Latest / Becker’s Healthcare Podcast / No Surprises Act’s Impact on Emergency Medicine Spending and IDR

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No Surprises Act’s Impact on Emergency Medicine Spending and IDR · Becker’s Healthcare Podcast

• 0:00
  - Hi, everyone. This is Lucas Voss with Becker's
• 0:02
  - Healthcare. Thanks so much for tuning in to
• 0:03
  - the Becker's Healthcare podcast series. It's great to
• 0:05
  - have you. I'm excited to welcome Patrick Veliki
• 0:07
  - to the podcast. Patrick is the chief external
• 0:10
  - affairs officer at HaloMD and has spent almost
• 0:12
  - two decades in the health care advocacy space
• 0:14
  - with a deep understanding of health care policy.
• 0:16
  - He's also spent time in Washington DC supporting
• 0:19
  - congressional representatives
• 0:20
  - and their offices there. We're talking about something
• 0:23
  - specific today. His latest paper, Patrick argues that
• 0:26
  - the no surprises act has
• 0:28
  - substantially lowered out of network emergency medicine spending,
• 0:32
  - preparing post NSA costs against a pre
• 0:35
  - NSA out of network baseline rather than in
• 0:38
  - network rates or QPAs as most prior research
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  - does, actually.
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  - He estimates a 13% to 52%
• 0:45
  - decline and concludes that the law is likely
• 0:47
  - reducing
• 0:48
  - overall medical costs. That's what we're talking about
• 0:51
  - today, Patrick. It's so great to have you.
• 0:52
  - Thanks for being here. Thanks, Lucas. Good to
• 0:54
  - see you. It's certainly a very dense topic.
• 0:57
  - Your your paper reflects that. There's a lot
• 0:59
  - to talk about. And, again, a lot of
• 1:01
  - this debate has focused on high r d
• 1:03
  - r... RDR
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  - awards.
• 1:06
  - What prompted you to look at the broader
• 1:09
  - pool, so to speak, of emergency medicine claims?
• 1:11
  - And, again, what are some of those findings
• 1:13
  - that might have surprised you or that you
• 1:15
  - were interested in?
• 1:16
  - Yeah. So,
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  - there's been a lot of research published on
• 1:19
  - the Nurse Prize Act, on the ADR process,
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  - and,
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  - I kept seeing a lack of a meaningful
• 1:25
  - baseline.
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  - Any way to compare
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  - the cost under the IDR process
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  - to what we were paying for the same
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  - care prior to the NSA and and IDR.
• 1:35
  - You can't really understand the impact of a
• 1:37
  - law unless you understand
• 1:38
  - that baseline impact.
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  - What were we paying? What are we paying
• 1:42
  - now? And how do those two things compare?
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  - So really saw an opportunity there to fill
• 1:48
  - in some gaps, and I'm glad I did.
• 1:51
  - The findings are are, in my opinion, really
• 1:53
  - pretty interesting and run counter to, I think,
• 1:56
  - what has sort of been accepted as,
• 1:59
  - the understanding of of the NSA's impact and
• 2:02
  - and the IDR process.
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  - To your point,
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  - ultimately, we found that, there was a pretty
• 2:08
  - substantial reduction in,
• 2:10
  - spending on emergency medical care pre versus post
• 2:13
  - NSA.
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  - One of the main drivers there is, again,
• 2:17
  - current research has really only looked at this
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  - tiny sliver of emergency medical claims that go
• 2:23
  - through the IDR process,
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  - which according to the health insurance plans for
• 2:27
  - 2024 was only about 6.2
• 2:30
  - of, emergency medical claims that were subject to
• 2:33
  - the NSA.
• 2:34
  - So when you pull back the aperture and
• 2:36
  - and look at the remaining, you know, 90
• 2:38
  - plus percent of claims that don't go through
• 2:41
  - arbitration,
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  - it really changes your understanding of, the cost
• 2:45
  - of of that care.
• 2:47
  - You mentioned the baseline piece and certainly the
• 2:49
  - comparison part, which is so crucial.
• 2:53
  - Why did you focus on that? Why do
• 2:55
  - the comparison of today's out of network payments
• 2:57
  - with out of network care costs before the
• 3:00
  - law rather than
• 3:01
  - with the in network rates or the QPA?
• 3:05
  - Yeah. It's a great question. So,
• 3:08
  - the QPA really isn't a a relevant baseline
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  - because, well, we weren't paying for out of
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  - network emergency care at the QPA
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  - preasset.
