ADVERTISEMENT
ADVERTISEMENT

When patients face a medical crisis, the emergency physicians, nurses and others who staff emergency departments are always there for them, no questions asked.

That fundamental fact is true across America. Every patient, regardless of insurance status or ability to pay, has the right to emergency medical care. As emergency physicians, that is a professional obligation we take on with pride. And thanks to a federal law known as the Emergency Medical Treatment and Active Labor Act (EMTALA), that ethical obligation has also been the law of the land since 1986.

The medical safety net is a guarantee that everyone can access life-saving medical care when they need it. In Tennessee, that guarantee is especially important for our rural communities, which already struggle with access to care. Sadly, one of our own lawmakers is now advancing legislation that threatens not just the medical safety net, but our entire health care delivery system.

Republican U.S. Sen. Lamar Alexander's proposal begins with a noble purpose: ending surprise medical bills. These bills happen when patients visit a medical provider outside their insurance network without knowingly doing so, often when they visit an emergency department. Instead of paying for necessary and possibly even life-saving care, insurance companies increasingly try to enhance their profit margins by passing these bills on to patients, who have done nothing wrong.

Doctors, patients and policymakers all agree on the need to protect patients and end surprise out-of-pocket bills. However, the "cure" advanced by Alexander is likely worse than the disease. It aims to address out-of-network bills by instituting a government price cap on the amount that insurers are required to pay for care — protecting insurance companies rather than just patients. His proposal would cap out-of-network reimbursement rates by benchmarking them to the insurer's own median in-network rate.

Benchmarking out-of-network rates to an insurer's own in-network rate gives insurance companies the power to arbitrarily set their own prices. If Alexander's bill becomes law, insurers can immediately begin canceling contracts with doctors to drive their median in-network rates as low as possible. They will be free to determine what they will pay for services doctors are legally required to provide in the emergency department. Given the opportunity, insurers will steadily pay less and less. This effect was seen in California, which adopted a rate-setting law in 2016 that now serves as the template for Sen. Alexander's legislation.

The problem with rate setting is not just that doctors make less money. Rate setting threatens to destroy our medical safety net, leading to painful repercussions for patients as well as providers. Most emergency departments lose money on the majority of patients. Providers are reimbursed at rates below the cost of doing business for treating the uninsured and TennCare patients, and barely break even on Medicare patients. That means private insurers have a critical role to play in the medical safety net — commercial reimbursements allow providers to stay in business and still meet their professional and legal obligations under EMTALA.

If insurers are allowed to unilaterally drive down their rates, doctors and hospitals will struggle to keep their doors open. Rural hospitals, which are already facing serious financial stress and serve communities that struggle with access to care, would be hit particularly hard.

Most doctors want to be in-network with health insurance plans because it encourages more insured patients to use our services and usually means faster and more reliable payment, which lowers our overhead costs. But unless a hospital or emergency physician group is part of a large regional or even national chain, we have little bargaining clout with insurers.

Alexander's rate-setting legislation won't solve the underlying problems that cause surprise medical bills. Insurers will pass more costs onto patients through narrower insurance networks. Doctor shortages and hospital closures will make it more difficult, if not impossible, for patients to see a doctor when they need one.

I urge the senator to reconsider giving the insurance industry the power to set its own payment rates and find another solution to surprise medical bills.

some text Andy Walker / Contributed photo

Dr. Andy Walker, a Signal Mountain resident, is a practicing emergency physician, member of the Tennessee Medical Association and chairman of the Government & National Affairs Committee of the American Academy of Emergency Medicine.

ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT