Latest / CareTalk: Healthcare. Unfiltered. / Has Surprise Billing Met Its Match?

Transcript

Has Surprise Billing Met Its Match? · CareTalk: Healthcare. Unfiltered.

• 0:00
  David: Surprise.
• 0:00
  David: Billing, hospital and insurance company, competition, price transparency, health industry lobbying, drug pricing.
• 0:07
  David: These are all critically important topics that need more reasoned, data-driven debate, and less bloviating and self-interest.
• 0:14
  David: But where can we find the unbiased answers to help ground and inform us?
• 0:18
  David: Our guest today is Yale Professor Zack Cooper, whose research on these very topics is helping clear the fog and leading to surprising.
• 0:26
  David: Including the No Surprises Act.
• 0:28
  David: Welcome to CareTalk America's home for an incisive debate about healthcare, business and policy.
• 0:33
  David: I'm David Williams, president of Health Business Group.
• 0:36
  John: And I'm John Driscoll, the president of Walgreens Health.
• 0:39
  David: Are you the kind of person who just can't get enough care?
• 0:42
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• 0:43
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• 0:45
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• 0:46
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• 0:49
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• 0:57
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• 1:01
  John: David, can we please get to the conversation with Professor Cooper?
• 1:06
  John: Zack, welcome.
• 1:08
  Zack: Thank you.
• 1:08
  Zack: I, I was, I like the intro.
• 1:10
  Zack: Everything except the, I can give you the facts.
• 1:12
  Zack: The bloviating, I think that's like my, my specialty, so I, oh boy.
• 1:16
  Zack: I, I'm afraid to, you know, I don't wanna get your audience hopes up.
• 1:20
  Zack: We're, we're gonna, we're gonna do a little bit of that, but, but
• 1:22
  John: Zack, this no surprise, this billing thing, I never thought there would be progress on that.
• 1:27
  John: I mean, th that's kind of how.
• 1:30
  John: I mean, hospitals make a lot of money.
• 1:32
  John: I mean, there was an entire Long Wall Street Journal article about, you know, uh, hospitals putting people into bankruptcy even in the state of Connecticut, if you recall a few years ago.
• 1:43
  John: And you like, how, what's going on with this?
• 1:46
  John: No surprise billing stuff and how did you, what did you find and how did it actually turn into law?
• 1:52
  Zack: Yeah, well thankfully it was, it was mostly the opposition of the, the emergency room physicians, so we, it was like divide and conquer the hospitals.
• 1:59
  Zack: They, you know, we, we still have some work on, on thinking about hospital pricing.
• 2:02
  Zack: So, you know, the, the sort of story on it was, gosh, it was like 2014 or or 2015, and Elizabeth Rosenthal, who's a amazing journalist, she was at the Times then was doing a series of articles called P Till It Hertz, where she was talking about, I remember it vividly.
• 2:18
  Zack: It was a, a father who took his kid to an emergency.
• 2:22
  Zack: And ended up with a, this ridiculously a $5,000 out of network bill from a, an emergency room doctor.
• 2:28
  Zack: And, you know, I remember at the time thinking, look, if this is one in, you know, every million cases, like the solutions GoFundMe page.
• 2:37
  Zack: But if it turns out this is happening pretty systematically, that's, that's different altogether.
• 2:41
  Zack: And, you know, I'd be out with friends, I'd be on airplanes.
• 2:44
  Zack: People would say what we, you do, and I'd say, I'm a health economist.
• 2:46
  Zack: They'd tell me their story and inevitably would have something to do without a network.
• 2:50
  Zack: And begged and pleaded for data.
• 2:52
  Zack: Finally got access to some data found to help that it was happening one in five times.
• 2:57
  Zack: So for the privately insured, one in five times, the person went to an in-network hospital in an emergency, they're getting treated by an an out-of-network physician.
• 3:04
  Zack: And you know, I, I think the story from then to now I, I waiver between whether it's a.
• 3:13
  Zack: Positive story or negative, inspiring or, or maybe the opposite.
• 3:17
  Zack: You know, we published some work.
• 3:18
  Zack: It was in the New England Journal of Medicine that showed, you know, one in, one in five patients got one of these bills.
• 3:23
  Zack: We did a follow up paper that was in the Journal of Political Economy showing that it was really one or two of these big physician staffing companies that were.
