Debate over Congress' proposals to ban surprise medical bills has intensified, as physicians, hospitals and insurers war over legislation.
On the surface, the lobbying fight is over which party—hospitals, physicians or insurers—should shoulder more of the out-of-network costs that are currently being offloaded to patients. But House and Senate committees want to go further than that, in order to capture what those costs actually are and curb their inflation.
On Wednesday, the House Energy and Commerce Committee will gather eight witnesses to discuss the panel's draft proposal to cap out-of-network charges at the regional insurers' in-network rate. The Senate health committee has proposed a similar limit as one of three options laid out last month in its draft legislation to lower healthcare costs.
Hospital and specialty physician groups intensely oppose any measure that sets hard limits on their rates or their contract practices—arguing that such a policy gives insurers too much leverage. Ultimately, they want Congress to stay flexible when it comes to what they can get paid.
A "single payment standard doesn't allow for differentiation in the marketplace based on value, quality or complexity and cost intensity of the practice location," Texas anesthesiologist Dr. Sherif Zaafran said in his testimony prepared for the House committee. "In particular, the inability to be compensated for the types of quality metrics that ultimately decrease the overall cost of care will inhibit providers who invest to create this value and drive everyone to an inefficient 'one-size-fits-all' reimbursement standard."
American Hospital Association Executive Vice President Tom Nickels likewise opposes a "fixed payment amount" for out-of-network care.
"Arbitrary reimbursement rates could disrupt local market forces in ways that could have significant negative unintended consequences," Nickels said in his testimony.
The opposition to any kind of hard line on rates is playing out uniquely, as specialty physician groups push hard for rival legislation pitched by lawmakers in lieu of the committee proposals.
Sen. Bill Cassidy (R-La.), who first launched draft legislation to stop balance bills last fall, has recruited nearly a quarter of senators to sign on to his proposal with Sen. Michael Bennet (D-Colo.) that gives doctors the option to challenge the median in-network rate to an independent arbiter.
But the bill would also trigger immediate payment for the doctor who treats an out-of-network patient, which some critics say could further deter physicians from joining an insurance network.
In the House, Reps. Raul Ruiz (D-Calif.) and Phil Roe (R-Tenn.) outlined a physician-sanctioned proposal a few weeks ago, but haven't formally introduced the legislation.
So far, they have been vague about the payment for physicians and hospitals—requiring only a "commercially reasonable rate."
Co-sponsors include Energy and Commerce members Reps. Larry Bucshon (R-Ind.) and Ami Bera (D-Calif.). All four lawmakers are physicians.
The fight over surprise billing has created several physician task forces to support their mission.
Physicians for Fair Coverage, a group chaired by Zaafran that represents specialty physician groups, labels their position as a fight to end the "surprise insurance gap." This group supports both the Cassidy-Bennet bill and the Ruiz proposal.
The group includes US Anesthesia Partners, Radiology Partners and US Acute Care Solutions. All these companies are physician-owned and contract with hospitals—so any rigid proposal on pay caps would hit their margins.
Radiology Partners, based in Southern California, received a $60 million capital investment from the New Enterprise Associates, a global venture capital firm. They have about 1,250 radiologists contracted with nearly 1,000 hospitals.
US Acute Care Solutions is an Ohio-based physician-owned group that contracts with hospitals to run emergency departments, obstetrics, pulmonary and critical care and more. Ruiz was the group's top recipient in the House's last campaign cycle, according to the Center for Responsive Politics.
At the other end of the issue, there's the Coalition Against Surprise Medical Billing, a new group that starkly opposes arbitration as expensive and burdensome. The groups behind this task force include America's Health Insurance Plans, America's Physician Groups, American Benefits Council, the Blue Cross and Blue Shield Association, and the ERISA Industry Committee.
The lobbying is poised to intensify as the House and Senate committees wrap up their work. Next week, the Senate health committee will follow with a hearing on the 165 pages of draft proposals to lower healthcare costs. These include three options to end surprise bills.