Sweeping Senate Healthcare Bill Aims to Ease Costs and Surprise Billing for Patients

May 31st, 2019

By Jill Drachenberg, Editor, Relias Media

The Senate health committee unveiled a mammoth healthcare bill that would create cost transparency, eliminate surprise medical bills, and lower drug prices, in addition to other consumer protections.

The bipartisan Lower Health Care Costs Act of 2019 is sponsored by Senate health committee Chairman Lamar Alexander, R-TN, and Ranking Member Patty Murray, D-WA. A large focus of the bill is to eliminate surprise bills that consumers may receive after receiving medical care — an issue that has become a hot topic in Congress this year.

The bill, if passed, would protect patients from responsibility for surprise medical bills and would only require them to pay the in-network cost-sharing amount for out-of-network emergency care and for treatment rendered by out-of-network providers working at in-network facilities. The bill does not offer one solution for implementing the plan, instead laying out the following three options:

• Hospitals and other healthcare facilities should guarantee patients that all clinicians are considered in-network. To ensure this, physicians can join in-network health plans with the facility, or remain out-of-network and bill for care through the hospital instead of sending a bill to patients or the health plan.
• The second option allows for arbitration between insurers and the facility/practitioner for surprise bills of more than $750. A third-party arbiter certified by the Department of Health and Human Services (HHS) would review best final offers from both insurer and practitioner and make a binding decision on the best offer. For surprise bills under $750, the health plan would pay the median rate for typical services in the area.
• Option three would simply require insurers to pay the median rate for the geographic area for services in surprise bills.

The act also includes consumer protections to improve transparency in costs and business practices, including:

• Banning gag clauses between hospitals and insurers and allowing patients to see all hospital cost and quality data;
• Requiring all bills to be sent to patients within 30 days of services. Patients would not be obligated to pay bills sent more than 30 days after the episode of care;
• Ending the practice of “anti-steering,” where hospitals — through insurer contracts — prevent patients from seeking care from other health systems;
• Ending “all or nothing” contracts that force insurers to contract with all providers in a health system or none;
• Eliminating contract clauses between insurers and providers that protect an insurer’s dominance in a market;
• Requiring pharmacy benefit managers to send quarterly reports on costs, fees, and rebates to plan sponsors;
• Controlling and reducing prescription drug costs by ensuring timely access to generics; preventing blocking of generics by first-to-file applicants; encouraging innovation and streamlining the pathway for biologic drugs; and patent transparency for biologicals.

The bill also authorizes HHS to award grants to states to improve maternal mortality rates, which have been increasing at an alarming rate. (For more information on maternal mortality and how hospitals can prevent these poor outcomes, see the July issue of Hospital Case Management.)

Alexander hopes markup will be completed by the end of June, with a completed bill on the president’s desk in July. Whether this ambitious bill will garner enough support from both sides of the aisle in this contentious Congress remains to be seen.