• 3:31
  Zack: We're using that as a, a deliberate strategy.
• 3:33
  Zack: Um, now that I say it, I'm, I'm probably gonna get sued again.
• 3:36
  Zack: Um, you know, they, I'm not their, their favorite person.
• 3:39
  Zack: Go for it.
• 3:39
  Zack: But, um, yeah, no, exactly.
• 3:41
  Zack: Thank you.
• 3:42
  Zack: Um, is the person not paying my, my, my legal fee?
• 3:45
  Zack: No.
• 3:45
  Zack: Um, you know, and, and the paper got a lot of traction, so it was the, the lead store and the front page of the Times, and, uh, Lamar Alexander, uh, was, uh, was really taken by the issue.
• 3:57
  Zack: And, you know, I think.
• 4:00
  Zack: In hindsight, while Alexander the, the,
• 4:01
  John: was he the, was he the Republican senator from Tennessee?
• 4:04
  John: Is that recall?
• 4:05
  John: Yes,
• 4:05
  Zack: sir.
• 4:05
  Zack: Exactly.
• 4:06
  Zack: And, you know, he was gonna retire and I think he made this his sort of last big piece of legislation and really championed it.
• 4:14
  Zack: And, you know, over the next sort of four or five years there was, you know, bipartisan agreement that, that this was a big issue.
• 4:21
  Zack: Uh, got to the point where it was inches from passing and, and it actually got blocked at the 11th hour by, uh, Member of Congress who, uh, I, I think made a, made a mistake in blocking it.
• 4:34
  Zack: And then a year later it came back and got signed into law by President Trump in 2021, off to the races in 2022.
• 4:41
  Zack: Um, it's now the sort of key provisions of it are, are under threat.
• 4:45
  Zack: The emergency room doctors are, are suing wherever they can.
• 4:49
  Zack: There's a, a lawsuit in, in whatever that district court is in Texas where you, you always try to get things blocked.
• 4:54
  Zack: The fifth, I think it's the fifth thing, the fifth, the fifth, fifth.
• 4:57
  Zack: Exactly.
• 4:57
  Zack: So they just actually stayed a, a key portion of law.
• 4:59
  Zack: So here's the optimistic side.
• 5:01
  Zack: You know, I think in six or seven years we went from an issue that we sort of knew about anecdotally to having really good academic evidence on it to having a law that's gonna protect, I think, millions of people.
• 5:14
  Zack: Right.
• 5:14
  Zack: That's, that's pretty cool.
• 5:17
  Zack: And, and that's a, a pretty short window.
• 5:18
  Zack: That's, that's the optimistic side.
• 5:20
  Zack: I think the, the side that makes me, Pessimistic sort of three parts of it.
• 5:28
  Zack: First, this was among the most egregious issues in healthcare, and if it was this much work to fix this one, like there are a lot of things that raise spending, make our system inefficient, that that don't have, for lack of a better word, as clear a villain and, and so I think it makes it really hard to make progress.
• 5:46
  Zack: The second is the amount of money spent on lobbying over.
• 5:53
  Zack: It was just gobsmack, right?
• 5:55
  Zack: Tens of millions, probably hundreds at some point on an ad campaign that was targeting senators not to vote for this thing.
• 6:03
  Zack: And you know, I think it just shows how hard it is to, to move the needle.
• 6:09
  Zack: The third is even once you got the thing passed, because there's so much money at play, the the big stakeholders are doing their best to, to sort of round the edges in their.
• 6:22
  Zack: And so if I'm optimistic, I say, look, I, I suspect this is gonna be hundreds of thousands, maybe millions who, who probably don't go bankrupt.
• 6:30
  Zack: That's amazing.
• 6:32
  Zack: Um, my pessimistic side is we know rising healthcare costs are putting immense weight on American families and our economy as a whole, and it makes me a little worried about our capacity to handle the even bigger issues that.
• 6:47
  David: You know, reminds me of the, uh, the old movie, uh, risky Business where they say, you know, never mess with a n never f with another man's livelihood.
• 6:54
  David: It's kind of in that same category.
• 6:56
  David: And, you know, you have a list of things on your, your, uh, 1% steps for Healthcare Reform project.
• 7:01
  David: And this is sort of, you know, number one of an issue, sort of, you know, chipping away from different pieces.
