Barron’s: For Telemedicine to Change Health Care, We Need to Change How we Pay Doctors.
Barron’s: For Telemedicine to Change Health Care, We Need to Change How we Pay Doctors.
Opponents of the role of consumers and markets in health care have one go-to argument above all others: that you can’t shop for health care when you’re unconscious. The rising problem of gargantuan, surprise medical bills in surgical wards and emergency rooms shows that they have a point. The good news is that constructive, bipartisan reforms may be on the horizon.
A close encounter with surprise billing
A few years back, my wife and I had an up-close look at how surprise billing works.
We were about to have our first child. I had warned my wife, Sarah, about the problem of surprise billing. She meticulously researched everything to make sure that the hospital she chose—part of the St. David’s HealthCare system in Austin—was part of our insurer’s provider network. She then did the same for her obstetrician and her anesthesiologist.
When Sarah went into labor, and we got to the hospital, the receptionist asked me to sign a form, agreeing to allow the on-call pediatrician to see our baby once he was born.
I asked, “Is the pediatrician in our network?” The receptionist, visibly annoyed, said, “I have no idea.” I replied, “Well, I’m not signing any form allowing for an out-of-network pediatrician to see our child. That could cost me thousands of dollars!”
Her frustration rising, the receptionist handed me a clipboard with a list of a hundred pediatricians on it, and said, “pick one.” So, as Sarah was being wheeled away, I pulled out my smartphone, went to the web browser, logged into my health insurer’s website, and began painstakingly typing in the names of the on-call pediatricians, one by one. Finally, after 15 tries, I found one who was in our network, and picked that one.
I was shaken by the experience. I guessed that fewer than 0.1 percent of Americans would have known to do what I did—to insist, in an emergency setting, on an in-network pediatrician. How can anyone accept such a system?
I was lucky, first because I had access to the internet in my hand, and second because it’s my job to read and write about health care policy. Prior to the birth of our child, I’d come across a 2014 front-page story in the New York Times by Elisabeth Rosenthal. In it, Rosenthal told the story of Peter Drier, a 37-year-old bank technology manager who had undergone surgery for herniated disks in his spine. The surgeon who operated on Drier participated in his insurance network, and so for the surgery, Drier’s out-of-pocket cost was $3,000 out of a total charge of $6,200. But later on, Drier received a bill for $117,000 from a neurosurgeon whom he never met, but may have stopped by to see Drier while he was unconscious: a practice dubbed “drive-by doctoring.”
The practice is especially egregious in emergency rooms, where freelancing, out-of-network doctors are granted free rein in hospitals to charge whatever they want to patients who, at best, are confused about what they’re agreeing to, and at worst, are being billed at insane rates while being wheeled into the ER after a car accident or a stroke.
Egregious pricing practices
An analysis by Ge Bai and Gerard Anderson of Johns Hopkins, published in the Journal of the American Medical Association, compared what physicians charge in the Medicare program to what they charge people who are privately insured or uninsured. Most of the medical specialties with the highest ratio of private prices to Medicare prices were related to surgeries and emergencies, including anesthesiology (5.8x the Medicare rate), emergency medicine (4.0x), neurosurgery (4.0x), and diagnostic radiology (3.8x). And that includes in-network prices for insured patients; out-of-network physicians charge 9 to 10 times what Medicare pays for the same service. And, rest assured, this isn’t because Medicare’s rates are too low; Medicare determines its reimbursement rates in large part by outsourcing the job to the very medical specialists who stand to benefit from higher Medicare prices.
Yale researchers Zack Cooper and Fiona Scott Morton looked at emergency department visits that occurred at hospitals that were in insurers’ networks, in a paper for the New England Journal of Medicine. “On average,” they found, “in-network emergency-physician claims were paid at 297% of Medicare rates,” while “out-of-network emergency physicians [within in-network hospitals] charged an average of 798% of Medicare rates.”
A study from UnitedHealthGroup, looking at its own claims nationwide, recently estimated that out-of-network emergency physicians increased health care charges by $6 billion per year.
