WHO | Recommended composition of influenza virus vaccines for use in the 2019 southern hemisphere influenza season

27 September 2018

It is recommended that egg based quadrivalent vaccines for use in the 2019 southern hemisphere influenza season contain the following:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus;
  • an A/Switzerland/8060/2017 (H3N2)-like virus;
  • a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage); and
  • a B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage).

It is recommended that egg based trivalent vaccines for use in the 2019 southern hemisphere influenza season contain the following:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus;
  • an A/Switzerland/8060/2017 (H3N2)-like virus; and
  • a B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage).

It is recommended that the A(H3N2) component of non-egg based vaccines for use in the 2019 southern hemisphere influenza season be an A/Singapore/INFIMH-16-0019/2016-like virus together with the other vaccine components as indicated above.

Source: WHO | Recommended composition of influenza virus vaccines for use in the 2019 southern hemisphere influenza season

Flu View Phase 6

Source: Flu View Phase 6

CDC Interactive Map – Weekly Influenza

A Weekly Influenza Surveillance Report Prepared by the Influenza Division

Source: FluView Phase 8

Lansing State Journal: State police want access to prescription drug monitoring system to fight opioid crisis

Lansing State Journal: State police want access to prescription drug monitoring system to fight opioid crisis.
https://www.lansingstatejournal.com/story/news/local/2018/12/16/opioid-crisis-prescription-drug-monitoring-bill-pitched-lame-duck/2257458002/

The New York Times: A Doctor’s Guide to What to Read on the Opioid Crisis

The New York Times: A Doctor’s Guide to What to Read on the Opioid Crisis.
https://www.nytimes.com/2018/12/17/books/review/opioid-abuse-drug-dealer-anna-lembke.html

New York Post : My mom’s medical emergency became a hospital horror show

New York Post : My mom’s medical emergency became a hospital horror show.
https://nypost.com/2018/12/15/my-moms-medical-emergency-became-a-hospital-horror-show/

CBS News: Fentanyl overtakes heroin as the No. 1 opioid overdose killer

CBS News: Fentanyl overtakes heroin as the No. 1 opioid overdose killer.
https://www.cbsnews.com/news/fentanyl-no-1-opioid-overdose-killer-over-heroin-vicodin-oxycontin/?ftag=CNM-00-10aag7e

New doctors group starts at ER;

After months of community concern about Envision Healthcare’s out of network billing practices, patients visiting Sutter Coast Hospital’s emergency department will be seen by a new physician’s group starting today.

Sutter Coast Hospital announced Monday that Sound Physicians will be staffing its emergency room in addition to continuing to provide inpatient services. According to a press release from the hospital, Sutter Coast has been working with Sound Physicians for about eight years.

“Over the years we’ve seen Sound Physician providers take on strong leadership roles in the hospital partnering with our staff to improve patient outcomes,” hospital CEO Mitch Hanna said in a written statement. “We are confident they are the right choice for our patients who seek care in our emergency department.”

At a Del Norte Healthcare District meeting Sept. 25, Ellie Popadic, the hospital’s director of ancillary services and business development, said Sutter Coast had not had any concerns with patients not having in-network providers through the hospital service Sound Physicians offered. She said Partnership, Medicare, Blue Cross are contracted with Sound Physicians and would be in-network.

According to the hospital’s press release, Sound Physicians has provided hospital medicine services for 17 years and has been providing emergency medicine service for about three years.

Sutter Coast Hospital issued a 90-day contract termination notice to Envision Healthcare, formerly known as EmCare, and reached an agreement with Sound Physicians in September.

The termination notice to EmCare came after the Del Norte Healthcare District, Crescent City Council and the Del Norte County Board of Supervisors, concerned about EmCare’s out-of-network billing practices, passed resolutions urging Sutter Coast to renegotiate its contract.

