As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

This article was published by Kaiser Health News on June 20, 2019.

By Rachel Bluth, Kaiser Health News

About 1 in 6 Americans were surprised by a medical bill after treatment in a hospital in 2017 despite having insurance, according to a study published Thursday.

On average, 16% of inpatient stays and 18% of emergency visits left a patient with at least one out-of-network charge. Most of those came from doctors offering treatment at the hospital, even when the patients chose an in-network hospital, according to researchers from the Kaiser Family Foundation. Its study was based on large employer insurance claims. (Kaiser Health News is an editorially independent program of the foundation.)

The research also found that when a patient is admitted to the hospital from the emergency room, there's a higher likelihood of an out-of-network charge. As many as 26% of admissions from the emergency room resulted in a surprise medical bill.

"Millions of emergency visits and hospital stays left people with large employer coverage at risk of a surprise bill in 2017," the authors wrote.

The researchers got their data by analyzing large-employer claims from IBM's MarketScan Research Databases, which include claims for almost 19 million individuals.

Surprise medical bills are top of mind for American patients, with 38% reporting they were "very worried" about unexpected medical bills.

Surprise bills don't just come from the emergency room. Often, patients will pick an in-network facility and see a provider who works there but isn't employed by the hospital. These doctors, from outside staffing firms, can charge out-of-network prices.

"It's kind of a built-in problem," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation and an author of the study. She said most private health insurance plans are built on networks, where patients get the highest value for choosing a doctor in the network. But patients often don't know whether they are being treated by an out-of-network doctor while in a hospital.

"By definition, there are these circumstances where they cannot choose their provider, whether it's an emergency or it's [a doctor] who gets brought in and they don't even meet them face-to-face."

The issue is ripe for a federal solution. Some states have surprise-bill protections in place, but those laws don't apply to most large-employer plans because the federal government regulates them.

"New York and California have very high rates of surprise bills even though they have some of the strongest state statutes," Pollitz said. "These data show why federal legislation would matter."

Consumers in Texas, New York, Florida, New Jersey and Kansas were the most likely to see a surprise bill, while people in Minnesota, South Dakota, Nebraska, Maine and Mississippi saw fewer, according to the study.

Legislative solutions are being discussed in the White House and Congress. The leaders of the Senate Health, Education, Labor and Pensions Committee introduced a package Wednesday that included a provision to address it. The legislation from HELP sets a benchmark for what out-of-network physicians will be paid, which would be an amount comparable to what the plan is paying other doctors for that service.

That bill is set for a committee markup next week.

Other remedies are also being offered by different groups of lawmakers.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

The OpenNotes project encourages doctors to share their notes with patients, and invites patients to ask for access to their doctor's notes.

This article was first published on Wednesday, June 19, 2019 in Kaiser Health News.

By Victoria Knight

When Pamela DeSalvo read the clinical note from her doctor's visit, the words on the page hit her hard: "clinically morbidly obese." She knew she was overweight, but seeing those three words together shocked her. It also inspired her to start losing weight.

"I needed to see it in black and white, what I actually in my heart already knew. It forced me to get honest with myself," DeSalvo said.

"Reading that note saved my life." Studies show that, indeed, reading your doctor's notes can improve your health.

DeSalvo lives in Metuchen, N.J., and works in health information technology. In the years after reading her doctor's notes, DeSalvo kept that experience in mind as she helped Atrium Health implement a system that allows doctors to share clinical notes.

Many patients go home with a summary of their office visit. That recap often includes a list of medications or reminders to schedule a follow-up. The full doctor's note has many more details —all the stuff the physician types into the computer during and after your medical appointment. Your medical history. The complaint that brought you to the office. Sometimes, physicians write down exactly what patients say. Mixed in are billing codes and the doctor's thoughts about what might be happening with the patient.

