Assessment of Out-of-Network Billing for Privately Insured Patients Receiving Care in In-Network Hospitals

Declining Inflation-Adjusted Medicare Physician Fees: An Unsustainable Trend in Hip Arthroscopy

INTRODUCTION

Although hip arthroscopy continues to be one of the most used arthroscopic procedures, no focused, comprehensive evaluation of reimbursement trends has been conducted. The purpose of this study was to analyze the temporal Medicare reimbursement trends for hip arthroscopy procedures.

METHODS

From 2011 to 2021, the Medicare Physician Fee Schedule Look-Up Tool was queried for Current Procedural Terminology (CPT) codes related to hip arthroscopy (29860 to 29863, 29914 to 29916). All monetary data were adjusted to 2021 US dollars. The compound annual growth rate and total percentage change were calculated. Mann-Kendall trend tests were used to evaluate the reimbursement trends.

RESULTS

Based on the unadjusted values, a significant increase in physician fee was observed from 2011 to 2021 for CPT codes 29861 (removal of loose or foreign bodies; % change: 3.49, P = 0.03) and 29862 (chondroplasty, abrasion arthroplasty, labral resection; % change: 3.19, P = 0.03). The remaining CPT codes experienced no notable changes in reimbursement based on the unadjusted values. After adjusting for inflation, all seven of the hip arthroscopy CPT codes were observed to experience a notable decline in Medicare reimbursement. Hip arthroscopy with acetabuloplasty (CPT: 29915) and labral repair (CPT: 29916) exhibited the greatest reduction in reimbursement with a decrease in physician fee of 24.69% ( P < 0.001) and 24.64% ( P < 0.001), respectively, over the study period.

DISCUSSION

Medicare reimbursement for all seven of the commonly used hip arthroscopy services did not keep up with inflation, demonstrating marked reductions from 2011 to 2021. Specifically, the inflation-adjusted reimbursements decreased between 19.23% and 24.69% between 2011 and 2021.

Radiologists' Out-of-Network Billing Trends, 2007 to 2021

PURPOSE

Given the financial hardships of surprise billing for patients, the aim of this study was to assess the degree to which radiologists effectively participate in commercial insurance networks by examining the trend in the share of radiologists' imaging claims that are out of network (OON).

METHODS

A retrospective study over a 15-year period (2007-2021) was conducted using claims from Optum's deidentified Clinformatics Data Mart Database to assess the share of radiologists' imaging claims that are OON. Radiologists' annual OON rate was assessed overall as well as for claims associated with inpatient stays and emergency department (ED) visits. Rates were assessed for all imaging studies as well as by modality. Linear regression was conducted to assess OON rate time trends.

RESULTS

From 2007 to 2021, 5,039,142 of radiologists' imaging claims (6.3%) were OON. This rate declined from 12.6% in 2007 to 1.1% in 2021. Over the study period, the OON rate was 5.0% during an inpatient stay and 2.1% on the same day as an ED visit that did not lead to an inpatient admission. The linear trend in the overall OON rate declined 0.74 percentage points annually (95% confidence interval [CI], -0.90 to -0.58 percentage points) over the study period. Likewise, the annual declines were 0.54 percentage points (95% CI, -0.71 to -0.36) and 0.26 percentage points (95% CI, -0.33 to -0.20 percentage points) for imaging claims associated with inpatient stays and ED visits, respectively.

CONCLUSIONS

Radiologists' imaging claims that are OON has significantly declined from 2007 to a minimal level in 2021. This may indicate effective negotiations between radiologists and commercial payers and new state-level surprise billing laws.

Increased rate of out-of-network surgeon selection for hip arthroscopy compared to more common orthopedic sports procedures

Background

Demand for hip arthroscopy (HA) has increased, but shortfalls in HA training may create disparities in care access. This analysis aimed to (1) compare out-of-network (OON) surgeon utilization for HA with that of more common orthopedics sports procedures, including rotator cuff repair (RCR), partial meniscectomy (PM), and anterior cruciate ligament reconstruction (ACLR), (2) compare the HA OON surgeon rate with another less commonly performed procedure, meniscus allograft transplant (MAT), and (3) analyze trends and predictors of OON surgeon utilization.

Methods

The 2013-2017 IBM MarketScan database identified patients under 65 who underwent HA, RCR, PM, ACLR, or MAT. Demographic differences were determined using standardized differences. Cochran-Armitage tests analyzed trends in OON surgeon utilization. Multivariable logistic regression identified predictors of OON surgeon utilization. Statistical significance was set to p < 0.05 and significant standardized differences were >0.1.

Results

410,487 patients were identified, of which 12,636 patients underwent HA, 87,607 RCR, 233,241 PM, 76,700 ACLR, and 303 MAT. OON surgeon utilization increased for HA, rising from 7.98 % in 2013 to 9.37 % in 2017 (p = 0.026). Compared to RCR, PM, and ACLR, HA was associated with higher likelihood of OON surgeon utilization. Usage of ambulatory surgery centers (ASCs) was predictive of higher OON surgeon rates along with procedure year, insurance plan type, and geographic region. HA performed in an ASC was 13 % less likely to have an OON surgeon (p = 0.047).

Conclusion

OON surgeon utilization generally declined but increased for HA. HA was a predictor of OON surgeon status, possibly because HA is a technically complicated procedure with fewer trained in-network providers. Other predictors of OON surgeon status included ASC usage, PPO/EPO plan type, and Northeast geographic region. There is a need to improve access to experienced HA providers-perhaps with prioritization of HA training in residency and fellowship programs-in order to address rising OON surgeon utilization.

Surprise billing in intensive care unit (ICU) hospitalizations

Intensive care unit (ICU) care is expensive for patients and providers, and utilization and spending on ICU resources have increased. The No Surprises Act, passed in 2022, specifically prohibits balance billing by ICU specialists (intensivists) for emergency and most non-emergency care. The potential economic impact of this remains unclear, given few data exist on the magnitude of balance billing in the ICU. Using the MarketScan Commercial (IBM) database, we studied hospitalizations in which ICU care was provided ("ICU hospitalizations") between 2010 and 2019. Hospitalizations were characterized as fully in-network, fully out-of-network, or "mixed" (contained both in- and out-of-network services). The share of "mixed" hospitalizations among all ICU hospitalizations rose from 26% to 33% over the study period. Over half of these mixed hospitalizations contained out-of-network services specifically delivered within the ICU. Total hospitalization spending averaged $81 047, with ICU spending averaging $15 799. On average, 11% of ICU spending within these hospitalizations was out-of-network. Patients were plausibly balance-billed in approximately one-third of ICU hospitalizations, for thousands of dollars per hospitalization. Given that the No Surprises Act prevents this type of balance billing, the portended revenue loss may lead to changes in provider negotiations with insurers concerning network status and prices, which could affect the care patients receive.