• 7:05
  David: And I saw it next to it.
• 7:06
  David: It says, you know, legislation signed into, into law.
• 7:10
  David: Are there other things that you think could be equal?
• 7:12
  David: Impactful or more so, and that you might be able to come and, you know, have the similar optimistic, pessimistic story, but at least make some progress?
• 7:19
  David: Or are we gonna get stuck on this very one?
• 7:23
  Zack: Yeah, I mean, so let's take a step back and, and just talk about the 1% Steps project for a second.
• 7:27
  Zack: You know, the, the idea is we have a 4.3 trillion healthcare system.
• 7:30
  Zack: If it was a country, it would be the fourth largest country in the world about the size of.
• 7:35
  Zack: And the way I think about what's wrong with healthcare in the US is it turns out there are a lot of dark alleys in Germany where crime takes place.
• 7:41
  Zack: And, you know, we can extend that metaphor to the US healthcare system.
• 7:45
  Zack: There are just a lot of dark alleys, and maybe it's not criminal, but certainly unethical behavior that that isn't good for, for anybody.
• 7:51
  Zack: And the idea was nobody writes country music songs about incrementalism, but I, I actually think the way we fix things is, is just step by step.
• 8:00
  Zack: Like I, I don't think there are single reforms that are gonna lower health spending in the us.
• 8:04
  Zack: 10%.
• 8:06
  Zack: But what we do know how to do is fix these small bids, or at least identify them, and then hopefully we can play whack-a-mole.
• 8:12
  Zack: You know, I, I think there are lots of examples.
• 8:13
  Zack: You know, one, you know, obvious one is, is just what happens in dialysis in the dialysis industry.
• 8:19
  Zack: You know, I think that's an industry that I think we can charitably say is, is maybe not working exclusively for the interest of, of patients, you know, and, and a good example is there's a big chain.
• 8:32
  Zack: Buys up lots of smaller chains and when they do, you actually see organ transplantation rates go down.
• 8:37
  Zack: Right.
• 8:37
  Zack: And that's cuz they have an economic interest in doing the dialysis, not seeing their patients get better with a, a transplant.
• 8:43
  Zack: I think that's right for, for policy intervention.
• 8:47
  David: Zack, it sounds like you might get sued, Zack, it sounds like you might get sued again if you keep going down that path.
• 8:53
  Zack: Oh,
• 8:54
  John: no, he's absolutely, he's absolutely, he's absolutely right though.
• 8:56
  John: I mean, Mike, Michael Kinsley once famously wrote that, what's, you know, d you know, deeply outrageous about what goes on in Washington is not what's illegal, but what happens legally in the clear that's unethical.
• 9:08
  John: And I, I, I think that what you're doing is, is absolutely, uh, you know, on target in calling out the legal villains, which are not, not just driving healthcare outcomes the wrong direction, but having, you know, it, but making, but being paid to do it.
• 9:25
  John: I mean, the incentives are all screwed up.
• 9:27
  John: And by the way, there are some really darn good country musics about incrementalism.
• 9:32
  John: They're generally.
• 9:33
  John: Modest success in a relationship, which I identify with.
• 9:37
  John: But let's get getting back on point.
• 9:39
  John: What, who, if you were to rank the villains, we've got, you know, price gouging in the ER when your kid is, is, is sick and bleeding out, and then you've got the dialysis folks.
• 9:52
  John: Who else is on the, uh, the, the Zack Cooper enemies of the people list?
• 9:58
  John: For, for, for Outrageous Healthcare, behav.
• 10:02
  Zack: Yeah, as long as David agrees to start my car in the mornings.
• 10:04
  Zack: We'll, we'll, we'll definitely have this conversation.
• 10:06
  Zack: No, I, exactly.
• 10:07
  Zack: So I, I, I don't think there's frankly anybody who's got a monopoly on virtue or a, a monopoly on Vice.
• 10:12
  Zack: I, I think in terms of dollars, uh, there's a reason I look at the hospital industry and it, it isn't because ne necessarily doing, I, I think the, the worst stuff, but it's the biggest chunk of, of healthcare spending.
• 10:26
  Zack: And I just think about some of the pricing patterns there and.