A research project in Boston, called OpenNotes, encourages doctors to share their notes with patients. On the flip side, it invites patients to ask for access to their doctor's notes. The project is housed at Beth Israel Deaconess Medical Center.

In one study, when researchers surveyed patients who'd looked at their doctor's notes, the majority of patients reported they felt more in control of their care and said they were more compliant taking medication. A small share — from 1% to 8% — said the notes caused confusion, worry or offense.

Liz Salmi, a woman living with brain cancer in Sacramento, Calif., was an experienced patient advocate and blogger when she first got a look at her doctor's notes on her. After Salmi's insurance changed, she requested her medical records. For $45, she received a 4,839-page PDF on a disk along with her brain scans.

And she got curious. "I was, like, what is on these disks?" Salmi said.

There was no big revelation. And she didn't uncover any mistakes.

But it was a nice way to re-hear what her doctors had told her through the years. Salmi said the records are a time capsule of sorts. As Salmi scanned the pages, she said, she discovered "meaningful nuggets" where her doctors quoted her verbatim.

"Just that level of detail made me feel like they were listening," said Salmi, who is featured in this week's episode of the podcast "An Arm and a Leg," which is co-produced by Kaiser Health News.

Eventually, Salmi went to work for OpenNotes, and today she's a senior strategist who does outreach and communications for the research group.

The Health Insurance Portability and Accountability Act, or HIPAA, which has been the law since 1996, allows patients to review and get copies of their medical records.

But researcher Dr. Harlan Krumholz said a legal right doesn't guarantee easy access.

Krumholz, a cardiologist and professor at Yale University, published a study in 2018 that examined the records-requesting process at 83 top-ranked hospitals in the U.S.

The results varied widely. Some hospitals didn't meet state deadlines for delivering the records, others charged exorbitant fees for the documents — well above the federal government's recommendation for electronic records.

"What is clear from this is, it is hard for Americans to get access to their own medical records," Krumholz said.

OpenNotes — the research group that advocates for better access — says that today about 40 million patients are a part of a health system that shares clinical notes through their electronic health record software. But each medical system is different, and it can take time and effort to navigate an online portal to find what you're looking for.

"I've been under the assumption for years that patients could access the notes whenever they wanted to, so I keep them objective and matter-of-fact," said Dr. Neda Frayha, an internist who practices at Ascension Medical Group in Baltimore.

She encourages her patients to review her notes.

"Being a patient is hard. Appointments take forever, and often clinicians don't spend a lot of time with patients," said Frayha. "For many patients, it is hard to make sense of what is happening. If access to their note provides them with knowledge and assurance, then that is important to provide."

Frayha said having her notes on display hasn't changed her behavior or note-taking much. But, she said, "I think it's actually good for us as a profession to be more mindful of the words we use."

Victoria Knight: vknight@kff.org, @victoriaregisk

 

Experts caution that as ECMO becomes more available, it is also being used as a last-ditch attempt to buy more time for dying patients with poor chances of survival.

This article was first published on Tuesday, June 18, 2019 in Kaiser Health News.

By Melissa Bailey

The latest miracle machine in modern medicine — whose use has skyrocketed in recent years — is saving people from the brink of death: adults whose lungs have been ravaged by the flu; a trucker who was trapped underwater in a crash; a man whose heart had stopped working for an astonishing seven hours.

But for each adult saved by this machine — dubbed ECMO, for extracorporeal membrane oxygenation — another adult hooked up to the equipment dies in the hospital. For those patients, the intervention is a very expensive, labor-intensive and unsuccessful effort to cheat death.

ECMO, the most aggressive form of life support available, pumps blood out of the body, oxygenates it and returns it to the body, keeping a person alive for days, weeks or months, even when their heart or lungs don't work.

The invention is creating "an entirely new paradigm," said Dr. Kenneth Prager, director of clinical ethics at Columbia University Irving Medical Center. "You have a heart that's not working, yet the patient is not dead."

