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Kaiser Permanente just invested in a housing complex. Here’s what it’s doing with it
Kaiser Permanente has gotten into the business of housing.
The health system announced in May that it would put $200 million toward initiatives targeting housing insecurity and homelessness in the communities it serves. On Tuesday night, it announced the first investment is the $5.2 million purchase of an affordable housing complex in Oakland, California, through a fund in partnership with Enterprise Community Partners and the East Bay Asian Local Development Corporation.
The 41-unit building is in an Oakland neighborhood “on the brink of gentrification” which puts the existing residents at risk for displacement. By purchasing the building, it will be blocked from redevelopment that prices out the existing residents, preventing displacement, Kaiser Permanente CEO Bernard Tyson said at a press event on Tuesday.
Preserving buildings like this is a “key component to addressing the national homelessness crisis,” he said. “We know that preserving affordable housing is more effective than building new units.”
It’s part of a comprehensive strategy, officials said, to invest in addressing the economic, social and environmental conditions that ultimately affect the health of their patients.
Kaiser also announced it is “adopting” 500 homeless individuals in the city, Tyson said. He said that several of the system’s employees focused for 12 weeks to expedite a strategy to partner with community groups to house older homeless patients with chronic conditions.
All 500 people identified by the system have at least one chronic condition. The system is working with local groups to secure housing and other needed services for this group.
The plans unveiled by the system on Tuesday also expand beyond Oakland and the Bay Area, where Kaiser is headquartered. On top of the two initiatives focused in that region, Kaiser and Enterprise are teaming up to launch a $100 million loan fund to create or maintain affordable housing units in all of the communities Kaiser Permanente serves.
Tyson said the health system will make future announcements about specific plans under that fund. Tackling this issue, he said, “ties into who we are and what we’re about as Kaiser Permanente.”
“This is the beginning of us being in traffic and backing our talk that we want to help to make a difference in Oakland, in the Bay Area, in this great country,” Tyson said.
Trump wants to bypass Congress on Medicaid plan
Block grants for states would achieve conservative dream on health program for poor.
The Trump administration is quietly devising a plan bypassing Congress to give block grants to states for Medicaid, achieving a longstanding conservative dream of reining in spending on the health care safety net for the poor.
Three administration sources say the Trump administration is drawing up guidelines on what could be a major overhaul of Medicaid in some states. Instead of the traditional open-ended entitlement, states would get spending limits, along with more flexibility to run the low-income health program that serves nearly 75 million Americans, from poor children, to disabled people, to impoverished seniors in nursing homes.
Capping spending could mean fewer low-income people getting covered, or state-designated cutbacks in health benefits — although proponents of block grants argue that states would be able to spend the money smarter with fewer federal strings attached.
Aware of the political sensitivity, the administration has been deliberating and refining the plan for weeks, hoping to advance an idea that Republicans since the Reagan era have unsuccessfully championed in Congress against stiff opposition from Democrats and patient advocates. During the Obamacare repeal debate in 2017, Republican proposals to cap and shrink federal Medicaid spending helped galvanize public opposition, with projections showing millions would be forced off coverage.
In addition to potential legal obstacles presented by moving forward without Congress, the administration effort could face strong opposition from newly empowered House Democrats who’ve vowed to investigate the administration’s health care moves.
“Hell no,” Sen. Bob Casey (D-Pa.) wrote on Twitter on Friday evening, vowing to oppose the administration’s block grant plan “through legislation, in the courts, holding up Administration nominees, literally every means that a U.S. Senator has.”
The administration’s plan remains a work in progress, and sources said the scope is still unclear. It’s not yet known whether CMS would encourage states to seek strict block grants or softer spending caps, or if new limits could apply to all Medicaid populations — including nursing home patients — or just a smaller subset like working-age adults.
A spokesperson for CMS did not comment on the administration’s plans but indicated support for the concept of block grants.
“We believe strongly in the important role that states play in fostering innovation in program design and financing,” the spokesperson said. “We also believe that only when states are held accountable to a defined budget — can the federal government finally end our practice of micromanaging every administrative process.”
