Targeting out-of-network radiologists, other specialties could cut healthcare spending by $40B
Privately insured patients frequently receive care from out-of-network radiologists and other specialties against their wishes, and reducing this trend could cut annual spending by $40 billion.
Yale University researchers recently made their pitch to address the practice of surprise medical billing in a new study, published Monday, Dec. 16, in Health Affairs. Poring over 2015 data from a large commercial payer, they found that about 10% of the time, patients visiting in-network hospitals are unexpectedly handed an “exorbitant” bill for out-of-network care.
The study’s findings underline the urgent need for federal action to address this practice, as lawmakers consider several different legislative remedies, authors argued.
“When physicians whom patients do not choose and cannot avoid bill out of network, it exposes people to unexpected and expensive medical bills and undercuts the functioning of U.S. healthcare markets,” author Zack Cooper, an associate professor of public health at Yale, said in a statement. “Moreover, the ability to bill out of network allows specialists to negotiate inflated in-network rates, which are passed on to consumers in the form of higher insurance premiums.”
Cooper’s study specifically targeted four hospital-based physicians that are typically not selected by patients—radiologists, assistant surgeons, pathologists and anesthesiologists. Analyzing data from nearly 4 million cases, they found that out-of-network billing at in-network hospitals occurred about 5.6% of the time for radiologists—around half the number for the other three physician types. For-profit hospitals and those located in concentrated markets with little competition were frequent users of this practice, the study found.
Mean out-of-network bills for such care averaged about $194 for radiologists, compared to $311 for pathologists, $2,130 for anesthesiologists and $7,889 for assistant surgeons.
Cooper and colleagues also explore several legislative levers that politicians might pull to address this issue. These included regulating contracts of out-of-network physicians who work in hospitals and requiring hospitals to sell a bundled package of services is their preferred course of action. But any sort of change is a step in the right direction, they believe.
“At the end of the day, patients are getting crushed, and we need a change to protect them,” Cooper said.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.