Most commonly used for newborns, ECMO use has been growing dramatically among adults. In the United States, procedures tripled from 2008 to 2014, up to an estimated 6,890, according to the federal Agency for Healthcare Research and Quality.

Experts caution that as ECMO becomes more available, it is also being used as a last-ditch attempt to buy more time for dying patients with poor chances of survival.

ECMO is not designed to be a destination, but a bridge to somewhere — recovery, transplantation or an implanted heart device. But when patients are too sick to reach those goals, ECMO can become a "bridge to nowhere," leaving the patient in limbo, possibly even awake and alert, but with no chance of survival outside the intensive care unit. Medical teams and families can be fiercely divided over when to pull the plug.

ECMO is very expensive, mostly due to the labor involved: A person on ECMO cannot live outside the ICU and must be continuously monitored for complications, such as blood clots, bleeding, infection and loss of blood to the limbs. Median charges for ECMO in 2014 were $550,000, making it the 15^th-most-costly procedure that year, according to the AHRQ.

In one recent case, a teaching hospital charged $4.2 million for a 60-day ECMO stay for a 19-year-old man with acute respiratory distress syndrome who was comatose the entire time and did not survive, according to Dr. Merrit Quarum, CEO and founder of WellRithms, a cost-containment company. Quarum said a self-insured health plan is covering the bill.

The number of U.S. hospitals offering ECMO has more than doubled from 108 in 2008 to 264 today, according to a registry run by the Extracorporeal Life Support Organization (ELSO), which tracks most but not all programs.

"In the United States, the competition between hospitals is so intense that every hospital wants the ability to provide this level of care," said Randy Bartilson, president of the ECMO Advantage consulting firm.

But "as ECMO expands, there's still a lot of places that still don't fully understand what it can do and how to use it," he said.

Four patient stories highlight the promise — and complexities — of this game-changing technology.

The Seven-Hour Code

Dr. Jessica Zitter was working in the ICU in an Oakland, Calif., hospital one day when she got summoned for a code blue. A 60-year-old patient had arrived with a heart attack. His heart went into ventricular fibrillation, where it just wiggled like "a bag of worms," she said.

Hospital staff started pumping their palms on the man's chest and put a tube in his throat to help him breathe. Every so often, they stood back and zapped his heart with an electric shock. It didn't work. So, they strapped onto his chest a LUCAS machine, which automatically performs chest compressions like a jackhammer.

The man's oxygen levels were plummeting. At the same time, Zitter recalled, he kept moving, giving her the feeling there was a life to be saved. The medical team decided to go to the next level: ECMO. Everyone waited, with the jackhammering compressions still going, as an ECMO team scrambled to get there from another hospital across the city.

Zitter watched in awe as the ECMO team from the University of California-San Francisco got to work. They stuck one huge tube in a femoral artery and one in a femoral vein. As they pumped his blood out, it was black from deoxygenation. But after it ran through the ECMO machine, she recalled, it transformed into a bright red.

Once on ECMO, the patient didn't need his heart, so it could sit idle and recover. Zitter watched as oxygen returned to his body and brain. He was whisked back to UCSF.

Zitter, who has written about the overuse of modern technology to prolong death, wasn't optimistic. The patient had coded, with people and machines ramming his failing heart, for an astonishing seven hours before ECMO arrived. But as she kept tabs on the patient, she was amazed to learn that he was able to recover and go home.

The case was a "big shocker," Zitter said.

But it was "a crazy, crazy, crazy outlier case with a crazy, crazy, crazy outlier response," she cautioned. "When these kinds of things happen, people tend to look at them and assume that they will have the same odds. The reality is that they won't."

When patients receive ECPR (ECMO for cardiopulmonary resuscitation), only 29% make it out of the hospital alive, according to international statistics from ELSO. Survival rates are higher for people who use ECMO for only the lungs (59%) or only the heart (42%), according to ELSO.