Republicans have sought to rein in Medicaid spending, especially as enrollment swelled under Obamacare’s expansion of the program to millions of low-income adults in recent years. CMS Administrator Seema Verma has warned increased spending on the Medicaid expansion population could force cutbacks on sicker, lower-income patients who rely on the program.
The administration wants to let states use waivers to reshape their Medicaid programs, but the effort could face legal challenges in the courts. Waivers approved by the Trump administration to allow the first-ever Medicaid work requirements for some enrollees, for example, are already being challenged in two states.
Also complicating the administration’s push: the newfound popularity of Medicaid, which has grown to cover about one in five Americans. Voters in three GOP-led states in November approved ballot measures to expand Medicaid, which has been adopted by about two-thirds of states. Newly elected Democratic governors in Kansas and Wisconsin are pushing their Republican-led legislatures to expand Medicaid this year.
Verma has been trying to insert block grant language into federal guidance for months but has encountered heave scrutiny from agency lawyers, two CMS staffers said. She mentioned interest in using her agency’s authority to pursue block grants during a meeting with state Medicaid directors in the fall but did not provide details, said two individuals who attended.
There is some precedent for the federal government capping its spending on the entitlement program. Former President George W. Bush’s health department approved Medicaid spending caps in Rhode Island and Vermont that would have made the states responsible for all costs over defined limits. However, those spending caps were set so high there was never really any risk of the states blowing through them.
In recent years, governors have complained about the rising costs of Medicaid, which is eating up a bigger share of their budgets. States jointly finance the program with the federal government, which on average covers 60 percent of the cost – though the federal government typically shoulders more of the burden in poorer states. The federal government covers a much higher share of the cost for Medicaid enrollees covered by the Obamacare expansion.
An official from a conservative state, speaking on background to discuss an effort not yet public, said states would consider a block grant as long as the federal government’s guidance isn’t overly prescriptive.
CMS is hoping to make an announcement early this year, but it could be further delayed by legal review, which has already been slowed by the prolonged government shutdown.
Some conservative experts said the administration’s plans ultimately may be limited by Medicaid statute, which requires the federal government to match state costs. However, they say the federal government can still try to stem costs by approving program caps.
“There’s no direct provision of authority to waive the way that the federal government pays the states,” said Joe Antos of the American Enterprise Institute, a right-leaning think tank. “However, that doesn’t mean that you can’t try to have some of the effects that people that like block grants would like to see, in terms of encouraging states to be more prudent with the ways they spend the money.”
Payer, provider trends to watch in 2019
https://www.healthcaredive.com/news/payer-provider-trends-to-watch-in-2019/545612/
Ripple effects from 2018 will continue well into the new year as players deal with some massive policy and business shifts.
The coming year for healthcare will see the industry reckon with some of the massive changes set in motion last year, such as megamergers like CVS-Aetna and Cigna-Express Scripts and a judge’s declaration that the Affordable Care Act is no longer constitutional.
On the policy front, newly-installed Democrats in Congress (and the party’s 2020 presidential candidates) will be pushing for more comprehensive health coverage plans while the GOP considers tougher Medicaid restrictions at the state, and potentially federal, level.
Meanwhile, some familiar storylines are likely to continue. Effusive digital health funding and increases in mobile and telehealth services show no signs of abating, and neither does general M&A activity.
Here’s a snapshot of a few big trends for the payer and provider crowds to watch for in 2019.
Providers: Behavioral care goes primary, investment in digital
1. Narrowing gaps in population, behavioral healthcare
Historically, behavioral health services have been mostly disparate, but increased spending in digital health and a focus on lowering out-of-pocket costs will help spur greater connectivity, Sandra Kuhn, national lead for behavioral health consulting at Mercer, told Healthcare Dive. She predicted “more partnerships between traditional medical and behavioral health carriers on smaller, targeted point solutions” as the industry already began to see last year.
The trend more broadly fits into the push to recognize and act on social determinants of health.
