May 24, 2019
Area(s) of Interest: AB 72 Advocacy Physician Leadership Out of Network Billing
Four physician congressman announced they would be introducing legislation with bipartisan support to protect patients and end surprise medical bills. The California Medical Association (CMA) is sponsoring this legislation, which is co-authored by physician congressmen Raul Ruiz, M.D., (D-CA), Phil Roe, M.D., (R-TN), Ami Bera, M.D., (D-CA) and Larry Bucshon, M.D. (R-IN), as well as Joseph Morelle (D-NY), Van Taylor (R-TX), Donna Shalala (D-FL) and Brad Wenstrup (R-OH).
Based on New York state’s successful law, this important proposal will protect patients from the financial hardship and emotional stress of surprise medical bills when their insurance fails them. The bill is based on the premise that patients should not be caught in the middle of insurance company-physician disputes. Unlike other surprise billing proposals introduced earlier this year, this legislation actually creates incentives for physicians and insurers to contract and resolve their differences.
The proposed legislation also addresses the underlying cause of the problem – the insurance industry’s oligarchic market dominance – that has allowed insurers to narrow their physician networks so patient access to physicians is limited.
It is modeled after the successful New York law that has been in effect since 2015. The law has helped keep insurance rate hikes in New York well below the national average.
The new proposal requires insurers to give patients a robust choice of physicians, including hospital-based emergency physicians, and on-call surgeons and anesthesiologist, who will be there for patients in life and death emergencies. It allows insurers to pay commercial rates for out-of-network care but if parties disagree, the proposed “baseball arbitration” system encourages insurers and physicians to resolve their disputes without costly lawsuits.
The other proposals currently being considered in Congress more closely mirror California’s AB 72 surprise billing law, which is not working. Over the last year, many insurers have refused to renew longstanding contracts with physicians, particularly anesthesiologists who are essential when a patient needs surgery. Some insurers are terminating contracts unless physicians accept a 40% payment reduction. Others are closing their networks to new physicians. This is happening because the California system does not incent physicians and insurers to contract. California’s private insurers have decided they don’t need to contract and can simply pay the low rate set by the state. Physician networks are not being enforced and the arbitration system is expensive and difficult. As a result, access to care is eroding and premiums are increasing.
“We are encouraged that there is sincere, bipartisan willingness to work together to help protect patients from surprise medical bills,” said David H. Aizuss, M.D., president of the California Medical Association. “But we must make sure Congress learns from the mistakes of California’s surprise billing law. This bill is the only patient protection measure that holds insurance companies accountable for ensuring patients have access to appropriate physician networks.”