The Record: Medical costs

THE RECORD earlier this year reported on a number of cases in which patients received unexpected medical bills after undergoing procedures they thought were covered by their insurance policy. A bill in Trenton was designed to fix the problem, but roadblocks soon emerged. There were a number of delays, and last week, the bill lacked the votes to get out of commit-tee, virtually killing it for this legislative session. For now, the road is closed.

The legislative process has many twists and turns, but in this case there's no mystery that consumers are the losers and special interests groups are the winners.

The bill can be reintroduced next year, but it's tough to be optimistic about its chances.

The facts scream out for reform. Horizon Blue Cross Blue Shield, the largest insurer in the state, estimates that out-of-network charges add $1 billion a year to health care costs in New Jersey. And a bipartisan state commission estimated that the bill would save at least $22 million and maybe as much as $98 million on insurance costs for state and public employees.

Much about the delivery of health care is complicated, but the core of this problem is easy to grasp. A patient goes to the hospital for surgery with the comfort of knowing that both the hospital and primary doctor are covered by his insurance policy. But what the patient does not know is that some of the specialists in his case — for example, the anesthesiologist — are not. That means the patient stands to get an unexpected, and often large, bill.

One aspect of the proposed bill would solve that problem by requiring the patient to be told in advance that part of his care would be provided by out-of-network doctors. Patients may still get high bills, but at least they will not be surprised.

In the case of emergency procedures, the health care provider would be prohibited from billing patients more than they would normally be billed under their insurance policies.

If outstanding charges still remain, the bill sets up an arbitration system to settle disputes. And that seems to be the crux of the problem.

The head of the Medical Society of New Jersey contends that this system could result in doctors' being underpaid.

"There are two parts to the surprise bill," Lawrence Downes told The Record. "There's the physician charge, but the second charge that happens that nobody talks about is the drastic underpaying that happens when the insurance company pays the bill."

The premise behind arbitration, however, is that all parties must be willing to compromise. No matter the procedure, both sides — and in this case the sides are health care providers and insurance companies — cannot expect to get all of what they want.

It's no surprise that key players in the health care system will fight for their interests. That's their job.

But state legislators have another job: to fight for consumers. And letting this bill die is not the way to do it.


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