Insurers and healthcare providers each oppose the other side's preferred solution to end surprise bills.

This article was first published on Thursday, May 9, 2019 in Kaiser Health News.

By Julie Rovner

President Donald Trump called on Republicans and Democrats to pass legislation this year to end surprise medical bills, in remarks made in the White House's Roosevelt Room on Thursday. "We're determined to end surprise medical billing for American patients," Trump said.

Bills like those have been featured in the NPR-Kaiser Health News series launched in February 2018. Two patients whose medical bills were part of the series attended the event.

Austin, Texas, teacher Drew Calver talked about the six-figure bill he received after having a heart attack. "I felt like I was exploited at the most vulnerable time in my life," he said. His bill was reduced to $332 after the NPR-KHN story was published.

A bipartisan group of senators has been working to come up with a plan for the past several months. They said Thursday that they hope to have a bill to the president by July.

But will bipartisanship be enough? Even political will might not overcome divisions within the health industry.

Specifically, lawmakers aim to address the often-exorbitant amounts patients are asked to pay out-of-pocket when they receive care at health facilities that are part of their insurance network but are treated by out-of-network practitioners. Legislators are also looking to address bills for emergency care at a facility that doesn't have a contract with patients' insurers.

"We're getting really close to an approach that we'll be able to unveil pretty soon," Sen. Maggie Hassan (D-N.H.) told reporters on a conference call Thursday with Sen. Bill Cassidy (R-La.).

And it's not just politicians and patients: Out-of-network doctors, insurance companies and hospital groups say they want the problem for consumers fixed, too.

Despite that broad agreement, a hurdle remains. Insurers and healthcare providers each oppose the other side's preferred solution to end surprise bills. That conflict makes it almost impossible for lawmakers to come up with a fix that won't leave one of the influential groups unhappy.

"It's a different axis than the partisan [conflicts] we're used to," said Loren Adler, who has been studying the surprise-bill problem for the USC-Brookings Schaeffer Initiative for Health Policy. The fight over how to fix it is less likely "to break down between Republicans and Democrats and more likely to break down to where the money is" and which group will have to take less of it.

"I don't see a coalescence around a solution," said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents for-profit facilities.

The divide is wide, despite the overall interest in protecting consumers.

"What we'd most like to see is clarity for the patients," said Bob Kneeley, a senior vice president for Envision Healthcare, which employs physicians to staff a variety of hospital departments, such as emergency rooms, neonatal units and anesthesiology. "This is a system that's just not working well for the patient, and we need to establish some appropriate guardrails."

"We want this to be solved. We know it needs federal legislation," agreed Molly Smith, a vice president at the American Hospital Association. She said hospitals believe that patients should "not have to be involved in any process if there's a dispute between the payer and the provider."

States have been working on the problem for several years. Nine now have programs aimed at protecting patients from surprise bills. But state laws cannot reach those with employer-provided insurance — more than half of all Americans — because those plans are regulated by a federal law called the Employee Retirement Income Security Act, or ERISA. That means only Congress can fix it for everyone.

Patients and groups that represent them say the problem is more urgent than ever.

"We are talking about situations in which families — despite enrolling in health insurance, paying premiums, doing their homework and trying to work within the system — are being left with completely unanticipated and sometimes financially devastating bills," Frederick Isasi, executive director of the consumer group Families USA, told a House Education and Labor subcommittee hearing in April. "This is inexcusable behavior on the part of hospitals, doctors and insurers. They each know — or should know — that patients have no real way to understand the financial trap they have just walked into."

Dr. Paul Davis, whose daughter received a bill for a $17,850 for a urine test after back surgery, also spoke at the White House on Thursday: "The situation is terrible. It is a national disgrace, and I think a lot of people would support me on that," Davis told a reporter. Their story was the first featured in the "Bill of the Month" project.

Still, it's not clear where compromise might be found.

By and large, doctors favor some sort of negotiated-fee system when there is a dispute about a bill, such as binding arbitration, in which an independent third party makes the ultimate payment decision.