The Impact of Unexpected Billing in Spine Surgery and How the Price Calculator Can Improve Patient Care

STUDY DESIGN

Survey study.

OBJECTIVE

The objective of this study was to determine the impact of unexpected in-network billing on the patient experience after spinal surgery.

SUMMARY OF BACKGROUND DATA

The average American household faces difficulty paying unexpected medical bills. Although legislative efforts have targeted price transparency and rising costs, elective surgical costs continue to rise significantly. Patients are therefore sometimes still responsible for unexpected medical costs, the impact of which is unknown in spine surgery.

METHODS

Patients who underwent elective spine surgery patients from January 2021 to January 2022 at a single institution were surveyed regarding their experience with the billing process. Demographic characteristics associated with unexpected billing situations, patient satisfaction, and financial distress, along with utilization and evaluation of the online price estimator, were collected.

RESULTS

Of 818 survey participants, 183 (22.4%) received an unexpected in-network bill, and these patients were younger (56.7 vs. 63.4 y, P <0.001). Patients who received an unexpected bill were more likely to feel uninformed about billing (41.2% vs. 21.7%, P <0.001) and to report that billing impacted surgical satisfaction (53.8% vs. 19.1%, P <0.001). However, both groups reported similar satisfaction postoperatively (Likert >3/5: 86.0% vs. 85.5%, P =0.856). Only 35 (4.3%) patients knew of the price estimator's existence. The price estimator was reported to be very easy or easy (N=18, 78.2%) to understand and very accurate (N=6, 35.3%) or somewhat accurate (N=8, 47.1%) in predicting costs.

CONCLUSIONS

Despite new regulations, a significant portion of patients received unexpected bills leading to financial distress and affecting their surgical experience. Although most patients were unaware of the price estimator, almost all patients who did know of it found it to be easy to use and accurate in cost prediction. Patients may benefit from targeted education efforts, including information on the price estimator to alleviate unexpected financial burden.

Association between "Balance Billing" Legislation and Anesthesia Payments in California: A Retrospective Analysis

BACKGROUND

Insured patients who receive out-of-network care may receive a "balance bill" for the difference between the practitioner's charge and their insurer's contracted rate. In 2017, California banned balance billing for anesthesia care. This study examined the association between California's law and subsequent payments for anesthesia care. The authors hypothesized that, after the law's implementation, there would be no change in in-network payment amounts, and that out-of-network payment amounts and the portion of claims occurring out-of-network would decline.

METHODS

The study used average, quarterly, California county-level payment data (2013 to 2020) derived from a claims database of commercially insured patients. Using a difference-in-differences approach, the change was estimated in payment amounts for intraoperative or intrapartum anesthesia care, along with the portion of claims occurring out-of-network, after the law's implementation. The comparison group was office visit payments, expected to be unaffected by the law. The authors prespecified that they would refer to differences of 10% or greater as policy significant.

RESULTS

The sample consisted of 43,728 procedure code-county-quarter-network combinations aggregated from 4,599,936 claims. The law's implementation was associated with a significant 13.6% decline in payments for out-of-network anesthesia care (95% CI, -16.5 to -10.6%; P < 0.001), translating to an average $108 decrease across all procedures (95% CI, -$149 to -$64). There was a statistically significant 3.0% increase in payments for in-network anesthesia care (95% CI, 0.9 to 5.1%; P = 0.007), translating to an average $87 increase (95% CI, $64 to $110), which may be notable in some circumstances but did not meet the study threshold for identifying a change as policy significant. There was a nonstatistically significant increase in the portion of claims occurring out-of-network (10.0%, 95% CI, -4.1 to 24.2%; P = 0.155).

CONCLUSIONS

California's balance billing law was associated with significant declines in out-of-network anesthesia payments in the first 3 yr after implementation. There were mixed statistical and policy significant results for in-network payments and the proportion of out-of-network claims.

EDITOR’S PERSPECTIVE

Price Increases Versus Upcoding As Drivers Of Emergency Department Spending Increases, 2012-19

Recent studies document a substantial increase in emergency department (ED) spending in the past decade, even though the number of ED visits per capita has remained relatively stable. Price increases and upcoding are sometimes cited as possible explanations, but their relative impacts are not known. We analyzed Blue Cross Blue Shield claims for patients of all ages who received care in EDs in five states in 2012 and 2019. We used estimates from spending regressions and regressions explaining coding intensity to decompose changes in spending between 2012 and 2019 into components attributable to price increases, changes in patient characteristics or treatment intensity, and upcoding. Prices accounted for at least half of the increase in ED spending per visit for four of the five states we examined. Increases in spending attributable to upcoding were notable but generally not as large. Future research should explore the associations between local market conditions, such as consolidation and ownership type, and both price increases and upcoding.

Definition, Practice, Regulations, and Effects of Balance Billing: A Scoping Review

Background

Additional billing is commonly and legally practiced in some countries for patients covered by health insurance. However, knowledge and understanding of the additional billings are limited. This study reviews evidence on additional billing practices including definition, scope of practice, regulations and their effects on insured patients.

Methods

A systematic search of the full-text papers that provided the details of balance billing for health services, written in English, and published between 2000 and 2021 was carried out in Scopus, MEDLINE, EMBASE and Web of Science. Articles were screened independently by at least 2 reviewers for eligibility. Thematic analysis was applied.

Results

In total, 94 studies were selected for the final analysis. Most of the included articles (83%) reported findings from the United States (US). Numerous terms of additional billings were used across countries such as balance billing, surprise billing, extra billing, supplements and out-of-pocket (OOP) spending. The range of services incurred these additional bills also varied across countries, insurance plans, and healthcare facilities; the frequently reported were emergency services, surgeries, and specialist consultation. There were a few positive though more studies reported negative effects of the substantial additional bills which undermined universal health coverage (UHC) goals by causing financial hardship and reducing access to care. A range of government measures had been applied to mitigate these adverse effects, but some difficulties still exist.

Conclusion

Additional billings varied in terms of terminology, definitions, practices, profiles, regulations, and outcomes. There were a set of policy tools aimed to control substantial billing to insured patients despite some limitations and challenges. Governments should apply multiple policy measures to improve financial risk protection to the insured population.