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  - Right? Prior to the passage of no surprises
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  - act,
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  - allowed amounts for out of network emergency medical
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  - care were greater than the in network rates
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  - for that that same care. So,
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  - if you just compare
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  - post NSA emergency medical spending to
• 3:34
  - pre NSA in network rates,
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  - you're you're really comparing apples and oranges. That's
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  - that's not how care was reimbursed pre NSA,
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  - and it doesn't give you a good picture
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  - of, how reimbursement
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  - for that care has changed over time.
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  - So, yeah, again, without that baseline, without a
• 3:51
  - way of saying,
• 3:52
  - what were we paying, what are we paying
• 3:54
  - now for the same care,
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  - you end up with a skewed picture that
• 3:58
  - doesn't actually tell the whole story.
• 4:01
  - We've touched on this in a... In another
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  - episode
• 4:04
  - that we did together.
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  - Most eligible
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  - emergency medicine claims never reach IDR. Again, we've
• 4:10
  - talked about that, but their their final payment
• 4:12
  - amounts aren't necessarily public.
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  - How did you account for those claims? How
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  - much does your estimated 30% of that 52%
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  - that I mentioned reduction depends
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  - on that specific assumption?
• 4:23
  - Yeah. That was the biggest challenge, because to
• 4:25
  - your point, we have data on exactly how
• 4:29
  - claims are are resolved through the IDR process.
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  - We don't have really good,
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  - certain data on how claims that don't go
• 4:37
  - through IDR are are reimbursed.
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  - So what we used as a proxy based
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  - on our own experience with claims data for
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  - the thousands of emergency physicians that that we
• 4:47
  - represented at HALO,
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  - as well as, some statements from CMS in
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  - some of their public rulemaking and another report,
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  - in in CRS. So well founded. Right? There's
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  - a lot of basis for assumption, but,
• 5:00
  - we substituted the QPA,
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  - for the payment rate, for the claims that
• 5:05
  - don't go through arbitration.
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  - Generally speaking, we've seen that those claims tend
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  - to have an initial payment, an initial allowed
• 5:13
  - amount at roughly the QPA.
• 5:15
  - Now because that was an assumption and we
• 5:18
  - wanted to be really transparent and really clear
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  - about the fact that we did have to
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  - make an assumption there, we thought it was
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  - also important to, one, disclose that really clearly,
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  - and, two, account for that in case,
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  - that assumption is is too conservative.
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  - There could be very good reasons that the
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  - QPA
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  - that we see in the arbitration process
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  - is actually lower than the QPA that you'd
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  - see outside of the arbitration process. And maybe
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  - maybe that's why these are ending up in
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  - arbitration in the first place. Right? Maybe those
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  - QPAs are,
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  - anomalously low.
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  - So, in order to ensure there was no
• 5:50
  - credibility and we were being conservative,
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  - we looked at the model
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  - using the QPA as the the substitute
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  - for those out of network claims. But then
• 6:00
  - we also substituted the QPA plus 50%
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  - and the QPA,
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  - times two.
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  - And what if those other QPAs are actually
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  - higher? What does that do to the savings
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  - or the cost?
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  - And even with those much more conservative assumptions,
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  - you know, assuming that an insurer is paying
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  - double the QPA disclosed in the IDR process
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  - for those other claims,
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  - you still end up with a savings of
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  - 13%
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  - on those out of network services
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  - compared to, the pre NSA rate. So, again,
• 6:32
  - even under what I think are are some
• 6:34
  - of the most conservative circumstances
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  - you could devise,
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  - emergency medicine is is simply being,
• 6:40
  - reimbursed at a a lower overall aggregate rate
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  - than it was pre NSA.
• 6:45
  - You touched on the transparency piece. I I
• 6:47
  - just wanna talk about that a little bit
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  - more because, again, Halen, do you specifically, you
• 6:51
  - you help providers pursue IDR claims.
• 6:54
  - How should listeners weigh that perspective specifically then
• 6:58
  - when they're looking at some of the numbers
• 6:59
  - that you've just outlined, some of the research
• 7:01
  - that you've just outlined? Yeah. It was really,
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  - really important that we not insult the intelligence
• 7:06
  - of folks who read the research. Yep. That
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  - we are, absolutely,
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  - a a biased party in this process. Right?
• 7:13
  - We represent the provider side. So, we wanted
• 7:16
  - to take that head on. And and, frankly,
• 7:19
  - we were confident enough in what our our
• 7:21
  - data would show
• 7:22
  - that we were more than happy to be
• 7:24
  - really transparent, disclose every assumption.