"That's consistent with what's working in some states," said Envision's Kneeley.

Among those frequently cited by doctors' groups is New York, which has one of the strongest state laws on surprise billing. There patients are not required to pay more than they would for an in-network doctor or hospital. For the remaining bill, an independent arbitrator settles any dispute between the provider and insurer.

But the insurance industry worries about that approach. "Our larger concern with arbitration is that it still relies on bill charges," said Adam Beck, a vice president for America's Health Insurance Plans, an insurance industry trade group. And insurers think those charges are too high.

A senior administration official also said on Thursday that the administration does not favor the arbitration approach, either.

Insurers — and many consumer groups — "believe if you have a clear benchmark pegged to reasonable rates, that will really solve this problem," Beck said, because insurers would be more likely to cover charges they found more in line with what they consider reasonable.

A "benchmark" payment might correspond to what Medicare pays for the same service, for instance.

But doctors don't like that idea one bit. "Even if [the benchmark] is on the high side, it's still rate-setting," said Kneeley.

Hospitals don't like it, either.

"We can't get behind any sort of rate-setting in statute," said Smith of the AHA. "We have too many concerns about getting that wrong." For example, she said, if the rate is set too low, hospitals might have trouble finding doctors willing to provide care.

Meanwhile, insurers and hospitals want to ban out-of-network providers from billing patients for whatever part of the charge the insurer won't cover, a practice called "balance billing."

Such bans are anathema to doctors, who instead believe insurers bear responsibility for doctors not being in their networks because they "don't have an incentive to offer fair rates," said Kneeley. Although insurers often feel they must contract with specific high-profile hospitals, he explained, the doctors who work there are often "invisible providers."

Addressing the underlying causes of high health costs, however, will be difficult, said Adler of USC-Brookings.

Doctors want to be paid more than insurers typically offer, he said, which is why some do not join insurance networks. And insurers "want the problems [with surprise bills to patients] to go away." The question for them, he said, is, "How much are insurers willing to pay to have their patients not get surprise bills?"

In the end, a settlement that eliminates surprise bills but builds the excess into everyone's premiums doesn't truly address healthcare's spending problem.

"I think there's a good chance it gets solved," Adler said, and that lawmakers will eventually agree on a plan. "But I'm pessimistic it gets solved in a way" that deals with healthcare's high costs.

KHN senior correspondent Fred Schulte contributed to this report. 

Julie Rovner: jrovner@kff.org, @jrovner

Anesthesiologists tend to tend to pick one of two gases and stick with it. Few understand that one is much worse for the environment.

This article was published May 8, 2018, by Kaiser Health News in partnership with Oregon Public Broadcasting and NPR.

By Kristian Foden-Vencil, Oregon Public Broadcasting

It was early morning in an operating theater at Providence Hospital in Portland, Ore. A middle-aged woman lay on the operating table, wrapped in blankets. Surgeons were about to cut out a cancerous growth in her stomach.

But first, an anesthesiologist—Dr. Brian Chesebro—put her under by placing a mask over her face.

"Now I'm breathing for her with this mask," he said. "And I'm delivering sevoflurane to her through this breathing circuit."

Sevoflurane is one of the most commonly used anesthesiology gases. The other big one is desflurane. There are others too, like nitrous oxide, commonly known as laughing gas.

Whichever gas a patient gets is inhaled, but only about 5% is metabolized. The rest is exhaled. And to make sure the gas doesn't knock out anyone else in the operating room, it's sucked into a ventilation system.

And then? It's vented up and out through the roof, to mingle with other greenhouse gases.

The two frequently used gases are fairly similar medically; sevoflurane needs to be more carefully monitored and meted out in some patients, but that's not difficult, Chesebro said.

Generally, unless there's a reason in a particular case to use one over the other, anesthesiologists simply tend to pick one of the two gases and stick with it. Few understand that one—desflurane—is much worse for the environment.

And that bothered Chesebro. He grew up on a ranch in Montana that focused on sustainability.

