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PRESIDENT’S PAGE
network. Patients are surprised because they believe that everyone at the hospital is in-network. The patients seeing the independent doctors in a hospital setting are left with a bill that they cannot pay. Proof that private insurers are lowballing independent physicians in Delaware is not lacking. Last year, the trend of primary care physicians being reimbursed below Medicare values led to the passage
of Senate Bill 227, which raised PCP pay to Medicare rates at minimum.3 Primary care physicians are not the only physicians reimbursed below Medicare. As a radiologist, I get reimbursed
87% of Medicare by Highmark. Ophthalmologists and nephrologists also report getting reimbursed below Medicare reimbursement levels by Highmark.
Currently, there is legislation concerning surprise out-of-network bills in Washington. We recently had a well- attended physician roundtable discussion with Sen. Tom Carper regarding surprise billing. All of the Washington proposals had faults and seemed less effective than the law enacted by the State of New York in 2015. The AMA proposals below are taken from the New York State law:
■ Establish benchmark rates that are fair to all stakeholders in the private market;
REFERENCES
benchmark rates should include actual local charges as determined through an independent claims database.
■ Establish a fair and independent dispute resolution (IDR) process to resolve disputes about payments from services rendered out of network to their
■ Protect patients from out-of-network billing and preserve patient access to hospital-based care by holding insurers
■ Require insurers to give patients a robust choice of physicians, including hospital-based emergency physicians, and on-call surgeons and anesthesiologists, who will be there for patients in life and death emergencies.
get the patient out of the process. This is between the hospital/health care provider and the insurance company, and the patient is not involved.
The second step of New York’s law is the application of a unique baseball- style arbitration process. The hospital/ health care provider and the insurer
each get one chance to name an appropriate settlement fee and the arbiter picks one of the two. Over 2,000 years in New York.5
The three important concepts of
price transparency, protecting the underinsured from surprise bills, and protecting the uninsured from the medical bills are important battlegrounds in medicine this upcoming year.
Large monopolistic insurers and
hospital systems wield incredible clout in the marketplace. The health care marketplace bears no resemblance to any type of free market. The large hospitals and insurers have power similar to utilities that lack competition. It is no surprise that they are lobbying against price transparency, surprise billing legislation, and any action that would charges.
Andrew W. Dahlke, MD
President, Medical Society of Delaware
1. www.washingtonpost.com/business/capitalbusiness/the-air-forces-10000-toilet-cover/2018/07/14/c33d325a-85df-11e8-8f6c-46cb43e3f306_story.html
2. www.whitehouse.gov/presidential-actions/executive-order-improving-price-quality-transparency-american-healthcare-put-patients-first
3. www.legiscan.com/DE/text/SB227/2017
4. waysandmeans.house.gov/sites/democrats.waysandmeans.house.gov/files/documents/2019-5-21%20AMA%20Statement%20on%20Surprise%20 Billing%20FINAL.pdf
5. www.vox.com/health-care/2019/3/19/18233051/surprise-medical-bills-arbitration-new-york
250 Del Med J | November/December 2019 | Vol. 91 | No. 6