One partnership is the Utah Alliance for the Determinants of Health, a coalition of providers, community organizations and government agencies banding together to reduce the impacts of SDOH. Their plan seeks to address socioeconomic stressors like housing instability, food insecurity and transportation — circumstances with a direct effect on mental and physical health — before patients show up in the ER lobby. Intermountain Healthcare, a primary stakeholder, invested $12 million in the initiative.
Early efforts include experimental EHR technologies, value-based payments for even more population health management programs and wraparound services. Health Affairs highlighted two separate initiatives, each making inroads on social determinants by carrying out existing population health programs in tandem with trusted community partners.
Overall, Kuhn said, more organizations will step up with tactical solutions to what has otherwise been an intractable problem. That includes payers like state Medicaid programs, many of which have begun value-based payments for behavioral health services.
Progress on behavioral and population health is happening in tandem with — or perhaps existing symbiotically alongside — the growth of telemedicine. At Riverside Health System, a rural health network in Newport News, Virginia, a long-term telebehavioral health initiative has improved coordinated care among psychiatrists and clinical social workers, as well as replaced a chunk of services offered at the system’s nursing homes.
Riverside isn’t the first to find success with telebehavioral health, but the system’s wider experimentation with programming, a happy accident triggered by a psychiatrist shortage, has certainly shown there’s a market for it — one that Quartet, Lyra and Teladoc have been quick to capitalize on. This year will see a swath of players from across the industry tackle behavioral health gaps by complementing primary care with telemedicine.
2. Doubling down on digital
While larger health systems tend to have the means to be early adopters of new and robust healthcare technologies, physicians are beginning to integrate such services into their practices.
Use of telehealth among the commercially insured has been gradually rising since the mid-2000s, having grown 52% annually from 2005 to 2014 before spiking 261% between 2015 and 2017, according to JAMA.
Revenue cycle management firm SYNERGEN Health estimates digital health tech for remote use will grow by 30% this year, allowing patients to better manage their own healthcare, giving clinicians an opportunity to spend more time with more patients and, of course, generating new revenue streams.
As more payers hop aboard the telemedicine train and more services are covered, hospitals will continue see costs fall. A 2017 report from the Rural Broadband Association found that telehealth services were associated with an annual cost savings of $20,841 per U.S. hospital on average. The caveat here for hospitals is the very real possibility that large facilities will become increasingly more obsolete and overhead costs will become too costly as patients find yet another reason to stay away from their doors.
3. Price transparency still a question mark
Many are hoping the days of the $629 hospital bill for a wet towel and a Band-Aid are coming to an end, but it’s not likely to happen in 2019.
Still, legislators and consumers alike are making price transparency an issue in hopes of curbing skyrocketing healthcare costs.
CMS took some action last year by finalizing a new rule mandating hospitals post chargemaster rates online in a machine-readable format. But the rule is effectively toothless. Hospitals were already required to make those prices available, and chargemaster rates only apply to the uninsured and balance billing. And despite the fact that the rule went into effect on the first day of the year, CMS admitted recently that it has no way of enforcing the mandate and would not comment on how many hospitals are currently in compliance with the rule.
“It is [our] expectation that all of them will comply,” CMS Administrator Seema Verma said on a call with reporters.
The rule doesn’t specify where hospitals need to post their charges. The only requirement is that they’re made available online, which has allowed health systems like mega-operator Ascension to bury their charges behind a tangled maze of clicks.
The company has previously defended itself in a statement to Healthcare Dive by arguing the costs can be confusing for patients, as they don’t take financial assistance and charity care into consideration. Chargemaster information, as some critics have pointed out, isn’t a very useful measure of pricing for consumers. It can actually be counterproductive.
Thomas Lee, chief medical officer at Press Ganey, speaking at the U.S. News Healthcare of Tomorrow conference, said economists don’t believe price transparency has a noteworthy impact on cost and efficiency.
“I’m predicting not much will happen and people won’t pay attention to it because the charges aren’t actually relevant to the vast majority of people,” Lee said. “If people are uninsured, I doubt they’re looking at these things either.”
