Keep up the insults: Missing the mark on surprise medical bills

Do you think I went too far in my last blog post, calling out some journalists as “pontificating parasites” who love nothing more than to slam physicians and blame us for the cost of healthcare?

If you do, then you must not have read Elisabeth Rosenthal’s latest salvo in the Feb. 16 New York Times, where she says physicians are in “a three-way competition for your money” with hospitals and insurers, as if we’re all equally well-funded players at a craps table.

Even National Public Radio, often no friend to physicians, acknowledges that physician pay adds up to a mere eight percent of total US healthcare costs.

What stings even more, hearing that kind of accusation from Ms. Rosenthal, is that she used to be a physician herself before she quit emergency medicine to edit Kaiser Health News. I’m sure it’s a better gig: no nights, no weekends, no holidays. But, as Julius Caesar noted, it’s always worse when the stab in the back comes from someone you thought of as a colleague, if not a friend.

Surprise medical bills

The topic of Ms. Rosenthal’s one-sided op-ed is out-of-network billing, also known as “surprise” billing. Emergency physicians (along with anesthesiologists) may be the doctors most often accused of not being “in-network” with insurance companies and sending patients large “surprise” bills after the fact.

However, the American College of Emergency Physicians (ACEP), which represents Ms. Rosenthal’s former colleagues, is no happier than anyone else about out-of-network bills. “Much of this conflict over surprise billing is playing out in the media,” ACEP notes, “and insurers have been trying their hardest to paint emergency physicians in a bad light.”

ACEP is right. The facts about out-of-network bills, and the history behind them, differ from what Ms. Rosenthal would have the public believe.

What is a narrow network?

After the Affordable Care Act (ACA) passed in 2010, new insurance exchanges were created. Their hallmark was the concept of keeping costs down by limiting the doctors a patient could see to those who would agree to the low payments the exchanges offered. This is the definition of a “narrow network”. You never heard the term before the ACA became law.

Today, Forbes estimates that nearly three-quarters, or 72 percent, of health plans in the ACA’s exchange market have narrow networks. It didn’t take long for insurers to catch on that this was a great way to maximize their profits beyond the ACA exchange market. They began to put pressure on physicians to accept lower and lower payment rates if they wanted to stay “in network”. That’s how Health Care Service Corp., which operates a network of Blue Cross Blue Shield health insurance plans, posted profits of $4.1 billion in 2018, and CEOs take home millions in pay and stock options.

The physicians who balk have been effectively shut out or black-balled by large insurance companies, which simply refuse to negotiate contracts with them.

We won’t abandon patients

Some primary care physicians choose the route of concierge medicine, where they stop dealing with insurers altogether and charge patients a direct monthly fee.

For physicians who deal with emergencies, though, including ER physicians, surgeons, and anesthesiologists, there’s no such choice: we won’t walk away and abandon our patients. We take care of you, whether or not your insurance company will contract with us, and whether or not your insurance company will do the right thing and pay your bill.

Few patients see how the huge, highly profitable insurance companies are squeezing physician groups out of business by refusing to negotiate contracts that even cover the group’s administrative costs. The result? More and more small groups are being absorbed by for-profit corporations, which are turning care into a depersonalized, assembly-line commodity.

The physician-staffing corporation TeamHealth recently cut its emergency physicians’ pay by four percent after it couldn’t reach a contract with UnitedHealth Group. It’s not far-fetched to expect that other large health systems will do likewise when insurers drive even harder bargains.

Don’t make the mistake of thinking that nurse practitioners or other advanced practice nurses will deliver cheaper care and solve the problem. Their services are paid for by the same insurers, often at similar rates to physician pay, and their payments are under the same downward pressure. (Meanwhile, as more “millennial” nurses elect to become nurse practitioners, the size of the RN workforce has dropped by up to 80,000 nationwide.)

The same tactics that the insurance companies are using against physicians are also driving hospitals out of business. For American hospitals, Medicare and Medicaid payments in 2018 fell short of meeting the cost of care by $76.6 billion. As private insurers continue to slash or delay payment for services, hospitals are going bankrupt – even large teaching hospitals like Hahnemann University Hospital in Philadelphia. Rural hospitals are under even more pressure, and their bankruptcies leave patients nowhere to go.

Can Congress help?

The plight of patients with huge bills after out-of-network care has provoked a justifiable outcry for a national legislative solution. Luckily, there is a good state model to follow. New York State in 2015 put into effect a law that protects consumers from surprise bills and creates a mechanism for fair resolution of disputed charges between physicians and insurers.

A national law based on the New York model – such as HR 3502, the “Protecting People from Surprise Medical Bills Act”, sponsored by Rep. Raul Ruiz of California – would solve the surprise bill problem permanently. HR 5826, the “Consumer Protections Against Surprise Medical Bills Act“, sponsored by Rep. Richard Neal, is a reasonable alternative though it could use some revision, and has the advantage of approval by the House Ways and Means Committee.

But that isn’t what the insurance companies want, of course. They want a bill based on “benchmark” prices for physician, practitioner, and hospital services – effectively setting price controls and fattening insurance company profits even more. That kind of bill is what passed in California (AB 72), and is enabling insurers to refuse to negotiate new contracts because it’s more profitable for them to keep physicians out of their networks.

