Transcripts For CSPAN House Ways Means Hearing On Surprise Medical Bills 20240714

Were getting this going after votes. The house subcommittee will come to order. Brief Opening Statements and then two panels. Welcome all of you for coming. This is the Third Session of congress in which i have introduced legislation to ban the practice of surprise billing. Todays bipartisan hearing represents an initial effort by this committee to finally offer some relief to patients whove been bearing the brunt of a dispute between their insurers and some of their Health Care Providers. For patients, you can take all the right steps in attempting to see that your care network is covered but you may still face big bills. One in seven americans have received a surprise bill as part of receiving care at a hospital that is actually within their Insurance Network. The problem in san antonio, one of the communities that i represent, has been so extensive that jay avola has initiated an entire Television Series called show me your bill. And i think a quick video clip from that adequately demonstrates the problem. Ill ask that it be shown at this point. [video clip] twothirds of americans say they worry about receiving an unexpected medical bill. A surprise bill you thought your insurance would cover. Tonight news 4 troubleshooter jay alvarez launching a way to fight back. Show me your bill. There are two main types of surprise bills. When you go to an emergency room thats not in your Insurance Network and they charge you for the portion your plan wont pay, or one of the doctors isnt in network. So you get a big bill from them. Then you get the runaround trying to straighten it all out. But starting tonight, show me your bill and well go to bat for you. Lavera vincent is a good example. She paid 750 a month for insurance coverage. One day she began suffering chest pain and says she actually called ahead to make sure the emergency room took her insurance. I got this cardiac issue going on but im still going to make sure im doing the right thing financially for me. And so they assured me that yes, i am in network. But, surprise. The metropolitan Methodist Emergency Center wasnt in network. Neither was Northeast Methodist Hospital where she was transferred for further testing. The total charge for two night hospitalization, 31,000. Laveras insurance paid only what it says was reasonable and customary. 9,700. Methodist health care billed her for the rest. 22,000. Ive never had a bill collector call me ever. And its a horrible feeling. Lavera says bmpefore it got to this point, she tried for two years to negotiate with both methodist and her Insurance Company. I felt like i was on a ferris wheel. I would get somebody and theyd say im not the person. Id tell somebody else my story, they would transfer me somewhere else. So she showed me her bill. After several phone calls i got a response from allied national who blamed the situation on the provider Methodist Health care. The provider is billing ms. Vincent their retail rate which no Insurance Company ever pays. Most providers when they take the time to look at the reimbursement rate would be more than satisfied with the payment made by her health plan. So i contacted Methodist Health care which said the Insurance Company was at fault. Ms. Vincents Insurance Plan limited her coverage. Allied insurance paid an arbitrary rate of reimbursement that did not appropriately cover the costs of Services Provided to ms. Vincent. At least i was able to go back and see her with gootd news. Methodist hospital says it has accepted what her insurance paid and canceled the rest of her bill. Instead of 22,000, she now owes nothing. I feel so relieved. I am so grateful. And i know shes relieved, but we cant rely on Media Exposure to solve these problems. Shes also not a typical consumer caught in this situation. She served as executive director of the San Antonio Restaurant Association and yet she had these kind of difficulties. Another example is drew calvert, a Public School teacher with Health Insurance from his school job. He received out of network care after a heart attack and he almost had another heart attack when he got the 100,000plus bill. Only after his story was reported at kut austin for npr did he get relief as the story got out. Others got relief also and drew was invited to the white house to tell his story with the president. With nams consent, im entering his statement about his experience into the record. But as we move forward, we have some protections from the states that are being implemented. In fact, one that was improved in texas last evening. But i think well hear that federal action is essential since in texas, for example, 40 of insured individuals are insured under arisa plans. To address the gap in protection, the in surprise billing act which i referred to is designed to protect insurance patients from being trapped between an insurer and an out of Network Provider. Its the sole focus of the bill. Originally that concept when i first introduced it faced a great deal of opposition. In texas, for example, the only remedy until this until yesterday and a bill that i think is not finally approved in the legislature, the only remedy offered