Latest / Becker’s Payer Issues Podcast / Healthcare Costs, IDR and the No Surprises Act: David Merritt on What’s Driving Affordability Pressures

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Healthcare Costs, IDR and the No Surprises Act: David Merritt on What’s Driving Affordability Pressures · Becker’s Payer Issues Podcast

• 0:02
  - GLP ones, Medicare Advantage Headwinds, a Medicaid landscape
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  - that looks different
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  - every quarter.
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  - Their leadership right now means making durable decisions
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  - in an environment that keeps moving, and the
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  - organizations pulling ahead are the ones that stopped
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  - before acting.
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  - Becker's fifth annual fall payer issues roundtable convenes
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  - and 70 plus speakers November second and third
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  - at the Swiss Hotel Chicago.
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  - Two days of senior level dialogue on affordability,
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  - benefit design, value based care, and the strategies
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  - shaping how care gets financed
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  - Click events in the upper right.
• 0:50
  - Hello, everyone. This is Jacob Emerson with the
• 0:53
  - Becker's Payer Issues podcast. I'm thrilled today to
• 0:55
  - be joined by David Merritt, who serves as
• 0:58
  - senior vice president of external affairs for the
• 1:00
  - Blue Cross Blue Shield Association.
• 1:02
  - David, appreciate you taking the time to chat
• 1:05
  - with me today. Great to be with you,
• 1:06
  - Jacob. Thanks for the opportunity.
• 1:08
  - Absolutely. And before we dive into everything we
• 1:10
  - wanna talk with you about, David, and and
• 1:11
  - what you are seeing,
• 1:14
  - driving up health care costs going into 2027,
• 1:16
  - what's affecting affordability for for those you represent.
• 1:19
  - Can you just fill in our audience for
• 1:21
  - those who might not be familiar,
• 1:23
  - the breadth of the companies that you represent
• 1:26
  - and a little bit more about what your
• 1:27
  - role entails at the association?
• 1:30
  - Sure. No. Happy to start there. Blue Cross
• 1:32
  - Blue Shield Association represents
• 1:34
  - every blue Blue Cross Blue Shield plan across
• 1:36
  - the country. So collectively, we cover, serve, and
• 1:40
  - support more than a 115,000,000
• 1:42
  - Americans every single day. So that's every single
• 1:45
  - ZIP code, and we've been doing that for
• 1:47
  - nearly a hundred years. So we are really
• 1:50
  - part of the fabric of these local communities.
• 1:52
  - We partner with more than 90% of the
• 1:55
  - doctors and hospitals,
• 1:57
  - across the country
• 1:58
  - and really just trying to,
• 2:01
  - balance, you know,
• 2:03
  - access to care with affordable coverage,
• 2:05
  - so people can get the care they need
• 2:07
  - to keep,
• 2:08
  - healthy if they're healthy and get better if
• 2:10
  - they're sick. So that's really our our
• 2:13
  - our foremost, you know, priority.
• 2:15
  - And, and my role specifically at the Blues,
• 2:18
  - for external affairs is, working with, you know,
• 2:21
  - members of the media like yourself,
• 2:23
  - working with policymakers
• 2:24
  - as well,
• 2:26
  - to really make sure that we are, you
• 2:28
  - know, trying to prioritize those solutions that actually
• 2:31
  - can bring costs down, that can expand coverage,
• 2:33
  - that can expand access so people can get
• 2:35
  - care,
• 2:36
  - and get the care they deserve.
• 2:38
  - Yeah. So fair to say you're you're a
• 2:40
  - busy guy, David, and I I appreciate you,
• 2:43
  - chatting with us briefly about what you're watching
• 2:46
  - going into next year and what is affecting
• 2:48
  - affordability
• 2:50
  - for for who you just mentioned, employers,
• 2:52
  - for for one in three Americans served by
• 2:55
  - the Blues
• 2:57
  - plans. And I know you've seen a lot
• 2:59
  - of the the most recent projections from from
• 3:01
  - consulting groups, from benefits firms over this last
• 3:04
  - month or so throughout this summer, projecting
• 3:07
  - health care cost increases of anywhere from nine
• 3:09
  - to 11%
• 3:11
  - going to next year. The drivers some of
• 3:13
  - the drivers, they're they're familiar on our end.