"Part of growing up on a ranch is taking care of the land and being a good steward," he said.

Now he lives in the city with his three kids and has gradually started to worry about their environmental future.

"When I look around and I see the stewardship on display today, it's discouraging," he said.

"I got depressed for a while, and so I hit the pause button on myself and said, 'Well, what's the very best that I can do?'"

He spent hours of his own time researching anesthesiology gases. And he learned desflurane is 20 times more powerful than sevoflurane in trapping heat in the Earth's atmosphere. It also lasts for 14 years in the atmosphere, whereas sevoflurane breaks down in just one year.

Opening a big, black notebook filled with diagrams and tiny writing, he showed how he computed the amount of each gas the doctors in his group practice used. Then he shared their carbon footprint with them.

"All I'm doing is showing them their data," Chesebro said. "It's not really combative. It's demonstrative."

One of the doctors he shared his analysis with was Dr. Michael Hartmeyer, who works at the Oregon Anesthesiology Group with Chesebro.

"I wish I had known earlier," Hartmeyer said. "I would have changed my practice a long time ago."

Hartmeyer said he was stunned when Chesebro explained that his use of desflurane was the greenhouse-gas equivalent of driving a fleet of 12 Hummers for the duration of each surgical procedure. It's "only" half a Hummer if he uses sevoflurane. Hartmeyer noted that outside the operating room he drives a Prius, a hybrid electric car.

"You try to be good," he said. "You take shorter showers or [don't] leave lights on, or whatever else. But you know there's always more that we could probably do. But this was, far and away, a relatively easy thing that I could do that made a huge impact."

The anesthesiology carts that get brought into operating theaters tend to have a row of gases to choose from. Hartmeyer was able to switch pretty much overnight.

Other anesthesiologists made the switch, too. And it didn't hurt that sevoflurane is considerably cheaper.

Hartmeyer's change saved his hospital $13,000 a year.

When Chesebro shared his findings with the anesthesia departments at all eight Providence Health hospitals in Oregon, they prioritized the use of sevoflurane. They now save about $500,000 a year.

Providence's chief executive, Lisa Vance, said the hospital system didn't change its use of the gas because of the money. It changed because the World Health Organization now says climate change is the No. 1 public health issue of the 21st century—and because of Chesebro.

Vance said Chesebro teared up in front of 2,000 people when talking about the gas, his children and the Lorax character created by Dr. Seuss.

"Unless someone like you cares a whole awful lot, nothing's going to get better—it's not," said Vance, quoting the book "The Lorax."

Dr. Jodi Sherman, an associate professor of anesthesiology at Yale School of Medicine, called Chesebro's efforts remarkable and important.

She said several hospitals around the country have tried to make this shift, but with mixed results. Some just gave anesthesiologists the information and not much changed. Other hospitals took desflurane away, but that left many anesthesiologists feeling disrespected and angry.

Chesebro succeeded, she said, because he chose to persuade his colleagues—using data. He showed doctors their choice of gas plotted against their greenhouse impact. And it helped that he showed them over and over, so doctors could compare their progress to their peers.

"Providing ongoing reports to providers is the best way for this movement to catch on and grow," she said. It can reinforce over time, she added, not just what their carbon footprint is, but also what progress they're making.

Sherman said efforts such as Chesebro's are sorely needed because the U.S. health sector is responsible for about 10% of the nation's greenhouse gases.

"We clinicians are very much focused on taking care of the patient in front of us," she said. "We tend to not think about what's happening to the community health, public health—because we're so focused on the patient in front of us."

In an emailed statement, one of the largest manufacturers of both the anesthesia gases—Baxter International—said it's important to provide a range of options for patients. The company also said inhaled anesthetics have a climate impact of 0.01% of fossil fuels.

"The overall impact of anesthetic agents on global warming is low, relative to other societal contributors, especially when you consider the critical role these products have in performing safe surgical procedures," the statement reads.

It's a fair point, Chesebro said, but he has a counterargument.

