Editor’s note: The issue of surprise medical bills for out-of-network services remains highly active in Congress. The status of legislation mentioned within this article may have changed since it was last updated on June 27.
A successful advocacy strategy requires direct engagement with members of Congress and their staff. As a key ongoing function, the AAOS Office of Government Relations (OGR) facilitates such engagement both in legislators’ offices and at political events.
Each year, the Board of Councilors, Board of Specialty Societies, and other select AAOS members gather in Washington, D.C., as part of the National Orthopaedic Leadership Conference (NOLC) to learn more about current trends in healthcare policy and to make crucial visits to Capitol Hill.
This year, approximately 350 orthopaedic surgeons participated in the event on June 6, resulting in 390 legislative office visits involving lawmakers from nearly every state. The Council on Advocacy selected the discussion topics, which included the Hospital Competition Act of 2019, the Competitive Health Insurance Reform Act of 2019, and the issue of patients receiving surprise medical bills following both emergency and nonemergency care. The topics were chosen for their relevance to patient care and for the ways they have the potential to lower healthcare costs—two important themes in the 116th Congress.
Increasing hospital competition
The Hospital Competition Act (H.R. 506), introduced by Representative Jim Banks (R-Ind.-3), focuses on ways the federal government can encourage competition and reduce potentially harmful consolidation among hospitals. For orthopaedic surgeons and patients, the legislation has five key principles. First, the legislation would authorize $160 million in additional appropriations for the Federal Trade Commission to hire staff to investigate anticompetitive mergers and practices related to inpatient and outpatient healthcare services. Second, it would authorize $1 billion in state grants each year for 10 years. The money would enable eligible states—those that do not have onerous certificate-of-need laws or those that vote to repeal—to take action to improve hospital competition. Third, the legislation would require Medicare to address the reimbursement discrepancy between off-campus, hospital-based providers and independent physicians. Fourth, H.R. 506 would mandate additional price transparency to enable patients to price-compare among providers. Lastly, the bill would repeal the ban on physician-owned hospitals.
Increasing health insurance marketplace competition
The Competitive Health Insurance Reform Act (H.R.1418, S.35), which seeks to repeal the health insurance aspects of the McCarran Ferguson Act of 1945, was the next topic explored by AAOS members on Capitol Hill. To help make health insurance more affordable for all Americans, the measures seek increased marketplace competition by providing greater transparency and oversight in the health insurance industry. Unlike physicians, health insurance companies are able to confer with each other on pricing without fear of antitrust violations. This liberty gives them an unfair advantage in rate setting. When health insurers overcharge or otherwise take advantage of consumers, the only course of action is to file a complaint with a state insurance commissioner. This bill, introduced by Representatives Peter DeFazio (D-Ore.-4) and Paul Gosar (R-Ariz.-4), would authorize greater federal antitrust enforcement in instances when state regulators fail to act. This is no different from the situation faced by all other industries in the United States. NOLC participants were able to gain several cosponsors for this legislation due to their legislative visits and advocacy.
Protecting patients from surprise medical bills
Lastly, participants delved into surprise bills for patients. This issue has been active in state legislatures for years and is rapidly garnering attention on Capitol Hill. “Surprise billing” occurs when a patient receives a bill for an out-of-network (OoN) service that he or she did not expect. AAOS supports a federal adaptation of New York state’s model, which holds patients harmless and sets up an arbitration process when a bill is being disputed between a physician and an insurer. The arbiter considers the physician’s bill and the offer from the insurance company, then the arbiter chooses one and the loser pays the arbitration costs. Crucially, the arbiter considers an independent database of charges called FAIR Health when making a decision. The model has been successful at bringing down instances of OoN bills in New York, as providers and plans are both incentivized to come to the table and negotiate a fair rate. Recently, Representatives Raul Ruiz, MD (D-Calif.-36), and Phil Roe, MD (R-Tenn.-1), introduced the Protecting People from Surprise Medical Bills Act, which contains similar arbitration principles. AAOS is supportive of the effort and continues to work with all 32 original cosponsors to promote the concept in both the House and the Senate.
Involvement in legislative advocacy
Involvement with federal and state lawmakers is critical for the continued success of AAOS and individual orthopaedic surgeons. To learn how to become more involved with the legislative process, contact Catherine Hayes at firstname.lastname@example.org.
Catherine Hayes is a senior manager of government relations in the AAOS OGR.