Catastrophic Health Expenditure in Patients with Lower-Extremity Orthopaedic Trauma

BACKGROUND

Health-care expenditures are a leading contributor to financial hardship in the United States. Traumatic orthopaedic injuries are unpredictable and result in substantial expense. Our objectives were to quantify the catastrophic health expenditure (CHE) risk of patients with orthopaedic trauma and to examine the impact of insurance status, socioeconomic status, sex, and race on CHE.

METHODS

We identified all isolated lower-extremity orthopaedic trauma cases at a safety-net, Level-1 trauma center from 2018 to 2020. We queried an institutional charge database to obtain total hospital charges, insurance status, and ZIP Code to determine out-of-pocket (OOP) expenditures. To evaluate financial hardship, we calculated the CHE risk as defined by the World Health Organization's threshold of OOP expenditures, ≥40% of estimated household post-subsistence income.

RESULTS

In our cohort of 2,535 patients, 33% experienced a risk of CHE. A risk of CHE was experienced by 99% of patients who were uninsured, 35% of patients with private insurance, 2% of patients with Medicare, and 0% of patients with Medicaid. Multivariable regression modeling showed that patients who were uninsured were significantly more likely to experience a risk of CHE compared with patients with private insurance (odds ratio, 107.68 [95% confidence interval, 37.20 to 311.68]; p < 0.001).

CONCLUSIONS

One-third of patients with lower-extremity orthopaedic trauma experience a risk of CHE, with patients who are uninsured facing a disproportionately higher risk of CHE compared with patients who are insured. Our results suggest that the expansion of public insurance options may provide substantial financial protection for those at the greatest risk for CHE.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Surprise Out-of-Network Bills for Hand and Upper Extremity Trauma Patients

PURPOSE

Patients may receive surprise out-of-network bills even when they present to in-network facilities. Surprise bills are common following emergency care. We sought to characterize and determine risk factors for surprise billing in hand and upper extremity trauma patients in the emergency department (ED).

METHODS

We used IBM MarketScan data to evaluate hand and upper extremity trauma patients who received care in the ED from 2010 to 2017. Our primary outcome was the surprise billing incidence, defined as encounters in in-network EDs with out-of-network claims. We used descriptive and bivariate analyses to characterize surprise billing and used multivariable logistic regression to evaluate independent factors associated with surprise billing.

RESULTS

Of 710,974 ED encounters, 97,667 (14%) involved surprise billing. The incidence decreased from 26% in 2010 to 11% in 2017. Mean coinsurance payments were higher for surprise billing encounters and had double the growth from 2010 to 2017 compared to those without surprise billing. Receiving care from different provider types-especially therapists, radiologists, and pathologists, as well as hand surgeons-was associated with significantly higher odds of surprise billing. Transfer to another facility was not significantly associated with surprise billing.

CONCLUSIONS

Although the incidence of surprise billing decreased, more than 10% of patients treated in an ED for hand trauma remain at risk. Coinsurance for surprise billing encounters increased by twice as much as encounters without surprise billing. Patients requiring services from therapists, radiologists, pathologists, and hand surgeons were at greater risk for surprise bills. The federal No Surprises Act, passed in 2020, targets surprise billing and may help address some of these issues.

CLINICAL RELEVANCE

Many hand and upper extremity patients requiring ED care receive surprise bills from various sources that result in higher out-of-pocket costs.

Prevalence, Burden, and Sources of Out-of-Network Billing in Elective Hand Surgery: A National Claims Database Analysis

PURPOSE

Surprise out-of-network (OON) bills can represent a considerable cost burden on patients. However, OON billing remains underexplored in elective, outpatient surgery procedures, which have greater latitude for patient choice. We aimed to answer the following questions: (1) What is the prevalence and magnitude of OON charges in hand surgery? (2) What are the sources of OON charges? and (3) What factors are associated with OON charges?

METHODS

We analyzed patient-level data from the Clinformatics Data Mart database. We identified patients undergoing carpal tunnel release, trigger finger release, wrist ganglion removal, de Quervain release, limited palmar fasciectomy, or thumb carpometacarpal arthroplasty at in-network facilities with an in-network primary surgeon. The primary outcome was the proportion of surgical episodes with at least 1 OON charge. Secondary outcomes included the magnitude of potential balance bills (portion of OON bill exclusive of the standardized payment and expected patient cost-sharing), sources of OON charges, and factors associated with OON charges.

RESULTS

Of 112,211 elective hand surgery episodes, 8% (9,158) had at least 1 OON charge. OON charges ranged from $1,154 (95% confidence interval, $1,018-$1,289) for wrist ganglion removal to $3,162 (95% confidence interval, $2,902-$3,423) for thumb carpometacarpal arthroplasty. In episodes with OON charges, the major sources of OON charges were anesthesiologists (75% of episodes), durable medical equipment (10% of episodes), and pathologists (9% of episodes). Site of service, geographic region, and health exchange-purchased plans were highly associated with OON charges.

CONCLUSIONS

Out-of-network billing can represent a substantial cost burden to patients and should be considered in perioperative decision-making in elective hand surgery.

CLINICAL RELEVANCE

Understanding the potential costs related to OON services during a surgical episode, and its drivers, allows surgeons to consider detailed cost discussions during perioperative decision making.

Quantifying Balance Billing for Out-of-Network Behavioral Health Care in Employer-Sponsored Insurance

OBJECTIVE

The study estimated balance billing for out-of-network behavioral health claims and described subscriber characteristics associated with higher billing.

METHODS

Claims data (2011-2014) from a national managed behavioral health organization's employer-sponsored insurance (N=196,034 family-years with out-of-network behavioral health claims) were used to calculate inflation-adjusted annual balance billing-the submitted amount (charged by provider) minus the allowed amount (insurer agreed to pay plus patient cost-sharing) and any discounts offered by the provider. Among family-years with complete sociodemographic data (N=68,659), regressions modeled balance billing as a function of plan and provider supply, subscriber and family-year, and employer characteristics. A two-part model accounted for family-years without balance billing.

RESULTS

Among the 50% of family-years with balance billing, mean±SD balance billing was $861±$3,500 (median, $175; 90th percentile, $1,684). Adjusted analysis found balance billing was higher ($523 higher, 95% confidence interval [CI]=$340, $705) for carve-out versus carve-in plans and for health maintenance organization (HMO) enrollees versus non-HMO enrollees ($156, 95% CI=$75, $237); for subscribers with a bachelor's degree, compared with an associate's degree or with a high school diploma or lower (between $172 [95% CI=$228, $116] and $224 [95% CI=$284, $163] higher, respectively); and for subscribers ages 45-54, compared with those ages 35-44 and 18-24 (between $57 [95% CI=$103, $10] and $290 [95% CI=$398, $183] higher, respectively). Balance billing was lower in states with more in-network providers per capita (-$8, 95% CI=-$10, -$5).

