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Health insurers are expected to pay for medical care, but it can be unclear whether they should be obligated to pay for promising, but unproven, procedures. KFF Health News profiled one patient whose doctor recommended a newer type of treatment. Initially, the insurer refused to cover the treatment, "claiming the treatment was not medically necessary." Soon after media became involved, the insurer changed course. Unfortunately, the patient started different treatment, precluding the recommended procedure.

To some extent, it is in the interest of insurers and those who pay premiums that unproven treatments are not automatically approved. At some point, however, a treatment shows enough promise that it should be considered. Given the advancements in medicine, it is impractical for patients to review an annual list of covered treatment options, and even if they could, there are probably not enough insurance plans for patients to reliably find a suitable option. This scenario raises the question of who should get to decide whether the insurer is obligated to pay for less proven treatments. Currently, the insurer does, but that poses a conflict of interest (similar to giving that power to patients). Theoretically, that decision could be left with physicians, but there is enough variation in the practice of medicine that patients could essentially "shop" for a doctor that would approve an experimental treatment. There could be a role for a panel of physicians to make such decisions for the coverage of experimental treatments.

KFF Health News published an article speculating about new scenarios in which patients might find themselves facing higher prices because of consolidation within the healthcare industry. This country has already seen consolidation among provider practices, but the article highlights that new mergers and acquisitions are more complex. One example would be insurers buying medical practices, and another would be health systems merging with others in different geographic areas of the country. The nature of some of these more recent mergers make it more difficult to determine whether they are anti-competitive. For example, an insurer bought a specialty pharmacy, and now customers of that insurer might have to buy injectable prescriptions through that pharmacy, even though the medication might be available elsewhere for less. The article also notes that the current administration is less eager to prosecute anti-competitive behavior than the previous one.

Unfortunately, "studies show the escalating consolidation in health care is driving up prices, harming patient outcomes, and decreasing choice for people who need care. A recent study found that six years after hospitals acquired other hospitals, they had raised prices by 12.9%, with hospitals that engaged in multiple acquisitions raising their prices by 16.3%." Widespread consolidation undermines a free market, but stopping that trend in this country relies on an administration willing to combat it and judges who agree.

KFF Health News reported on different ideas being presented regarding how the $50 billion fund of the Rural Health Transformation Program should be spent over the next five years. The program was added to the July federal spending bill to address concerns about the nearly trillion dollar reduction in Medicaid spending over the next decade.

In theory, one might think that $50 billion could go a long way towards creating successful pilot demonstrations that might eventually transform rural health, perhaps substantially reducing costs in the long run. In practice, however, the $50 billion seems completely inadequate in comparison to the projected Medicaid spending cuts. Several of the ideas highlighted in the article seem interesting, but would require substantial recurring funding: "access to healthy food," "statewide universal health care," and "safe and stable housing." Even if these pilot projects demonstrate positive results, states will most likely struggle with continuing to fund them, especially considering the financial challenges that rural health will face over the next ten years.

KFF Health News published an account of a doctor who was treated in an emergency room, and struggled with the ensuing bills. The hospital charged almost $64,000, including a charge for an overnight stay. Unfortunately, the insurer denied the overnight stay, deeming it not medically necessary. Since the medically appropriate ankle surgery was bundled with the overnight stay, the insurer denied the entire bundle. The subsequent followup attempts by the doctor to reduce the bill suggests that the status quo is not practical: apparently, the doctor was supposed to leave the hospital while taking opioid painkillers to avoid having to pay for the overnight stay, allowing the insurer to cover just the care that was deemed medically appropriate.

While the story concludes with a resolution favorable to the doctor, it appears that it was mostly the hospital that reduced its charges, rather than the insurer agreeing to cover more. Either way, patients who did not have as many resources might very well have been stuck with a much higher bill than this doctor ended up with.