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Surprise Medical Bills and the Abrupt U.S. Congressional Bill of 2019

Originally published at https://www.datadriveninvestor.com on September 30, 2019.


Photo by Teona Swift from Pexels


Any soul with a sound judgment may concur healthcare is not a free service. Whether considered a government-run program or a private direct pay model, it will eventually require to be reimbursed for by someone in one way or another. Although few may dissent under the presumptuousness that programs like "Medicare for all" may be accessible to economically disadvantaged, in realism. Yet, the destitute have had to bear their share of the dues at some point in their lives. The main problem isn't necessarily who pays for the medical services, but how would or should be reimbursed for, at what rate, and who determines the set value or price for that particular medical care. That marks the origin of significant contention and serves as the mother of all misconceptions.

Today the focus of all public media pertains to who pays for the medical care of citizens beyond trying to scrutinize. And that how it may be deliverable under the existing legislative system on the outside of being subject to abuse and malicious overtake by the hands of those who have the slightest respect for human lives besides the mission of profiteering from the loopholes they were categorically granted. Every service is ultimately paid for through the billing process, primarily by sending an invoice or a bill to customers; in this case, for the medical care rendered to the patient or goods delivered to them. Electronic Medical billing has been the accepted method of reimbursement practice within the United States health system and most other countries alike. Although execution of invoices is commonly processed between the consumer and the provider of the service, but in the typical current healthcare system, a 3rd party corporate player is often involved in the procedure. In which case, the middleman has the power to control how the physicians are reimbursed.

In the United States, third-party healthcare payers occupy the majority of the letter market. Medical billing has become a painstakingly complex task, and without proper training, physician Practices may lose revenue. With the advent of initiated merit-based reimbursement models, they are even prone to penalties and disciplinary actions. Henceforth, In response to said complexity, the service providers (corporations including hospitals, pharmacies, or diagnostics) have the experts of their own to take on the Billing responsibility for covered and non-covered benefits under the patient insurance coverage. Hence, submitting a bill for non-covered services prompts the so-called "Surprise bill."

Surprise bill (also called Balance billing) primarily refers to a scenario when a patient receives an unexpected service bill after receiving care from the out-of insurer network physician, facility, or healthcare provider. The fact that the part or full payment for the particular rendered service was unpaid for by the patient's insurance. As such, receipt of such bill is unexpectedly after the clinic visit makes it inconvenient and Surprising. Balance bills are the sequel of the decades-old complex healthcare reimbursement models that are incorporated within the U.S. It's merely designed to justify the difference between in-network versus out-of-network costs for a particular insurance carrier. In contrast, for the patient, it solely means nothing but extortion.

Even though third-party billing enactment may have started as a transparent insurance company paying for the covered medical expenses on a patient's behalf. But over decades, this recitation has turned into a sophisticated covert socioeconomic program dictating who, how, from whom, for what cost, and when a patient can get medical care. The changeover from Direct billing practice into an overwhelmingly tiresome reimbursement process in the aftermath of alienation of physicians on the one hand and coup of the healthcare by corporate bureaucracy and rapacity oriented strategies on the other. In reality, the progeny with surprise bill stems from the corporate takeover of the medical practice transformation, despite having to a greater extent, got to do with the clangor of consumerism and the dissuaded price setting.

Price Rate setting

The concept of imposed pricing by government legislators is a common phenomenon, as practiced in countries across the globe. Such exercise, nonetheless, has been expeditiously applied by some "constitutionally" sovereign governments with robust socialized bases. Meaning, in a country where the law of the land places the power of control on the people, for the people, by the people and where the free market is the constitutionally accepted driver of such economy; placing a limit on prices would mirror sealing a solitary loophole while others remain wide open, leaving the system licentious for depravity and monopoly.