was for the patient to negotiate directly with the Health Care Provider in a little known mediation system that has helped some but omitted many. Fortunately there now appears to be a growing consensus, most recently joined by President Trump, that holding the patient harmless should form the foundation for any surprise billing proposal. Under the legislation that i advance, patients would only be charged in network costs in emergency situations. In nonemergency situations, out of Network Billing would be permitted only after receiving effective notice regarding any providers and Services Together with estimated charges. No other bill addressing this issue has yet been filed here in the house. But there is a very useful discussion draft proposal that is being circulated on a bipartisan basis by the house energy and Commerce Committee. And theres several proposals that have serviced in the senate. While every proposal currently begins with the basic premise of the in surprise billing act, conflict remains on how to ensure provider disputes. Thats what well hear about today from those that have the most direct stake in it. Our house subcommittee hearing has been organized on a bipartisan basis to hear what they have to say to see if we can find ways of resolving that dispute. But my primary concerns remains to ensure that nothing stands in the way of federal action to remove the patient from being in the middle of a dispute. That the patient cant control. The leading proposals have pros and cons that well hear about. And i think that while condemning surprise billing, President Trump has rejected two principal approaches. One for arbitration and one for rate setting. And its unclear exactly which proposal he supports, but i think his support is very important to resolving this. The administration has offered bundling payments as a result as well. I support any solution that can get 218 votes here in the house and protect patients, gain senate approval, and his signature. And i look forward to the discussion that well have today to identify points of agreement so that patients no longer bear the brunt of this dispute. And with that, i would ask mr. Nunes for his opening statement. Thank you, mr. Chairman. I appreciate your willingness to work in a bipartisan manner on this important issue. I want to thank all of you for your attendance here today. Theres going to be a lot of perspectives and im very grateful for the members of congress that are here today. Miss porter and miss mcmorse rogers. Unfortunately, butler cannot be here because shes nine months pregnant. So hopefully everything is going well and hopefully she doesnt receive any surprise billing. But i want to be clear. Critical sectors from our economy could not come to find a way to Work Together to protect patients from these huge surprise bills. Instead we are here exploring a government solution to the problem. Weve all heard the ridiculous stories. 600 bandaids, 60 ibuprofen, 5,751 ice pack. The patient with the 5,000 ice pack reportedly went to the emergency room after hitting her head and cutting her ear but ended up leaving without care because the Plastic Surgeon who would see her was an out of network for her Insurance Plan. She wanted to avoid a big bill so she left the ice pack and a bandage. Her Insurance Plan paid 862 which it deemed appropriate and responsible fee for services. The hospital then sent the patient a bill for 4,889. My state of california already has a pretty robust protections against balance billing patients. Going so far as to set a requirement reimbursement scheme. Which im sure some of you like and some of you do not like. But im not interested in watching a food fight between everyone. I want to hear common sense targeted solutions that can help solve different aspects of the surprise billing problem. I want to talk about the policies that increase price transparencies. And help make informed decisions about their health care. In nonemergency schedule situation, doctors and hospitals should be able to work with the Insurance Companies they contract with to get patients an estimate of their total cost of care and their total cost sharing obligation before they get services. Or treatment. And patients should be notified about whether or not the Health Care Providers who will be involved in their care in their Insurance Network. That could go a long way with preventing these eyepopping bills. Another type of surprise happens when people were unknowingly seen by an out of network doctor. Perhaps hospitals responsible for those practices in the walls should be held responsible for issues between democracyoctors and Insurance Companies in such circumstances. One of them wont surprise the patient later with an out of Network Balance bill. To me the organizations represented on our second panel have the power and i would argue the responsibility to solve the issue for patients. I think there are a lot of different steps you should voluntarily take to protect your patients and policy holders. Many states are working on solutions either improving existing laws or creating new ones. I know both sides of the aisle in congress are interested to find a solution that protects patients. I