The Second Opinion

Why ‘surprise medical bills’ are an important statehouse story

March 18, 2016
Photo: AP

Your doctor tells you that you may need heart surgery. So you contact a cardiologist, making sure to find someone who’s in your insurance network. When the day of the operation comes, all goes well and you’re soon back home recuperating. It seems like it’s been a good experience with the healthcare system, until, some time later, you get a bill for thousands of dollars that you weren’t expecting. Turns out the hospital works with an anesthesiologist who’s not in your insurance network, and who now wants to be paid for work your carrier won’t cover—something you never thought to ask about, and wouldn’t have had much choice over in any case.

These are “surprise medical bills,” also known by the blander phrase “balance billing.” Though they’re not new, they are a real and growing problem in healthcare, and they’re having a little bit of a media moment: Time, PBS NewsHour, and The Huffington Post have all covered the issue this month. Continued national coverage is needed—but, because insurance regulation is handled at the state level, this is also very much a statehouse story. So it was encouraging to see some good recent coverage from Florida, where lawmakers last week passed a significant reform measure in the waning hours of the legislative session.

The bill was subject to intense lobbying and legislative maneuvering before its last-minute approval, and the political dynamic was captured well by the Miami Herald’s Daniel Chang in a story that ran a few days before the final vote. Chang’s piece got to the nub of the balance billing dispute. Standing in the way of consumer protections, he wrote, “is a lot of money.”

“The issue in dispute—with doctors and hospitals on one side, and insurance companies on the other,” he reported, “is what constitutes fair payment for medical care when there is no contracted rate.” Often, these disputes involve providers like anesthesiologists and radiologists; the providers argue that reforms to limit balance billing give insurers too much power to set prices, while insurers and some advocates see the providers as looking for opportunities to stick patients with big bills. In Florida, these provider groups were among the key opponents to the legislation, Chang explained.

“It’s a glaring irony,” Chang told me in an interview, that some of the goals of the Affordable Care Act seem contrary to the realities of the marketplace. While provisions in the ACA try to move the health system to more team-based care and collaboration, “physicians are silo-ing themselves into group practices that are, as a business model, not employed by the hospital and not contracting with insurers.”* For complex treatments, every provider who interacts with a patient submits a separate bill. But, as he explained in his story, the rise of “narrow networks,” which keep premium costs down by offering access to fewer hospitals and doctors, means that insurers are less likely to have a deal with each provider. (In the Miami-Dade area, many patients belong to “exclusive-provider organizations,” or EPOs, which leave them especially exposed to out-of-network costs.) The confluence of those trends exacerbates the surprise billing problem.

Consumers stuck in the middle can end up with huge unexpected bills, and their plight is often featured in media coverage. That makes sense—but a human-interest focus can mean that “explaining the role of the different interests is missing,” says Chuck Bell, program director at Consumers Union, which is running an advocacy campaign for state legislation to protect consumers. “It’s seen as inside baseball.” It was the willingness to get into the details about how these fights pit industry groups against each other in business—and how the fight then carries over to the statehouse—that made Chang’s reporting, including an earlier November article, stand out.

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The Herald wasn’t the only Florida outlet to follow the legislative debate, though. At The Palm Beach Post, Charles Elmore offered play-by-play updates on the bill’s progress at his “Protecting Your Pocket” blog. The NBC affiliate in Miami aired a surprisingly detailed piece, and other outlets weighed in, too.  This isn’t the first time the state’s media have focused on the issue, either—the Tampa Bay Times was reporting on it in 2014. 

We need more coverage of balance billing around the country, both in states like Tennessee and New Mexico, where the issue is on the agenda, and in places where it is not. And, for that matter, in Florida, New York and Connecticut, which have all now passed comprehensive consumer protection measures, to follow up and see how these laws are working. For reporters who may be looking to get up to speed, Chang’s coverage for the Herald is a good model.

*Correction: A word was inadvertantly omitted from this quotation when this story was first published. The missing word has been restored.

Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for CJR's Covering the Health Care Fight. She also blogs for Health News Review and the Center for Health Journalism. Follow her on Twitter @Trudy_Lieberman.