CONCLUSIONS

Balance billing for out-of-network behavioral health claims may be burdensome. Expanded behavioral health networks may improve access.

Private Equity and Its Increasing Role in US Healthcare

Private equity investments in health care and surgery are on the rise. There are potential advantages and drawbacks of private equity investment in health care. However, if done under the right parameters, PE investment may have the potential to address some of the challenges and inefficiencies of the current health care system.

Patient cost consciousness in the emergency department: A brief report

BACKGROUND

'Surprise billing', or the phenomenon of unexpected coverage gaps in which patients receiving out-of-network medical bills after what they thought was in-network care, has been a major focus of policymakers and advocacy groups recently, particularly in the Emergency Department (ED) setting, where patients' ability to choose a provider is exceedingly limited. The No Surprises Act is the legislative culmination to address "surprise bills," with the aim of promoting price transparency as a solution for billing irregularities. However, the knowledge and perceptions of patients regarding emergency care price transparency, particularly the degree to which ED patients are cost conscious is unknown. Accordingly, we sought to quantify that perception by measuring patients' direct predictions for the cost of their care.

METHODS

We conducted an in-person survey of patients in Emergency Departments (EDs) over an 10-month period at two campuses within a large academic hospital system in southern Connecticut. We surveyed a convenience sample of patients at the bedside regarding demographics, care seeking perceptions and their estimates of the total and out-of-pocket costs for their ED care. Survey data was linked to institutional hospital finance datasets including actual charges and payments. We then later obtained the actual costs and billed amounts and compared these to the patients' estimates using a paired t-test. We also analyzed results according to certain patient demographics.

RESULTS

A total of 600 patients were approached for survey, and data from 455 were available for the final analysis. On average, patients overestimated the cost of their care by $2484 and overestimated out-of-pocket cost by $144; both of these results met statistical significance (p < .005). Patients were better able to predict both total and out-of-pocket costs if they were: college educated or above; unemployed or retired; aged 65 or older; or had private insurance. Uninsured patients could better predict total cost but not out-of-pocket costs. One in 4 patients reported considering the cost of care prior to visiting the ED. Only 12 patients reported trying to look up that price before coming.

CONCLUSIONS

This study is the first to our knowledge that sought to quantify how patients perceive the cost of acute, unscheduled care in the ED. We found that ED patients generally do not consider the price before going to the ED, and subsequently overestimate the negotiated total costs of acute, unscheduled emergency care as well as their out-of-pocket responsibility for care. Certain demographics are less predictive of this association. Notably, patients with Medicare/Medicaid and those with high school education or below were of the furthest off in predicting the actual cost of care. This lends credence to the established trend of patients' limited knowledge of the total cost of healthcare; moreover, that they overestimate the cost of their care could serve as a barrier to accessing that care particularly in more vulnerable groups. We hope that this finding adds useful information to policymakers in sculpting future legislation around surprise billing.

Preventing Financial Strain for Low- and Moderate-Income Adults: a Comparison of Medicaid, Marketplace, and Employer-Sponsored Insurance

BACKGROUND

Medicaid expansion and subsidized private plans purchased on the Affordable Care Act's (ACA) Marketplaces accounted for most of the ACA's coverage gains.

OBJECTIVE

Compare access to care and financial strain between Medicaid and Marketplace plans, and benchmark these against employer-sponsored insurance (ESI) plans.

DESIGN

Cross-sectional survey PARTICIPANTS: A nationally representative, non-institutionalized sample of 37,219 non-elderly adults with incomes up to 400% of the federal poverty level between 2015 and 2018, and a sub-group of individuals with chronic diseases.

MAIN MEASURES

Self-reported barriers to accessing care, cost-related medication non-adherence, and financial strain.

KEY RESULTS

Marketplace enrollees were more likely than Medicaid enrollees to delay or avoid care due to cost (19.3% vs 10.0%; adjusted difference (AD), 8.6 [95% CI, 6.8 to 10.4]) and report difficulties affording specialty care (7.7% vs 6.6%; AD, 1.8% [95% CI, 0.3% to 3.3%]), while there were no differences in having insurance accepted by a doctor or ability to afford dental care. Marketplace enrollees were also more likely to report cost-related medication non-adherence (21.5% vs 20.0%; AD, 4.0 [CI, 1.5 to 6.4]), be very worried about not being able to pay medical costs in case of a serious accident (32.3% vs 25.8%; AD, 6.4 [CI, 4.2 to 8.6]), have expenses exceeding $2000 (22.4% vs 5.4%; AD, 8.3 [CI, 6.2 to 10.3]), and have problems paying medical bills (18.4% vs 15.6%; AD, 1.8 [CI, 0.3 to 3.9]). Marketplace-Medicaid differences were larger among persons with a chronic disease. Individuals in ESI plans fared better for most, but not all, outcomes.

CONCLUSION

Medicaid offers better protections than Marketplace plans on most measures of access and financial strain.

The No Surprises Act: What Do Plastic Surgeons Need to Know?

Background:

Out-of-network, or “surprise” bills, have grown common in recent years and have raised substantial concern for patients. Congress recently enacted the No Surprises Act, effective on January 1, 2022, ending the majority of out-of-network bills for privately insured patients. The aim of this review is to briefly summarize the history of surprise billing, describe the regulations of the No Surprises Act, and examine the impact this legislation will have on the field of plastic surgery.

Methods:

A PubMed and Google Scholar literature search was conducted on out-of-network billing, or surprise bills, and the No Surprises Act. Media outlets, governmental agencies, and local and national medical organizations were additionally queried for surprise billing and the No Surprises Act.

Results:

Under the No Surprises Act, privately insured patients are protected from surprise medical bills in emergency and nonemergency settings, and uninsured or self-pay patients must be provided a good faith estimate of service fees before receiving nonemergent care. Plastic surgeons may consent patients to receive out-of-network bills if consent is obtained at least 72 hours before rendering a nonemergency service. Despite these patient protections, this act may influence plastic surgeons’ reimbursement rates and incentivize surgeons to alter their network status.