Saving 'Santa'

A more common outcome for ECPR looks something like what Dr. Haider Warraich of Duke University Medical Center came across three or four years ago during his cardiology training.

Warraich was called to the waiting area of a lung transplant clinic, where a man in his 60s had collapsed on the floor due to a heart attack. The man, who had white hair and a scraggly beard, played Santa every Christmas, Warraich later learned. "Santa" — as Warraich refers to him in his upcoming book, "State of the Heart" — had received a new set of lungs after his were wrecked by smoking and lung disease.

The man's heart, starved of oxygen, sped up into a malignant rhythm. CPR and electric shocks didn't bring it back. Motivated to save not only the patient but the new set of lungs he had received, the team called in ECMO.

The ECMO squad arrived with catheters "the size of small javelins," Warraich recalled. Once Santa was hooked up on ECMO, the exhausted CPR team could stop. Cardiologists did surgery on a blocked artery, but they never got his heart back to normal. The man lingered for a month, using ECMO for his heart, a ventilator for his lungs and dialysis for his kidneys, before he died.

In this case, using ECMO felt appropriate, Warraich said. But he said doctors need more guidance to determine which patients would benefit the most and to prevent overuse.

"If you have someone who is dying in front of you, it's really hard to step back and think about it," he said.

The technology, developed in the 1970s, was initially used primarily for newborns. Early clinical trials in adults were discouraging. But in 2009, the CESAR trial in the United Kingdom showed positive results for ECMO in adults with severe respiratory failure. Those findings, combined with improved technology and an epidemic of swine flu, prompted a swift growth of ECMO among adults. The average age for U.S. adults receiving ECMO is 51, one study found. About 1 in 10 ECMO cases are for people over 65.

Warraich and other experts say they are now concerned that new organ-donation rules may inadvertently spur hospitals to place more patients on ECMO: Under guidelines approved by the Organ Procurement and Transplantation Network last October, patients on ECMO jump to the front of the heart transplant waiting list.

An 'Unbearable' Choice

Once a patient is on ECMO, deciding when to stop can cause moral distress and division among medical staff, said Dr. Robert Truog, director of the Center for Bioethics at Harvard Medical School.

In one case Truog described in The Lancet, a 17-year-old boy came to the ICU at Boston Children's Hospital, where Truog works as a physician. The boy, who had already had one lung transplantation for cystic fibrosis, was now in end-stage respiratory failure. The only way to save his life was to give him another set of lungs. He started on ECMO as a bridge therapy while he awaited transplantation.

The boy was fully conscious, doing homework, texting friends and visiting with family. But after two months of living in the ICU, he was diagnosed with untreatable cancer that made him ineligible to receive new lungs.

Clinicians were deeply divided over what to do next, Truog said. Some wanted to stop ECMO immediately because its original goal — a bridge to transplantation — was no longer possible.

Others argued that even though he couldn't survive outside the ICU, the boy seemed to have a good quality of life on ECMO, and his family and friends "derived benefits from his continued survival," Truog wrote. They argued that the family should have the right to continue this form of life support, just as with dialysis, ventilation or an artificial heart.

A third argument arose, Truog said: If leaving this patient on ECMO was appropriate, then in fairness "why don't we put everyone with respiratory failure on ECMO?"

For the parents, Truog said, it was "unbearable" to choose a day or moment to turn off ECMO, because they knew their child would immediately die.

Clinicians devised an alternative the family would agree to: They decided not to replace the ECMO oxygenator, a part that needs to be changed every week or two when it develops blood clots. After about a week, the oxygenator gradually failed and the patient lost consciousness and died, Truog said.

The solution "allowed him to die in a way where we didn't feel like we were choosing the moment of his death," he said.

The solution was not optimal, Truog said. But "no matter how you do this, it's going to be very emotionally upsetting to everyone. These are the cases that make some people leave the profession because they're so hard."

A Long Goodbye

Karen Ayoub had never heard of ECMO until her husband became direly ill.