• 3:16
  - Catastrophic claims,
• 3:18
  - are increasing,
• 3:19
  - especially drug spending around GLP ones, oncology drugs,
• 3:23
  - provider consolidation.
• 3:25
  - New this year, AI enhanced billing practices showing
• 3:27
  - up in actuarial reports for the first time,
• 3:30
  - and I know the association has put out
• 3:31
  - some really interesting research around that this year.
• 3:34
  - And then, of course, the IDR process under
• 3:36
  - the no surprises act. So
• 3:38
  - all that being said, what are you watching
• 3:40
  - most closely
• 3:42
  - going into the next year?
• 3:43
  - Yeah. Well, where where we start is,
• 3:46
  - is is just looking at the impact that
• 3:48
  - rising costs have on real families because this
• 3:51
  - is an abstract for millions of people every
• 3:53
  - day. They you know, we're we're all paying
• 3:55
  - more
• 3:57
  - for gas, for groceries,
• 3:58
  - housing, health care.
• 4:00
  - For folks who are living paycheck to paycheck,
• 4:02
  - like, it is a daily struggle. And so
• 4:04
  - that's truly what drives us,
• 4:07
  - to take on some of these, cost drivers.
• 4:10
  - And and when you actually add in the
• 4:11
  - family budget and all those things I mentioned,
• 4:14
  - you gotta start making trade offs when costs
• 4:16
  - continue to go up across the board. And
• 4:18
  - in health care,
• 4:20
  - you know, we see folks skipping or or
• 4:22
  - stretching a medication,
• 4:24
  - because it costs too much. We see folks
• 4:26
  - skipping an appointment because of the cost. And
• 4:29
  - and that's why for Blue Cross Blue Shield,
• 4:32
  - fixing the affordability
• 4:33
  - crisis truly is our number one priority. It
• 4:36
  - has been we have been, I think, the
• 4:37
  - most vocal
• 4:39
  - payer out there trying to push solutions
• 4:42
  - on many of those cost drivers that you
• 4:43
  - just mentioned,
• 4:44
  - because we do hear from our pay our
• 4:46
  - our customers every single day, the businesses that
• 4:49
  - we partner with.
• 4:50
  - You know, you hear
• 4:52
  - folks say that this is unsustainable, and and
• 4:54
  - certainly 10 plus percent increases year over year
• 4:57
  - is unsustainable.
• 4:59
  - And that's why we are pushing so hard
• 5:02
  - on solutions
• 5:03
  - that can truly try and and mitigate some
• 5:05
  - of these pressures.
• 5:07
  - The the the hard thing though is that
• 5:09
  - it's no no single cost driver. Like, you
• 5:11
  - just mentioned three or four of them. You
• 5:14
  - know, it's a combination of all these factors.
• 5:16
  - But the bottom line is when the cost
• 5:18
  - of care goes up,
• 5:20
  - the cost of coverage goes up. And that's
• 5:22
  - truly just simple math. You know? It's like
• 5:24
  - it's like when you build a house or
• 5:26
  - build a car, if the cost of the
• 5:28
  - materials go up, the cost of the house
• 5:30
  - or the car goes up. And so we
• 5:32
  - are truly trying to drive solutions,
• 5:35
  - that can bring down the pressure on those
• 5:38
  - cost drivers,
• 5:39
  - and and hopefully bring some relief to to
• 5:42
  - the American people. Yeah. No. Absolutely. And I
• 5:44
  - appreciate you humanizing what some of the the
• 5:46
  - real life impact of of these,
• 5:49
  - more granular issues that you and I are
• 5:51
  - are talking about on a daily basis, and
• 5:53
  - how it affects
• 5:54
  - real people. It seemed like this year, especially
• 5:57
  - on on on insurers' earnings calls,
• 6:01
  - in in rate filings,
• 6:03
  - for for marketplace coverage,
• 6:05
  - we were seeing the IDR process, the arbitration
• 6:07
  - system under the no surprises act really start
• 6:09
  - to pop up more and more. And I
• 6:11
  - know it's not a new issue in terms
• 6:13
  - of a cost pressure, but it seems to
• 6:15
  - be or or it is intensifying.
