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MASSPIRG joins consumer, faith, provider organizations in urging state lawmaker to include 2 key consumer protections in the final Health Care Bill currently being negotiated. If adopted the prescription drug transparency reform will allow for better scrutiny of escalating precription drig prices and will end what is commonly known as "surprise billing", when a consumer through no fault of their own, is charged for an approved medical procedure as one compenent, like the anesthesiologist,  is billed as "out of network" and not covered.

check out our letters for more details: 

RE: Conference Committee Recommendations, Health Care Reform (H 4639) (S 2573)

Promoting transparency in tackling the high cost of prescription drugs

On behalf of a coalition of consumer groups we urge the Conference Committee to adopt measures to better evaluate and tackle the problem of skyrocketing prescription drug prices.

Prescription drug costs are currently the fastest growing healthcare expense – by far. For both public and private plans – increases in pharmacy costs far outpace every other expense. Rising drug prices are increasing health care costs, placing significant burden on consumers and putting pressure on the state budget.          

The Health Policy Commission’s (HPC) most recent cost trends report finds that prescription drug spending has grown faster than overall commercial trends in the past three years and that drug costs now account for more than 20 percent of commercial insurance spending in Massachusetts. The report also finds that prescription drug cost growth is the largest factor in state spending exceeding the cost growth benchmark.

What is further compounding the problem is that, as noted by the HPC, “transparency on pricing trends, rebates, discounts, and pharmaceutical benefit managers is lacking.”  The HPC urged the legislature to increase transparency as a step to increase accountability for drug cost growth. Actual prices paid for drugs are hidden behind a complex veil of intermediaries, and effective transparency provisions would allow the public and policymakers to understand the causes of high prices and cost growth. Transparency is the first step toward understanding why prescription drug costs have increased so dramatically and what can be done to manage costs more effectively. 

Recognizing this, both the House and Senate bills include provisions advancing drug price transparency. We believe that an effective provision must provide for robust disclosures that cover a substantial number of the most expensive drugs and those with substantial increases from the prior year. A complete assessment of the appropriateness of a drug’s price requires analysis based on disclosure of the research and development costs, identifying those costs funded by public funds; revenues and net profits; and amounts spent on marketing and advertising, particularly noting advertising aimed directly at consumers and marketing conducted via discounts or product vouchers offered to consumers. Cross-subsidies can be identified by seeking data comparing the amount charged for the drug in Massachusetts to the amount charged for the same product elsewhere.  In addition, because the goal of the provision is to enable public accountability, the bill should include a mechanism for sharing information with the public to the extent permitted.

Based on these factors, we recommend that the Conference Committee adopt the Senate language on drug price transparency in the final bill (section 35). The Senate sections provide for more extensive disclosures and would strengthen the ability of policymakers and the public to judge if we are getting good value for our billions spent on prescription drugs. We believe that Massachusetts should join a number of other states that have enacted strong transparency requirements to further the goals of affordable care.

Sincerely,

Deirdre Cummings, Legislative Director, MASSPIRG

Brian Rosman, Director of Policy and Government Relations, Health Care for All

Wells Wilkinson, Senior Staff Attorney, Health Law Advocates

Robert Restuccia, Executive Director, Community Catalyst

Carolyn Villers, Executive Director, Massachusetts Senior Action Council

 

 

Protecting Consumers by ending “Surprise Billing”

On behalf of a coalition of consumer and provider groups, we urge the Conference Committee to protect consumers by shielding them from a relatively new and unfair outcome of insurance designs commonly known as “surprise billing.”

Out-of-network billing occurs when patients receive out-of-network care that they did not or could not intentionally choose to receive, and they are subsequently faced with unexpected medical bills. Health Care For All has heard from patients, for example, who go to a hospital that is in their network, choose a surgeon that is in their network and then find out after the fact that the anesthesiologist was out of their network resulting in thousands of dollars in charges to the consumer.

In many cases, the patient has done everything in their power to pursue an in-network hospital or doctor, but nevertheless is hit with a costly bill from a provider the patient did not know was out of network. These bills are contributing to the growing problem of consumer medical debt, which is a significant cause of personal bankruptcy today.