• 10:30
  Zack: Uh, what happens, how the industry's gotten consolidated in a system where we rely on hospitals, insurers, bargaining over prices when one party's just got lots of market power, that's not a recipe for, for success.
• 10:42
  Zack: Zooming back out, you know, I think the big issue in the US as a whole is, is actually one of politics.
• 10:47
  Zack: You know, I, I'll keep coming back to it, and the reason I say that is there's no constituency for efficiency in the us right?
• 10:54
  Zack: There's a constituency for.
• 10:57
  Zack: Insurance constituency for diabetics, for cancer patients, certain doctor's groups, there's nobody who's sort of out there saying, look, we need a healthcare system that's more efficient.
• 11:06
  Zack: And I think a lot of what stands in our way isn't a question of what do we do?
• 11:11
  Zack: It's sort of a, a question of political will.
• 11:13
  Zack: And a lot of my work that I'm, I'm doing now is thinking about how a lot of the benefits from our healthcare system accrue, I suspect are the people who listen to this podcast and the three of us.
• 11:25
  Zack: Participating in this podcast, right, like my livelihood is, is in a sense from healthcare, the costs of the system being inefficient, often disproportionately fall in the most vulnerable.
• 11:33
  Zack: And I think that's just emerging, is really the sort of key theme in my work is we've got a healthcare system, which at root is, is designed to, yeah, we hope make people's lives better.
• 11:43
  Zack: It it's actually Paradoxy system that puts a, a really undue burden on.
• 11:52
  Zack: Probably the most vulnerable in society, financially.
• 11:55
  Zack: Uh, and we gotta just figure out how to, how to fix that.
• 11:58
  Zack: So
• 11:58
  David: let me put a optimistic spin on the, on the politics side and say, where, how could the politics actually work for, uh, cost reduction?
• 12:04
  David: See what you think about it.
• 12:05
  David: So there's going to be presumably a, a fight, uh, over raising the debt ceiling.
• 12:10
  David: And we've heard from everybody sort of agreed, we're not gonna cut Medicare, Medicaid, a different story, but let's focus on Medicare for a minute.
• 12:17
  David: And so Biden is basically challenging Republicans saying, let's actually negotiate more drug prices and let's do it sooner.
• 12:25
  David: And so in a sense you could say, well, that's the way we're gonna avoid cutting benefits.
• 12:28
  David: Let's actually go after costs with drug pricing and get at drug pricing in a way that was just started, um, you know, uh, last year.
• 12:36
  David: Does, is that a possible path or are we gonna end up in a, in a negative situation there too?
• 12:41
  Zack: So look, I, I think pro any progress is better than, than no progress.
• 12:47
  Zack: I'm actually teaching, uh, my lecture tonight for my students on drug pricing and one of the things I'm gonna start with is why do we even care, right?
• 12:55
  Zack: So actually a pretty small percentage of health spending about 14% when there are lots of parts that that account for a lot more.
• 13:01
  Zack: So why, why are we focusing on it?
• 13:03
  Zack: That, that's sort of my answer.
• 13:06
  Zack: To, to your question, you know, we go after it because in a sense for drug pricing, people pay a bigger share of the, the spend out of pocket.
• 13:11
  Zack: And so it becomes very, very politically salient.
• 13:14
  Zack: I think if we really wanna meaningfully reduce healthcare spending in this country, it, it isn't gonna be through reducing drug prices.
• 13:20
  Zack: Frankly.
• 13:21
  Zack: You could make our drug spend or drug prices look like the UK and we're still gonna spend a whole lot more than other countries.
• 13:28
  Zack: I, I think the challenge is you gotta be ready to start touching the third rail, which is.
• 13:33
  Zack: And you know, the challenge is you look congressional district, a congressional district in the US and by and large, who's the largest employer.
• 13:40
  Zack: It's the hospital.
• 13:43
  John: So, so do you, you don't think that there's, there's juice other, that, that's where you'd go.
• 13:49
  John: Cause, uh, to take the sigh of the hospitals, they're, they're losing money.
• 13:53
  John: More money than they've ever lost before.
• 13:55
  John: They, they were the heroes of covid.
• 14:00
  John: Rural hospitals are closing in an alarming click.
• 14:03
  John: Um, particularly in areas where if the hospital closes, the care goes away.
• 14:08
  John: You know, that's, that's the, would be the, the, the, the, the, the, the sad refrain of a country, uh, uh, song.