• 6:17
  - So I wonder if you can contextualize for
• 6:19
  - that for us.
• 6:21
  - Like we mentioned, there's a lot of different
• 6:22
  - things pressuring costs going into next year.
• 6:26
  - What's what's the
• 6:28
  - where does the, the no surprises, the IDR
• 6:31
  - process fit into that broader picture? Just how
• 6:33
  - big of a deal is this right now?
• 6:35
  - Yeah. That's a great question and a really
• 6:37
  - timely one, because it is undoubtedly one of
• 6:40
  - those pressures that that is driving premiums higher.
• 6:43
  - And what's unfortunate about it is that the
• 6:45
  - no surprises act, the legislation that was actually
• 6:47
  - passed with bipartisan majorities,
• 6:50
  - solved a real problem for patients, and that
• 6:53
  - was eliminating
• 6:54
  - surprise medical bills. You know, millions of people
• 6:56
  - got these from doctors and hospitals and others
• 6:58
  - that,
• 6:59
  - were unexpected and often ran, you know, thousands
• 7:01
  - of dollars.
• 7:02
  - The problem though is that the arbitration process
• 7:06
  - now how to resolve those, you know, billing
• 7:08
  - disputes between payers and providers.
• 7:10
  - That's the process is now driving overall costs
• 7:14
  - higher, not just for patients, but businesses,
• 7:17
  - every day.
• 7:18
  - Just last week, researchers at Georgetown,
• 7:21
  - put out a study that said in just
• 7:23
  - a couple of years,
• 7:25
  - the price tag on that process is $22,000,000,000.
• 7:29
  - That's in administrative fees. That's in awards that
• 7:32
  - are above market rates.
• 7:34
  - And and the
• 7:35
  - business group on health recently estimated that nearly
• 7:38
  - a third of the premium increases that we're
• 7:40
  - seeing can be attributed
• 7:42
  - to this problem.
• 7:44
  - And and, unfortunately, when you look at the
• 7:46
  - trends,
• 7:47
  - they really are getting worse. And and it's
• 7:50
  - being, honestly, it's just being gamed by a
• 7:53
  - small group of
• 7:54
  - of private equity backed providers, and they're maximizing
• 7:58
  - revenue. Because when you look at the data,
• 8:01
  - there are two things that are really driving
• 8:02
  - it, and that's the volume of claims
• 8:05
  - and the amount of the awards.
• 8:07
  - So the on on the claims and the
• 8:09
  - volume, it truly is being, like, flooded with
• 8:11
  - these cases,
• 8:12
  - many of which aren't even ineligible or they
• 8:15
  - are ineligible.
• 8:17
  - That same study said that claims grew by
• 8:19
  - 77
• 8:20
  - last year.
• 8:21
  - We're talking millions and millions of claims over
• 8:24
  - the estimated, you know, ten, twenty thousand claims
• 8:27
  - that should that CMS originally estimated.
• 8:30
  - And of those,
• 8:31
  - our estimates are that 40% of them should
• 8:34
  - not be heard in the first place, yet
• 8:36
  - half of those actually result in awards and
• 8:39
  - required payments.
• 8:41
  - And that's the second part of the problem
• 8:42
  - is that the awards we're seeing
• 8:45
  - are just egregious. You know, there
• 8:48
  - was a a a a nearly a $500,000
• 8:50
  - breast reduction.
• 8:51
  - There was a CT scan that normally costs
• 8:54
  - around $2,100,
• 8:55
  - was almost $40,000.