According to a 2016 study from the Kaiser Family Foundation about three in 10 (32 percent) of those who had problems paying medical bills while insured say they received care from an out-of-network provider that their insurance wouldn’t pay for. For many, these bills came as a surprise. Seven in 10 (69 percent) of those who had problems paying for care received from an out-of-network provider say they were unaware that the provider was not in their plan’s network when they received the care.

And more recently a 2018 survey by the West Health Institute out of the University Chicago found that nationally, 54% of all Americans say they received a medical bill in the last year for care they thought was covered by their health plan.

A 2017 report by HPC found that 90% of out of network claims were due to ambulance and to emergency services for ambulance, radiology, anesthesiology, or pathology. This report also notes that the out-sourcing of emergency staffing is a “leading contributor to out-of network billing” and that “1/3 of Massachusetts hospitals substantially outsource “Emergency Department” staffing….”

Even when the carriers pay the full costs of out-of-network billing, HPC concluded that this can also lead to higher premiums, and to reduced savings and efficiency for payers, driving up health care costs.

To address this growing problem, a comprehensive approach to protecting consumers is required. It includes strong transparency and disclosure requirements on the part of providers and carriers, a clear prohibition on “balance billing” consumers in emergency situations and other situations where a consumer unknowingly sought care from an out-of-network provider, and a well-defined process for determining payment of surprise out-of-network bills. Both the House and Senate bills address surprise out-of-network billing, and we recommend that the Conference Committee adopt certain provisions from each bill to ensure the strongest protections for consumers.

First, we recommend that the Conference Committee adopt the House language regarding comprehensive carrier and provider disclosures of the network status of a provider in order to decrease the likelihood of surprise bills in the first place. The House language requires carriers to include more comprehensive information regarding out-of-network services in evidence of coverage documents (section 101) and provides for price transparency telephone numbers and websites, including a mechanism for the member to request the estimated consumer cost in writing (Section 104). The House bill further includes requirements for comprehensive and accurate provider directories, which are necessary for patients to obtain accurate information about which providers and facilities they can use in-network, as discussed above.

We also strongly support the House bill’s provision requiring providers to determine and disclose to the patient their own network status, including the cost for out-of-network services if applicable, prior to any scheduled non-emergency service (section 68).

Second, we applaud both the House and Senate for including strong language prohibiting “balance billing” of consumers facing surprise bills, and we recommend adoption of the House language that specifies that patients cannot be billed for non-emergency services unless the out-of-network provider has obtained clearly defined prior written consent from the patient (sections 68 and 105).

Third, we recommend adopting the provision in the Senate bill providing a legal remedy under chapter 93A when a provider or carrier requests payment from an enrollee in these situations, other than for the applicable coinsurance, copayment, deductible or other out-of-pocket expense (section 138).

Finally, we support the Senate bill provision that creates an independent process for the determination of non-contracted commercial rates for emergency and non-emergency services. Under this process, the HPC will hold a public hearing and submit recommended rates to DOI for further review and approval (section 26). We believe this process will utilize the appropriate expertise of both the HPC and DOI in determining a maximum rate for out-of-network services that is both reasonable for out-of-network providers and is not at such a high level as to discourage providers from participating in an insurance network.

The conference committee has an opportunity to protect patients stuck in a costly situation due to no fault of their own. We urge you to prioritize these consumer protections as you reconcile the out-of-network billing provisions of the two bills.

Sincerely,

Brian Rosman, Director of Policy and Government Relations, Health Care for All

Deirdre Cummings, Legislative Director, MASSPIRG

Wells Wilkinson, Senior Staff Attorney, Health Law Advocates

Rev. Burns Stanfield, President, Greater Boston Interfaith Organization, GBIO

Robert Restuccia, Executive Director, Community Catalyst

Carolyn Villers, Executive Director, Massachusetts Senior Action Council

Sophie Hansen, LCSW, Political Director, National Association of Social Workers- Massachusetts Chapter

Mary Grant, Director, American Nurses Association, Massachusetts Chapter

Joseph Weeks, Director of Public Policy & Legislation, Massachusetts Mental Health Counselors Association, MaMHCA

Kathleen Andolina, Treasurer, Massachusetts Association of Advance Practice Psychiatric Nurses, MAAPPN

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