In May 2019, Reps. Frank Pallone (D-NJ) and Greg Walden ( R-OR) jointly released a draft of a bill that would forestall patients from facing unexpected surprise charges after they visit the emergency room or medical care from out-of-network providers. According to the USC-Brookings Schaeffer Initiative for Health Policy, Loren Adler, This Bill is the most forceful proposition engaged at the federal level to date. It's one of the rarest bipartisan bills. Surprisingly enough was also welcomed by President Donald Trump. The Senate seems to have adopted a bill of its own concerning the outrageous surprise billing practice. Despite solid bipartisan efforts, still, some politicians sturdily oppose the bill. For instance, Sen. Rand Paul (R-Kentucky) recognizes the implications of price controls better than most other politicians. He trusts; the bill's core provision aims to end surprise billing by totally eliminating out-of-network care. The bill, according to him, drives the creation of the perverse incentive for insurance companies to narrow their networks. It pushes hospitals to leave networks, physicians find alternate ways to compensate for revenue deficit and ultimately cause a shortage of medical care delivery services. Besides, within the midst of all and under reasoning, radical bipartisan move to stop corporate monopoly and preserve patient sovereignty has offset the controversy of its own. Irrespectively, almost everyone seems to agree that the controversial surprise bill by nature is indeed a carrier of the unethical and unfair occurrence. All also agree; the heart and soul of the line of reasoning are around the strategic approach to tackle such a fundamental predicament.

An anon group has initiated a major campaign by spending a record-breaking $13 million on advertisements on behalf of a group called "doctor-patient unity." The drives behind such a mission presumed by media members are to create chaos and inconsistency within the developing fervid congressional controvert around the subject of a surprise bill. Primary agenda concerns pushing back against prices set by hospitals, private equity firms, American Medical Association (AMA), and even some physician and healthcare groups. The argument is merely focusing on the fact that rate setting can unfairly favor insurance companies.

According to a recent blog published on health affairs — within the rarity of the bipartisan efforts, we have reached a moment that politicians on both ends of the mainstream ideological spectrum agree on the patients' vulnerability in the face of already lacking proper healthcare coverage. They also correspond that the current turmoil may potentially get out of control, winding up with a limitless and unpredictable bill for services determined at the mercy of insurance companies- a knee-jerk like compensatory billing by hospitals, facilities, and consolidated groups. Forasmuch as the "surprise" prices charged are neither approved nor presented to patients in advance, they are the precipitators of indignation and extortion against the society's most vulnerable, i.e., "patients" who are forced to seek out network care. Furthermore, since they are not bound by firsthand legal contracts, affected patients are liable for every penny billed, thus subject to collection proceedings by the service provider.

Congress's priority is to protect the interest of the patients by solving the reimbursement issues between physicians, healthcare providers, and insurers. And it's distinctly pertinent to the fact that the patient would be picking up the cost to whatever has not been reciprocally agreed upon by the two parties at reciprocal sides of the service conveyance. But on the other extreme, enforcing rate setting may hinder the healthcare price competition somewhat from the U.S. market panorama. Beyond proper checks and balances, the fictitiously vicious circle of price inflation and insurer withholding to reimburse would be prone to spin out of control.

Having said that, yet- is the Federal rate setting the way to go?

Sure- the upshot seems to constitute the tipping point for the U.S. health system. But, the center for American Progress (CAP) says, rate setting and price cap are the way to go! According to CAP, United States Hospitals today capture $1 out of every $3 spent on healthcare. The hospital care costs in 2019 are projected about $1.3 trillion. Over the past decades, hospitals have been able to produce staggering profits using high prices beyond capturing market power, which has grown in anticipation of even more competitiveness through consolidation, mergers, and acquisitions.

According to another source published in the Health affair blog in May 2016, most hospitals lost money on every patient care. The publication outlined Hospitals that treated the largest population of Medicare-eligible patients had much higher costs per adjusted discharge. Noteworthy is that all the latter cases were located in counties with a high proportion of uninsured patients or in states with a dominant health maintenance organization (HMO), hence had lower profitability.

In March 2019 blog letter, a right-wing coalition group denounced the proposed rate-setting bill. They rationalized that the government's excessive unconstitutional power will stamp out competition and situate the private insurance industry at the convenience of vantage, thus jeopardizing patient commitment.

Undoubtedly, by stepping back and observing the big picture, one can distinctly delineate the scenario representing the Clash of consumerism and entitlement attitude in our utterly broken partisan political system. Thus, it is crucial to conceptualize the metaphorical differences between them as "apples" and "oranges," where rate setting may have worked reasonably well in socialized administrative systems and governments full-fledged centralized autocratic control. Still, in a constitutionally capitalist framework, such a mission imposes chaotic consequences like opening a "can-of-worms." By no means in our system, fixed price enforcement without bona fide transparency and accountability delivers the same result as Canada, Europe, or the rest of the world.