According to healthcare district Chairman Dr. Greg Duncan, who has been reviewing patients’ hospital bills during the 24 years he’s been practicing in Crescent City, Envision Healthcare had been charging $2,054 for its highest level billing code, which is about triple to what its predecessor, Valley Emergency Physicians had charged.

In September, Hanna told the Triplicate patients should not be getting out of network billing from emergency room physicians.

Source: New doctors group starts at ER;

Utah State lawmaker is renewing efforts to end balance billing

SALT LAKE CITY, Utah (ABC4 News) – Utahns are getting stuck with tens of thousands of dollars in medical debt, even though they have health insurance.

One state lawmaker says enough is enough, and he’s running a bill to change it.

Imagine this; you suffer a medical emergency, you’re unconscious and someone calls for help on your behalf. Then you are taken to an emergency room that is out-of-network.

It’s called balance billing, and it’s leaving some with an insurmountable bill.

Mike Lyons of Millcreek is one of them. Earlier this year, he was at a rock climbing facility when he suffered a traumatic back injury.

“I was taken to the hospital by ambulance and was unconscious, so I was just taken, I assume, to the hospital that was closest or best equipped to take care of my back injury,” Lyons said.

That hospital was Intermountain Medical Center in Murray, which is an out-of-network provider for his insurance policy through Regence.

“Now, almost a year later I’m getting a bill for $42,000,” he said.

Federal law requires the insurance company to pay what they would pay an in-network provider for an emergency room visit, but the out-of-network provider can then go after the patient for the balance.

Representative Jim Dunnigan says it’s a big problem in Utah.

“It does not seem right to me that if you are taken to an emergency room, and your insurance plan pays everything they are required to by law that you should worry about receiving a bill for additional charges, above what they have paid,” said Dunnigan, (R) Taylorsville.

In 2017, Dunnigan unsuccessfully ran a bill to eliminate balance billing.

In the meantime, he’s been working with insurance companies and medical providers to try to broker a solution and is bringing the bill back this year.

He wants to require insurance companies to pay providers a reasonable and fair amount for emergency services, and for the provider to leave the patient out of it.

“They did everything they were supposed to. They had health insurance and it covered the emergency room, so it sends them into bankruptcy. It’s just catastrophic, it destroys them,” Dunnigan said.

That’s exactly the reality Lyons is facing, as he goes back and forth with the companies trying to get something worked out.

“My house needs a bunch of repairs and I need to put a new roof on it, and I don’t know how I can pay for that when I have to pay a $42,000 bill that I had, I had no input in terms of what hospital they were going to take me to,” said Lyons.

A spokesperson for Intermountain says they have been working with Representative Dunnigan to find a “good resolution” and they believe they are “very close to one.”

Tuesday, the Health Reform Task Force will take up the issue.

Representative Dunnigan would like anyone who has gone through this to show up and share their stories.

The meeting starts at 1 pm. in room 445 of the State Capitol.

Source: State lawmaker is renewing efforts to end balance billing

Lawmakers pledge crackdown on free-standing ER billing practices – Houston Chronicle

Texas lawmakers on Monday vowed to crack down on the state’s booming free-standing emergency room industry in the wake of a troubling AARP Texas survey and a Houston Chronicle story that both showed how some facilities are sending confusing messages to patients.

The AARP Texas survey showed that 30 percent of the state’s 213 for-profit free-standing emergency rooms “appear to not comply fully with state disclosure laws,” according to findings presented at a state Senate committee meeting in Austin.

The statewide survey also found that 77 percent said they “take” or “accept” major health insurance plans but were actually outside the network for those plans. And when AARP asked the centers’ staff directly, less than half were able to answer a “yes” or “no” question about health plan coverage.

The survey was presented the same day the Houston Chronicle published a story about how 90 percent of the area’s 52 free-standing emergency rooms are outside the Blue Cross and Blue Shield of Texas network, leaving unsuspecting patients potentially vulnerable to enormous surprise medical bills. The story further said that while many of the Houston facilities prominently advertise on their websites they “accept” all major insurers, an admission that they are out of network can be more difficult to find.