"Well, if it's there, it's bad. And if I can reduce my life's footprint by a factor of six … why wouldn't you do it?'"

The surgery Chesebro was involved in that morning at Providence was a success. Chesebro estimates that by using sevoflurane on his patient, the amount of greenhouse gases produced was the same as in a 40-mile drive across the Portland region. If he'd used desflurane instead, he said, it would have been like driving the more than 1,200 miles from Seattle to San Diego.

Now Chesebro's hospital bosses are hoping other doctors will follow his lead, research their own pet peeve and maybe solve a problem no one's thinking about.

This story is part of a partnership that includes Oregon Public Broadcasting, NPR and Kaiser Health News.

An analysis of insurance claims from more than 350 commercial carriers found that plastic and maxillofacial surgeons billed out-of-network more frequently than any other type of specialist in an inpatient setting.

This article was first published on Monday, May 6, 2019 in Kaiser Health News.

By Michelle Andrews

Bob Ensor didn't see the boom swinging violently toward him as he cleaned a sailboat in dry dock on a spring day two years ago. But he heard the crack as it hit him in the face.

He was transported by ambulance to an in-network hospital near his home in Middletown, N.J., where initial X-rays showed his nose was broken as were several bones of his left eye socket. The emergency physician summoned the on-call plastic surgeon, who admitted him to the hospital and scheduled him for surgery the next day.

Shortly before surgery, the doctor introduced Ensor to a second plastic surgeon who would assist in the 90-minute procedure. Entering through Ensor's nose, the physicians realigned his facial bones, temporarily sewing Ensor's left eye shut so that the lids would stay in place as the bones knitted back together.

Six weeks later, as Ensor, then 65, continued to make an uneventful recovery, a collection agency called to inquire how he and his wife planned to pay the $71,729 bill for the assistant surgeon. Ensor's company health plan had denied payment because the surgeon wasn't part of its contracted physician network.

There was more bad news. Ensor received notice that the health plan wouldn't cover the $95,885 charged by the first plastic surgeon either because he also was out-of-network.

"The hospital knew these doctors were out-of-network and didn't bother to tell us," said his wife, Linda Ensor, noting they faced more than $167,000 in charges. "We were panicked."

Riverview Medical Center in Red Bank, N.J., where Ensor was treated, said that it "empathizes with patients who are trying to navigate the complexity of the healthcare billing system" and that transparency in billing has not always been optimal for emergency department patients

As surprise out-of-network billing becomes a politically charged issue, Americans want the federal government to take action. In an April survey, more than three-quarters of consumers said the government should protect them from such bills, according to the Kaiser Family Foundation's monthly health tracking poll. (KHN is an editorially independent program of the foundation.)

An analysis of insurance claims from more than 350 commercial carriers found that plastic and maxillofacial surgeons billed out-of-network more frequently than any other type of specialist in an inpatient setting. Examining hospital admissions in 2016, researchers at Johns Hopkins Bloomberg School of Public Health found that plastic and maxillofacial surgeons billed their services out-of-network 23% of the time, more than any of the other 50 specialties analyzed.

That leaves patients like Ensor, whose care requires plastic or maxillofacial surgery, extremely vulnerable. It also catches patients off guard: When a parent brings in a child with a cut and a triage nurse asks if they'd prefer a plastic surgeon, many reflexively answer "yes" not understanding whether there is an actual need nor anticipating the charges.

According to one survey of emergency department directors at more than 440 hospitals, 81% reported they had inadequate plastic surgery coverage, a higher percentage than reported shortages of any other type of surgical specialty.

The reasons these specialists are such frequent out-of-network billers are fairly straightforward.

Many plastic surgeons don't participate in health plans because they have flexibility other physicians may not have — their practices often focus on elective cosmetic procedures like nose reshaping and breast augmentation that patients pay for on their own.

Also, general surgeons and heart surgeons generally want to maintain good relations with the hospitals — and be on call for the ER— since the ER is a source of patient referrals and their patients often require inpatient care. In contrast, plastic surgeons often operate at outpatient centers.

