years in which CMS illegally cut reimbursement rates, as outlined in a letter to HHS secretary Xavier Becerra.
"We are concerned, however, that despite the Supreme Court's conclusive decision, resolution of these issues could be bogged down in needless litigation, and that hospitals will not be appropriately compensated at a time when they are weathering significant financial challenges on many fronts," AHA writes.
The hospital organization notes that when a federal district court initially ruled that the cuts were unlawful, the prior Administration took actions to delay repayments.
Along with requesting a remand to HHS to determine the appropriate remedy, the prior Administration conducted notice-and-comment rulemaking on that remedy. It also opposed the AHA's motion for an expedited remedy and offered that affected hospital be repaid on a case-by-case basis.
AHA specifically highlights the prior Administration's position that HHS is required to maintain budget neutrality when determining the appropriate remedy.
"As you know, that position would mean that some hospitals will be forced to pay back money spent years ago — including during the COVID-19 pandemic — because the federal government made a legal error," the AHA writes. "Hospitals should not have to pay for the agency's mistakes. Instead, this Administration should take the sensible (and legally correct) position that budget neutrality is not required when a court — here, all nine Justices of the Supreme Court — concludes the agency violated the law."
Finally, AHA points to HHS unlawfully citing a 2020 survey for proposing even bigger reimbursement cuts.
The survey, AHA says, failed to meet the statutory requirement for response rate because it was issued during the onset of the COVID-19 pandemic, with only 7% of hospitals responding with acquisition of cost data. It also did not meet statutory requirements when it specified that only 340B hospitals were required to complete the survey.
The quicker 340B hospitals are repaid, AHA argues, the less damage they will incur in their role serving vulnerable communities.
A study by the Proceedings of the National Academy of Sciences (PNAS) explores what a single-payer universal healthcare system would look like in the COVID-19 climate.
In an alternate universe where a Medicare for All healthcare system was in place in the United States, 338,594 lives and $105.6 billion could have been saved during the COVID-19 pandemic, according to a study by PNAS.
The U.S., which does not provide universal healthcare as some other nations do, has particularly been hit hard by COVID-19 cases and deaths. PNAS attempted to quantify just how much the absence of a single-payer universal healthcare system has affected the country in past few years.
To determine the hypothetical, the peer reviewed journal calculated the elevated mortality attributable to the loss of employer-sponsored insurance and to background rates of uninsurance, combined with higher COVID-19 mortality due to low insurance coverage.
The findings were immense, with researchers estimating that universal healthcare would have saved about 212,000 lives and $459 billion in 2020 alone.
"The COVID-19 outbreak has underscored the societal vulnerabilities that arise from the fragmented healthcare system in the United States," the authors wrote. "Universal healthcare coverage decoupled from employment and disconnected from profit motivations would have stood the country in better stead against a pandemic.
"Emergence of virulent pathogens is becoming more frequent, driven by climate change and other global forces. Universal single-payer healthcare is fundamental to pandemic preparedness."
Even if, theoretically, another pandemic isn't on the way, universal healthcare has the potential to address inequality and alleviate spending.
Compared to the current system, single-payer universal healthcare could have saved $438 billion in 2019, according to the study.
When health insurance is tied to employment, the ramifications can be dire when individuals lose their jobs. As such, socioeconomic factors play a significant role in determining which segment of the population is the most vulnerable with the current healthcare system.
As the pandemic exposes the gaps in the system, it provides further evidence for prioritizing healthcare access going forward.
"To facilitate recovery from the ongoing crisis and bolster pandemic preparedness, as well as safeguard well-being and prosperity more broadly, now is the time to transition to a healthcare system that can better serve the American people," the researchers concluded.
When breaking down the results by individual procedures, 21% and 18% of hospitals provided the required information to be compliant for CPT codes 27447 and 27130, respectively, while 18% and 19% of hospitals did so for DRG codes 469 and 470.
Since the price transparency rule went into effect on January 1, 2021, CMS requires hospitals to provide five types of online price information for selected services: the total charge, the charges the hospital privately negotiated with health insurers, the minimum and maximum negotiated charges, and the amount the facility is willing to accept in cash.
Researchers of the study stated they chose to investigate price transparency for TJA procedures because of how widely used they are, making it some of the most commonly sought-after pricing information for orthopedic surgery patients.
The low compliance rates found in the study suggest hospitals are either struggling to implement the necessary changes to be compliant or are willfully ignoring the mandate.
"It is possible that hospitals have delayed compliance with the hope that related requirements may change or that current delays in enforcement may continue," the authors wrote. "Although it is unclear whether legislation will change, the low rates of compliance demonstrated in our analysis should encourage hospitals to provide related information to avoid penalties expected to be enforced starting July 1, 2022."
The study looked at 400 hospitals in December 2021 and searched each hospital's website for a machine-readable file providing the five requirements for compliance. The researchers also considered hospitals pseudocompliant if they provided some type of gross price information.
