Smart protections from surprise medical bills | Column

Dr. Michael Lozano
Dr. Michael Lozano
Published July 26, 2019

While the United States grapples with how to manage health care costs and promote price transparency, patients continue to fear surprise medical bills and fuel the debate on how to best eliminate those unanticipated medical costs. Recognizing the undue burden placed on patients, Florida passed legislation several years ago to protect patients from surprise bills. Now, as Congress evaluates federal protections for patients, there's an opportunity to learn from Florida and other states and consider a bipartisan solution proposed by Rep. Donna Shalala of Miami that we know will work.

In 2016, Florida passed a ban on balance bills, a subset of surprise bills related to out-of-network care. The law protects patients from paying more than the equivalent of the in-network rate when they see an out-of-network physician — such as for an emergency visit or scheduled procedure at an in-network hospital where the physician happens to be out of the patient's insurance network. However, there's more that can be done to protect patients.

Despite being one of the nine states considered to have "comprehensive" protections by the Commonwealth Fund, a recent study by the Kaiser Family Foundation found that patients in Florida are among the most likely to get surprise bills. The bipartisan effort to pass federal legislation is an opportunity to better protect more patients across the country — including in Florida — from surprise bills. Balance bills are just one example of when a patient receives a bill for care they incorrectly believed their insurance company would cover.

An often-overlooked component of our complex health care system is that all stakeholders — physicians, hospitals, policymakers and insurance companies — have a shared responsibility to provide Americans with access to affordable and quality care. Unfortunately, it doesn't always work that way. Surprise bills stem from the misleading premise that patients with private insurance are largely covered for the care they receive.

For example, emergency departments are open 24 hours a day, 365 days a year to provide patients with access to care when they need it most. When I see patients in the emergency department, my sole focus is on diagnosing and treating them. The Emergency Medical Treatment and Active Labor Act bars me from asking about a patient's insurance and requires me to treat every patient regardless of insurance status or ability to pay — an important protection for both patients and doctors. However, insurance companies are not required to pay for that care.

Instead, insurers are increasingly leaving patients with the bill unless they have met their deductible and are treated by an in-network physician. In some cases, your deductible may be even greater if you are treated by an out-of-network physician. Patients cannot be held responsible for finding an in-network doctor when they are facing a life-threatening emergency.

The Protecting People from Surprise Medical Bills Act is a bipartisan solution in the U.S. House that offers a truly comprehensive approach.

Rep. Raul Ruiz, D-Calif., an emergency physician who understands the health care landscape, introduced a bill in Congress that advocates for patients. That process provides a sensible and simple check and balance rather than allowing one side or the other to unfairly dominate the situation. Shalala, who served more than eight years as secretary of the Department of Health and Human Services, was an original co-sponsor of the bill. As a Floridian and a health policy expert, she is pushing for patient protections that will work and the proposal is gaining support. An independent dispute resolution process has been successful in states such as New York and, most importantly, it is the only solution that has been effective at keeping patients out of the fray of billing issues. In the New York experience, health care costs have been growing at a slower rate than surrounding states without such patient protections.

If we want to truly remove patients from the middle and protect their access to high-quality and affordable healthcare, the House's solution to settle disputes via an independent dispute resolution process is the only one that will work.

Dr. Michael Lozano is a practicing emergency physician at Envision Healthcare and the medical director for Hillsborough County Fire Rescue.