Health care is often provided by large health systems. What does that mean for us?

When hospitals were run by local charities, the focus was more on treating the sick in the community than on meeting a profit margin set by a board of directors. Most of today’s patients get care from large multi-state health care systems that integrate hospitals, clinics, and physician practices. There is no doubt that hospitals operate as a business.  And patients are the customers.

U.S. PIRG’s senior health care director, Patricia Kelmar joined a panel discussion on “The Corporate Transformation of Health Care” sponsored by the Georgetown University Center on Health Insurance Reform. She shared the challenges that people face today in navigating their insurance coverage and medical bills in a large corporate system of health care services. 

Here is a summary of the points that Patricia shared. And to hear the thoughts of Elizabeth Rosenthal of KFF and Dr. Vicki Norton of the American Academy of Emergency Medicine, you can watch the 50 minute webinar for free.

How can people lower their medical bills?

Tips – and the traps that people sometimes can’t avoid:

Get your care from in-network doctors and clinics. 

Trap:  Network directories are notoriously outdated. So we tell folks to call the provider and confirm network status. And many people find there is no in-network ambulance in their community because the ambulance company contracted with the city or county is not in-network with their insurance. This results in a situation where patients might face a large surprise out-of-network ambulance bill. 

Check whether you need “pre-authorization” from your insurance plan for your planned care. 

Trap: Your provider doesn’t always know you need pre-authorization so check with your insurance, otherwise you’ll end up paying the entire bill.  

Watch out for urgent care centers that bill like an emergency room. 

Trap: Beware of facilities that look like a neighborhood urgent care center but are licensed as an “off-campus” emergency room. It’s almost impossible to know but if the facility bills for your service as an “ER”, the claim will be denied if you’ve gone for non-emergency care, like a strep throat test.

Ask whether the appointment will trigger a bill with “facility fees”. 

Trap: As large health systems buy up doctor practices, they start billing like a hospital. “Facility fees” or higher co-insurance amounts based on “hospital” billing codes will add costs to your final bill, even though you never set foot in a hospital. 

What policy solutions will lower health care bills? 

Sometimes policy makers are tempted by what seems like an easy solution – cap out-of-pocket payments to relieve patients’ wallets. Although that might offer temporary relief for some, we need solutions that get to the root of the problem – high prices in health care. Those higher prices are the result of business decisions made by health care executives to increase their income stream. 

As a consumer organization, we work to tackle high health care costs by both minimizing an individual’s out-of-pocket costs and lowering prices for the system as a whole. Our goal is to focus on health care solutions that eliminate extra fees and charges without impacting individual patient care. Here are three ideas we think Congress and the states should consider:

1. Ban add on charges like “facility fees” for outpatient care and telehealth services. These fees do nothing to improve a patient’s quality of care. Neither patients nor insurers should be paying these fees. If there is no political will yet to ban them, require health care providers to report what fees they charge, how much these fees are and how many patients received bills with these add-on fees. The data should convince policy makers that these fees are driving up the costs of care for everyone without improving patient care. 
2. Implement a “same service, same price” policy. Otherwise known as site neutral payments policy, this solution eliminates higher hospital charges for services that can safely be done in outpatient settings. Why should patients be charged more for a service just because it is located in a hospital?  
3. End ambulance surprise bills. Too many communities are served by just one ambulance company, and about half the time it is out of network. The best policy is a statewide process to set reasonable ambulance charges to cover the actual costs of the service. Then require insurers to pay that rate and prohibit ambulances from sending a surprise balance bill. 

We can’t afford to wait to solve the high cost of health care. We need to find the savings that don’t negatively impact patient care but lowers costs for patients and reduces costs for our tax-funded health care, such as Medicare.