The pseudocompliance rates were moderately higher, with 36% and 31% of hospitals offering total charges for CPT codes 27447 and 27130, respectively, and 34% and 50% of hospitals doing so for DRG codes 469 and 470.
Additionally, 13% of hospitals failed to provide machine-readable files, while 21% required users to provide personal information.
A recent JAMA study highlighted hospitals' avoidance of price transparency, with the findings showing roughly 51% of facilities did provide either a machine-readable file or a shoppable display.
Only two hospitals, Northside Hospital Atlanta and Northside Hospital Cherokee, have so far been fined by CMS for failing to comply with price transparency requirements.
More fines are expected, but the authors of the TJA study believe hospitals should not only act to comply for the sake of their wallets, but also for the sake of their patients.
"Given the potential influence compliance and price sharing may have on empowering patients’ healthcare decisions and reducing healthcare expenditures in the United States, hospitals should use our analysis to identify where their compliance is lacking and to understand how to make their pricing information more readily available and comprehendible for the patients that they serve," the researchers concluded.
Compliance was higher in less competitive hospital referral regions (HRRs) and for hospital systems with greater market shares. Multihospital systems, for-profit hospitals, and teaching hospitals had higher compliance, as did hospital systems with more beds.
Meanwhile, government hospitals, critical access hospitals, and hospitals lacking intensive care units all were found to have lower compliance.
The authors of the study note that higher compliance rates in less competitive markets is "consistent with safeguarding of negotiated prices in the presence of greater competition."
In total, the research included 2,892 hospital systems representing 4,484 hospitals in 306 HRRs as of December 2021, with the mean compliance rate at 68% (46% standard deviation).
To collect the data, the authors manually gathered compliance information from hospital websites and verified whether payer-specific prices were reported. The hospital-level characteristics came from the American Hospital Association, the CMS Provider of Services File, and the Dartmouth Atlas of Health Care.
One of the limitations of the research is that it defines compliance based on availability of payer-specific negotiated prices, while failing to include other CMS requirements like availability of a shoppable service tool. A stricter definition of compliance, the authors admit, would likely have led to lower compliance rates in the research.
These findings follow another recent JAMA study which found that roughly 51% of hospitals did not adhere to either price transparency requirement.
Of the 5,239 hospital websites evaluated, 14% had a machine-readable file but no shoppable display, while 30% had a shoppable display but no machine-readable file. Less than 6% were compliant with both requirements.
However, the researchers of that study found that hospitals located in moderately or highly concentrated markets were significantly less likely to be compliant. Other hospital characteristics—total gross revenue, size, emergency service capabilities, and ownership type—were not associated with compliance.
CMS has so far fined only two hospitals, Northside Hospital Atlanta and Northside Hospital Cherokee, for violating the price transparency mandate after a total of 352 warnings were issued as of early June.
Officials warned payers of their legal obligation to cover contraception at no cost under the Affordable Care Act (ACA).
In the wake of the Supreme Court's ruling overturning Roe v. Wade, the Biden administration reminded health insurers they are legally required to provide contraceptive coverage at no cost under the ACA.
HHS secretary Xavier Becerra and Labor secretary Marty Walsh met with leaders from insurers and employee benefit plans, while the two joined Treasury secretary Janet L. Yellen in issuing a letter to payers underlining contraceptive coverage obligations.
The ACA guarantees coverage of women's preventative services, including birth control and contraceptive counseling at no cost for individuals and covered dependents in all 50 states. However, some insurers are not complying with the regulations, according to the secretaries.
"The Biden-Harris Administration is committed to strengthening access to care and coverage," the secretaries wrote in the letter. "We are calling on the industry to remove impermissible barriers and ensure individuals have access to the contraceptive coverage they need, as required under the law. It is more important than ever to ensure access to contraceptive coverage with no out-of-pocket costs under the Affordable Care Act."
Payers are required to cover at least one form of contraception in each contraceptive category, along with Food and Drug Administration-approved contraceptive products that an individual and their provider have deemed medically appropriate.
The departments expect insurers to immediately take the necessary steps to ensure compliance and avoid future enforcement actions.
The meeting with industry leaders was attended by America's Health Insurance Plans, Association for Community Affiliated Health Plans, Centene, Humana, Business Group on Health, CVS Health, ERISA Industry Committee, HR Policy Association, AFL-CIO, Blue Cross Blue Shield Association, National Coordinating Committee for Multiemployer Plans, Express Scripts, Optum, United Health Group, Kaiser Permanente, and Alliance of Community Health Plans.
"We are calling on your organizations to remove impermissible barriers and ensure individuals in your plans have access to the contraceptive coverage they need, as required under the law," the secretaries wrote. "It is more important than ever to ensure access to contraceptive coverage without cost sharing, as afforded by the ACA."