Philip Ayoub, 58, an accountant and former comptroller for the National Football League, was a "huge personality" and a family man; the couple raised twin boys in Greenwich, Conn. Heart disease, which ran in his family, hit him early: He had his first coronary bypass surgery at age 30 and his second at 43, she said.

"He knew that his life might be foreshortened" and "tried to pack as much living into it as possible," said Karen Ayoub, 55. Her husband told her he didn't want any extraordinary lifesaving measures — he was happy with the life he had lived, she said.

In December 2017, he had a third bypass surgery at a hospital on Long Island, and it didn't go well. His heart was weaker than anticipated. He became unconscious, and it wasn't clear if he would ever wake up. He was transferred to Columbia University Irving Medical Center, which has an ECMO program.

Karen Ayoub said it was a fairly easy decision to put her husband on ECMO: "I thought he deserved any chance possible to recover," she said. But she didn't know how he'd react.

"I wasn't sure if he was going to wake up and say, 'Why did you do this? I didn't want any of this!'" she recalled.

When her husband regained consciousness, he mouthed the words: "Why am I here?"

He remained in the ICU for two months, on a feeding tube, breathing tube, ECMO and dialysis. His time there was not easy, she said: Her husband, who had endured a series of mini-strokes during the bypass surgery, began to experience post-traumatic stress disorder, night terrors and side effects from medications.

The only option for further treatment, she said, was to get an implanted device that would help his heart pump. But as he weighed that decision, and the quality of life he would have, the window of time closed when he was eligible for the device, Karen Ayoub said.

When further treatment became out of reach, it was clear her husband was going to die.

"His body was failing him," Karen Ayoub said. "It was time."

She said the two months in the ICU felt like "a gift," because she and her children got to spend extra time with her husband.

"I'll always love you, I'll always be with you," he told his wife over and over during that time.

She said she would make the same choice again to initiate ECMO, but "I don't know about him — he was the one laying in that bed for two months, being tortured by needles and night visions."

After they ran out of treatment options, the family gave permission for the hospital to discontinue life support. Philip wasn't afraid, she said: As his final day approached, he told her, "I can't wait to see what comes next."

Philip was sedated before ECMO was turned off. Karen Ayoub laid her head on her husband's chest and held his hands as he died.

"It was peaceful and respectful," she said, "exactly what he wanted."

'Futile' Care

While the Ayoub family bravely accepted their fate, other families can't bring themselves to let go, said Dr. Shunichi Nakagawa, a palliative care doctor at Columbia who cared for Philip Ayoub.

Some ECMO patients have severe, irreversible brain damage, can't participate in decision-making and bear no chance of making it out of the hospital alive. For them, ECMO represents "the most extreme form of medical futility," Nakagawa argued in an article he and Prager co-authored with a colleague in the journal Circulation. They argue that clinicians should have the authority to end or limit life support in such hopeless cases, even if the family objects.

Whether they can do that depends on where they practice: Laws in states such as Idaho, Oklahoma and New York make it difficult to withdraw life-sustaining treatment like ECMO without consent from patients or their families, said Thaddeus Mason Pope, director of the Health Law Institute at Mitchell Hamline School of Law in St. Paul, Minn. But in states like California, Texas and Virginia, clinicians may withdraw ECMO without consent, he said.

Dr. Robert Bartlett, a pioneer of the ECMO field and professor emeritus at the University of Michigan, said he trains doctors that once ECMO becomes a bridge to nowhere, they should tell the family, "We talked about futility, and now we're there. So we're going to turn the circuit off tomorrow."

"It's extremely discourteous to the family to ask the family what to do," he said.

At Cedars-Sinai Medical Center in Los Angeles — where patients with poor chances of survival were being put on ECMO, and families were getting conflicting messages about the potential benefit — staff launched an improvement effort that has created more consensus and consistency around appropriate ECMO care, according to Dr. Michael Nurok, medical director of the cardiac surgery ICU.