"Fortunately for some plastic surgeons with alternative revenue streams, they don't need to participate with insurance companies," said Dr. Gregory Greco, the board vice president for health policy and advocacy of the American Society of Plastic Surgeons, who has a solo practice in New Jersey and Manhattan. Greco participates in the employee plans at the institutions where he has hospital privileges, but he doesn't accept other insurance plans.

The society did not respond to a request for information regarding the percentage of plastic surgeons who participate in insurance networks.

That can spell trouble in emergency care. Under the federal Emergency Medical Treatment and Labor Act (EMTALA), hospital emergency departments are required to screen and stabilize any patient who walks through the door, whether or not they can afford to pay. Hospitals often rely on a roster of on-call specialists to treat emergency patients, but studies show many specialists are reluctant to be on call, and low rates of insurance reimbursements may play a role in those decisions.

Data from a New York state program to arbitrate surprise medical bills — a 2015 state law holds patients harmless for such charges — highlights the scope of the problem with plastic surgery coverage.

Emergency care involving out-of-network plastic surgery services was by far the most common type of bill reviewed, according to figures from the state Department of Financial Services. By late 2018, there had been 543 decisions regarding such bills, compared with 335 for emergency physician care and 263 for orthopedists.

In New York, the surprise billing law has discouraged plastic surgeons from charging extremely high fees for out-of-network work, said Dr. Andrew Kleinman, a plastic surgeon in suburban New York City who is a former president of the Medical Society of the State of New York. Under the program, which uses a process called "baseball arbitration," the insurer and provider each submits a proposed dollar amount and the arbitrator picks one.

"Baseball arbitration gives the physician an incentive not to bill an outrageous rate because they're going to lose," Kleinman said. If a doctor charges $20,000 for services provided, but the insurer offers $500, "the insurer will win every time," he said.

More than two dozen states have passed laws that address surprise bills to some extent — although they do not protect the many patients covered by plans regulated by national rules. Congress is debating measures that would address surprise bills at the national level.

In the meantime, patients remain vulnerable. Dr. Meghan Candee was visiting family in Riverhead, N.Y., last summer when her daughter, who was 4 at the time, fell against a wooden bench and got a small cut underneath her left eyebrow. Candee, a pediatric neurologist in Salt Lake City, took her to the emergency department nearby, where she opted for a plastic surgeon, who put in a single stitch, without any sedation.

Candee paid the $100 copayment for the emergency department visit and took the stitch out herself five days later.

A few weeks later, Candee's insurer sent a $25,175 check to pass on to the out-of-network plastic surgeon, who had charged that amount for his work.

Assuming there was an error, Candee called the plastic surgeon's billing office but was told the amount was correct. Even though she wasn't herself on the hook, Candee was "outraged."

"This is why people have issues with physicians, and they think most of us are out there trying to get money," she said.

In New York, the average out-of-network charge at a hospital or other setting for an injury like Candee's daughter's — a simple repair of a superficial wound on the face that is 2.5 centimeters or less in length — is $438.01, according to FAIR Health, a national, independent nonprofit organization that collects and manages an extensive database of insurance claims. In the Great Neck/Port Washington area of Long Island, the area with the highest charges for that repair nationwide, the average charge is $1,067.25.

Patients should know that a plastic surgeon may not be covered in-network and is not necessary in many cases. "It's not uncommon for a family to say they would like a plastic surgeon," said Dr. William Jaquis, president-elect of the American College of Emergency Physicians. "But, in the vast majority of cases, a well-trained emergency physician can do most of the repairs." A plastic surgeon makes sense when there's extensive, deep-tissue damage and the skin is not cleanly torn, especially on the face, he said. A dog bite or an eye socket injury like Ensor's is a classic example.

Luckily for the Ensors, the sailing club stepped in to take up his case with the out-of-network plastic surgeons. Since sailing club members were required to volunteer on work projects to keep membership costs in check, the club's insurer agreed to cover the accident as a workers' compensation case. It paid 100% of the outstanding bill.