The problem is especially bad in Texas, where, according to Cooper and Morton, in some regions a majority of in-network hospital visits were accompanied by an encounter with an out-of-network physician. On top of that, Texas has seen a proliferation of for-profit, free-standing emergency rooms, that refuse to contract with insurers, so as to retain their flexibility to charge the highest prices possible to patients with medical emergencies. The free-standing ERs make even more money by resembling urgent care clinics, luring in patients who need treatment for minor conditions, but end up with bankruptcy-inducing bills. Overall, the incidence of surprise billing in Texas doubles the national average.
The solution: Learn from Medicare Advantage
Legislators at both the federal and local level are trying to do something about the problem of surprise billing, what wonks often call “balance billing.” A modest, bipartisan measure proposed by state legislators in Texas would penalize emergency rooms that charge more than 200 percent above the average hospital charge for a comparable service.
A plethora of bills introduced in the U.S. Senate, including one from a groupled by Sens. Michael Bennet (D., Colo.), Tom Carper (D., Del.), Bill Cassidy (R., La.), Chuck Grassley (R., Ia.), Claire McCaskill (D., Mo.), and Todd Young (R., Ind.), would limit out-of-network prices in the emergency setting to the greater of (1) the median in-network rate for a particular geographic area; or (2) 125 percent of the “average allowed amount” in a geographic area: a proxy for what hospitals charge regardless of insurer contracts.
Both of these bills represent constructive—but insufficient—improvements upon the status quo.
There are two problems that legislation should try to solve here. The first is the surcharge of out-of-network prices relative to in-network prices. The second is the surcharge of in-network prices relative to Medicare prices. As I mentioned above, in-network prices for emergency care are also exploitative; out-of-network prices even more so.
Here, we can learn from Medicare Advantage. For the most part, Medicare forbids out-of-network providers from charging more than what traditional Medicare would pay for a given service. This has given insurers critical leverage against hospital monopolies, because the worst-case scenario is paying an out-of-network provider at Medicare rates. That means insurers have the ability to negotiate even lower rates with in-network providers.
Similarly, the solution to exploitative pricing in the private market is to cap out-of-network prices at the lower of the median privately contracted rate and Medicare’s rates. Not only will such a policy end price exploitation by out-of-network emergency care providers, but also by in-network providers. It will also give market participants the opportunity to do better than Medicare, whether through value-based contracts, simple price competition, or other innovations.
The provider lobby is no longer all-powerful
Politicians are understandably scared of crossing hospital lobbyists, who represent the second-largest employer in your typical congressional district, right behind the public schools. But we’re at a point now where the average household is spending more to pay for hospital bills—between out-of-pocket payments, insurance premiums, and subsidies for others’ coverage—than they send to the IRS each year. This cannot last.
If we do nothing, the problem will get far worse. If we do something that is too incremental, we’ll pat ourselves on the back and then be forced to revisit the problem in a few years.
Americans deserve market-based alternatives to single-payer health care. Without reform of exploitative hospital prices, we’ll never get there.
A bill allowing health care providers to offer diagnoses over the phone to patients they have never seen in person or via a video connection cleared a House committee on Tuesday after an unsuccessful attempt last month.
The House Committee on Public Health, Welfare and Labor advanced House Bill 1220 after it was amended to require the provider to have access to a patient’s medical record.
Claudia Duck Tucker, vice president of Dallas-based Teladoc, said that record could be a questionnaire that the patient filled out online.
Sponsored by Reps. Dan Sullivan, R-Jonesboro, and Justin Gonzales, R-Okolona, the bill would amend a 2017 law requiring a professional relationship to be established through more than just an audio-only phone call, even when combined with the patient’s responses to an online questionnaire, before a provider can treat a patient using telemedicine.
The law allows the relationship to be established through an in-person examination or through several other means, including those specified by state licensing boards.
A state Medical Board regulation allows the relationship to be established through an examination using “real time audio and visual telemedicine technology.”
Annette Guarisco Fildes, chief executive of the ERISA Industry Committee, which represents large employer health plans, said the current law presents a barrier for people without broadband Internet connections.
Employers “want their employees to receive access to care when and how they need it,” she said.
David Wroten, executive vice president of the Arkansas Medical Society, said the 2017 law was crafted in consultation with large employers, including J.B. Hunt.
He said HB1220 was being pushed by Teladoc, which offers health services over the phone through employer health plans.
“The other vendors are not here asking for this change, because most of them do not utilize this type of a business model,” he said.