At the University of Southern California's Keck Hospital, every family of an ECMO patient meets weekly with palliative care and other clinicians to talk about goals of care — conversations that have been "transformative" for families, said Dr. Sunita Puri, medical director of palliative medicine and supportive care.

In Boston, Dr. Daniela Lamas, a critical care doctor at Brigham and Women's Hospital, said she has seen ECMO's promise and its limitations.

"With every escalation and fancy machine comes a lot of hope," Lamas said. "It's really hard to temper that hope with the realities that with each new thing comes a host of ethical questions and dilemmas."

ECMO, she said, is "a fantastic example of 'just because you can, doesn't mean you should.'"

Melissa Bailey: mbailey@kff.org, @mmbaily

Over and over again, the high cost associated with air ambulance service gives patients the biggest sticker shock.

This article was first published on Friday, June 14, 2019 in Kaiser Health News.

By Rachel Bluth

In April 2018, 9-year-old Christian Bolling was hiking with his parents and sister in Virginia's Blue Ridge Mountains, near their home in Roanoke. While climbing some boulders, he lost his footing and fell down a rocky 20-foot drop, fracturing both bones in his lower left leg, his wrist, both sides of his nose and his skull.

A rescue squad carried him out of the woods, and a helicopter flew him to a pediatric hospital trauma unit in Roanoke.

Most of Christian's care was covered by his parents' insurance. But one bill stood out. Med-Trans, the air ambulance company, was not part of the family's health plan network and billed $36,000 for the 34-mile trip from the mountain to the hospital. It was greater than the cost of his two-day hospitalization, scans and cast combined.

"When you're in that moment, you're only thinking about the life of your child," said Christian's mother, Cynthia Bolling, an occupational therapist. "I know that I am being taken advantage of. It's just wrong."

The rising number of complaints about surprise medical bills is spurring efforts on Capitol Hill and at the White House to help consumers. Over and over again, the high cost associated with air ambulance service gives patients the biggest sticker shock — the subject has come up at nearly every Capitol Hill hearing and press conference on surprise medical bills.

Yet air ambulance costs are not addressed in any of the proposals introduced or circulating in Congress. Even a congressional decision last year to set up a panel that would study air ambulance billing hasn't gotten off the ground.

"We're doing a disservice to patients if we protect them from hospital bills but bankrupt them on the way there," said James Gelfand, senior vice president for health policy for the ERISA Industry Committee, known as ERIC, a trade association for large employers.

The issue came up again Wednesday at a House Energy and Commerce subcommittee hearing where Rick Sherlock, president and CEO of the Association of Air Medical Services, the industry group for air ambulances, was among eight witnesses.

Rep. Ben Ray Luján (D-N.M.) sharply questioned Sherlock why costs for air ambulance services have risen by 300 percent in his state since 2006.

"I'm trying to get my hands around why this is costing so much and why so many of my constituents are being hit by surprise bills," Luján said.

Sherlock said that reimbursements from Medicare and Medicaid do not cover the cost of providing services, so charges to private patients must make up that difference.

Air ambulances serve more than 550,000 patients a year, according to industry data, and in many rural areas air ambulances are the only speedy way to get patients to trauma centers and burn units. As more than 100 rural hospitals have closed around the country since 2010, the need has increased for air services.

More than 80 million people can get to a Level 1 or 2 trauma center within an hour only if they're flown by helicopter, according to Sherlock.

The service, though, comes at a cost. According to a recent report from the Government Accountability Office, two-thirds of the more than 34,000 air ambulance transports examined were not in the patients' insurance networks. That can leave patients on the hook for the charges their insurers don't cover, a practice known as "balance billing."

In 2017, GAO found that the median price charged nationally by air ambulance providers was around $36,400 for helicopter rides and even higher for other aircraft. The total generally includes the costs for both the transportation and the medical care aboard the aircraft.

