2021 has arrived, and along with it has come several sunny winter days and a slightly flatter COVID-19 case curve than our region experienced a month ago. While we all need to remain vigilant about social distancing and other public health measures, there are reasons for optimism. In particular, the long-awaited and heavily debated federal actions outlined below, which position our health system to deliver better health care value to patients and communities. They hold promise for the future.

Most Surprise Medical Bills Soon to be Stopped

After years of failed legislative efforts, Congress acted late December to protect patients from most surprise bills. Beginning January 1, 2022, patients will no longer be able to be charged more than they would have paid for an in-network service in two types of scenarios: (1) when they find themselves in an out-of-network facility or air ambulance in an emergency situation, or (2) when they use the service of an out-of-network provider while seeking care in an in-network facility. Ground ambulances, the most common type of surprise bills, were left out. This was due to congressional leaders’ inability to understand the impact on the diverse types of ambulance companies, particularly those serving small municipalities. In an effort to stop these as well, a commission to study surprise bills for ground ambulances was established. The law now requires the out-of-network provider and insurance company to arbitrate and set guidance for the factors to be considered by the independent arbitrator in establishing a fair price.

Hospital Transparency is Expanded
Widely contested price transparency measures went into effect January 1, 2021, after the courts fail to be swayed by the American Hospital Associations’ claims of unfair burden and upheld the Trump administration’s rules for price transparency. Facilities must post the following information on their website for each service and product: (1) charges, (2) negotiated rates with insurance company, noting the lowest and highest negotiated price, without disclosing which insurer received which rate, (3) self-pay price offered to patients without coverage or paying their own claim, and (4) the bundled price for 300 common “shoppable” procedures or services, 70 of which have been defined in the rule by HHS. These are to be posted online, in a machine-reasonable and consumer-friendly format. A quick look at several local hospital websites did not find them to be fully compliant. Yet, there are signs that they are moving to become more transparent. Similar regulations, effective January 2022, have been imposed on insurers.

Payment Alignment Lays Foundation for Stronger Primary Care 

CMS has prevailed in making changes to the CPT coding system and payment rules designed to streamline provider documentation and realign payments to better reward physicians for their time spent in evaluation and management of patients, as compared to the time spent doing procedures. It went into effect January 1. Devised to be budget neutral, the expected $9.9 billion in higher payments has been offset by decreases in the conversion factors for some services. The AMA estimates the impact to provider practices will range between a decrease of 10 percent and an increase of 16 percent. This is a long-awaited and important step in advancing primary care in the U.S. health system. More details can be found here .

Moving into the New Year, the BHC will continue to monitor legislative activities on a local, state, and federal level that have an impact on health care quality, affordability, and safety, as well as employer-sponsored benefit plans. We welcome the opportunity to connect with your organization’s policy leaders to discuss priorities and shared action that can be taken in 2021.

Warm Regards,

Louise Y. Probst,
BHC Executive Director