HB1220 last month fell three votes short of the 11 it needed to clear the committee. On Tuesday, it cleared the committee without a vote to spare. It next goes to the full House.
Austin White, CEO and Founding Partner at OnMed, joined Cheddar to discuss the new technology that makes going to the doctor as easy as stepping into the a phone booth.
Over the last several years, virtual health has grown exponentially in the United States, overcoming political hurdles, legislation, and medical societies fighting tooth and nail to stop its proliferation. Employers are starting to recognize the value of telemedicine as well, with 65 percent of companies offering telemedicine through their health plan.
The Dallas-Fort Worth Business Group on Health hosted a luncheon on the current and future state of telemedicine, bringing in a panel of experts on the topic. Moderator Eric Bassett, who is Senior Partner and the Central Market Business Leader for Mercer Health and Benefits, talked about how telemedicine is being implemented by small employers and those with 5,000 or more employees, but many of the middle market companies have been slow to adopt.
Nita Stella, the vice president of product and strategy at Teladoc, a leading telemedicine company, said that telemedicine is responsible for sees 2 million consults a year, comparing it to the transition to digital banking in the way it keeps most of us out of a bank. “Telemedicine is here to stay,” she said. In Texas, Senate Bill 1107 opened the door for telemedicine in 2017, but Stella is looking to see how it can move beyond primary care and into mental health, prenatal support, and other areas where access to healthcare can be difficult.
But connecting employees to telemedicine isn’t always straightforward. Stella discussed the disconnect employers and their employees often experience. In their studies, employers are more interested in biometric screening and diabetes measurement, while employees are concerned with weight loss and saving money. Creating systems that address all those needs is possible but not always easy.
Stella stressed the importance of a clear entry point, comprehensive clinical services, and integrating other providers when implementing telemedicine. Overall, when properly implemented, she said telemedicine should be able to simplify access, change behavior, reduce costs and connect the dots between the entire health ecosystem while improving outcomes. She highlighted increased efficiency for mental health appointments, which she said can result in a 45-day wait through normal avenues but take less than 5 days when using Teladoc.
Andrea Cockrell, the Administrative Services Manager for the City of Plano spoke about their use of telemedicine. She noted that city government is not always the quickest to adopt the latest technology, and that many employees are out in the city and don’t have easy access to technology throughout the day, but that their implementation had been relatively successful.
For Plano, the low cost of telemedicine visit (just $5) had lowered the barrier to use. Many panelists noted that the major challenge was getting an employee to use telehealth for the first time, and that they were often hooked on the service after the first visit. A low copay provides an incentive. She also said sharing testimonials can be a great motivator for others to join. “Word of mouth tends to go a long way; people don’t trust HR,” she said.
The speed (average visit was 5 minutes with a 7 minute wait time), quality (4.94 out of 5 stars) and impact (83 percent of appointments resulted in a prescription) of the program made it worthwhile for Plano, but they also experienced cost savings by avoiding urgent care or the emergency room. In one year, the city went from 300 to 550 virtual visits.
Bassett closed the program explaining how telehealth could help relieve physician shortages, especially in rural areas, but he isn’t sure if it will improve efficiency enough. “It is something we are all going to have to watch, especially in rural locations. That is where these things have the most promise.”
In February, a bill arrived at our house. It was from some doctor we’d never heard of, who, the bill said, “assisted” in some relatively minor surgery my husband had in early November, more than three months before.
Turns out, the bill had already been through my husband’s insurance company which covered just a small amount ($28). There was a sizable discount, but we were still left with a bill of about $275. My husband had never been told by the surgeon about the need to bring in an assistant, before or after. We had thought we’d settled all the bills months before
Something similar had happened to me several years ago involving a different doctor and a different medical insurer. When I received the unexpected demand for payment I contacted the insurance company and they told me in no uncertain terms not to pay it. They didn’t owe it and I didn’t owe it. They had approved the procedure in advance and it did not include tacking on additional personnel after the fact, they said. And that, was the end of that.
So naturally I urged my husband to contact his insurance company to go to bat for him. Which he did the next day and after 30 delightful minutes on the phone with them, he was informed that the insurance company was still not paying anything more but that he had to.