The back-to-back revelations come 15 months after a Texas law went into effect that mandated that the facilities disclose declarations including that they are an emergency room and charge facility fees, inform patients what insurance plans they accept and if they are part of those insurance networks. They are also required to include the warning that a physician may bill separately from the facility.

Committee members on Monday voiced concern over the AARP findings and said they would consider stronger laws when the Legislature reconvenes Jan. 8.

“There was recognition that more needs to be done in both enforcing existing laws and to make new laws to protect consumers,” said Blake Hutson, associate state director of AARP Texas, who testified at the hearing. He added that many seemed surprised at the breadth of the problem.

“We need to do something about this,” state Sen. Judith Zaffirini, a Democrat from Laredo, said at the hearing.

Larry Taylor, a Republican senator from Friendswood, called the AARP findings disappointing and suggested getting tough.

“Send a letter that you get into compliance or we’re coming after you,” he suggested during testimony.

The Texas Association of Free-Standing Emergency Centers, the trade group for the facilities, said in a statement to the Houston Chronicle on Monday it “looks forward to working with AARP and other stakeholders during the 86th Legislative Session. In fact, leaders of the free-standing ER industry are already in touch with legislators about their desire to put into place a more robust set of best practices which will benefit Texas patients seeking emergency care.”

Health policy advocates say the stakes of network status are enormously high because if a provider is out of network, any portion of the billed charge not fully covered by insurance can be shifted to patients to make up the difference in a practice called balance billing. In-network providers are prohibited from balance billing.

The free-standing emergency room industry has argued that network status is not important in emergency situations because another piece of insurance law requires insurers to cover those at in-network benefit rates. Many of the facilities post such reassurance on their websites.

But consumer advocates and insurers warn that just covering at in-network rates may not pay the entire bill nor preclude a provider from later balance billing after the benefit is processed. It also does not protect patients if the visit is later determined not to be a true emergency.

On Monday, state Rep. Tom Oliverson, a Harris County Republican and anesthesiologist, who sponsored the bill last year that was supposed to bring consumer protection tweeted the Chronicle story along with the message “We need to solve out-of-network balance billing once and for all. I am committed to doing that.”

Source: Lawmakers pledge crackdown on free-standing ER billing practices – Houston Chronicle

Emergency care for elderly can be dangerous

In 2005, when physician Kevin Biese was a medical resident in Boston, a 92-year-old woman with a urinary tract infection arrived by ambulance at a hospital emergency room. Her behavior — confusion and lethargy — suggested she also was suffering from hypoactive delirium, a cognitive disorder.

She was alone, without family or friends. The doctors decided to admit her, but a bed wasn’t yet available. So she had to wait. “She spent 24 hours on a cot in the hallway,” Biese recalls. “She came in during the day on a Thursday and was still there Friday morning. I got mad.”

The emergency care system should “not allow that to happen to those who deserve the most respect in our society,” he says.

Nobody enjoys a trip to the ER. But it can be especially difficult — sometimes even dangerous — for the elderly. Many emergency health-care settings are frenzied and noisy, with glaring lights and slippery floors, often without handrails. Cots and gurneys are hard on fragile bodies. Privacy is scarce.

“The emergency department is not a great place to hang out for anyone, but it can be especially tough if you are older,” says Denise Nassisi, director of the geriatric emergency department at the Mount Sinai Hospital in New York. “Many older patients are frail and have difficulty getting up and down from a gurney, or getting to a restroom. Some have cognitive dysfunction and don’t know their medical history. Some may have impaired vision or hearing. A crowded chaotic environment is not the best for them.”

In recent years, recognition has been growing that older patients need a better ER environment and specialized care than the rest of the population. This has prompted many hospitals to introduce structural changes and new procedures to make their ERs age-friendly. The American College of Emergency Physicians launched an accreditation program last spring for the nation’s emergency departments to encourage them to adopt a more comprehensive and standardized approach for geriatric patients.