If the ACA taught economists and legislators anything about American consumers, it’s that they want healthcare, but don’t want to take the time to shop around for it. In a recent Health Affairs survey, just 13% of respondents responsible for cost-sharing in their last healthcare encounter sought cost information before receiving care. Only 3% compared prices of different providers.
History seems to be repeating itself, as CMS hopes its “first step toward price transparency” will be picked up by market forces. By mandating the information be made available in a different file format, CMS believes it has “set the stage” for that data to be used by private third parties that can develop tools for consumers to use.
“There’s nothing in the rule that prevents hospitals from going further with this,” Verma said. “Hospitals can do that today.”
But they aren’t. In fact, the percentage of hospitals unable provide patients with price information jumped from 14% to 44% between 2012 and 2016, according to a JAMA study.
In short, the CMS rule is much more of a light nudge than a forceful shove into price transparency, and without regulation and the means of enforcing it, hospitals have little to no incentive to change. But expect the wheels of the price transparency conversation to continue turning in 2019, regardless.
Payers: Contract fights, a focus on value and more managed care
1. Contentious negotiations and contract disputes
As insurers have bulked up in scale after blockbuster mergers last year, Fitch Ratings expects relationships between providers and payers to be even more contentious during contract negotiations even in a value-based payment setting.
Some recent headline-grabbing squabbles include UnitedHealthcare’s contract impasse with Envision Healthcare, an ER staffing firm. Tenet and Cigna’s contract negotiations stalled and finally reached a multi-year deal this year.
Hospitals can also expect low rate increases from commercial insurers, according to Moody’s.
In markets where there is a dominant insurer and multiple hospitals, “Each hospital will need to demonstrate why it is indispensable to the insurer … and why it should be included in a network,” Moody’s reports.
However, there are potential glimmers of hope. As more states have expanded Medicaid, it puts pressure on other states to do so, which would provide a means of payment for hospitals that have gone without payment caring for the uninsured.
2. Value-based momentum
Payers and providers will continue to enter into value-based contracts in 2019 at varying degrees, according to Moody’s.
Many hospitals are engaging in contracts that offer incentives or alternative payment models for reaching certain quality measures, but very few are taking on full risk, or both the upside and downside risks within a contract, according to Moody’s.
That will continue into 2019: few are likely to take on downside risk, or the possibility of losing money, Moody’s reports.
However, while the popularity and use of these payment models continues, its cost-savings benefits have yet to be realized, according to a recent report.
Meanwhile, CMMI continues to test for ways to drive change in the healthcare by paying for quality as opposed to quantity. For instance, CMMI is testing whether it can reduce utilization and ultimately costs by addressing social-needs such as housing for Medicare and Medicaid beneficiaries. CMMI’s director Adam Boehler said he won’t force organizations to take on risk, but will help them take on a level of riskthey’re comfortable with.
But in an about-face, the Trump administration seems to be signaling that it may institute mandatory payment models that could put providers at risk of losing money.
3. Medicare Advantage still lucrative, popular
Medicare Advantage will continue to be a profit center for insurers, which typically enjoy a 5% margin, according to 2016 data from the Medicare Payment Advisory Commission.
As the population ages, it presents a growth opportunity for payers. Enrollment in MA plans grew by 8% from 2016 to 2017, according to a recent MedPAC report, as many more seniors are choosing to enroll in plans run by traditional insurers. About 34% of beneficiaries choose MA, a significant increase from a decade ago when just 10% enrolled in such plans.
Beginning this year, MA plans have greater flexibility to offer non-traditional benefits such as adult daycare, meals or in-home care to improve the overall health of patients, particularly those will high needs. CMS Administrator Seema Verma previously said 270 MA plans will offer these new benefits in 2019.
These new benefits also pose an opportunity for nontraditional healthcare companies such as Lyft and Uber, which are looking for ways to shuttle seniors to appointments and pharmacies.
Payers including Cigna touted the future growth opportunity it sees for MA. “We are well positioned today and going forward for existing and new markets,” Cigna CEO David Cordani said of MA, according to Forbes.