• 8:58
  - So it's it's a group of providers that
• 9:00
  - are staying out of network so they can
• 9:02
  - go through that process to get those awards.
• 9:05
  - And and the awards are typically,
• 9:07
  - you know, four to 500%
• 9:10
  - higher than the market rates. And the market
• 9:12
  - rates are negotiated by plans and doctors,
• 9:16
  - every day in their local markets.
• 9:18
  - And so those higher payments really do ripple
• 9:20
  - through the system, you know, flowing down into
• 9:23
  - premiums. And that's why we have really tried
• 9:25
  - to put
• 9:26
  - targeted reforms,
• 9:28
  - tightening eligibility,
• 9:29
  - you know, arbiter oversight,
• 9:31
  - and really just some guardrails over the account
• 9:34
  - over the the entire process to really just
• 9:36
  - rein it in because it is a broken
• 9:38
  - process that really is driving costs higher. Yeah.
• 9:40
  - No. Absolutely. And I know, just going off
• 9:43
  - of that Georgetown study that you just cited,
• 9:46
  - put out last week, the $22,000,000,000
• 9:48
  - in excess spending over the initial four years,
• 9:52
  - that's up from an initial $5,000,000,000 estimate from
• 9:54
  - the year prior.
• 9:56
  - I know providers have been winning roughly 86%
• 9:58
  - of disputes. The dispute volume hit 2,600,000
• 10:01
  - cases last year, and it's running even higher
• 10:04
  - in the first half of this year. And
• 10:06
  - then, of course, the system has seen more
• 10:07
  - than 17,000 new disputes roughly every two days,
• 10:10
  - and that's according to the Georgetown
• 10:12
  - research.
• 10:13
  - We've seen a lot of,
• 10:15
  - like like you mentioned, plastic surgery, radiology, orthopedic
• 10:18
  - cases seem to really be
• 10:20
  - at the heart of a lot of this.
• 10:22
  - And I know this has also become a
• 10:23
  - really,
• 10:24
  - a hot button political issue because every time
• 10:27
  - new research is put out, a new news
• 10:29
  - article, new analysis,
• 10:31
  - another side comes in with their perspective on
• 10:33
  - why that new research is quote, unquote, wrong.
• 10:36
  - And so
• 10:37
  - for for the for the health plan executives
• 10:39
  - listening in, David, can you walk us through
• 10:43
  - how is this actually flowing down to premiums,
• 10:46
  - what the real world cost impact looks like
• 10:48
  - for the employers,
• 10:50
  - ultimately, for for the members.
• 10:52
  - I know you said
• 10:53
  - a third of premium increases now can trace
• 10:56
  - back to this.
• 10:58
  - But can you explain the pipeline from from
• 11:00
  - the IDR, the arbitration
• 11:02
  - system back down to the premium itself?
• 11:06
  - Sure.
• 11:06
  - When a when a provider stays out of
• 11:09
  - network, that means there is not a negotiated
• 11:11
  - market price between local providers and local plans.
• 11:15
  - To us, that is the most important
• 11:18
  - data point is because that is a market
• 11:21
  - rate. Like, that is what the
• 11:23
  - the the private parties have agreed upon.
• 11:25
  - And when that is not,
• 11:27
  - utilized
• 11:28
  - or or at least, not even part of
• 11:31
  - the equation,
• 11:32
  - you have groups that will stay out of
• 11:34
  - network
• 11:35
  - and deliberately use this as a business model.
• 11:37
  - So they will continue to seek care, but
• 11:40
  - use this process,
• 11:43
  - for routine services. You just, you know, mentioned
• 11:46
  - a few of them.
• 11:47
  - And and and what we're seeing is that
• 11:49
  - when they
• 11:51
  - get awards that are, you know, 400, 500,
• 11:54
  - a thousand percent higher than those market rates,
• 11:57
  - someone has to pay in the end.