The percentage of Americans 65 or older is growing. It was 14 percent in 2012 and is projected to be 20 percent by 2030, according to the Centers for Disease Control and Prevention. About 49.2 million older adults live in the United States today, according to the American Geriatrics Society.

During 2012-2013, the incidence of adults older than 65 who sought emergency care was 12 per 100 persons for injury and 36 per 100 for illness, according to the CDC. The most common complaints that bring elderly patients to emergency departments are falls, abdominal pain, difficulty breathing, fever, chest pain, confusion or other cognitive issues, according to experts.

“Older adults are more vulnerable and have less reserve,” says Susan Zieman, a medical officer in the geriatrics and clinical gerontology division at the National Institute on Aging. “Somebody might fall and just plunk down on the floor, a ‘low mechanism’ fall for someone younger. But an older person can do serious damage — break a hip, for example. Also, sometimes they feel less pain, or show up with atypical symptoms, such as nausea, rather than chest pain, when they are having a heart attack. When people get into their 70s and 80s, there are some clear differences, [and] it takes specialty training to pick up these things.”

Moreover, many emergency departments, while effective in dealing with acute problems, don’t always look at the big picture when it comes to older patients. This means comprehensive screening procedures to check all medications and health history, as well as conditions at home, with the aim of not having to admit them to the hospital. Hospitalizing the elderly brings its own risks, and many of these patients have difficulty returning to their earlier functioning state.

“We want to look at all their needs and problems, including medical and social problems,” says Zia Agha, chief medical officer at the West Health Institute in San Diego, which has a special geriatric emergency care unit. “We need to be aware of their risk of falls, unexpected complications from patients taking multiple medications, cognition and mental status, among other things. Is the person getting the food they need? Is their home safe from basic fall hazards?”

This also means ensuring that patients aren’t showing up “with an acute problem with a chronic basis that keeps them coming back to the emergency room,” says Ula Hwang, an emergency medicine researcher at Mount Sinai, which has introduced numerous “age-friendly” practices. “We need to make sure we aren’t just treating [the emergency], but treating it well enough so the patient doesn’t have to come in with the same problem once a month.”

The new voluntary accreditation includes certain requirements, such as having both doctors and nurses with specialized geriatric training, and environmental criteria, such as mobility aids and easy access to water. The new program so far has accredited 22 hospital emergency departments, but Biese, who manages the program, predicts more of the nation’s estimated 5,000 emergency departments will apply and receive geriatric certification.“We have conversations with health-care systems every week anxious to get theirs online,” he says, pointing out that numerous health-care systems not yet accredited provide geriatric-appropriate emergency care. “Just because a department doesn’t yet have accreditation doesn’t mean it isn’t doing a great job.”

Holy Cross Hospital in Silver Spring is one of them.

It established its seniors emergency center in 2008 and is considering applying for accreditation. Believed to be the first such center in the nation, it was the idea of Kevin J. Sexton, the former chief executive whose mother had a bad ER experience at a hospital outside Maryland.

“It was created to reduce anxiety and confusion in [older] patients and their loved ones,” says James DelVecchio, the center’s medical director, adding that its focus is on “quality care, dignity, safety and comfort.”The Holy Cross center has installed walls to separate its treatment bays, rather than curtains, to ensure added privacy and quiet. Older patients are assigned cots with thicker mattresses and given heated blankets, and have access to special speakers that make it easier to listen to music or watch TV, and telephones and remotes with large buttons. The area features softer lighting, handrails and nonslip floors.

Upon arrival, patients receive a thorough screening that extends beyond their acute emergency. A centrally located nursing station monitors each patient, and later — after discharge — checks up on them by phone to make sure everything is going well.

The latter is especially key, experts say.

