AMA President: "Blame Insurers"
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Wednesday, February 20, 2019 04:12 PM

Blame the insurer when a patient gets a massive bill because a treating clinician was outside the insurer’s network, said Barbara McAneny, MD, president of the American Medical Association (AMA). The problem with such so-called “surprise billing” is that insurers have not fought hard enough to protect their patients.

“I look at it as … inadequacy of the insurance companies to successfully negotiate a network. I recognize that [insurers] make more money when they have a very narrow network, but that’s not fair to patients who expect full coverage," McAneny said. She said insurers and insurance commissioners must insure that networks aren’t so narrow that essential slices of the healthcare workforce are excluded. 

The AMA and dozens of other medical societies expressed concerns regarding out-of-network “surprise" bills and have pressed Congress to hold insurers accountable for these surprise charges, calling for stronger network adequacy standards, suggesting patients pay only in-network cost-sharing rates, and urging that any legislation lawmakers pass include a process of mediation or "alternative dispute resolution."

The AMA opposed capping physician payment for out-of-network charges using a benchmark such as Medicare rates.  There are those health plans that we can cost-shift from, and there are those health plans that we can cost-shift to. With commercial payers I have to negotiate a sufficient rate that I can fill in the Medicare hole, the Medicaid hole, the Indian Health Services hole, where it’s below my costs of operation.  When we hear these proposals where the insurance companies don’t want to have to negotiate fairly with me, they want to just say, “Well, we’ll pay you Medicare rates,” what they’ve done is put some of the commercial plans and included them in the column which do not adequately cover operating costs.

I am required to have a number of certain things in order to practice. I’m required to do HIPAA security plans. All those things are important, but they're not accounted for in the costs of what we pay for Medicare or Medicaid, or the Indian Health Service. So, if we're going to have a system, we have to recognize that there's certain costs to delivering care, and we don't have a way around that. We have to cover those costs.

The AMA supports universal healthcare. We want everyone to have access to healthcare, but because Medicare pays for 80% of the cost of doing care, if the whole country is paying 80% of my cost, do I tell my nurses that they get a 20% pay cut? Can I go to the light company and say "You should only charge me 80% of my light bill?" How do I manage those costs?

The AMA policy is still to have a whole menu of different healthcare options for patients and doctors across the country. One size is not gonna fit all and therefore we need to be able to have a health payment system that mirrors what physicians are doing in a given specialty in a given market. And that's why we think that having anyone just lay down the law and say "here's the deal" is not going to work for a lot of specific markets.

What are your priorities for the opioid epidemic?  We need less stigma and we need more people who know how to treat opioid use disorder.  What we do not need are artificial caps on prescription amounts because there are patients who are stable and functional with chronic pain who can be productive members of society, whose doses are not increasing, and they're not diverting drugs. The legislatures of various states should not be in the prescribing business.

As an oncologist, my drugs are incredibly expensive, and it’s terrible for my patients who have to pay a level of copay or coinsurance to afford these life-saving drugs. However, [pharmacy] benefit managers (PBM) account for about 42% of the price. They may initially have provided some useful function, but now I believe that they just add to cost, and I do not believe they add any value. Part of the PBM's process is orchestrating higher rates and therefore higher co-pays for patients at the point or service -- the pharmacy counter. And often the cost that they would pay out-of pocket is less than their copay, if they only knew that.  So, we are very much in favor of getting rid of those gag clauses.