One of the significant challenges of our time is the public perception of the quality and the seriousness of the healthcare problem. For some is utterly oblivious that the public minds are focused in one direction and actions in another. Time and again, I have tried to convey my thoughts on the seriousness of critical themes. The Healthcare care dilemma of our country can't be solved utilizing the solutions of the other systems. The days for arm twisting mandates and prohibiting pledges are chapters written in the history books pertinent to the big corporations.

Physicians are waking up independent practices are starting to challenge and rebound to the unfairness of the policies by creating their own consolidated groups, still leaving patients at the mercy of corporate greed. Some may refer to the perception as "it always turns worse before getting better, "but betterment is a relative phenomenon, and political rhetoric is the major player of that notion.

Hypocrisy is the foe of achieving the scrupulous outcome and best result. The convenience of the straightforward, efficient tactics' comes from within. One can reach it by working through what the agenda of the current system foresees. For instance, if the country is contemplating following open market policies where prices are determined by consumerism, then every individual should be entitled to the Fair prospect, unprejudiced price, and competitive market without corporate bigotry. At the opposite extreme of the spectrum, a closed market necessitates total government takeover of the market, retaining full responsibility for its commitment. To point out, the open market requires full transparency for the peerless act.

Nevertheless, under government inspects transparency in every step of the market process may not serve detrimental in a closed system. Ultimately, Accountability can be effectively implemented if enough oversight exists on the market through direct government possession or unmitigated open market transparency. Thus, the most important about the fair market value of the goods and services, be it Government or public control, rests within the particular constitutionality of the given operation. Over the past decades, we have seen systems that don't conform to one of the two extreme ends of the market spectrum. Closed market systems with partial freedom are commonly implemented in most European economies, counting other countries worldwide.

In a well-structured and centralized social system, implanting capitalist programs like the free market is doable though not perfect. Because a well-regulated and non-corrupt socialized system has fewer loopholes for corporations to take advantage of utilizing stricter oversight. Building a Social government-run entitlement program including a national health system on a fundamentally capitalist constitution not only will fail but will serve as a nidus for more monopoly and deprivation. Latter opens a new discourse; the Construct of double standard and promoting corporatism. Looking back into the history from the time corporate entities were granted the title of personhood, they merely have enjoyed the same privileges as a living person, holding the collective power and control of a group of elite who also have the freedom of the political magic stick. With patients, physicians, or general individual interests at stake, unilateral government intervention will go so far before it fails.

One can't fight the surprise bill when countless loopholes are drilled into the core of the free market system by the first hands of the same corporate entities over aggressive lobbying and monopoly.

In a constitutionally capitalist system mandating government price-setting would resemble a game of the Russian roulette. Handcuffing the individuals while hospitals, consolidated groups, corporate insurance, and the pharmaceutical industry continue profiteering freely is absurd and unfair. Not necessarily the balance billing, government takeover of the market is a significant concern, as is finding the right solution given the type of system in place. All hybrid economic systems don't translate into the same outcome. The Capitalist scheme on top of a socialist base system will have the opposite result than a socialist program on top of the capitalist base framework. Corporate personification is a pseudo-capitalism mongrelized by price control. One such scenario is Medicare or the concept of Medicare-for-all.

Politicians, consolidated groups, and corporations prone to payoff and bribery, but people's rights are priceless.
Empowering patients, physicians, healthcare stakeholders

More regulation is not a better ordinance. Rate setting will potentially limit the opportunity for the physicians unless the central government takes end-to-end control of the healthcare arcade. If enforced, the price-setting must parallel with constitutional reform. However, in the face of size, diversity, and social mindset of the citizens in the United States and the extreme polarity of our political mainstream, such reform is highly implausible. The unwavering solution under the present-day scenario would entail full market transparency, deregulation, fair trade, corporate de-personification, and accountability. Anything short of the aforementioned is a winner for corporations, another political try for lawmakers, but the repeated revilement to individual liberty.

#surprisebill #healthcarepolicy


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