“Not everyone can change their lighting and flooring,” Hwang says. “Structural changes are great, but the approach is even more important — checking their medications, looking for cognitive risk, looking at transitions after discharge. You can splash on some paint, change your lighting and flooring, but if the clinicians and staff don’t change their approach, you won’t be making a real difference for these patients.”

At Mount Sinai, one of the nation’s first hospital emergency departments to be accredited, nurses and social workers assess patients’ cognitive function, medications, at-home risk for falls, and the stress level on their caregivers.

“They talk to the patient and make sure there is good follow-up,” Hwang says. “We don’t target every patient older than 65, but those in the ‘gray zone,’ who are not a clear discharge or a clear admission.”

She conducted a study released this year that found geriatric patients seen by ER transitional care teams in three hospitals — Mount Sinai among them — were less likely to be admitted to the hospital and less likely to return during the month following treatment. “They were safely discharged,” Hwang says.

Biese says he believes that such a program could have made a difference for his elderly patient of 13 years ago. Today, her urinary tract infection would have been treated quickly with intravenous antibiotics, and she would have undergone further evaluation with the aim of discharging her with follow-up care at home, he says.“Today, emergency departments are instituting processes and enhancements to address older patients’ vulnerabilities, and make them more comfortable,” Biese says. “These programs matter. They matter to the patient and to the community. When our loved ones have an emergency, we deserve to know that there is a [geriatric] emergency department ready to take care of them.”

Source: Emergency care for elderly can be dangerous – The Washington Post

Updated Pa. guidelines: All ERs should treat addicted patients with medication

In an effort to curb opioid addictions, Pennsylvania has announced updated guidelines for doctors prescribing opioid medications in the emergency room.

The new advice reflects state law limiting opioid prescriptions for people discharged from the emergency room to no more than a seven-day supply and recommends other medications for first-line pain treatment.

“These guidelines are intended to improve patient outcomes, and to supplement, but not replace the individual physician and provider’s clinical judgment,” said Rachel Levine, Secretary of Health for the Commonwealth of Pennsylvania.

But besides looking to prevent avoidable addictions to opioid painkillers, the guidelines say all emergency departments in the state should be ready to treat patients who are already addicted with medications that prevent painful withdrawal symptoms and help people stop using illegal opioids: specifically, medications such as Suboxone that contain the drug buprenorphine.

Currently, not all emergency rooms regularly prescribe these medications when people show up there after a drug overdose.

Jeanmarie Perrone, a professor of emergency medicine at the Hospital of the University of Pennsylvania, led a committee of physicians who authored the updated guidelines.

“Everyone agreed that this was the responsibility of every state emergency department,” she said.

All hospital emergency rooms encounter at least some patients struggling with addiction, she added, ranging from people looking for help with their addiction to those needing treatment for ailments related to injection drug use. Many of them don’t go to the doctor otherwise, she said.

“So it’s really our only touch with these patients, and if we can’t be treatment ready then, then we really can’t help people,” Perrone said.

Doctors need to complete a special training course to get a waiver from the federal government that allows them to prescribe buprenorphine for patients to take home. The requirement has created an obstacle to expanding access to medication-assisted treatment in an emergency room setting.

Perrone said the University of Pennsylvania Health System was encouraging emergency physicians to get the certification by giving them time off to complete the eight-hour course and paying for the required fees. The number of them working in the system’s Philadelphia hospitals who can prescribe buprenorphine jumped from half a dozen to about 50 as a result of that effort, Perrone said, representing about two-thirds of all of the emergency physicians working there.

The guidelines were also updated to stress the importance of sending overdose survivors home with the naloxone, the opioid-overdose antidote, even when doctors can’t prescribe buprenorphine.

“We have absolutely learned in this crisis that it’s impossible for someone to get into treatment and then recovery if they’re dead,” Levine said.

