WASHINGTON -- Blame the insurer when a patient lands in the hospital with a catastrophic illness, and then gets a massive bill because one of the treating clinicians was outside the insurer's network, said Barbara McAneny, MD, president of the American Medical Association (AMA).
The problem with so-called "surprise billing" is that insurers have not fought hard enough to protect their patients, she told MedPage Today in a recent interview.
"I look at it as somewhat different than 'surprise billing.' I look at it as inadequacy of the insurance companies to successfully negotiate a network. I recognize that [insurers] make more money when they have a very narrow network, but that's not fair to patients who expect full coverage," McAneny said.
She said insurers and insurance commissioners must insure that networks aren't so narrow that essential slices of the physicians workforce, such as radiologists, are excluded.
In a Feb. 7 letter to Senate Health, Education, Labor, and Pension Committee Chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.), the AMA and dozens of other medical societies expressed concerns regarding out-of-network "surprise" bills and laid out principles to address the problem.
The medical groups pressed Congress to hold insurers accountable for these surprise charges, calling for stronger network adequacy standards, suggesting patients pay only in-network cost-sharing rates, and urging that any legislation lawmakers pass include a process of mediation or "alternative dispute resolution."
MedPage Today sat down with McAneny on Monday, one day before the AMA's National Advocacy Conference, to discuss the challenge of surprise bills, high drug prices, and the opioid epidemic.
A press representative was present during the interview, which has been edited for clarity and brevity.
MPT: In addressing this idea of surprise bills, the AMA opposed capping physician payment for out-of-network charges using a benchmark such as Medicare rates. Why?
McAneny: There are those health plans that we can cost-shift from, and there are those health plans that we can cost-shift to. In my own practice that I manage, Medicare covers about 80% of my costs of doing business. ... Therefore with commercial payers I have to negotiate a sufficient rate that I can fill in the Medicare hole, the Medicaid hole, the Indian Health Services hole, where it's below my costs.
When we hear these proposals where the insurance companies don't want to have to negotiate fairly with me, they want to just say, "Well, we'll pay you Medicare rates," what they've done is taken some of the commercial plans and taken them out of the column where I can cost-shift from and into the column where I have to cost-shift to.
MPT: And the AMA remains opposed to a single-payer healthcare system?
McAneny: In order to have a chemotherapy infusion suite, I'm required to have a pharmacy that meets certain criteria for safety, I'm required to have an electronic health record that can do certain things, I'm required to do HIPAA security plans. All those things are important, but they're not accounted for in the costs of what we pay for Medicare or Medicaid, or the Indian Health Service. So, if we're going to have a system, we have to recognize that there's certain costs to delivering care, and we don't have a way around that. We have to cover those costs.
We support universal healthcare. We want everyone to have access to healthcare, but because Medicare pays for 80% of the cost of doing care, if the whole country is paying 80% of my cost, do I tell my nurses that they get a 20% pay cut? Can I go to the light company and say "You should only charge me 80% of my light bill?" How do I manage those costs?
MPT: If "Medicare for All" is not the answer, how do you get to universal healthcare?
McAneny: The AMA policy is still to have a whole menu of different healthcare options for patients and doctors across the country. One size is not gonna fit all and therefore we need to be able to have a health payment system that mirrors what physicians are doing in a given specialty in a given market. And that's why we think that having anyone just lay down the law and say "here's the deal" is not going to work for a lot of specific markets.
MPT: Switching gears, what are your priorities for the opioid epidemic?
McAneny: We need less stigma and we need more people who know how to treat opioid use disorder.
What we do not need are artificial caps on prescription amounts because there are patients who are stable and functional with chronic pain who can be productive members of society, whose doses are not increasing, and they're not diverting drugs. The legislatures of various states should not be in the prescribing business.
MPT: The Trump administration recently advanced a number of proposals aimed at curbing drug prices: eliminating pharmacy benefit manager rebates, banning gag clauses, including list prices in direct-to-consumer ads. Which changes do you see as having the most potential?
McAneny: As an oncologist, my drugs are incredibly expensive, and it's terrible for my patients who have to pay a level of copay or coinsurance to afford these life-saving drugs.
However, [pharmacy] benefit managers account for about 42% of the price. They may initially have provided some useful function, but now I believe that they just add to cost, and I do not believe they add any value. So, that is the first place that we should look.
Part of the PBM's process is orchestrating higher rates and therefore higher co-pays for patients at the point or service -- the pharmacy counter. And often the cost that they would pay out-of pocket is less than their copay, if they only knew that.
So, we are very much in favor of getting rid of those gag clauses.
MPT: What more would you like to see the administration do to lower drug prices?
McAneny: We struggle with the International Pricing Index. As part of that process, the administration would want a new vendor to deliver Part B drugs directly to my office.
The Part B system as it is, where physicians are administering the drugs through our office, has actually been a pretty patient-friendly and efficient system. We buy in bulk for the medicine and then we have a supply that we can use for patients, so that if I change the regimen, I don't have to make the patient go away and come back another day.
Also, when physicians are treating patients, we continue to give patients their treatment even when they are unable to pay their copays and deductibles, because we know that cancer can't wait. I don't want some for-profit company to be able to deny my patients treatment because they didn't make their copay for the last dose.
I would like some protections for my patients in any policy that comes out with the IPI. I don't want doctors and patients caught in the middle.
MPT: The complaint from critics of the current Part B payment system is that doctors are incentivized to prescribe the higher-priced drug because they get a cut based on the price.
McAneny: I am personally offended by that. As a cancer doctor, there are a lot of diseases I used to treat with morphine and sympathy, but now I have chemotherapy and they're not interchangeable. There's clearly the best choice and then the second best choice. And we use the best drug as long as it's working and then we use the second best, as long as it's working and if there is a third best drug, we use that, depending on what the patients wants. So, the idea that I can manipulate this for profit is offensive to me as a physician.
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