Ms. Rosenthal’s op-ed, unfortunately, plays right into insurance company hands. She tells lawmakers not to listen to doctors or hospitals, as though we’re equally powerful contenders with the insurance lobby. If only that were true. She writes as though she’s stuck in a time warp where all physicians are wealthy old white men who play golf on Wednesday afternoons.

Perhaps she should wake up and look at today’s physicians and today’s medical school classes, filled with young men and women from all kinds of different backgrounds. Many are the first in their families to attend college. They finish medical school with an average of more than $250,000 in educational debt. I bet few of them play golf.

I’m sure it was a clever move on Ms. Rosenthal’s part to bail on actual patient care. Many physicians, young and old, are following her example. Meanwhile, I keep on wondering who’ll be left to take care of all the sick people in another ten years. Best of luck.

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For more information about the real truth behind surprise medical bills and proposed legislation to fix the problem, please visit the website Out of the Middle.

12 COMMENTS

Thank you so much, Dr. Sibert, for standing up for physicians in this absurd surprise billing fiasco. It’s sad to see someone like Ms. Rosenthal, as knowledgeable and experienced as she is, taking the position she does. It’s a sellout position as I see it.

I would offer one slight correction to your wonderful article: Concierge physicians, by and large, still take insurance. It’s Direct Primary Care doctors that do not. They accept a monthly, quarterly or annual subscription amount for which they provide a defined set of services at no additional fee. This model typically covers about 85% of the average person’s health care needs and offers same day or next day appointments and 24/7 access for an average monthly fee of less than $80.00. Just a point of clarification.

Thank you again for pointing out the discrepancy in Ms. Rosenthal’s assessment of the surprise billing mess.

[Reply]

karen

Thank you so much for the comment and helping us all understand the difference between concierge practice and direct primary care. I appreciate your takine the time to read and reply.

All the best,

Karen Sibert

[Reply]

The SETT Group

The Surgical Economics Think Tank agrees: What is needed is insurer reform, not billing reform. We have written extensively on the topic.

[Reply]

Eduardo

From Argentina. Thanks Karen for bravely pointing out this problem. The results of the battle you are fighting would affect the physicians similar battles all over the World. Please, don’t give up, go ahead.
Best regards,

[Reply]

Patricia Watson

Dr. Siebert,
Thank you for tackling bias against physicians head on. Physicians and medical trainees make great sacrifices and constantly do amazing things, yet where are those stories? It is extremely frustrating to attempt to find positive reports about physicians when it appears the polarization encouraged by social media believes negative stories about doctors are so much more interesting to read and therefore write and publish. Thank you for fighting the fight and calling out falsehoods.

I am also writing to you regarding something that seems curiously intentional in your post. You refer to Dr. Rosenthal as “Ms. Rosenthal” despite clearly understanding that she has been awarded an M.D. In this world of substantial gender bias against women physicians, your choice to repeatedly refer to her by “Ms” gives succor to those who are hostile to women physicians, it undermines women who actually practice medicine (I suspect this is the antithesis of your intent in using “Ms”), and it undermines your own message. The issue you are writing about is important and powerful, why lessen it with a covert ad hominem attack?

I look forward to supporting you in your mission to change how physicians are portrayed in the media.
P. K. Watson, MD

[Reply]

karen

Dear Dr. Watson,

Right under Elisabeth Rosenthal’s byline, in the columnn I was referring to, the Times states: “Ms. Rosenthal, a journalist and physician, is a contributing opinion writer.” I can only assume that if she objected to that, she would let the Times know. I am simply following their lead. She is not listed as certified by the ABEM, nor is she listed as a licensed physician in California, where Kaiser Health News is based. Her opinions seem so out of date regarding the current situation of surprise billing that I have no trouble believing it has been a long time since she has been a practicing physician.

Thank you so much for taking the time to read and comment, and I appreciate your support!

All the best,

Karen Sibert

[Reply]

Jeffrey Shapiro, MD

Brilliant. Your words are pointed and true. Thank you for giving physicians and especially anesthesiologists a voice of reason and clarity.

[Reply]

Davvid Grubb,MD

Hi,
Good article.
Now, did you send it to the Washington Post, or even better, directly to Case, Deaton, and Cascio? Or whoever? Preaching to the converted doesn’t help much, but it is good to hear that others have similar viewpoints.
David Grubb, MD

[Reply]

Henry

Great web site.

I was born in Yale hospital 79 years back. Seven people in the family went to school there. Grew up in Berkeley, Ojai, and went to University High School in L.A., Class of 1959.

How to call you about extending a payment plan here in Virginia, the tax-credit for charity-care, “Donations of Professional Services”, available online? Extending it to states, commonwealths, and I.R.S. will not solve population problems, but will make medicine more nearly equitable and pay doctors for treating indigent patients.

Annelore is a pediatrician. We were in private practice for 5 years, then we joined the Army, went to Europe, put our 3 kids in German schools where they learned English with a British accent, and later transferred to the Navy. Socialized medicine with travel. Loved it. All you have to do is treat patients, not bill them.

Henry E. Butler III M.D., F.A.C.S.
Home: 757-397-7283
[email protected]

[Reply]

Henry

“Donations of Professional Services” — Code of Virginia

Extending this Virginia law to our states, 3 more commonwealths, and to the I.R.S. would make medicine more nearly equitable and pay doctors for treating indigent patients.

Henry E. Butler III M.D., F.A.C.S.
[email protected]

[Reply]

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