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Getting Patients Back To Hospitals

sign indicating the direction of a hospital emergency room.
Emergency rooms are a notorious site for "balance billing." Photo by wp paarz on Flickr (www.weisspaarz.com).

While news coverage of overcrowded hospital conditions in New York City and other COVID-19 hot spots is now a familiar sight, many hospitals face the opposite problem: emergency rooms that are worryingly empty.

The Wall Street Journal reported last week that doctors are alarmed at dropping hospitalization rates for conditions unrelated to the novel coronavirus. Health care providers across the country have urged patients to seek emergency attention if they need it, even for conditions unrelated to COVID-19. Yet health care workers who treat people with conditions such as heart disease, epilepsy and cancer say that their workload is lighter than it should be. Claims data from insurer Cigna Corp. supports their observations. It isn’t that fewer people are affected by heart attacks or strokes; people are just more reluctant to seek care.

Such reluctance can be fatal in some cases. In others, doctors say, patients can suffer permanent damage by delaying treatment. Akshay Khandelwal, the associate head of cardiology at the Henry Ford hospital in Detroit, told the Journal that a patient with evident heart-attack symptoms recently delayed a trip to the emergency room. That patient survived, but at the cost of irreversible damage to the heart.

In most places, there are plenty of professionals ready and willing to help people in this sort of distress. Outside of areas like New York City, many emergency room staffers report that conditions can be almost eerily quiet. So if it’s not an overcrowding issue, why are people staying away?

For some, the reluctance to visit an emergency room is mainly due to wanting to avoid infection. But for others, the choice may be a financial one – especially if patients have had a previous run-in with “balance billing.”

Balance billing, which is also sometimes called surprise medical billing, is a pernicious feature of insurance plans that distinguish between in-network and out-of-network providers, as nearly all do. A patient who seeks care at a hospital in their network would reasonably expect that any care they receive there is an in-network service. But often, patients unknowingly receive care from an out-of-network doctor or other professional at an in-network facility. The provider then bills the patient for the difference between the cost of care and what the insurer is willing to pay. The result is a large, unexpected bill.

Balance billing was already a problem before the pandemic. In emergencies, patients often have no way to know in advance that they will receive out-of-network care. Depending on their condition, they may not be capable of making any choices at all. And most Americans don’t have the savings available to pay tens or hundreds of thousands of dollars in medical bills. A Bankrate survey taken before the novel coronavirus reached the United States found that nearly one in four Americans had no savings at all, and another 22% had less than three months’ worth of expenses saved. In the wake of a pandemic that has meant millions face job loss or reduced income, temporary or otherwise, these figures are doubtless higher. The financial downturn the pandemic caused has made American households less prepared than ever to cope with surprise medical bills.

As I wrote in this space a few years ago, health care providers and insurers blame each other for the opacity that makes balance billing an unwelcome surprise for patients. Up to this point, the practice has been governed by state law, which means some patients are more likely to experience balance billing than others. More states have enacted laws since I last wrote about balance billing; by the end of 2018, 25 states had laws on this topic. More have enacted them since. These laws cover commercial insurance, often including both health maintenance organizations, or HMOs, and preferred provider organizations. But state regulators say they do not have the power to subject large company self-insured plans to these rules. Patients who receive treatment across state lines – for example, due to a medical emergency while traveling or the need for specialized care – also forsake any of their home state’s protections.

The good news is that Congress may finally step in. As part of negotiations over the next round of coronavirus relief, lawmakers have revisited the idea of banning balance billing nationwide.

Congressional advocates for such a ban reached a bipartisan agreement to that effect in December, with the president’s stated support. At the time, they couldn’t get it included in year-end spending legislation. Coronavirus relief may prove a natural fit, especially since lawmakers already stipulated that health care providers who receive federal aid can’t stick COVID-19 patients with surprise bills. (Due to the Department of Health and Human Services’ position that “every patient [is] a possible case of COVID-19,” some analysts think balance billing may be effectively banned at some hospitals already, at least for the pandemic’s duration.)

Rep. Greg Walden, R-Ore., put it succinctly: “There’s a certain irony here that we were able to put into statute that you can’t surprise-bill a Covid patient and nobody objected, but if you have a heart condition that pops up and you’re out of network, it’s OK? I don’t think so.”

The end of balance billing is not a sure thing, however. Some opponents don’t want general policy changes bundled with measures meant for coronavirus relief. Others have suggested that getting rid of balance billing could hurt hospitals at a time when they are already struggling. Neither of these arguments justify the collateral damage the practice inflicts on Americans’ health, physical and financial. And with more than half the states already restricting the practice to varying degrees without destroying their health care systems, the arguments against federal limitations collapse.

The fear of catching COVID-19 in a hospital setting will likely linger until effective testing, treatment and eventually vaccination are widespread. But lawmakers can take steps to reduce the potential for patients who do seek the care they need to suffer a nasty financial shock. Nobody needs the added stress of trying to stay on top of the details of their network when they face a life-or-death situation. Nobody needs to deal with billing problems in the aftermath of a health crisis, whether their own or a loved one’s. Congress should make sure that Americans have at least one less thing to worry about in a deeply worrying time.

Larry M. Elkin is the founder and president of Palisades Hudson, and is based out of Palisades Hudson’s Fort Lauderdale, Florida headquarters. He wrote several of the chapters in the firm’s recently updated book, Looking Ahead: Life, Family, Wealth and Business After 55. His contributions include Chapter 1, “Looking Ahead When Youth Is Behind Us,” and Chapter 4, “The Family Business.” Larry was also among the authors of the firm’s book The High Achiever’s Guide To Wealth.

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