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

Most downgraded homes had payroll records that showed no RN hours at all for four days or more. The remainder failed to submit payroll records or sent data that couldn't be verified.

This article was first published  on Friday, May 3, 2019, in Kaiser Health News.

By Jordan Rau and Elizabeth Lucas

The federal government accelerated its crackdown on nursing homes that go days without a registered nurse by downgrading the rankings of a tenth of the nation's homes on Medicare's consumer website, new records show.

In its update in April to Nursing Home Compare, the Centers for Medicare & Medicaid Services gave its lowest star rating for staffing — one star on its five-star scale — to 1,638 homes.

Most were downgraded because their payroll records reported no registered-nurse hours at all for four days or more, while the remainder failed to submit their payroll records or sent data that couldn't be verified through an audit.

"Once you're past four days [without registered nursing], it's probably beyond calling in sick," said David Grabowski, a health policy professor at Harvard Medical School. "It's probably a systemic problem."

It was a tougher standard than Medicare had previously applied, when it demoted nursing homes with seven or more days without a registered nurse.

"Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes," the agency announced in March. "CMS found that as staffing levels increase, quality increases."

The latest batch of payroll records, released in April, shows that even more nursing homes fell short of Medicare's requirement that a registered nurse be on-site at least eight hours every day. Over the final three months of 2018, 2,633 of the nation's 15,563 nursing homes reported that for four or more days, registered nurses worked fewer than eight hours, according to a Kaiser Health News analysis. Those facilities did not meet Medicare's requirement even after counting nurses whose jobs are primarily administrative.

CMS has been alarmed at the frequency of understaffing of registered nurses — the most highly trained category of nurses in a home — since the government last year began requiring homes to submit payroll records to verify staffing levels. Before that, Nursing Home Compare relied on two-week snapshots nursing homes reported to health inspectors when they visited — a method officials worried was too easy to manipulate. The records show staffing on weekends is often particularly anemic.

CMS' demotion of ratings on staffing is not as severe as it might seem, however. More than half of those homes were given a higher rating than one star for their overall assessment after CMS weighed inspection results and the facilities' own measurement of residents' health improvements.

That overall rating is the one that garners the most attention on Nursing Home Compare and that some hospitals use when recommending where discharged patients might go. Of the 1,638 demoted nursing homes, 277 were rated as average in overall quality (three stars), 175 received four stars, and 48 received the top rating of five stars.

Still, CMS' overall changes to how the government assigns stars drew protests from nursing home groups. The American Healthcare Association, a trade group for nursing homes, calculated that 36% of homes saw a drop in their ratings while 15% received improved ratings.

"By moving the scoring 'goal posts' for two components of the Five-Star system," the association wrote, "CMS will cause more than 30 percent of nursing centers nationwide to lose one or more stars overnight — even though nothing changed in staffing levels and in quality of care, which is still being practiced and delivered every day."

The association said in an email that the payroll records might exaggerate the absence of staff through unintentional omissions that homes make when submitting the data or because of problems on the government's end. The association said it had raised concerns that salaried nurses face obstacles in recording time they worked above 40 hours a week. Also, the association added, homes must deduct a half-hour for every eight-hour shift for a meal break, even if the nurse worked through it.

"Some of our member nursing homes have told us that their data is not showing up correctly on Nursing Home Compare, making it appear that they do not have the nurses and other staff that they in fact do have on duty," LeadingAge, an association of nonprofit medical providers including nursing homes, said last year.

Kaiser Health News has updated its interactive nursing home staffing tool with the latest data. You can use the tool to see the rating Medicare assigns to each facility for its registered nurse staffing and overall staffing levels. The tool also shows KHN-calculated ratios of patients to direct-care nurses and aides on the best- and worst-staffed days.

Jordan Rau: jrau@kff.org, @JordanRau

Elizabeth Lucas: elucas@kff.org, @eklucas