• 11:59
  - And the way that that businesses have seen
• 12:02
  - this, you know, self funded companies across the
• 12:04
  - country, and we're talking huge companies, you know,
• 12:06
  - Fortune 10 companies, Fortune 100 companies,
• 12:09
  - who in the end, when they provide coverage
• 12:11
  - to their members and they are the ones
• 12:13
  - that are that are truly paying
• 12:16
  - tens of millions of dollars that are unexpectedly
• 12:18
  - I mean, they're basically getting surprise
• 12:21
  - surprise billed at this point.
• 12:23
  - And they have to come up with hundreds
• 12:25
  - of millions of dollars in these awards. They
• 12:27
  - have to make up for that somewhere.
• 12:29
  - And in the end, where it's made up
• 12:31
  - is in higher premiums.
• 12:33
  - It's just one of those underlying
• 12:35
  - cost pressures that,
• 12:37
  - you know, businesses,
• 12:39
  - unions as well, unions that run their own
• 12:41
  - health plans,
• 12:42
  - that cover, you know, tens of millions of,
• 12:45
  - of union members across the country, they are
• 12:47
  - also seeing the same pressures.
• 12:50
  - So when you have bipartisan
• 12:51
  - policymakers,
• 12:53
  - seeing the consequences of this broken process,
• 12:56
  - You also see businesses and unions coming together.
• 12:59
  - I mean, very seldomly do you see, you
• 13:01
  - know, businesses and labor working together.
• 13:04
  - But we have been locked in arms because
• 13:06
  - we are partners with trying to drive costs
• 13:09
  - down,
• 13:10
  - and reforms to the process can actually drive
• 13:12
  - those costs down. But we really need to
• 13:15
  - put those guardrails in so those, you know,
• 13:18
  - initial claims
• 13:20
  - don't result in higher premiums when those, you
• 13:22
  - know, hundreds of millions of dollars in awards,
• 13:26
  - fall onto
• 13:27
  - businesses and unions and and consumers across the
• 13:30
  - country. Certainly. And I and I'm glad you
• 13:32
  - brought that that last point up there, David,
• 13:34
  - around how public employers are really being affected
• 13:37
  - by this because we we've heard similar from
• 13:39
  - other insurers,
• 13:40
  - out there talking about how unions,
• 13:42
  - municipalities,
• 13:43
  - state,
• 13:44
  - employee plans have really been hit hard disproportionately
• 13:48
  - by this issue.
• 13:49
  - I wonder, you know, one critique we've heard,
• 13:52
  - about,
• 13:53
  - the the high provider win rate, from
• 13:56
  - provider groups saying that that just reflects money
• 14:00
  - that they were originally owed.
• 14:01
  - That stat that reflects insurers,
• 14:04
  - lowballing them from the beginning in their words.
• 14:07
  - How would you respond,
• 14:08
  - to that to that critique?
• 14:11
  - Yeah. I I I don't buy it,
• 14:14
  - because when these awards
• 14:16
  - are so outrageous and so unreasonable,
• 14:19
  - when they are, you know, 500%
• 14:22
  - above a truly a market rate that has
• 14:24
  - been privately negotiated between the parties,
• 14:28
  - that doesn't mean that we're low balling. That
• 14:30
  - means that the arbiter themselves, the IDR entity,
• 14:34
  - is choosing to side with the providers.
• 14:37
  - And and the reasons we see that, honestly,
• 14:40
  - are because the process is truly designed to
• 14:42
  - incentivize
• 14:43
  - more volume.
• 14:45
  - The arbiters themselves, they get paid when they
• 14:49
  - actually make a decision on a claim.
• 14:51
  - So and and we've seen tremendous growth in
• 14:54
  - the administrative fees that these arbiters are actually,
• 14:58
  - taking in over the years. So more than
• 15:01
  - a billion dollars
• 15:02
  - and just in the last couple of years.