4. Medicaid managed care growth
As states weigh expanding Medicaid, it’s another potential opportunity for managed care plans to contract with states. As more states expand the program, it puts pressure on the remaining holdouts.
Last year, some red states took the issue to the ballot box and got approval for expansion, potentially providing a roadmap for stakeholders to replicate in other states where the legislatures balk at expansion. California Gov. Gavin Newsom is backing an idea that would expand Medicaid eligibility in his state to undocumented young adults, providing another opportunity for Medicaid managed care firms.
Likely potential winners are Centene and Molina. Centene is the nation’s largest Medicaid managed care firm with operations in 21 states covering more than 8 million people. Molina serves more than 3 million in 13 states and Puerto Rico.
Just recently, Molina CEO Joseph Zubretsky said even without expansion ushered in by the Affordable Care Act, $1 billion of new revenue opportunity exists in Molina’s existing footprint because of states like Illinois that are expanding Medicaid managed care statewide.
Healthcare M&A now more about strategy than opportunity, Kaufman Hall says
Dive Brief:
- The size of the companies involved in healthcare M&A continues to grow. The average size in revenue of sellers was $409 million last year, nearly 14% higher than a decade ago, Kaufman Hall said in a new report.
- Kaufman Hall found that seven transactions in 2018 involved sellers with net revenues of at least $1 billion.
- Healthcare M&A today is more of a strategic decision than one about opportunistic growth. Fewer deals last year involved financially distressed sellers, according to the report.
Dive Insight:
Healthcare M&A isn’t so much about saving a struggling hospital now. Instead, these deals often involve strong health systems looking to expand into new areas.
Nearly one-third of healthcare transactions last year involved companies with revenues of between $100 million and $500 million. About one-fifth of deals were at least $500 million.
Nearly half involved not-for-profit companies acquiring other nonprofits and about one-quarter were not-for-profits buying for-profits. Another nearly 25% involved a for-profit acquiring either another for-profit or nonprofit.
Kaufman Hall said M&A activity isn’t about taking advantage of a struggling competitor. A mere 20% of deals involved a distressed company. Instead, health systems want strategic advantages.
“Health system leaders are seeking to acquire organizations that bring embedded expertise and resources to the deal, making these transactions more of a strategic partnership than an asset acquisition,” according to the report.
Kaufman Hall said it has found that health systems with “strong operational or clinical capabilities” are looking beyond their local markets.
New competitors in the market are offering larger scale and resources, including annual revenues as much as nearly 10 times the levels of the biggest not-for-profit systems. The CVS Health-Aetna deal kicked off a trend that continued with Humana-Kindred Healthcare and Optum-DaVita Medical Group and goes on with Amazon’s efforts to enter healthcare.
“New combinations across healthcare verticals and new market entrants are creating competitors that dwarf the scale of even the largest health systems,” according to the analysis. “The forces that are reshaping the industry affect not-for-profit and for-profit health systems alike and are causing not-for-profit and for-profit strategies to converge.”
Kaufman Hall found that consolidation is happening faster in some states than others. Not surprisingly, Texas led with eight deals in 2018. Florida (seven), Pennsylvania (six) and Louisiana and Tennessee (five each) ranked next.
Texas ($6.8 billion) and Florida ($3.6 billion) led in terms of revenue of announced deals. Kaufman Hall said 16 states didn’t have any healthcare transactions. However, some of those states, such as Kentucky and Massachusetts, have seen a high volume or large deals in recent years.
One downside of M&A is consolidation that can limit competition. The Center for American Progress recently reported that provider consolidation has led to higher healthcare prices. That report also found that consolidation isn’t lowering costs and improving care coordination, which is a common argument in favor of M&A activity.
Cartoon – Not Hearing Impaired
Universal Health Services finance chief Steve Filton on cost containment and challenges hospital CFOs face
As CFO of one of the nation’s largest hospital management companies, Steve Filton understands the challenges hospitals face.