Source: Updated Pa. guidelines: All ERs should treat addicted patients with medication | News | witf.org

Despite law to force clarity, confusion over free-standing ERs persists – HoustonChronicle.com

Fifteen months after Texas enacted a law to bring transparency to the state’s for-profit free-standing emergency rooms, many of the facilities continue to send mixed messages about insurance coverage that could expose unsuspecting patients to enormous surprise medical bills.

A Houston Chronicle review of websites representing the 52 free-standing emergency rooms in the Houston area shows a pattern in which many of the facilities prominently advertise that they “accept” all major private insurance. Some even list the insurers’ names and logos.

But often tucked under pull-down tabs or at the bottom of the page is a notice that the facilities are outside the networks of those insurers, followed by a reassurance that under the Texas insurance code, network status does not matter in emergency treatment, implying patients needn’t worry about coverage.

What the websites fail to disclose is that out-of-network status can result in insurance reimbursements far below the charges, leaving patients on the hook for the remainder of the bill — sometimes thousands of dollars.

“The word ‘accept’ means something very different to them than to the consumer, and they know that when they write their websites,” said Stacey Pogue, senior health policy analyst at the Austin-based Center for Public Policy Priorities. “They do not tell the rest of the story.”

On HoustonChronicle.com: A shift in coverage has even the insured skipping medical care

For example, many of the Houston-area facilities advertise that they accept Blue Cross and Blue Shield of Texas, the state’s largest insurer. But the Chronicle’s review found that only five — about 10 percent — are in that insurer’s network.

Those findings are consistent with a statewide report by AARP Texas, to be released Monday at a state Senate committee hearing, that found 77 percent of the state’s 215 free-standing emergency rooms said they “take” or “accept” Blue Cross and Blue Shield insurance, but were out-of-network.

Free-standing emergency rooms defend their websites, describing concerns raised by advocacy groups and Texas lawmakers as manufactured outrage.

“I don’t see a problem with saying they ‘accept,’” said Dr. Carrie de Moor, CEO of Code 3 Emergency Partners, a Frisco-based network of free-standing emergency rooms, urgent care clinics and a telemedicine program. She insisted that patients understand that accepting someone’s insurance is different from being in that company’s network.

It may seem like a hair-splitting distinction, but it can carry high costs, health policy experts said.

Free-standing websites are technically correct when they cite state insurance code requiring insurers to cover emergencies regardless of network status, said Jamie Dudensing, CEO of the Texas Association of Health Plans, the state’s insurance trade group. That provision is in place to make sure a patient experiencing a life-threatening emergency does not have to worry about finding an in-network doctor or facility.

But she cautions that covering emergency treatment is not always the same as footing the entire bill. A facility outside an insurance network is not bound by the negotiated reimbursement rates and has no limit on how much it can bill.

Further, under a practice know as balanced billing, out-of-network providers can charge some patients for the portion of a bill not paid by insurers. In-network providers are prohibited from balanced billing.

“They are twisting the language to make it seem like patients are always protected,” Dudensing said of the websites. “They are not.”

Stream of complaints

The for-profit, free-standing emergency room got its start in Houston nearly a decade ago and ballooned into a health care phenomenon. The idea was to offer patients easy access to a fully equipped emergency room in their neighborhood and avoid lengthy waits at hospitals. Visits to free-standing emergency rooms now account for more than a quarter of all emergency visits in Texas, according to a report by the insurer UnitedHealthCare.

Patients have complained for years about exorbitant bills from the facilities after believing they were in-network and treatment would be paid by insurance. Sometimes, they were confused because the facilities, typically located in retail centers, look like the nearby — and often in-network — urgent care centers. Often, they found out too late that the cost difference can be staggering.

Consider a case of strep throat. A UnitedHealthCare analysis of claims found that in Texas the average cost billed at a free-standing emergency room was $2,732, or 21 times higher than the $128 average cost at a physician’s office. At an urgent care clinic, the average cost was $159, the analysis found.