look forward to all of the constructive testimony today. And i hope we can deliver some solutions. With that, i yield back. Thank you. Thank you for your helpful statement. We have two panels today. The first composed of two of our colleagues. Congresswoman katie porter, congresswoman Cathy Mcmorris rodgers. Mrs. Porter, if you begin. Thank you for holding this hearing today. I am concerned about surprise billing as someone whos dedicated my life to protecting consumers. But also because i have had to fight my own battle with surprise billing. On august 3rd last year when i was on the campaign trail, i started to feel pain in my abdomen. At 1 00 p. M. , i could not continue and i went home. At 4 31, i texted my Campaign Manager that i needed to go to the emergency room. I couldnt safely drive through the pain and i remember sitting on my front porch so if i lost consciousness, somebody might find me and i wouldnt be home alone. I didnt call an ambulance because i was concerned about the cost. I could not drive and i asked my manager to please take me to hoge hospital. I chose to hospital even though it was farther away from other providers because i knew hoge was an inNetwork Facility. When i got to the hospital, i waited six hours alone in the emergency exam room without treatment. When i finally went to surgery, my doctor told me it was nothing to worry about. Just a routine appendectomy. I was given anesthesia. When i awoke, the team around me was panicking. They couldnt get my temperature to drop and couldnt get the Blood Pressure to rise. My appendix ruptured hours before with an infection making my whole body sick. I spent the next five days in the hospital receiving powerful iv antibiotics. A few weeks later i received the bill from this Insurance Company. The idea of an astronomical medical bill weighed heavily on me. I was happy to see the cost of my emergency room treatment and assessment hospital charges and nearly all of my Inpatient Services were covered. I remember sitting at my Kitchen Table and taking a deep breath filled with relief. But a few days later, i received another bill. This one from my surgeon. While the hospital i had gone to was in network, the Insurance Company now claimed the surgeon was not. Even though they had sent me a notification telling me that my surgeon was in network. Enclosed in that bill for nearly 3,000 was a handout from my surgeon detailing the steps i would have to take while recovering in order to fight to have my Insurance Company cover the care. So many of his patients had been put in this situation, that this medical doctor had used his staff to address patient billing problems. Thats not what he trained for in medical school. These socalled explanations of benefits and the surgeons handout explained he was being treated as an out of Network Provider even though he was employed by and worked at an innetwork hospital. As someone in an emergency situation, i had no ability to assess whether he was in or out of network and in those cases. But i got that bill because my insurer put profits before patients. I called my Insurance Company to request an appeal. The benefits manager kept asking me questions to guide me and coach me toward saying that it was my surgeons fault, to blame him for overcharging me. She asked me to call the surgeon and attack my doctor for his bill. Apparently to anthem blue cross, 3,000 was too high a price for saving my life. The tens of thousands in premiums i paid to that company over the years were not enough to have them cause them to cover the lifesaving care. Nearly five months after i was hospitalized, the surgeon simply requested payment. And at that point, i reached out to my employer, the university of california irvine. Thats when i learned that uc irvine has a designated patient advocate. A medical doctor whose sole job is to help University Employees get the Health Insurance that the university and the employees pay for. Can we just reflect on that for a moment . The university is paying a medical doctor to do nothing but navigate insurance. Finally, the patient advocate invoking the fact that i had been just elected to congress, was able to get the Insurance Company to agree to pay my surgeons bill. But heres what i learned from getting sick. I am well educated. I had an employer prepared to help me. I have professional experience fighting for consumer rights. But there are thousands of americans with fewer resources than me who are surprised with bills far more devastating than mine. Im here today because i refuse to accept this as the status quo. I refuse to stand by while families go bankrupt because of Surprise Medical Bills. Any solution to this issue must rely must not rely on the patients ability to go to war with the insurer or with their provider. That is not the solution. Its time we start putting patients first. Thank you for inviting me here today. Thank you for sharing your experience, miss mcmorris rodgers. Thank you. Try this again. Ch thank you for holding this important hearing on protecting patients from surprise medical billings. Im grateful for your leadership to examine this problem so congress can work on a bipartisan solution. You know, theres so many stories