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  - The research actually walks through
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  - every mathematical formula used and explains
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  - how and why it it was used.
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  - So if anything, really,
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  - the fact that
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  - we really needed to be transparent and needed
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  - to demonstrate that, we were overcoming our own
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  - biases,
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  - I think, is ultimately a strength.
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  - It forced us to be really rigorous about
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  - how we did the work because, well, we
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  - knew that folks would take a skeptical eye
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  - toward it.
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  - When we're looking at
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  - IDR specifically,
• 7:58
  - again, we we know it's been rise... We
• 8:00
  - talked about it. We've... We know it's been
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  - rising since 2024 consistently every single year.
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  - How... In connection to that, how much further
• 8:07
  - would utilization or awards have to rise before
• 8:10
  - those estimated savings start disappearing?
• 8:13
  - Yeah. That's a a great question. And,
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  - very much to the point of growth in
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  - the process,
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  - sure, it's not costing now. Are are we
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  - just on the precipice of it becoming a
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  - coster?
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  - The answer is is no. I actually include
• 8:27
  - in the research paper itself,
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  - a sensitivity analysis where you can look for
• 8:32
  - yourself and say, alright. So maybe right now,
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  - we're only at a a 6%
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  - utilization rate,
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  - and awards are, you know, roughly,
• 8:42
  - you know, 600 ish dollars.
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  - What if those double? What if the awards
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  - are, you know, $1,200
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  - and
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  - utilization balloons to to 30%?
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  - You're actually still saving money. So we are
• 8:56
  - a long, long ways away from utilization and
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  - award amount,
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  - making emergency medicine into a coster. And, again,
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  - the best part is that you can look
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  - at it for yourself. You can
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  - forecast, hey. I think there's gonna be 50%
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  - utilization,
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  - and awards are gonna grow to, you know,
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  - $800
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  - per ED claim. And You can see right
• 9:17
  - there, they're still saving money.
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  - So we are,
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  - deeply, deeply in a savings
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  - setting when it comes to emergency medicine, and,
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  - that's really important to understand with the policymakers.
• 9:30
  - Patrick, I know you do this all the
• 9:31
  - time. You you you live and breathe
• 9:34
  - this type of research.
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  - What's
• 9:37
  - the most... For you personally too and and
• 9:39
  - your colleagues maybe, what's the most important piece
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  - of evidence that's still missing
• 9:44
  - for you before we can really judge the
• 9:47
  - overall effect here on spending?
• 9:50
  - Yeah. I think,
• 9:51
  - really getting a look at the in network
• 9:54
  - rates and whether there have been changes to,
• 9:56
  - in network negotiations over time. And I would
• 9:59
  - really love to expand this same research into
• 10:02
  - other specialties.
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  - Right? Unfortunately, we only have really good publicly
• 10:07
  - available data for emergency medicine, which is why
• 10:09
  - that's where we focused, on this research.
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  - So we are are looking into... Can we
• 10:15
  - partner with some third party firms that have
• 10:17
  - access to
• 10:18
  - a wider range of data and, recreate this
• 10:22
  - analysis using, again,
• 10:23
  - that claims data to even get rid of
• 10:25
  - the assumptions that we do have to make
• 10:27
  - and broaden the analysis to other specialties and
• 10:30
  - the other network environment on the whole.
• 10:33
  - Patrick,
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  - as always, you make this so easy to
• 10:36
  - understand.
• 10:38
  - It's so great to have you. Again, to
• 10:40
  - our audience,
• 10:41
  - make sure that you download the white paper.
• 10:42
  - There's a lot of interesting data in there.
• 10:44
  - There's a lot of interesting explainers of how
• 10:46
  - this works. Again, Patrick highlighted
• 10:49
  - the independence of this and the fact that
• 10:51
  - it is data that's
• 10:53
  - verifiable by everybody, and you can look at
• 10:55
  - it. I just wanna thank you again for
• 10:57
  - for taking some time and bringing... Making this
• 10:59
  - so easy to understand for us. Thanks. I
• 11:01
  - was really appreciate it. A lot of fun.
• 11:03
  - And we also want to thank our podcast
• 11:04
  - sponsor, Halo and d. You can tune in
• 11:06
  - to more podcasts from Becker's Healthcare by visiting
• 11:08
  - our podcast page at beckershospitalreview.com.