• 14:16
  John: If it was written by the American Hospital Association and played in DC this afternoon, how do you respond to that?
• 14:23
  John: Is that a country song?
• 14:24
  John: Johns, let's respond for
• 14:25
  Zack: rock and roll.
• 14:27
  Zack: Yeah.
• 14:28
  Zack: Um, so, you know, I'll, I'll pick on my own institution cuz I think it's, it's a little easier.
• 14:35
  Zack: You know, they'll talk a lot about how they lose money or we, Yale Haven Hospital on, on Medicare patients and they act as if that's some sort of fat accompli.
• 14:44
  Zack: I think the answer is we're a monopoly.
• 14:47
  Zack: We get very, very high private.
• 14:50
  Zack: And we make those private rates.
• 14:52
  Zack: And at some point, whether it's said out loud or not, we sort of say it's sort of unconscionable or un unseemly that we maybe make 15 or 20% profits.
• 15:00
  Zack: And so we're gonna build a new cancer center, or maybe we will remodel the the Greenwich Hospital and put a self playing piano in the library.
• 15:07
  Zack: And what's really nice about that is that actually shifts the books and starts to look like a cost.
• 15:11
  Zack: And over time you say, well, next year, now that we've got that piano and we got our cancer, We're gonna lose money on Medicare patients.
• 15:19
  Zack: It wasn't as if those costs were preordained.
• 15:21
  Zack: It's like if I build a, a really nice swimming pool next year and two years later say, look, I I'm losing money cuz I gotta fill up this darn pool every year.
• 15:29
  Zack: You gotta, you gotta pay me more.
• 15:31
  Zack: Right?
• 15:31
  Zack: Some costs aren't required and I think it's an industry that hasn't faced really a huge amount of financial pressure.
• 15:39
  Zack: And I think it's one where the arguments you've just made.
• 15:42
  Zack: Look, we all needed the hospital sector during Covid, and we need them now.
• 15:46
  Zack: We need it in the future.
• 15:47
  Zack: We need a vibrant hospital sector.
• 15:49
  Zack: But the idea that that means that we shouldn't think about health spending or think about costs isn't right because I think one of the things we know very, very well from theory is that when healthcare spending comes up because of employer sponsored health insurance, it's paid for by us out of our wage.
• 16:05
  Zack: We just don't see it really, really clearly.
• 16:07
  Zack: And you know, I, I think for a lot of towns and cities and frankly states, Connecticut being an example, rising healthcare costs are, are sort of slowly bleeding out the rest of the economy, right?
• 16:18
  Zack: It makes it hard for businesses to want to come in, makes it hard to attract labor.
• 16:23
  Zack: It ends up being some of the highest input costs to the, the products that we produce.
• 16:27
  Zack: And I think unless we're willing to, to have really tough conversations about trade offs.
• 16:33
  Zack: It's gonna be in a pretty ugly place.
• 16:36
  David: Well, that's it for yet another episode of CareTalk.
• 16:39
  David: Our guest today has been Yale Professor Zack Cooper.
• 16:41
  David: We have a heck of a lot more to talk about, cause I know John's not gonna be satisfied with those answers.
• 16:45
  David: Nonetheless, we'll have, well, professor Cooper, there's
• 16:48
  John: gotta be, yeah, I
• 16:49
  Zack: mean, come on.
• 16:49
  Zack: Ending on an optimistic note, huh?
• 16:51
  David: Yeah, that was all the, no, I think it's as optimistic as the rest of it.
• 16:54
  David: In any case, I'm David Williams, president of Health Business.
• 16:58
  John: And I'm John Driscoll, the president of Walgreens Health.
• 17:00
  John: If you like what you heard or you didn't, please subscribe on your favorite service and please give us a review.
• 17:07
  John: It means a, a great deal of, and thank you, Zack, for that uplifting talk.
• 17:11
  John: Uh, even though I don't think you're giving yourself enough credit for in, for your investment in research that made a change that's gonna lift up, uh, and avoid.
• 17:22
  John: I think bankruptcy for hundreds of thousands of Americans.
• 17:25
  John: So thank you for your contributions and we look forward to having you back when you regain your confidence and your optimism of the impact of your research, which is already showing a great, a great, a bigger yield in healthcare form than you could imagine.