Health Watched

Little-known issues considered by Washington Legislature become or remain Law: Who Benefits? Part 2

Another piece of 2010 legislation that is destined to affect the  pocketbooks of consumers was a measure backed by the Washington State Medical Association to allow doctors to engage in “balance billing. ” This practice now banned in 47 states for insurance plans’  in-network providers, and for the entire Medicare program. Balance billing  refers to charging patients for the difference between the  dollar amount that a physician or other provider bills for a service, and the amount that an insurance company is willing to pay. Despite the fact that both parties, i.e. providers and insurers ,may have negotiated an agreed amount per service, some providers persist in billing the patient for the remaining balance above the contracted price. According to the recent report Unexpected Charges: What States Are Doing about Balance Billing,–prepared for the California HealthCare Foundation by Georgetown University’s Health Policy Institute, and the National Academy for State Health Policy –laws to regulate balance billing began focusing on managed care plans, and increasingly extended the scope of consumer protections to HMOs and also PPOs.

Balance billing can bankrupt insured patient families, as the Kaiser Health News reported early this year:

The Price They Paid :How a Virginia family got permission to get out-of-network treatment for one son’s heart defect, and still ended up drowning in debt.

Other major media reports on the topic included 2008 articles in Business Week and the Wall Street Journal. A blog piece and companion article in were just published  April 30 in the New York Times, describing the controversial and often illegal practice of balance billing. A Medical Bill You May Not Have to Pay links to the article on troubleshooting one’s medical bills, and also discusses the additional problem that the new federal health care reform law does not directly remedy unfair business practices like balance billing.

There seems to be limited information available in the public domain about the lobbying efforts that went into the success in blocking the proposed ban on balance billing in Washington.  The legislative analysis section of the Washington State Medical Association‘s website is restricted to members only. A brief legislative report on the topic is available on the site of the Washington Association of Health Underwriters:

House Kills Controversial Measure Regarding Coverage for Emergency Health Care Services. The House Ways and Means Committee has killed HB 2779—a measure that was intended to clarify the circumstances involving coverage for the delivery of health care services by non-participating providers, and to prevent balance billing. The bill was killed when it was not brought to a vote before the cut-off for committee action. The measure was introduced by Rep. Eileen Cody, Chair of the House Health Care & Wellness Committee. Rep. Cody argued that consumers need to be protected from balance billing by non-participating providers. The Washington State Medical Association, together with the Washington State Hospital Association and the American College of Emergency Physicians testified in opposition to the measure. The WSMA hired former Insurance Commissioner Deborah Senn to testify in opposition to the bill. Opponents argued that the bill amounts to price-fixing, and damages Washington health care providers who are already paid less than providers in other states under Medicare. A companion bill in the Senate—SB 6400—was also killed in committee when it was not brought to a vote before the cut-off for action

It is of note that  banning balance billing at the very least for emergency care, is considered best practice, as patients need to be able to receive care based on proximity. And in the case of accidents, patients are brought to a facility by first responders. It should go without saying that ER patients, even if conscious, certainly cannot  be expected to interview the members of a facility’s medical team to determine if all of them participate in the network of a patient’s insurance plan. Even for planned surgeries, it is usually impossible for patients to learn whether or not all providers who will be involved in every step of the procedure, belong to the patient’s insurance network.

The  defeat of  this Washington legislation was hailed at the national level by the American Medical Association:

Physicians’ right to balance bill protected in Washington State,  AMA Advocacy News, March 22, 2010.
The Washington State Medical Association (WSMA) achieved an impressive legislative victory this month. WSMA defeated three bills (H.B. 2779, S.B. 6400 and S.B. 6532) that would have prohibited physicians’ right to balance bill. The AMA worked with WSMA for several months on the balance billing issue and will continue to work with WSMA and others to defeat similar proposals this year and in 2011

Conclusion:  Parts 1 & 2

What do the developments discussed these two posts mean for Washingtonians? For starters, we need to learn more about these issues, do the necessary opposition research, and take action to make sure that access to care is genuine.

Regarding medical innovations, without access they are meaningless.  And whether it’s providers or insurers who are not playing fair with medical bills, they must be held accountable, with genuine regulation. We need to get hard data on whether Washingtonians are benefiting from the treatment advances developed in our state; the same holds true here and nationwide for all R&D supported by us via federal and other public funding.  We know that Big Biopharma’s lobbying efforts on the biologics pathway got their desired results from Congress in healthcare reform; the states are targets too.   If anyone still is wondering what’s next, headlines like the following are strong indications of what’s in store, unless popular efforts can restore the political will to do what’s right :

Gaps in insurance policies make oral drugs too pricey for some cancer patients

Despite the somewhat misleading title attributing the access problem just to insufficient insurance coverage, the article goes on to discuss the cost problem and how industry justifies the exorbitant prices.

Another new item of note is this one ,written after the approval last week of  a prostate cancer vaccine whose medical value may still be uncertain, developed by Seattle biotech company Dendreon:

Provenge, a New $93K Cancer Drug, Will Be Extremely Effective — on Taxpayers

This is one reason the price of Provenge was set so much higher than analysts expected: Dendreon knew that patients were covered mostly by Medicare and not private insurance, and that the government’s own rules prevent Medicare from negotiating prices.

’nuff said.