• 15:04
  - And so when you have providers who wanna
• 15:07
  - stay out of network and maximize maximize their
• 15:09
  - revenue through this process,
• 15:11
  - and you have arbiters who want them to
• 15:14
  - submit claims so they can rule on the
• 15:16
  - claim
• 15:17
  - and make the award and therefore themselves get
• 15:19
  - paid,
• 15:20
  - it really is incentivizing
• 15:22
  - more volume and higher awards.
• 15:24
  - And so, we just need to bring balance
• 15:27
  - to the process, and we have some solutions
• 15:29
  - that we've been pushing
• 15:30
  - along with those businesses, along with those unions
• 15:33
  - and and patient groups,
• 15:35
  - that shine a spotlight into the arbiters themselves
• 15:38
  - to ensure that they're being balanced and and
• 15:40
  - not biased,
• 15:42
  - rooting out those ineligible claims to begin with,
• 15:45
  - and then using real market rates
• 15:47
  - to help determine more reasonable awards. We think
• 15:50
  - that it's a you know, a a lot
• 15:52
  - of,
• 15:53
  - things in health care seem intractable.
• 15:56
  - The good news is this is a process
• 15:58
  - problem.
• 15:59
  - And and I know it's complicated, but at
• 16:01
  - the same time, there are reforms that can
• 16:03
  - go into place,
• 16:05
  - to really turn around some of the egregious
• 16:07
  - trends that we're seeing. Yeah. No. Certainly. And
• 16:09
  - I do wanna get into possible solutions and
• 16:11
  - reforms in just a second. But I I
• 16:13
  - did wanna make sure to ask you in
• 16:14
  - terms of what you're hearing and seeing from
• 16:16
  - employers,
• 16:18
  - how this is all affecting their benefit design
• 16:21
  - decisions, especially as we go into next year
• 16:23
  - renewal season, and how the leaders the health
• 16:26
  - plan leaders listening to this right now should
• 16:28
  - be thinking about protecting their employer clients around
• 16:30
  - this issue?
• 16:31
  - Yeah. Well, employer provided coverage has has been
• 16:34
  - a bedrock. It's been the foundation of our
• 16:36
  - health care system and certainly our coverage for,
• 16:39
  - for many, many decades. And so what we
• 16:42
  - should be focusing on are solutions that actually
• 16:45
  - bring down costs and and reduce the burden
• 16:48
  - that businesses across the country, both big and
• 16:50
  - small, are facing every day. And and like
• 16:52
  - I started with those individuals,
• 16:55
  - businesses make those same kind of trade offs
• 16:57
  - when they see
• 16:58
  - upcoding and consolidation and the pressures that you
• 17:01
  - mentioned, not to mention just,
• 17:03
  - the the typical pressure we see on pharmaceutical,
• 17:07
  - pricing.
• 17:08
  - So
• 17:09
  - employers have really struggled and have made trade
• 17:11
  - offs to increase co coinsurance and and cost
• 17:15
  - sharing with employees.
• 17:16
  - They've trimmed benefits,
• 17:18
  - in many cases,
• 17:19
  - and and that puts a burden on, you
• 17:22
  - know, their employees to access the care that
• 17:24
  - they need. And so,
• 17:27
  - that's only sustainable for, you know, a short
• 17:29
  - amount of time. That's why these long term
• 17:32
  - root causes
• 17:33
  - of rising costs are, so important to address,
• 17:37
  - because the longer that businesses shoulder that burden
• 17:40
  - of of rapidly rising health care costs,
• 17:43
  - the worse the consequences and the worse the
• 17:45
  - trade offs are gonna be, when it comes
• 17:47
  - to covering their employees. And and I'd also
• 17:49
  - even say all these cost drivers that we've
• 17:51
  - talked about,
• 17:53
  - except for IDR, which is somewhat limited, it
• 17:55
  - it affects every single market, whether you're covered
• 17:58
  - through Medicare or Medicaid,
• 18:00
  - the exchanges or private insurance through an employer.
