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Opponents of the role of consumers and markets in health care have one go-to argument above all others: that you can’t shop for health care when you’re unconscious. The rising problem of gargantuan, surprise medical bills in surgical wards and emergency rooms shows that they have a point. The good news is that constructive, bipartisan reforms may be on the horizon."
Avik Roy, President, Foundation for Research on Equal Opportunity

Out of Network Emergency Department Physician Costs
The problem is many decades old: surprise medical bills for patients, and or significant higher costs for health plans due to out of network hospital based physicians, even when practicing out of network hospitals. UnitedHealthGroup has released a report finding that  "OON emergency physicians charged an average of 150 percent more per ED visit than in-network physicians were paid.

OON Physicians Charged 150% More per ED Visit than Payments to In-Network Physicians

The UnitedHealthGroup report estimated these higher charges national cost $6 billion per year, with "the greatest total inflated charges by OON physicians during in-network ED visits were for the following health conditions:
 - $1.9 billion in inflated charges for abdominal pain: 138% more per ED visit ($1,044 vs. $439)
 - $1.6 billion in inflated charges for breathing problems: 158% more per ED visit ($841 vs. $326)
 - $1.0 billion in inflated charges for chest pain: 136% more per ED visit ($1,155 vs. $490)
 - $800 million in inflated charges for cuts, scrapes, and bruises: 153% more per ED visit ($754 vs. $298)"

The report also tells us that over one-quarter of visits to in-network emergency departments resulted in out of network physician changes (12 million OON ER physician visits out of a total 44 million in network emergency visits.)

A recent USC-Brookings Schaeffer Initiative for Health Policy paper on surprise out-of network billing cited two separate studies pegging emergency department bills at 22% and 19% respectively, of all surprise out-of-network bills. Their paper goes on to point out that hospital based physicians also enjoy much high contracted payment rates relative to Medicare rates: 344% for anesthesiologists, 306% for emergency physicians, and 200% for radiologists compared to 128% overall for all physicians. And as UnitedHealthGroup points out, OON physicians are getting 150% above that.

This was the topic this week for a Terry Gross Fresh Air NPR interview with Vox reporter Sarah Kliff, who gave a number of patient case examples with many thousands of dollars at stake for each. So summarizes that "so one of the most common things we see is out-of-network doctors working at in-network emergency rooms. So you know, you have an emergency, you look up a hospital, you see their ER is in network, so you go there. It turns out that emergency room is staffed by doctors who aren't in your insurance. There's pretty compelling academic research that suggests 1 in 5 emergency room visits involves a surprise bill like that one."

Sarah Kliff, like the USC-Brookings team, tell us policy change is coming: "So we're actually seeing a lot of action on this in Congress. There's some pretty strong bipartisan support for tackling this specific issue and essentially holding the patient harmless.....And some state laws will set certain amounts that are allowed to be charged, other ones will force the insurance company and the hospital into an arbitration process. But the general concept is to take the patient out of this billing situation."

For More Information:

Why An ER Visit Can Cost So Much — Even For Those With Health Insurance
NPR, March 13, 2019

Out-of-Network Emergency Physicians Increase Health Care Prices for Consumers by $6 Billion Each Year
UnitedHealthGroup, March 8, 2019

State approaches to mitigating surprise out-of-network billing
USC-Brookings Schaeffer Initiative for Health Policy, February 19, 2019

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By Clive Riddle, March 15, 2019

Nashville-based HCA Healthcare has just announced that HCA will become the majority owner of the parent company of Galen College of Nursing, one of the largest educators of nurses in the nation. HCA, of course, is one of the nation’s leading providers of healthcare services, comprising 185 hospitals and approximately 1,800 sites of care .... Click to continue
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