Turns out, the “assistant” was out of network, the insurance company told him. But my husband had specifically selected the doctor he did because the surgeon was in-network and the medical center where the procedure was performed was in-network. This was no emergency surgery, but a longtime planned procedure complete with pre-op scrutiny and paperwork.
We paid the bill. And while the amount was not enormous, it was hard not to think about other times in our adult lives a $275 payment would have been difficult to come up with on the spot and that for many individuals and families it would still be a significant hurdle, one that might keep someone from paying other bills like rent or utilities. My husband sent a letter to the surgeon who did the operation expressing in polite terms his thanks for his surgery but his disappointment in the unexpected bill from the doctor’s non-network associate. To date there has been no reply.
Far more egregious cases occur every day in Texas, a state with a bad reputation for these distinctly unpleasant post-treatment surprises. Reports are legion of fully-insured Texans buried under thousands of dollars of bills because the medical facility they went to or the doctor they used was not in network. Or, like us, because someone in that operating room was out of network.
In fact, according to the trade group The Texas Association of Health Plans in Texas: “More than 65 percent of out-of-network ER doctor claims occur at network hospitals.”
Even more grinding: “300 of the 407 hospitals in Texas have NO network ER doctor for the three major health plans,” according to the association which represents health insurers, health maintenance organizations and other health-related groups.
Apparently it doesn’t matter how smart or knowledgeable you are, how much you do or don’t research your policy and its coverage ahead of time, how lucky you are that you’re on one of the major health plans and not some obscure fly-by-night concern – chances are better than 50-50 that are going to get nicked for some out-of-network bills.
Because of that, it appears some bi-partisan consensus has been reached on how to fix at least part of this – something that makes sense to a whole lot of people.
Under Senate Bill 1264 all emergency room visits would be considered in-network. Patients who went to an in-network facility would be covered by insurance, no matter who saw them. Kelly Hancock (R-North Richland Hills) has sponsored the bill in the Senate and Trey Martinez Fischer (D-San Antonio) has introduced a companion bill in the House. Doctors could not charge patients for what the insurance company didn’t cover.
Another important point is that when there are disputes over who should pay what, it will be the responsibility of the doctor and not the patient to start mediation with the insurance company.
It didn’t take long for the very powerful Texas Medical Association to raise its hand and demand state legislators hear from the doctors’ side of the equation. And as frustrating as this may be for patients looking for a quick cure to hear, TMA has its points as well.
The TMA insists the blame should not be placed on the medical personnel but on the insurance companies, who it says often deny doctors network status. On their website right now is a testimonial from a Beaumont anesthesiologist Ray Callas who, the story says, “is tired of beating his head against the wall trying to get ‘in-network’ with health insurance companies. And he’s tired of the surprise bills his patients receive when he can’t get in.”
“My responsibility as a patient’s physician is to know the risks of administering anesthesia, not administering their personal insurance plan,” Callas is quoted as saying. “Frankly, educating patients regarding their insurance plan and what is and is not covered, and how to meet deductibles — that’s the responsibility of the plan. Don’t just hand them a 75-page booklet and tell them their benefits are described within.”
One of the problems pointed out by the TMA is that approved provider information isn’t always up to date. While the split between Blue Cross Blue Shield from Kelsey-Seybold in October 2016 was well documented and patients received countless messages about it from both the insurer and the medical system, TMA notes that there are often abrupt changes that patients aren’t aware of. In its own legislative agenda, TMA wants a requirement that health plans “provide accurate information on physicians’ network status, updated in real time.”
Another is that insurance benefit explanations are often unnecessarily complicated, the TMA says. It urges a rewrite of insurance companies’ policies, putting them in plain language so patients can make sense of them.
Add in the complication of free-standing ERs who say they “take” or “accept” insurance but are not in major plans’ networks and you have a guaranteed recipe for surprise billing. And according to TAHP, out-of-network emergency care prices “are extremely high compared to what is usually accepted in the market.”
TMA wants doctors to be able to bill patients for all their costs and whatever insurance doesn’t pay, to still be able to recover that. Certainly, no one wants to see doctors not paid for their work. That’s not fair.
Family upset after ‘robot’ doctor informs patient he doesn’t have long to live
The powerful Texas Medical Association has come out swinging in its opposition of proposed bipartisan legislation that seeks to end surprise emergency room billing in the state.