Mr. Filton has served as executive vice president and CFO of King of Prussia, Pa.-based Universal Health Services since 2003.
He joined the company in 1985 as director of corporate accounting and in 1991, he was promoted to vice president and controller.
Mr. Filton spoke with Becker’s about some of the challenges facing CFOs and his top cost-containment strategies.
Question: What is the greatest challenge hospital and health system CFOs faced in 2018? Do you expect this to be their biggest challenge in 2019 as well?
Steve Filton: I think effectively we’re in an environment where our payers have all concluded that costs and medical spending have to be reduced, and a lot of that burden ultimately falls on providers, like hospitals and doctors. As a [result], I think hospitals are tasked with the difficult goal of continuing to provide the highest quality care in more efficient ways. I think that was the biggest challenge last year and will be the biggest challenge this year. I think, frankly, for the foreseeable future, that’s the challenge of being a provider in today’s healthcare environment.
Q: How do you feel the CFO role has evolved in recent years?
SF: I think CFOs have a particularly challenging role in that our organizations explore the ways to deliver high quality care that’s best for our patients and try to create an environment that is satisfying for our employees. We as CFOs then say, ‘How do we accomplish these things and remain efficient and remain profitable?’ [That way organizations] can continue to do all the things we have to do as far as investing and reinvesting in the business and continuing to be competitive with our labor force and do all the things that allow us to continue to run high quality facilities, which in many cases involve significant expenditures.
Q: What are your top cost-containment strategies?
SF: I think a lot of our cost-containment strategies are focused on what I describe as driving the variability out of our business. I think so many other industries and businesses are accustomed to delivering their products and services in very standardized ways that are determined to be most efficient. I think healthcare has sort of long resisted that, and as a [result], we have lots of variability in the way that we deliver services in our various geographies. Various clinicians will deliver services differently. And I think we could benefit by following the lead of some of our peer industries and becoming much more focused on … delivering all our care and service in that standard way in accordance with best practice protocols. Driving out excess utilization and driving out rework and re-dos and errors — those things I think are a significant focus of getting the hospital industry to be more efficient and cost-efficient.
Question: During your tenure at UHS, what has been one of your proudest moments as CFO?
SF: What I take great pride in is the growth of the company. When I joined the company in the mid-1980s, it had maybe 35 [or] 40 hospitals around the country and maybe $500 million of consolidated revenues. This coming year we’ll have well over 300 domestic facilities and another 100 or so in the United Kingdom and over $11 billion of revenue. And what I’m proud of is not just the growth of the company, but … the way the company has grown and yet really adhered to its core principles. When I joined the company 30 some odd years ago, it was very committed to high quality patient care and to the satisfaction to our employees. And honestly, if anything, I think the company has recommitted itself to those core principles over the years, and to be a much bigger company [and] not have abandoned our core principles, at least for me, is a source of great pride.
Q: If you could pass along one nugget of advice to another hospital CFO, what would it be?
SF: I tell the folks who work with me and for me all the time that it’s so important to behave every day with the highest level of integrity. I think at the end of the day you can’t replace that. People, I think, will give you a lot of leeway if they trust you, if they believe that you’re behaving transparently and with great honesty. And so I encourage everyone who works for me to do that, and I certainly endeavor to try to do that as best I can. And it’s tough. There are all kinds of pressures on folks in a financial role in this sort of environment. But I think if you behave with integrity, everything else will follow from that.
State Efforts to Protect Consumers from Balance Billing
Health insurance rates for working-age Americans have improved over the past decade. But not everyone with health insurance today has adequate financial protection. About one-fourth of insured Americans are underinsured because they have significant coverage gaps or high out-of-pocket costs. And all consumers are vulnerable to surprise medical bills, or balance bills for out-of-network care. These balance bills arise when insurance covers out-of-network care, but the provider bills the consumer for amounts beyond what the insurer pays and beyond cost-sharing, as well as in situations where out-of-network care is not normally covered but the selection of provider is outside the consumer’s control.