Conclusions:

The No Surprises Act provides significant protections for patients. However, it may have adverse effects for plastic surgeons. Plastic surgeons will only get paid in-network fees while providing care to patients unless consent is properly obtained in a nonemergent setting.

Association Between Changes in Postoperative Opioid Utilization and Long-Term Health Care Spending Among Surgical Patients With Chronic Opioid Utilization

BACKGROUND

There is growing interest in identifying and developing interventions aimed at reducing the risk of increased, long-term opioid use among surgical patients. While understanding how these interventions impact health care spending has important policy implications and may facilitate the widespread adoption of these interventions, the extent to which they may impact health care spending among surgical patients who utilize opioids chronically is unknown.

METHODS

This study was a retrospective analysis of administrative health care claims data for privately insured patients. We identified 53,847 patients undergoing 1 of 10 procedures between January 1, 2004, and September 30, 2018 (total knee arthroplasty, total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery, transurethral resection of the prostate, or simple mastectomy) who had chronic opioid utilization (≥10 prescriptions or ≥120-day supply in the year before surgery). Patients were classified into 3 groups based on differences in opioid utilization, measured in average daily oral morphine milligram equivalents (MMEs), between the first postoperative year and the year before surgery: "stable" (<20% change), "increasing" (≥20% increase), or "decreasing" (≥20% decrease). We then examined the association between these 3 groups and health care spending during the first postoperative year, using a multivariable regression to adjust for observable confounders, such as patient demographics, medical comorbidities, and preoperative health care utilization.

RESULTS

The average age of the sample was 62.0 (standard deviation [SD] 13.1) years, and there were 35,715 (66.3%) women. Based on the change in average daily MME between the first postoperative year and the year before surgery, 16,961 (31.5%) patients were classified as "stable," 15,463 (28.7%) were classified as "increasing," and 21,423 (39.8%) patients were classified as "decreasing." After adjusting for potential confounders, "increasing" patients had higher health care spending ($37,437) than "stable" patients ($31,061), a difference that was statistically significant ($6377; 95% confidence interval [CI], $5669-$7084; P < .001), while "decreasing" patients had lower health care spending ($29,990), a difference (-$1070) that was also statistically significant (95% CI, -$1679 to -$462; P = .001). These results were generally consistent across an array of subgroup and sensitivity analyses.

CONCLUSIONS

Among patients with chronic opioid utilization before surgery, subsequent increases in opioid utilization during the first postoperative year were associated with increased health care spending during that timeframe, while subsequent decreases in opioid utilization were associated with decreased health care spending.

Out-of-Network Billing in Privately Insured Patients Undergoing Elective Orthopaedic Surgery

BACKGROUND

Out-of-network charges during hospital care can result in unexpected or surprise bills for the patient. The aim of this study was to ascertain the frequency of out-of-network (OON) billing by the primary orthopaedic surgeon for commonly performed elective, inpatient procedures: total hip arthroplasty (THA), total knee arthroplasty (TKA), anterior cervical diskectomy and fusion (ACDF), and posterior lumbar fusion (PLF).

METHODS

Patients undergoing TKA, THA, one-level ACDF, and one-level PLF from 2010 to 2018 were queried using a commercially insured claims database with Current Procedural Terminology codes. The in-network (IN) versus OON status of the primary surgeon's submitted charges and the payor's reimbursement was recorded for each case. All costs were adjusted for inflation and reported in terms of 2018 real dollars. Bivariate analyses were performed.

RESULTS

Among the 549,868 elective orthopaedic cases, 6.7% were billed as OON by the primary orthopaedic surgeon: 6.1% TKA cases, 6.5% THA, 9.9% ACDF, and 8.5% PLF. From 2010 to 2018, a declining trend was seen in proportion of cases billed as OON by orthopaedic surgeons (P < 0.001 for each case). Mean reimbursement for claims paid as OON was 2.6 times higher than claims paid at the IN rate (range: 1.5 to 3.1 times higher; P < 0.001). The mean OON payments were higher by $1,284 for TKA, $2,516 for THA, $10,097 for ACDF, and $15,104 for PLF compared with mean IN payments (P < 0.001 for each). Compared with health maintenance organization-type plans, preferred provider organization-type plans reimbursed a greater percentage of the submitted claims at the OON rate (14.3% versus 44.5%, P < 0.001).

CONCLUSION

OON billing by the orthopaedic surgeon for TKA, THA, ACDF, and PLF is an uncommon and declining phenomenon.

LEVEL OF EVIDENCE

IV.

Preoperative Opioid Utilization Patterns and Postoperative Opioid Utilization: A Retrospective Cohort Study

BACKGROUND

Among chronic opioid users, the association between decreasing or increasing preoperative opioid utilization and postoperative outcomes is unknown. The authors hypothesized that decreasing utilization would be associated with improved outcomes and increasing utilization with worsened outcomes.

METHODS

Using commercial insurance claims, the authors identified 57,019 chronic opioid users (10 or more prescriptions or 120 or more days supplied during the preoperative year), age 18 to 89 yr, undergoing one of 10 surgeries between 2004 and 2018. Patients with a 20% or greater decrease or increase in opioid utilization between preoperative days 7 to 90 and 91 to 365 were compared to patients with less than 20% change (stable utilization). The primary outcome was opioid utilization during postoperative days 91 to 365. Secondary outcomes included alternative measures of postoperative opioid utilization (filling a minimum number of prescriptions during this period), postoperative adverse events, and healthcare utilization.

RESULTS

The average age was 63 ± 13 yr, with 38,045 (66.7%) female patients. Preoperative opioid utilization was decreasing for 12,347 (21.7%) patients, increasing for 21,330 (37.4%) patients, and stable for 23,342 (40.9%) patients. Patients with decreasing utilization were slightly less likely to fill an opioid prescription during postoperative days 91 to 365 compared to stable patients (89.2% vs. 96.4%; odds ratio, 0.323; 95% CI, 0.296 to 0.352; P < 0.001), though the average daily doses were similar among patients who continued to utilize opioids during this timeframe (46.7 vs. 46.5 morphine milligram equivalents; difference, 0.2; 95% CI, -0.8 to 1.2; P = 0.684). Of patients with increasing utilization, 93.6% filled opioid prescriptions during this period (odds ratio, 0.57; 95% CI, 0.52 to 0.62; P < 0.001), with slightly lower average daily doses (44.3 morphine milligram equivalents; difference, -2.2; 95% CI, -3.1 to -1.3; P < 0.001). Except for alternative measures of persistent postoperative opioid utilization, there were no clinically significant differences for the secondary outcomes.

