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Kaiser Health News reported on what can happen when a major health insurer (in this case, UnitedHealthcare) dominates a clinic's payer mix. The insurer might have its own reasons for dropping a provider from its network; if nothing else, insuring the majority of a clinic's patients gives that insurer much leverage in rate negotiations.

Kaiser Health News reported on what can happen when a major health insurer (in this case, UnitedHealthcare) dominates a clinic's payer mix. The insurer might have its own reasons for dropping a provider from its network; if nothing else, insuring the majority of a clinic's patients gives that insurer much leverage in rate negotiations.

In theory, something similar can happen in reverse, when insurers feel they must have a specific provider group in its network. In that case, that particular provider group can more easily negotiate for higher rates. The broader issue is that concentration of market share can give disproportionate leverage to one side or another.

Kaiser Health News published a piece analyzing why surprise medical bills remain so prevalent despite the backlash against them. According to the piece, it is because insurers, hospitals, and doctors do not want to upset the status quo and they all have political allies to prevent meaningful change.

Kaiser Health News published a piece analyzing why surprise medical bills remain so prevalent despite the backlash against them. According to the piece, it is because insurers, hospitals, and doctors do not want to upset the status quo and they all have political allies to prevent meaningful change.

The piece notes that relevant legislation is coming at the state level and posits that perhaps this upcoming election will upend the status quo. While there is much outrage about surprise medical billing, the issue seems unlikely to dominate voters' decisions.

Kaiser Health News published another article in the fight over surprise medical billing, where a patient thinks that s/he is receiving in-network services but is billed at out-of-network rates. Patient frustration with being stuck with large surprise medical bills has mounted enough that legislatures (both state and federal) have considered a variety of bills to address the issue. Now, however, some doctors are lobbying to have such legislation incorporate terms that are more favorable to physicians.

Kaiser Health News published another article in the fight over surprise medical billing, where a patient thinks that s/he is receiving in-network services but is billed at out-of-network rates. Patient frustration with being stuck with large surprise medical bills has mounted enough that legislatures (both state and federal) have considered a variety of bills to address the issue. Now, however, some doctors are lobbying to have such legislation incorporate terms that are more favorable to physicians.

Perhaps not surprising, Kaiser Health News reported that physician organizations that have heavily lobbied for changes in surprise medical bills are related to specialties where the context is time-sensitive (e.g. emergency medicine, anesthesia) -- those specialties probably have a number of physicians that benefit financially from the current confusion.

Surprise medical billing seems like a mostly solvable problem. For example, insurers could require that all services rendered at an in-network facility are billed at in-network rates, thereby pushing the problem to the facility to coordinate and recruit physicians that accept the same insurance plans. In turn, insurers might pay extra for imposing that condition, but their members would be much less likely to be stuck with what they consider an outrageous bill. If this conflict keeps simmering, I expect there to be additional legislative efforts to be considered.

The provider practice of surprise billing has made the news over the last few years. Kaiser Health News reports on a practice of insurance companies that I have not heard of before: retrospectively requiring pre-authorization. The practice of pre-authorization is commonplace and the intention is to help ensure that providers do not get too carried away and perform medically unnecessary tests and procedures. However, it appears that some insurers are not clear which procedures require pre-authorization and perhaps go as far as indicating that a patient does not need pre-authorization and then reverse their positions. Even worse is indicating to a patient that a procedure is pre-authorized and then denying payment for the procedure as "medically unnecessary" (Kaiser Health News notes footnotes on pre-authorizations to the effect of "This is not a guarantee of payment"). Obviously, this can cause financial and emotional hardship for patients who think they are abiding by the insurers' policies.

The provider practice of surprise billing has made the news over the last few years. Kaiser Health News reports on a practice of insurance companies that I have not heard of before: retrospectively requiring pre-authorization. The practice of pre-authorization is commonplace and the intention is to help ensure that providers do not get too carried away and perform medically unnecessary tests and procedures. However, it appears that some insurers are not clear which procedures require pre-authorization and perhaps go as far as indicating that a patient does not need pre-authorization and then reverse their positions. Even worse is indicating to a patient that a procedure is pre-authorized and then denying payment for the procedure as "medically unnecessary" (Kaiser Health News notes footnotes on pre-authorizations to the effect of "This is not a guarantee of payment"). Obviously, this can cause financial and emotional hardship for patients who think they are abiding by the insurers' policies.

It is unclear how common this practice is compared to before, but this issue might gain more news coverage. If the industry is unable to resolve the issue in a reasonable manner, people will look to the government to intervene, similar to how laws against surprise medical billing have been enacted.

Kaiser Health News published a piece investigating whether a president can meaningfully reduce drug prices without legislative action (as proposed by Senator Warren). Surprisingly (to me at least), the analysis is in the affirmative. The piece talked about the powers of Section 1498, which apparently allows the government to "take over patents" if the price is deemed too high. This law has been used before, and has also been used by the Department Of Defense for non-medicinal purposes. While this law is not meant to be applied broadly, it could address the cost of some popular drugs.

Kaiser Health News published a piece investigating whether a president can meaningfully reduce drug prices without legislative action (as proposed by Senator Warren). Surprisingly (to me at least), the analysis is in the affirmative. The piece talked about the powers of Section 1498, which apparently allows the government to "take over patents" if the price is deemed too high. This law has been used before, and has also been used by the Department Of Defense for non-medicinal purposes. While this law is not meant to be applied broadly, it could address the cost of some popular drugs.

Clearly, use of this law would be controversial and would draw sharp criticism from the pharmaceutical industry. However, as Americans' frustration with rising healthcare costs continues to mount, politicians will be looking at more alternatives.