Additionally, the ongoing "Bill of the Month" investigative series by Kaiser Health News and NPR has received more than a dozen such bills, ranging from $28,000 to $97,000.

Cynthia Bolling said her insurance company paid about a third of Christian's air ambulance bill and the family settled this week with Med Trans by agreeing to pay $4,400 out-of-pocket.

Reid Vogel, director of marketing and communications for Med Trans, said the company cannot talk about a private patient because of privacy rules. But he added that the company works with patients to find "equitable solutions" when their bills are not covered by insurance.

Since nearly three-quarters of flights are for patients insured by low-paying Medicare, Tricare and Medicaid, he said, "providers must shift costs to insured patients."

Private insurers usually will pay only an amount close to what Medicare reimburses, which is around $6,500. That gives air ambulance companies an incentive to remain out-of-network, according to a 2017 GAO report.

"A representative from a large independent provider noted that being out of network with insurance is advantageous to the provider because a patient receiving a balance bill will ask for a higher payment from the insurance company, which often results in higher payment to the air ambulance provider than having a pre-negotiated payment rate with the insurer," the GAO said.

In an interview, Sherlock, of the trade association, disputed the report's findings, saying his members are actively trying to be in-network in more places, although he couldn't provide any specific numbers.

"I think that everywhere they can, they're incentivized to be in-network," he said.

States are hampered in their efforts to ease the strain for residents.

The Airline Deregulation Act of 1978, which was intended to encourage more competition, forbids states to regulate prices for any air carrier, which applies to air ambulances. What's more, many large employers' health insurance is not governed by states but regulated by the federal labor law, known as ERISA.

So a remedy likely has to come from Congress. And it's proven to be a heavy lift.

For example, the committees that deal with regulation of the air industry — the Commerce Committee in the Senate and the Transportation Committee in the House — don't make health policy or regulate health insurance.

Last year, some lawmakers sought to let states regulate air ambulances with a provision in the bill reauthorizing the Federal Aviation Administration.

But that measure was ultimately eliminated. Instead, the bill called for the creation of an advisory committee to study air ambulance prices and surprise bills.

"The air ambulance lobby did a very good job playing defense during FAA authorization," said ERIC's Gelfand.

The panel, which was supposed to be formed within 60 days of the law's enactment date — Oct. 5 — still has not been created.

Representatives from the air ambulance industry don't think congressional action is necessary, although they are calling for higher reimbursements from Medicare.

Chris Eastlee, vice president for government relations for the Association of Air Medical Services, said his group does not favor more congressional regulation of prices but would support mandatory disclosure of costs to the secretary of Health and Human Services. The organization argues that greater transparency will help companies negotiate more in-network contracts.

A fix for surprise bills supported by some researchers and advocates would require every provider within a medical facility to accept any insurance plan that contracts with that hospital. It might also help bring down air ambulance bills, said Loren Adler, associate director of USC-Brookings Schaeffer Initiative for Health Policy.

It would avoid the situation where someone picks an in-network hospital only to find out that a surgeon or anesthesiologist at that hospital doesn't take their insurance. Air transport should also be included in the rule, he said.

"It's the exact same situation as with the out-of-network emergency facility rates," Adler said. "The same solutions should apply."

Gelfand suggested also that the House Ways and Means Committee mandate that air ambulance companies seeking to participate in Medicare must charge in-network rates.

That would require only a small tweak of the legislative language, as he sees it. "Every proposal that includes something to address surprise bills for emergency care, all you have to do is add in the words 'air ambulances,'" Gelfand said.

Right now, the closest any surprise billing proposal has come to addressing air ambulances is a draft legislative plan on medical costs from Sen. Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.). They would require bills for air ambulance trips to be itemized to show both medical charges and the transportation charges so patients and health plans can understand them better.

Rachel Bluth: rbluth@kff.org, @RachelHBluth