CONCLUSIONS

Changes in preoperative opioid utilization were not associated with clinically significant differences for several postoperative outcomes including postoperative opioid utilization.

EDITOR’S PERSPECTIVE

Healthcare spending in U.S. emergency departments by health condition, 2006-2016

BACKGROUND

Healthcare spending in the emergency department (ED) setting has received intense focus from policymakers in the United States (U.S.). Relatively few studies have systematically evaluated ED spending over time or disaggregated ED spending by policy-relevant groups, including health condition, age, sex, and payer to inform these discussions. This study's objective is to estimate ED spending trends in the U.S. from 2006 to 2016, by age, sex, payer, and across 154 health conditions and assess ED spending per visit over time.

METHODS AND FINDINGS

This observational study utilized the National Emergency Department Sample, a nationally representative sample of hospital-based ED visits in the U.S. to measure healthcare spending for ED care. All spending estimates were adjusted for inflation and presented in 2016 U.S. Dollars. Overall ED spending was $79.2 billion (CI, $79.2 billion-$79.2 billion) in 2006 and grew to $136.6 billion (CI, $136.6 billion-$136.6 billion) in 2016, representing a population-adjusted annualized rate of change of 4.4% (CI, 4.4%-4.5%) as compared to total healthcare spending (1.4% [CI, 1.4%-1.4%]) during that same ten-year period. The percentage of U.S. health spending attributable to the ED has increased from 3.9% (CI, 3.9%-3.9%) in 2006 to 5.0% (CI, 5.0%-5.0%) in 2016. Nearly equal parts of ED spending in 2016 was paid by private payers (49.3% [CI, 49.3%-49.3%]) and public payers (46.9% [CI, 46.9%-46.9%]), with the remainder attributable to out-of-pocket spending (3.9% [CI, 3.9%-3.9%]). In terms of key groups, the majority of ED spending was allocated among females (versus males) and treat-and-release patients (versus those hospitalized); those between age 20-44 accounted for a plurality of ED spending. Road injuries, falls, and urinary diseases witnessed the highest levels of ED spending, accounting for 14.1% (CI, 13.1%-15.1%) of total ED spending in 2016. ED spending per visit also increased over time from $660.0 (CI, $655.1-$665.2) in 2006 to $943.2 (CI, $934.3-$951.6) in 2016, or at an annualized rate of 3.4% (CI, 3.3%-3.4%).

CONCLUSIONS

Though ED spending accounts for a relatively small portion of total health system spending in the U.S., ED spending is sizable and growing. Understanding which diseases are driving this spending is helpful for informing value-based reforms that can impact overall health care costs.

Past experiences with surprise medical bills drive issue knowledge, concern and attitudes toward federal policy intervention

Scholars and journalists have devoted considerable attention to understanding the circumstances in which Americans receive surprise medical bills. Previous research on this issue has focused on the scope of the problem, including the conditions that are most likely to lead to surprise bills. However, the existing literature has almost exclusively relied on claims data, limiting our understanding of consumer experiences and attitudes toward policy changes to address surprise billing. Using a survey administered to a nationally representative sample of 4998 Americans, we analyze consumer experiences with surprise billing, knowledge of the issue, how concerned Americans are about receiving surprise bills and how past experiences influence policy preferences toward federal action on surprise billing. Our analysis demonstrates that knowledge and concern about surprise billing are the highest among the educated and those who have previously received a surprise bill. These factors also predict support for federal policy action, with high levels of support for federal policy action across the population, including among both liberals and conservatives. However, more detailed federal policy proposals receive significantly less support among Americans, suggesting that stand-alone policy action may not be viable. Our results show bipartisan support among American consumers for federal action on surprise billing in the abstract but no consistent views on specific policy proposals.

Financial Profit in Medicine: A Position Paper From the American College of Physicians

The steady growth of corporate interest and influence in the health care sector over the past few decades has created a more business-oriented health care system in the United States, helping to spur for-profit and private equity investment. Proponents say that this trend makes the health care system more efficient, encourages innovation, and provides financial stability to ensure access and improve care. Critics counter that such moves favor profit over care and erode the patient-physician relationship. American College of Physicians (ACP) underscores that physicians are permitted to earn a reasonable income as long as they are fulfilling their fiduciary responsibility to provide high-quality, appropriate care within the guardrails of medical professionalism and ethics. In this position paper, ACP considers the effect of mergers, integration, private equity investment, nonprofit hospital requirements, and conversions from nonprofit to for-profit status on patients, physicians, and the health care system.

The Price of Otologic Procedures: Variation in Markup by Surgical Procedure and Geography in the United States

OBJECTIVE

To characterize and analyze variation in price markup of seven common otologic surgeries by procedure and geographic region.

STUDY DESIGN

Retrospective Analysis of the Centers for Medicare and Medicaid Services database of 2017 Medicare Provider Utilization and Payment Public File.

SETTING

Inpatient and outpatient centers delivering Medicare-reimbursed services.

PATIENTS

Full sample of patients undergoing procedures with Medicare fee-for-service final action claims during 2017.

INTERVENTIONS

Seven procedures (myringotomy, tympanoplasty, mastoidectomy, tympanomastoidectomy stapedotomy/stapedectomy, cochlear implant, bone-anchored hearing aid).

MAIN OUTCOME MEASURES

Markup ratio (MUR) is defined as the ratio of total charges to Medicare-allowable-costs; Variation in MUR was measured using coefficient of variation (CoV).

RESULTS

Among all providers, the median MUR was 2.4 (interquartile range: 1.9-3.1). MUR varied significantly by procedure, from 2.3 for myringotomy to 8.7 for mastoidectomy (p < 0.01). MUR also varied significantly within procedure, with the least variation found in myringotomy (CoV = 0.46), and the greatest in cochlear implants (CoV = 0.92). Using the national average as baseline, MUR varied 71% between states, ranging from 1.75 to 6.24. Within the same state, significant variation was also noted, varying by 4% (CoV = 0.04) in Montana compared with 138% (CoV = 1.38) in Pennsylvania. MUR was not significantly correlated with patient comorbidity or Centers for Medicare and Medicaid Services risk scores.

CONCLUSIONS

There was significant variation in the price of otologic surgery across geographic regions and procedures. The MUR for otology is lower or comparable to that reported in other surgical fields.