• 18:03
  - You know, rising hospital costs, consolidation,
• 18:06
  - technology,
• 18:08
  - GLP one expansion.
• 18:10
  - All of those are cost pressures no matter
• 18:12
  - where you get your coverage. So that's why
• 18:14
  - we at at the Blues,
• 18:16
  - place such a high priority because it really
• 18:18
  - does affect everyone across the country.
• 18:21
  - So, David, in in talking about what could
• 18:23
  - be done
• 18:23
  - about all of this,
• 18:25
  - obviously, as you know, there was a an
• 18:27
  - operations rule finalized by the administration in May
• 18:30
  - to lower administrative fees, trying to streamline some
• 18:33
  - of this process, but insurers broadly, the industry,
• 18:36
  - including the association, said it didn't go far
• 18:38
  - enough,
• 18:39
  - to address some of these issues.
• 18:40
  - And then, legislatively, we've we've seen the no
• 18:43
  - surprises act enforcement act introduced.
• 18:46
  - I know that's not, in favor by insurers.
• 18:49
  - And, of course, you know, the the physician
• 18:51
  - groups, the AMA and other specialty physician groups,
• 18:55
  - are are fighting to preserve
• 18:57
  - this process as it is. And so
• 19:00
  - what what's the path forward look like in
• 19:02
  - congress, and and what are you hearing in
• 19:03
  - terms of, what actually might be possible right
• 19:06
  - now? Yeah.
• 19:07
  - You mentioned the operations rule, and and there
• 19:10
  - was some cleanup that was necessary. And overall,
• 19:12
  - it was helpful,
• 19:14
  - though it did lower the barrier to file
• 19:17
  - a claim,
• 19:18
  - which we think will simply increase volume. We're
• 19:21
  - we we think you need to decrease volume
• 19:23
  - and really target it to those
• 19:25
  - disputes that are that are more legitimate.
• 19:28
  - So while it was helpful, I think it
• 19:30
  - did have a pretty significant,
• 19:32
  - consequence.
• 19:33
  - I think the first I've mentioned it is
• 19:35
  - is just stopping these ineligible
• 19:37
  - cases, and you can do that by restructuring
• 19:40
  - the fees
• 19:41
  - and also by just screening them out early
• 19:43
  - in the process so that, you know, arbiters
• 19:46
  - are not incentivized to move them through and
• 19:48
  - be compensated even though they may be ineligible.
• 19:51
  - And, also, it will it will make the
• 19:53
  - process just more efficient. You know, we had
• 19:56
  - one plan that said a single provider group
• 19:59
  - filed about 350
• 20:01
  - disputes a day,
• 20:03
  - and 80% of them were ineligible. And just
• 20:06
  - by gumming up the works, it allows the,
• 20:09
  - more high cost,
• 20:11
  - claims to, you know, sometimes go unanswered because
• 20:13
  - we simply can't respond to all of them.
• 20:16
  - So I think on the front end, that's
• 20:17
  - the most important thing that happened.
• 20:19
  - Secondly,
• 20:21
  - real transparency
• 20:22
  - and accountability for these decisions.
• 20:25
  - We've been,
• 20:26
  - you know, happy to see a lot more
• 20:28
  - coverage and by Becker's and many other national
• 20:31
  - outlets that are looking at this,
• 20:33
  - and and shining a spotlight on the problem.
• 20:37
  - And we think that, that leads to accountability
• 20:40
  - for the decisions and for the process. It
• 20:42
  - has been a black box, and we think
• 20:44
  - there are reforms that can happen,
• 20:46
  - to provide that transparency and accountability.
• 20:49
  - And then I think looking at the,
• 20:52
  - middlemen who are
• 20:53
  - really abusing this process,
• 20:57
  - by making it a business model. You know,
• 20:59
  - there was a one company, HaloMD.
• 21:01
  - It didn't exist before the no surprises act,
• 21:04
  - and now it accounts for more than half
• 21:07
  - of all
• 21:08
  - claims that are filed.
