The Senate health committee approved its major healthcare package on Wednesday, but with one change to the proposed ban on surprise medical billing and potentially more to come ahead of a full Senate vote expected later this month.
As it stands, the provision on surprise medical bills would cap out-of-network physician or hospital charges at a rate already negotiated by insurers. An amendment to that provision came from Sen. Bill Cassidy (R-La.) and would make insurers post all the physician and hospital options in their networks so patients could see their choices of doctor before deciding on a plan.
But Cassidy and other colleagues—who were driving forces behind an arbitration model to settle any payment disputes between physicians, hospitals and insurers—made it clear they will keep working to move the bill toward a more provider-friendly form as hospital and physician groups continue to strongly oppose the benchmark rate cap. The Senate's benchmark rate proposal tracks closely with the House Energy and Commerce bill, which has yet to have a panel vote.
Just before the Senate panel voted on the legislation, titled the Lower Health Care Costs Act, committee Chairman Lamar Alexander (R-Tenn.) promised he would keep working with Cassidy and other senators who still want to appoint an outside arbiter to field payment disputes.
Specialty physician groups, who don't want any absolute cap on what they can bill for out-of-network care, are intensely pushing for this policy.
After the committee approved the amended legislation, Alexander told reporters that work on the bill will continue over the next few weeks.
"Sen. Cassidy, as well as Sens. (Lisa) Murkowski and (Maggie) Hassan, have made some very strong arguments about the possibility of unintended consequences, especially in rural or underserved areas, of the requirement of an absolute benchmark," Alexander said.
He added: "There clearly are possibilities to continue to improve the bill and move in the direction Sen. Cassidy wants to go."
In the amended bill text released on Monday, the health committee leaders had already tweaked the surprise billing provisions to make HHS write its regulations according to geographic area, with rural healthcare access in mind. The regulations could also be periodically updated based on HHS assessments of how it's working.
With the lobbying pressure already intense, the next few weeks will likely fuel more tension until the legislation finally goes to the floor. Insurers and hospitals have pushed back against the bill's transparency provisions and the American Hospital Association has asked all its member hospitals to urge their senators to oppose the sweeping contract reform proposals as well as the benchmark rate cap for surprise medical bills.
Cassidy, Hassan and Murkowski have framed their push for an arbitration option for balance billing disputes as critical to keep fair reimbursement rates for rural hospitals or prevent them from getting squeezed out of insurer networks. This claim is pushed by hospital and physician lobbyists, although policy analysts working on the issue view it with skepticism.
Murkowski emphasized her stance during the committee vote as she discussed the changes she wants to see made to the bill.
"I fear the direction that we head when we see a situation in rural America where people cannot get basic healthcare services because there are no facilities," she said. "We cannot get to a system where only people who live in urban areas can access healthcare. That's just not right."
The rural healthcare claim drew skepticism from Loren Adler, associate director of USC-Brookings Schaeffer Initiative for Health Policy, who has worked extensively on the balance billing issue.
"There's no reason to think that surprise billing solutions, even aggressive ones, would have any impact one way or the other on the vast majority of rural hospitals," Adler said after the committee vote.
He argued that only rural hospitals that are "actively getting paid by doctors to allow them to surprise bill patients" would potentially see an impact.
"Is that really the funding mechanism for rural hospitals we want, one that only benefits the rural hospitals willing to bankrupt patients?" he said, contending that the benchmark rate cap proposal isn't likely to have any significant impact.
"Most rural hospitals are the only one in their markets, so the median in-network rate for their anesthesiologists would be exactly what they get paid today, and hence they'd see no changes under (the health committee's) proposed solution," Adler said.
Murkowski also asked the committee to reopen debate over a late addition that extends the cap on out-of-network charges to air ambulances. Air ambulances play an outsize role in transporting patients around Alaska.
The air ambulance industry was surprised last week when the committee formally introduced the legislation and included them in the surprise billing ban. This led to a lobbying effort launched against the provision on Monday through the so-called Save Our Air Medical Resources (SOAR) Campaign.
Now that the legislation has passed out of committee, Alexander is still eyeing a Senate floor vote before August. As of Monday, the package incorporates a priority for Senate Majority Leader Mitch McConnell (R-Ky.) to raise the legal age to buy tobacco products to 21.
On Thursday, the Senate Judiciary Committee will report its own package of bills on drug pricing. The Senate Finance Committee has yet to introduce its expected legislation as leaders haven't been able to agree on key provisions.
The only members of the health committee to vote against the legislation were Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.) who are running for president, and Rand Paul (R-Ky.). Warren and Sanders did not attend the panel markup.