Out-of-Network Facility Charges for Patients Undergoing Outpatient Total Joint Arthroplasty

BACKGROUND

The utilization of outpatient (OP) total joint arthroplasty (TJA) is increasing. Although many arthroplasty surgeons and hospitals have longstanding agreements with insurance companies, it may take time for ambulatory surgery centers (ASCs) to establish in-network agreements. The purposes of this study are to investigate trends in out-of-network facility charges for OP-TJA, as well as compare rates of out-of-network facilities between ASC and hospital outpatient department (HOPD) OP-TJA.

METHODS

This is a retrospective study of the MarketScan commercial claims database of OP-TJAs (same-day discharge) performed at ASCs or HOPDs from 2007 to 2017. Detailed demographic, geographic, operative, insurance, temporal, and financial details were collected. Out-of-network facility utilization was trended over time. Adjusted regressions compared the prevalence of out-of-network facilities between ASCs and HOPDs.

RESULTS

There were 13,031 OP-TJA patients (58.8% total knee arthroplasty). Utilization of out-of-network facilities significantly decreased over time, from 27.8% of surgeries in 2007 to 9.5% in 2017 (P_trend < .001); however, this was non-linear with a significant increase in 2013-2015 corresponding to rising use of out-of-network ASCs. Patients treated at ASCs were significantly more likely to be out-of-network than those treated at HOPDs (odds ratio 4.88, 95% confidence interval 4.28-5.57, P < .001; odds ratio 7.70, 95% confidence interval 6.42-9.25, P < .001 among the 11,870 patients with in-network surgeons). About 10.4% of patients with in-network surgeons were treated at out-of-network facilities.

CONCLUSION

Although the utilization of out-of-network facilities has decreased, over 10% of patients with in-network surgeons face out-of-network facility charges, which may often come as a surprise. Efforts are warranted to reduce the out-of-network facility burden for OP-TJA patients, including accelerating insurance contracting and reviewing patients' coverage statuses.

Emergency Physicians Recover A Higher Share Of Charges From Out-Of-Network Care Than From In-Network Care

Surprise medical bills occur when a patient unexpectedly or involuntarily receives care from an out-of-network provider and is billed for the amount not covered by insurance. Past studies were unable to observe whether bills for such care were sent to patients and, if so, how much patients paid directly to out-of-network providers. We used data from the Medical Expenditure Panel Survey to measure how much privately insured emergency patients paid when they likely received a surprise bill and how much physicians received in these situations. Physicians collected 65 percent of the charged amount for likely surprise bills compared with 52 percent for other cases. Patients who likely received a surprise out-of-network bill for emergency care paid physicians more than ten times as much as other emergency patients paid, on average.

Frequency and Costs of Out-of-Network Bills for Outpatient Laboratory Services Among Privately Insured Patients

IMPORTANCE

Patients may be unaware of which laboratory is processing their clinical tests, limiting their ability to choose an in-network laboratory. Out-of-network laboratory services could increase patients' out-of-pocket costs and their reluctance to obtain necessary tests.

OBJECTIVE

To evaluate the frequency and cost of out-of-network bills for outpatient laboratory services compared with other services.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of claims data from the Truven MarketScan Commercial Claims database evaluated claims from 3 946 210 individuals (30.5% of the total) in the MarketScan database who were continually enrolled in health maintenance organization plans, preferred provider organization plans, exclusive provider organization plans, or consumer-driven health plans/high-deductible health plans with at least 1 outpatient clinical laboratory service in 2018. Outpatient laboratory services occurred in independent laboratories, physician offices, and outpatient centers. Laboratory bills from January 1, 2010, to December 31, 2018, were studied.

EXPOSURES

Receipt and cost of outpatient laboratory service.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of outpatient laboratory services billed as out of network. The secondary outcome was the total potential out-of-pocket cost associated with the out-of-network bill, the sum of observed cost sharing, and the potential balance bill.

RESULTS

Of the 12 958 130 in the total sample, 30.5% (3 946 210) had a laboratory test, of whom 5.9% received an out-of-network laboratory test. In comparison, 7.1% of the total sample had an emergency department visit, of whom 4.9% had a service billed as out of network, and 1.6% had an inpatient anesthesiology service, of whom 3.4% had an out-of-network service. Observed out-of-pocket spending was $24.59 higher for an out-of-network laboratory service than an in-network laboratory service. In addition, patients with an out-of-network laboratory service may receive an additional balance bill from the laboratory service; the estimated mean balance bill was $80.63. For the most common laboratory services, the total potential out-of-pocket cost associated with an out-of-network bill ranged from $15.68 for venipuncture to $88.09 for lipid panel but was as high as $303.18 for a drug screening test.

CONCLUSIONS AND RELEVANCE

In this cohort study, out-of-network laboratory services were 5 times more common than out-of-network emergency department visits and 34 times more common than out-of-network anesthesiology services. It is important for patients that consumer protections against out-of-network bills apply to laboratory services.

Insurance Reimbursement in Plastic Surgery

SUMMARY

The ambiguity of medical finances, both to the patient and to the provider, has direct effects on the quality of care that is delivered to the patient. To encourage transparency in health care, physician reimbursement is a process that must be understood to ensure patient satisfaction, a physician's willingness to deliver care, and the success of health care facilities. Furthermore, physicians should be aware of the effects that legislative action, such as the Patient Protection and Affordable Care Act, has on their income. As a field that encompasses both cosmetic and reconstructive surgery, plastic surgeons must know this process intimately to ensure efficient services and appropriate reimbursement. In particular, plastic surgeons should be familiar with how the Affordable Care Act affects their income, practice, and the patient's access to care. As Medicare and Medicaid continue to increase health care access for many Americans, specialists such as plastic surgeons will need to reinforce the value of the specialty in the continuum of care. As the health care industry moves away from a fee-for-service system to one of value-based care, plastic surgeons need to be at the forefront of this transition to ensure that they are delivering quality care, and receiving appropriate reimbursement. The authors have provided data from the University of Michigan to demonstrate the reimbursement patterns seen in plastic surgery. This Special Topic article provides insight into the reimbursement process in the era of the Affordable Care Act and the various challenges that may be encountered within this field.

Improving Surgical Informed Consent: Unanswered Questions

Objective

This study reviews randomized clinical trials that have attempted to improve the process of informed consent. Consent should be guided by the ethical imperatives of autonomy, beneficence, and social justice.

Summary Background

Informed consent is constantly evolving. Yet our review of the randomized trials done to improve the surgical informed consent process raises a number of questions: How does one define surgical informed consent? What interventions have been tried to measure and improve informed consent? Have the interventions in informed consent actually led to improvements? What efforts have been made to improve informed consent? And what steps can be taken to improve the process further?