• 21:09
  - So they are, you know, a private equity
• 21:12
  - backed company, and, they're they're doing what they
• 21:14
  - should,
• 21:16
  - you know, trying to maximize revenue.
• 21:18
  - But it's maximizing revenue on the backs of
• 21:20
  - businesses and and unions and patients.
• 21:23
  - And we think that there are some reforms
• 21:24
  - that that really need to happen
• 21:26
  - to clean up the process. The ones I
• 21:28
  - just walked through are more on the administrative
• 21:31
  - side, and we think the Trump administration,
• 21:34
  - has, has acknowledged that there are lots of
• 21:37
  - problems with this process that they can take
• 21:39
  - action to move.
• 21:40
  - But congress is increasingly being
• 21:43
  - asked to take a second look at it
• 21:45
  - as well. And there are bipartisan leaders in
• 21:47
  - both the house and senate that are looking
• 21:49
  - at this.
• 21:50
  - And, fundamentally,
• 21:52
  - restoring the
• 21:54
  - qualified payment amount and those those privately negotiated
• 21:57
  - market rates in each of in each of
• 21:59
  - the local markets,
• 22:01
  - that is where we should start the debate
• 22:04
  - around what is a reasonable award.
• 22:06
  - And and centering that, as part of the
• 22:09
  - congressional debate,
• 22:10
  - we think can really turn around the problem.
• 22:13
  - Yeah. Absolutely. And just for fairness sake, David,
• 22:15
  - I do wanna make sure, to put it
• 22:17
  - on the record for our listeners that HaloMD
• 22:19
  - has disputed to us on the record that
• 22:21
  - they are not private equity backed.
• 22:23
  - But before we go,
• 22:25
  - anything else we're missing on this topic? Anything
• 22:28
  - else you want to make sure to highlight
• 22:30
  - or any advice you'd wanna offer,
• 22:33
  - the other industry leaders listening in?
• 22:36
  - Yeah.
• 22:37
  - Look. This is a process that can be
• 22:39
  - fixed.
• 22:41
  - This is not one of those intractable
• 22:43
  - intractable
• 22:44
  - problems.
• 22:45
  - We just need policymakers
• 22:47
  - to really take action. And, you know, the
• 22:49
  - trend lines
• 22:50
  - are really troubling.
• 22:52
  - And every business we talk to, every union
• 22:54
  - group we talk to, if these continue to
• 22:57
  - drive and and escalate at this at this
• 23:00
  - rate that we're seeing,
• 23:02
  - it will cost, you know, tens and hundreds
• 23:04
  - of billions of dollars over the course of
• 23:07
  - the of the coming years. So this is
• 23:09
  - a snowball that is,
• 23:11
  - growing. It's still fairly small, but it can
• 23:14
  - pick up a lot of speed if these
• 23:16
  - trends aren't reversed.
• 23:17
  - And we know that there are common sense
• 23:20
  - solutions that both regulators and legislators can take
• 23:23
  - to clean up the process. And and there's
• 23:25
  - something states can even do. This is all
• 23:27
  - about the federal process. You don't see a
• 23:30
  - lot of these problems in states that have
• 23:32
  - a reasonable state process.
• 23:35
  - California is a good example where they've they've,
• 23:38
  - minimized a lot of this because they have
• 23:39
  - good guardrails in place.
• 23:41
  - So
• 23:42
  - we just want policymakers take a a really
• 23:45
  - close look and take immediate action before the
• 23:48
  - problem gets too big.
• 23:50
  - David, can't thank you enough for taking the
• 23:52
  - time to chat with us, for simplifying what
• 23:55
  - is a very complicated
• 23:56
  - issue.
• 23:58
  - Thank you for being with us. Glad to
• 24:00
  - do it. Appreciate you, having me on, Jacob.
• 24:03
  - Thanks. Absolutely. Anytime. And to our listeners, if
• 24:05
  - you'd like to listen to more podcasts from
• 24:08
  - Becker's, you can visit beckershospitalreview.com.