The lobbying group that represents 53,000 doctors in the state began blanketing lawmaker’s offices with a flier this week demanding legislators instead “hold health insurers accountable for the products the sell to Texans.”
On Feb. 28 state Sen. Kelly Hancock, a Republican from suburban Fort Worth, introduced sweeping legislation that would treat all emergency room visits as in-network and bar doctors from billing patients for any portion of a charge that insurance does not pay. In addition it would protect unsuspecting patients who go to an in-network facility, such as a hospital or surgical center, and later discover they were treated by an out-of-network provider.
Texas Medical Association has contended surprise billing is not the fault of doctors, but rather insurers who severely limit networks and refuse to allow willing physicians into networks. The group also accuses the insurance companies of under-paying them and arbitrarily denying legitimate claims.
“Some of the most frequent, and most irritating intrusions into physician’s daily lives come from health insurance companies,” the flier said. It further stated that “we strongly oppose” Hancock’s proposed legislation, calling it mere “window dressing” to protect patients.
The medical group said the law would allow health plans to “determine unilaterally what they pay for care provided out of network” and lets insurers “skirt responsibility for the products they sell.”
Hancock, who for the past decade has battled against surprise billing, said in a statement: “It’s a shame the association chose to take a staunch position against patient protections instead of working with us on the bill.”
Texas has one of the worst records of surprise medical billing in the nation. Internal claims data from the three largest insurers in the state shows that two of three emergency physician claims in 2017 occurred at in-network facilities.
The measures introduced by Hancock and Martinez Fischer would also remove patients from the middle of billing disputes between doctors and insurers under the state’s mediation process. Patients would only pay in-network rates for such things as deductibles and co-pays. If doctors believe they have been wronged by insurers it will be up to them to start mediation, not the patients.
While many Texans remain ineligible for the mediation process, the proposed legislation would allow some to opt-in.
Previously, the Texas Medical Association has said it opposes removing removing patients from the mediation process because they can help influence insurers to pay more.
The medical group, in its flier, said it does support other legislation introduced this year that takes aim at health maintenance organization (HMO) plans that require prior authorizations for certain treatments. Other legislation the group supports would require insurance directories for in-network doctors to be updated every two business days and force the Texas Department of Insurance to review network adequacy requirements at least every two years.
There is little doubt a fight over patient billing is building in Texas. After Hancock’s bill was unveiled last week, Gov. Greg Abbott tweeted: “Sweeping legislation takes aim at shock emergency room bills in Texas. This issue must be resolved this session.”
Insurers could get tax breaks worth as much as $30 million and use out-of-state health providers in their networks under a House bill meant to champion the use of “telehealth” in Florida.
Members of the House Health Quality Subcommittee this week approved the bill (HB 23) and included a tax credit for insurers and HMOs willing to reimburse health providers for telehealth services. The tax credit — in an amount equal to one-tenth of 1 percent — could be applied against corporate income taxes or insurance premium taxes.
Rep. Carlos Guillermo Smith, an Orlando Democrat who was one of only two members of the panel to oppose the measure, said he didn’t think the state needs to give an incentive to insurance companies and HMOs for agreeing to reimburse for the services.
“Thirty million is a fairly large budget hole,” he said.
Florida providers and hospitals lag behind their peers nationally in the use of telehealth, according to a state-created telehealth advisory task force. Telehealth, a term insurance companies have coined, involves using the internet and other technology to provide services to patients remotely. Telehealth is not a type of health care service but rather is a mode to deliver the services.
There’s little dispute about the definition, but there is dispute about the name. Physicians prefer to call this mode of health-care delivery “telemedicine.”
The Legislature has for years grappled with telehealth and how it should best be used and regulated.
In December 2016, the Agency for Health Care Administration issued the findings of a survey it conducted with the state insurance department and the state health department. The results showed that 45 percent of hospitals responding to the survey said they provided telehealth, while only 6 percent of practitioners, such as physicians, did.
House Speaker Jose Oliva, R-Miami Lakes, has included expanding the use of technology as a priority in pursuing an overall agenda to lower health-care costs.
But disagreements between insurance companies and physicians were on display Tuesday when the bill was considered by the House panel.
