“Do we really want patients and physicians to be arguing over whether a test is needed or not, based on cost? To me, that’s a barrier in my ability to take care of my patients. What we want is a balanced approach.”
Smith said. “We wanted to do this in a way that benefits the patient, without causing an undue burden on practices. This [law] is pegged to a nice simplicity, and it goes back to the physician and the patient. Physicians provide the service. They bill for it. And they have a price. All this legislation says is, let’s encourage patients to know that price beforehand.” On the other hand, Massachusetts
Medical Society leaders expressed con- cern about the burden a new law places on physicians and hospitals in requiring them to give patients any information they request to calculate their out-of- pocket costs. That includes CPT codes for anticipated services, contracted amounts, and phone numbers for facili- ties involved. State law had already required health
plans to provide patients with cost esti- mates. As of Jan. 1, the new law means physicians must provide any additional information to help insurers do that.
• Physicians and hospitals to disclose their billing policies;
• Hospitals to provide patients with estimates of their charges, including discounts, when patients ask; and
• Physicians to give cost estimates if the requesting patient seeks out-of- network care or is uninsured.
The IHCQE board in a 2012 report
recommended fully implementing and enhancing existing transparency initia- tives like SB 1731 that encourage a wide range of players—physicians, hospitals, payers, employers, and consumer groups
—to make quality and cost information more widely available and that encour- age patients to seek it. The Texas Department of Insurance
(TDI) meanwhile is looking for ways to improve a website it launched last year to provide consumers with aver- age costs for various medical services. The online database, also mandated by SB 1731, combines claims data TDI col- lects from the state’s private health plans and displays average billed charges and contracted and paid amounts for in- and
40 TEXAS MEDICINE July 2014
out-of-network care in a particular re- gion, likeWest Texas. TDI officials acknowledge certain shortcomings with the existing tool, such as a lack of market-specific costs and user-friendliness for patients who are likely to “shop” based on a treatment event versus a single billing code. TMA’s transparency workgroup is in- vestigating other states’ experiences, as well. The interim legislative charges also ask the Senate State Affairs Committee to “analyze relevant reforms” beyond Texas’ borders. Dr. Carter points to a Maine law that
requires physicians and other health care professionals there to publicly post an estimate of their fees for the most com- mon procedures they perform and only for uninsured patients. The law passed in January with support from the Maine Medical Association (MMA). When it comes to calculating the
impact of insurance copays, deduct- ibles, and other cost-sharing on patients’ medical bills, “that’s the responsibility of the insurance company and the patient,” MMA Executive Vice President Gordon
States laws get an “F” Any laws that put the burden on patients to piece together their medical costs de- serve failing grades, says HCI3’s Mr. de Brantes. He likened the scenario to buying a
car and assembling the cost from a list price of every component. “It’s absurd. Clearly, the individual will never be able to assemble all of this without having an incredible amount of knowledge. So for the average person, it’s virtually impos- sible to know the price [of health care] until after everything has happened,” he said. “We have to think about this from the consumer’s perspective, not the in- siders who think it’s too complicated, but the person who’s making $30,000 a year and paying $3,000, on average, out of pocket on deductibles. That’s 10 percent of that person’s salary. Doesn’t he or she have the right to be informed?” The transparency report card lauds
states with robust transparency laws and regulations requiring them to cre- ate public websites with comprehensive price information based on actual paid claims. But the report card downgraded most states, including Texas, because the websites are poorly designed and patients cannot access the information.
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