It's a Surprise

We are, it appears, shocked -- shocked! -- that there are "surprise" bills in healthcare.  That is, bills from out-of-network healthcare professionals, even when patients thought they were going to in-network professionals/facilities.  The problem is bad enough that even our deeply divided Congress has bipartisan agreement that it should act (although whether it will, of course, remains to be seen). 

Of course, surprise billing shouldn't come as a surprise to anyone who knows much about healthcare; it is more of a symptom of problems with our healthcare system than a problem itself. 

Credit: LAUREN GIORDANO / THE ATLANTIC

Kaiser Health News/NPR deserve much credit for getting more attention for the issue, with their Bill of the Month crowdsourced investigation.  They profiled a number of people who had done their best to follow their health plan's rules, only to subsequently find themselves liable for tens or hundreds of thousands of dollars of uncovered bills, often from healthcare professionals they had not chosen and might not even been aware they'd used.   

Sarah Kliff of Vox did similar work with her focus on outrageous emergency room bills. 

Some patients ended up in collection -- even having liens placed on their houses -- due to these bills, although some had their bills reduced once KHN/NPR shone the spotlight on them.  About half of the states have already enacted some type of legislation to combat these kinds of bills, although no one thinks we've quite found the "right" solution yet (e.g., states can't regulate self-funded employer health plans). 

Like most things, the "solutions" will lead to other problems, some of which are foreseeable now and some of which are not.  E.g., the money to pay these bills has to come from somewhere; either healthcare professionals get paid less, or health plans pay more (which mean consumers pay higher premiums).  It might lead to health plans making their networks skimpier, knowing they can always rely upon the new "out-of-network" prices. 

Many believe surprise billing is a problem of transparency: make healthcare prices more transparent, and there won't be any surprises.  The current Administration has pushed for this in hospitals and prescriptions, and are looking to widen these efforts.  Unfortunately, it is neither clear what those prices mean, nor how many consumers will be able to understand them.   

There's no doubt that surprise bills are a shameful consequence of the profit-seeking nature of too much of our healthcare system, especially when it comes to charges from professionals/organizations that patients had no choice in (e.g., ERs, ambulances/air ambulances, anesthesiologists, radiologists,
lab/pathology).  But it may be not so much about greed as it is arrogance. 

Take "consent to treat."

Example of e-signature form

When you go to a healthcare professional or visit a healthcare facility, chances are you'll be asked to sign a consent to treat form.  It may be called something different, and may include "consent to bill" or have be asked to sign that separately.  You may not bother to read the language; in my local healthcare system, you're asked to electronically sign on a keypad, without actually seeing either the document or your signature.   Whether you read it or not, you are not getting services until you sign.

The wording may vary, but the thrust of what we are being asked to sign is this:

• You agree that they can treat you, reserving their right to involve others in your treatment should they choose;
• You may agree to a specified treatment, but they reserve the right to perform other treatments in addition to/in lieu of it should they deem them medically appropriate;
• You agree that they can bill your health plan, but also agree that you are responsible for any costs not covered by the health plan, no matter how large they are or where they come from.

 In this kind of environment, surprise billing is not a surprise, it is inevitable.

Imagine if buying a car was like this.  You might go into a car dealer with a fairly good idea of what car you wanted, with what features and at what price, but instead you agree to let a car buying specialist handle the purchase.  He/she may seek to get you what you wanted, but might decide that you needed other features, perhaps even a different car, regardless of cost to you, and might even bring in some other car buying specialists whose expertise you also have to pay for.  "Sticker shock" would take on whole new kinds of meaning. 

Car dealers would drool to be able to sell like healthcare. 

Our healthcare system is based on the assumptions that our healthcare professionals know what is best for us, and act in our best interests.  That may have once been true, but, sadly, it no longer always is.  Patients are more armed with information, and often have clear preferences and expectations.  Healthcare professionals and organizations have learned how to maximize revenues, too often without thinking enough about where those revenues come from. 

Credit: Marketwatch/iStockphoto

It's one thing to gouge health plans (e.g., Rand's recent study on hospital pricing), even Medicare/Medicaid, since the impact on premiums/taxes is further downstream and more widely distributed, but increasingly it's happening directly to consumers.  Thus the furor over surprise billing, as well as high deductibles.

 Sure, let's do something about surprise bills.  It's bad and shouldn't happen, at least not to the extent it is.  But let's not pretend we're really solving anything.  It's only a band-aid on bigger issues.  Likewise, we should have more price transparency, but unless we simplify and clarify healthcare prices, it's not going to do much -- especially when it often isn't clear what we need prices for, or from whom. 

Healthcare needs to stop using things like consent to treat agreements that gives professionals/ facilities carte blanche, and start being open and honest with the people it supposedly is serving. 

That'd be a surprise.