Jeff Scott, general counsel of the Florida Medical Association, told lawmakers that Florida physicians support telemedicine and that state medical boards have adopted rules to regulate its use for in-state and out-of-state providers.
“The foundation for telemedicine is in place,” he said, adding, “the major impediment to expanding telemedicine is the reluctance of insurance providers to fully pay for this service. For telemedicine to reach its full potential in Florida, the issue of payment parity needs to be addressed.”
The Telehealth Advisory Council, in a 2016 report to the Legislature, recommended that the state pass a parity requirement. Essentially, the mandate would require health plans to pay practitioners and facilities for services at rates that are equivalent to reimbursement rates for the same services if performed face-to-face.
According to a 2018 report from the Center for Connected Health Policy, 39 states and the District of Columbia have laws that govern telehealth reimbursement policies.
But Scott noted that the House bill doesn’t have a mandate. Meanwhile, it contains a provision that would allow out-of-state providers to be included in insurance-company and HMO networks.
The providers would have to meet certain requirements and register with the state health department. But Scott said that didn’t go far enough to protect patients.
Bill sponsor Clay Yarborough, R-Jacksonville, indicated, however, that he favors using incentives to encourage insurance companies, rather than issuing mandates.
“That’s not the approach that I’m poised to take, where we are going to force (insurance companies) to do it,” Yarborough told The News Service of Florida following the meeting. “As time goes on, given that more providers are going to want to do telehealth, they’ll eventually have that realization that we need to do this anyway. Right now, it’s a kick-start to incentivize them to do it.”
Congress is taking another stab at legislation that would expand telehealth access for Medicare beneficiaries seeking mental health services at home.
The Mental Health Telemedicine Expansion Act (HR 1301), reintroduced last month by Reps. Suzan DelBene (D-WA) and Tom Reed (R-NY), would include the patient’s home in the list of originating sites for telehealth, thus enabling providers to be reimbursed through the Centers for Medicare & Medicaid Services for home-based telemental health.
The bill, which failed to make it through Congress last year, does include one caveat: It requires that the provider and patient have an in-person meeting before using telehealth.
“Everyone – regardless of where they live – should have access to telemedicine services from the comfort of their home so they can be treated for mental health conditions ranging from anxiety and depression to addiction and suicidal thoughts,” DelBene said in a press release issued with Reed when the bill was first introduced in 2018. “This bill is an important step in the right direction for those in need.”
“In Washington state, there are 158 areas with a shortage of mental health professionals, but many patients still face challenges accessing care even when they don’t live in health professional shortage areas,” the press release added. “More than 3.6 million people each year miss or delay care due to lack of transportation to their physician. Telemedicine allows those patients to take off less time from work and spend less time sitting in traffic.”
The bill is the latest in a national effort to increase access to mental health services via telehealth and telemedicine. Several states, including Massachusetts, Maryland and Washington, are considering or have enacted new guidelines aimed to boost coverage and access.
Telemental health was also on the minds of analysts at Epstein Becker & Green. The national law firm released a report in December 2018 that took note of state efforts to expand telehealth coverage for mental health services while also bemoaning a lack of reimbursement options for providers.
“Despite Medicaid’s fewer restrictions on telehealth coverage as compared to its Medicare counterpart, there is limited federal guidance or information regarding the implementation of telehealth services in state Medicaid programs or coverage parameters for states choosing to offer such services,” the attorneys noted in a press release. “Healthcare practitioners who treat Medicaid populations are at risk for steep penalties for noncompliance, including fines and the potential loss of their professional licenses.”
“(P)ublic recognition of the benefits of utilizing telehealth technology to provide greater access to healthcare services has significantly increased,” they pointed out in an overview of the report. “While the shortage of behavioral health providers has long been acknowledged, the growing use of telehealth technologies as a strategy to increase access to psychiatrists, psychologists, counselors, therapists and other behavioral health professionals continues to gain attention and validation as an alternative model of care delivery.”
The bill’s reliance on an in-person consult to establish the doctor-patient relationship could draw scrutiny. That requirement was at the center of a years-long battle between the Texas Medical Boards and telehealth vendor Teladoc one that made its way through the courts before Texas lawmakers amended state laws to loosen the reins on telehealth.