Methods

A literature search for randomized controlled trials (RCTs)on informed consent identified 70 trials. Demographics, interventions, assessments, and a semi-quantitative summary of the findings were tabulated. The assessments done in the RCTs, show the surrogate for patient autonomy was comprehension; for beneficence, satisfaction and mental state (anxiety or depression); and, for social justice, language, literacy, learning needs, and cost.

Results

There were 4 basic categories of interventions: printed matter; non-interactive audiovisual tools; interactive multimedia; and a smaller group defying easy description. Improvement was documented in 46 of the 65 trials that studied comprehension. Thirteen of 33 trials showed improved satisfaction. Three of 30 studies showed an increase in anxiety. Few studies tried to assess primary language or literacy, and none looked at learning needs or cost.

Conclusions

No single study improved all 3 principles of informed consent. Validated interventions and assessments were associated with greater impact on outcomes. All 3 ethical principles should be assessed; autonomy (as comprehension), beneficence (as satisfaction, anxiety), and social justice. Not enough consideration has been given to social justice; appropriate language translation, standardized reading levels, assessment of learning needs, and cost to the individual are all important elements worthy of future study.

Understanding Surprise Out-of-Network Billing in Hand and Upper Extremity Care

Surprise billing occurs when insured patients receive unexpected out-of-network charges and fees even when the emergency department, facility, or primary physician who provided care is in their insurance network. This issue is particularly relevant for hand surgery. The multidisciplinary nature of hand care and the number of ancillary services involved result in various levels at which out-of-network billing can be introduced, even when the hand surgeon is in-network for the patient. In addition, surprise billing is often associated with emergency department encounters, elective surgeries, and ambulance and helicopter transfers. In this article, we review surprise billing as it pertains to hand surgery. Little is known about surprise billing in hand care; however, we believe that these practices may substantially affect the patient population. We define key elements of surprise billing, review the literature, discuss the relevance and potential of surprise billing in hand surgery in various settings, and provide an overview of the status of health policy surrounding this practice. It is imperative for hand surgery as a field to understand the prevalence, operationalization, and policies of surprise billing better to prevent the exploitation of patients.

The U.S. Health Care System on the Eve of the Covid-19 Epidemic: A Summary of Recent Evidence on Its Impaired Performance

Four decades of neoliberal health policies have left the United States with a health care system that prioritizes the profits of large corporate actors, denies needed care to tens of millions, is extraordinarily fragmented and inefficient, and was ill prepared to address the COVID-19 pandemic. The payment system has long rewarded hospitals for providing elective surgical procedures to well-insured patients while penalizing those providing the most essential and urgent services, causing hospital revenues to plummet as elective procedures were cancelled during the pandemic. Before the recession caused by the pandemic, tens of millions of Americans were unable to afford care, compromising their physical and financial health; deep-pocketed corporate interests were increasingly dominating the hospital industry and taking over physicians' practices; and insurers' profits hit record levels. Meanwhile, yawning class-based and racial inequities in care and health outcomes remain and have even widened. Recent data highlight the failure of policy strategies based on market models and the need to shift to a nonprofit social insurance model.

Financial Hardship After Traumatic Injury: Risk Factors and Drivers of Out-of-Pocket Health Expenses

BACKGROUND

Trauma-related disorders rank among the top five most costly medical conditions to the health care system. However, the impact of out-of-pocket (OOP) health expenses for traumatic conditions is not known. In this cross-sectional study, we use nationally representative data to investigate whether patients with a traumatic injury experienced financial hardship from OOP health expenses.

METHODS

Using data from the Medical Expenditure Panel Survey from 2010 to 2015, we analyzed the financial burden associated with a traumatic injury. Primary outcomes were excess financial burden (OOP>20% of annual income) and catastrophic medical expenses (OOP>40% of annual income). A multivariable logistic regression analysis evaluated whether these outcomes were associated with traumatic injury, adjusting for demographic, socioeconomic, and health care factors. We then completed a descriptive analysis to elucidate drivers of total OOP expenses.

RESULTS

Of the 90,964 families in the cohort, 6434 families had a traumatic injury requiring a visit to the emergency room and 668 families had a traumatic injury requiring hospitalization. Overall 1 in 8 households with an injured family member requiring hospitalization experienced financial hardship. These families were more likely to experience excess financial burden (OR: 2.04, 95% CI: 1.13-3.64) and catastrophic medical expenses (OR: 3.08, 95% CI: 1.37-6.9). The largest burden of OOP expenses was due to prescription drug costs, with inpatient costs as a major driver of OOP expenses for those requiring hospitalization.

CONCLUSIONS

Households with an injured family member requiring hospitalization are significantly more vulnerable to financial hardship from OOP health expenses than the noninjured population. Prescription drug and inpatient costs were the most significant drivers of OOP health expenses.

Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills

"Surprise" out-of-network bills have come under close scrutiny, and while ambulance transportation is known to be a large component of the problem, its impact is poorly understood. We measured the prevalence and financial impact of out-of-network billing in ground and air ambulance transportation. For members of a large national insurance plan in 2013-17, 71 percent of all ambulance rides involved potential surprise bills. For both ground and air ambulances, out-of-network charges were substantially greater than in-network prices, resulting in median potential surprise bills of $450 for ground transportation and $21,698 for air transportation. Though out-of-network air ambulance bills were larger, out-of-network ground ambulance bills were more common, with an aggregate impact of $129 million per year. Out-of-network air ambulance bills averaged $91 million per year, rising from $41 million in 2013 to $143 million in 2017. Federal proposals to limit surprise out-of-network billing should incorporate protections for patients undergoing ground or air ambulance transportation.

Out-of-Network Bills for Privately Insured Patients Undergoing Elective Surgery With In-Network Primary Surgeons and Facilities

IMPORTANCE

Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills ("surprise bills") from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians.

OBJECTIVE

To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116 749]; laparoscopic cholecystectomy [82 372]; hysterectomy [67 452]; total knee replacement [42 313]; breast lumpectomy [18 018]; colectomy [14 074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017.

EXPOSURE

Patient, clinician, and insurance factors potentially related to out-of-network bills.

MAIN OUTCOMES AND MEASURES

The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service.

RESULTS

Among 347 356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P < .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P < .001). Among 83 021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill.

CONCLUSIONS AND RELEVANCE

In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.

Markups on Emergency Medicine and Anesthesiology Services in the United States From 2012 to 2016

This cross-sectional study analyzes Medicare Part B claims to assess the association of changes in hospital charge master markups over time with hospital characteristics.