Consumers are most likely to receive surprise medical bills from health providers outside their insurance plan’s network after receiving emergency care or medical procedures at in-network facilities. In the latter cases, for example, consumers may select a surgeon and facility in network, but discover that other providers, such as an anesthesiologist or surgical assistant, are out of network. These unexpected medical bills are a major concern for Americans, with two-thirds saying they are “very worried” or “somewhat worried” that they or a family member will receive a surprise bill. In fact, these bills are the most-cited concern related to health care costs and other household expenses.
While employers and insurers may voluntarily protect employees or enrollees from some types of balance billing, no federal law regulates charges submitted by out-of-network providers. States can help protect enrollees from unexpected balance bills. However, state protections are limited by federal law (ERISA), which exempts self-insured employer-sponsored plans, covering 61 percent of privately insured employees, from state regulation.
Despite Recent State Activity, Consumers in Most States Are Not Protected from Balance Billing
We conducted a study, published in June 2017, that found that 21 states had laws offering consumers at least some protections in a balance billing situation. But only six of those states — California, Connecticut, Florida, Illinois, Maryland, and New York — had laws meeting our standard for “comprehensive” protections.
Critical elements of state laws that offer “comprehensive” protections against balance billing:
- Extend protections to both emergency department and in-network hospital settings
- Apply laws to all types of insurance, including both HMOs and PPOs
- Protect consumers both by holding them harmless from extra provider charges — meaning they are not responsible for the charges — and prohibiting providers from balance billing, and
- Adopt an adequate payment standard — a rule to determine how much the insurer pays the provider — or a dispute-resolution process to resolve payment disputes between providers and insurers.
In 2017 and 2018, states continued taking steps to protect consumers. Four states — Arizona, Maine, Minnesota, and Oregon — created balance-billing consumer protections for the first time, and two states — New Hampshire and New Jersey — substantially expanded existing protections. We now classify New Hampshire, New Jersey, and Oregon as states offering comprehensive protections against balance billing. As of December 2018, 25 states have laws offering some balance-billing protection to their residents, and nine of them offer comprehensive protections.
New Jersey has met our criteria for comprehensive protection by creating a strong dispute-resolution process to establish a payment amount for the out-of-network service. Other states have recently acted to protect consumers from balance billing in a more limited way that does not meet our criteria. For example, Missouri’s protections against balance billing apply only if the provider and insurer voluntarily agree to participate in the process.
Interest in a Federal Solution to Balance Billing
At the same time, interest has grown in federal measures, in part, because only federal legislation can protect those in self-funded insurance plans that are exempt from state regulation. During the 115th Congress, proposals were released by Senator Bill Cassidy (R–La.), Senator Maggie Hassan (D–N.H.), Representative Lloyd Doggett (D–Texas), and Representative Michelle Lujan Grisham (D–N.M.). The Cassidy proposal has bipartisan support, with three Democrats and two other Republicans as cosponsors.
Federal approaches vary along some of the same lines as state laws. For example, the Hassan bill relies most heavily on a dispute-resolution approach. By contrast, the Cassidy proposal relies on a payment standard that is the greater of a) the median in-network rate paid by the insurer or b) 125 percent of the average allowed amount across payers. Several federal proposals make protections contingent on failure of providers to notify the consumer that they could be billed by an out-of-network provider. States that have enacted protections have mostly viewed such contingent protections as an insufficient means of protecting consumers. Federal proposals also vary in the degree to which they allow a state role in implementing protections.
Some federal proposals, like some state laws, have potential gaps. For example, some address balance bills only from hospital-based physicians such as anesthesiologists and radiologists. Also, state laws and federal proposals mostly do not address ground or air emergency transport providers.
Looking Forward
The bipartisan interest in the surprise billing issue offers the potential for federal action in the new Congress. States are frustrated by their inability to address all insurance plans. And states without laws have often faced opposition from stakeholder groups, even when there is a consensus around protecting consumers. A federal solution could offer a more comprehensive approach, while giving states appropriate flexibility to seek an approach fitting their particular market environments.
HENRY KOTULA 