The free-standing emergency room cost was even higher than a traditional hospital emergency room, which would have charged on average $1,784, the insurance analysis said.

The free-standing industry defends its fees and billing practices because the facilities must be staffed with physicians around-the-clock, see all patients and offer the same level of treatment and testing as a hospital emergency room. Sometimes patients may not know all that goes into their treatment, particularly when it involves expensive tests to rule out a more serious ailment, the industry says.

The volume of consumer outrage led state Rep. Tom Oliverson, a Harris County Republican and anesthesiologist, last year to introduce House Bill 3276, which required free standing-emergency room websites to properly identify the facility, disclose network status, and include a warning that physicians providing care may bill separately from the facility.

The legislation passed easily and went into effect Sept. 1, 2017.

Nearly a year later, though, murkiness remains.

Take, for instance, the prominent graphic on the website for Clear Creek Emergency and Urgent Care that touts “No Wait No Worries. All private insurance accepted.”

But only after opening a pull-down tab for “patient resources” does this statement appear: “For most insurance providers, we are considered out-of-network. However, we honor all in-network deductibles and benefits.” The website then adds: “If your health insurance company attempts to treat your classified medical emergency as out-of-network, you can consider it a violation of the law and take action by contacting your billing company or your insurance agent.”

“Reading all of that together,” said Pogue, the health analyst for the Center for Public Policy Priorities, “there is no way for a consumer to make heads or tails of it.”

The company did not respond to requests for comment.

Other websites seem to downplay the importance of network status altogether.

Elite Care Emergency Center in League Center, for example, offers this message: “Some of our hospital-based competitors make much of the fact they are contracted and thus ‘in-network’ with most of the major health insurance plans. When you see this marketing message, you can assume that it really means that they do not have much else good to say about themselves.”

Chad Bush, managing director for Elite Care, acknowledged in an emailed statement: “We do not give a lot of credibility to in-network status as it specifically relates to emergency care” because of protections in place. Still, he said the website’s “bold language” may need to be reviewed.

Another unaddressed issue occurs when a patient’s out-of-network emergency room visit is later determined not to be a true emergency. In August, Blue Cross and Blue Shield of Texas launched a controversial measure to add heightened scrutiny to out-of-network emergency claims in its health maintenance organization (HMO) plans. The company has said that if an after-the-fact review determines that the patient should have sought treatment at a less-expensive option, the insurer may not pay the claim.

On HoustonChronicle.com: Texas allows Blue Cross Blue Shield to deny some ER payments

Free-standing emergency officials say insurers are tricking patients, not them.

“We have seen an alarming increase in the efforts made by insurance companies to confuse patients about where they can and should go for medical care in emergencies,” said Brad Shields, executive director of Texas Association of Free-Standing Emergency Centers. “The reality is simple: In-network and out-of-network are irrelevant concepts when it comes to emergency care.”

Blake Hutson, associate state director of AARP, says the dizzying finger-pointing between insurers and providers only further confuses patients.

“People want to understand their health insurance, to have an explanation of how they’re going to be covered and their cost,” he said. “At free-standing emergency rooms in Texas, that all breaks down.”

Try, try again

Oliverson said he thought the law he sponsored would prompt the industry to police itself and to clearly inform patients.

“Some have done a good job, others I’m not so happy with,” he said. “The whole point of the law was to make it more plain that ‘accept’ is not the same as ‘in-network.’ ”

He vowed to introduce additional legislation in the 2019 session. He is considering modeling a New York measure, which is one of the strongest in the nation for consumer protection. Under the New York law, when a patient receives a surprise bill, the insurer and provider are forced to the table to fight it out and the consumer is removed from the middle. In Texas, it is up to patients to initiate a state-sponsored mediation.

“We need to solve out-of-network balance billing once and for all,” Oliverson said.

Source: Despite law to force clarity, confusion over free-standing ERs persists – HoustonChronicle.com

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