out there. I was going to share another story of a lady from Washington State who had a massive heart attack and ended up in a surgery place, hospital in oregon which led to all kinds of challenges. And to save her life, she had bypass surgery, a valve replacement and repair. She ended up spending a whole month in the hospital recovering from the surgery ranging from an infection and needing more powerful antibiotics. She was discharged and she received her bill. She owed nearly 227,000. So this one was more than a surprise bill. It was massive. It was suppresstressful. And it was devastating. She eventually was able to get help and relief with a complicated medical charity care waiver. But it took six months of uncertainty and countless phone calls from collection agencies. It shouldnt have to be this way. Especially when someone is recovering from a heart attack. What makes this story even more painful is that nobody told her that she could have been transferred to an innetwork hospital. Which could have saved tens of thousands of dollars. As she said, there should be fairness and equality in the system. You shouldnt have to file a complaint. This should be engrained into the system so when you have a problem and youre due relief, you get it. And shes right. So whats the solution . There must be more transparency. Right now it is too difficult to be an informed patient. If your care is out of network and you will be charged for it, you should know. Im grateful that President Trump is making this a priority to end surprise billing. And i agree that this Congress Needs to work towards a bipartisan solution. Chairman pallone and Ranking Member walden on the energy and Commerce Committee is also working on this issue to protect patients and Keep Health Care costs down. We cant end end surprise billing and give patients the certainty they need over their health care. Again, there shouldnt be any surprises. People should be able to trust that they know how much theyre going to be billed especially when theyre in some of the most stressful situations of their lives. So thank you, everyone. All the members here today for participating in this hearing. I look forward to working with you. And the rest of my colleagues on the energy and Commerce Committee to address this issue. I will yield back. Thank you, both, for coming to share your experiences. Consistent with our committee practice. We wont have you stay for questioning, but we welcome your continued commitment to help us get this problem resolved. Thank you, both, very much. And ill ask our second panel to come up at this point. Thank you, all, for being here. Were pleased to have leadership from four groups that have a great interest in the problem weve been discussing. First id like to welcome Bobby Mukamala who is a head and neck surgeon who has worked with the board of trustees for the last couple of years. He practices in flint, michigan. Doctor, thank you for being here. And then miss Jeanette Thornton will be next. Shes more american insurance programs. She has helped physicians with omb and Social Security administration. Next well hear from tom nichols who is the executive Vice President for Government Relations and Public Policy for the American Hospital association. Hes previously worked with the American College of Emergency Physicians and the American Nurses association. And right here in the house previously as well. Finally the committee will hear from dr. James gelfin for arisa industry committee. So we appreciate each of you being here. Your statements will be made part of the record. As you know, we ask you is summarize your testimony in five minutes. Then well get underway with questions. The light system gives you a warning with the yellow. When you see the red light, if youll conclude your remarks. Doctor, would you begin . Good afternoon, chairman doggett, Ranking Member nunes, and members of the subcommittee. I am a Board Certified head and neck surgeon in private practice in flint, michigan, and a numbermember of the board of trustees. It is an honor to provide testimony on the important issue of unanticipated out of network care. Often referred to as surprise billing. I very much appreciate your willingness to explore solutions to this problem that have significant consequences for our patients. The ama has long been concerned about gaps in out of Network Coverage and is committed to working on solutions to protect patients from the Financial Impact of surprise coverage gaps. The ama believes that Workable Solutions can come in many forms. But the best solutions have several common principles at their core. First, protection for patients. Patients should be kept out of the middle of payment negotiations. In situations where patients do not have the opportunity to select an inNetwork Provider, they should not be charged any more than the innetwork amount and payments should count towards their deductibles. Second, Network Adequacy must be regulated. Krital to any billing solution is a focus on increasing theed a ed a adequacy. To ensure that appropriate market incentives remain in place, any solution must incorporate a mechanism to ensure fair payment to providers. Such mechanisms could include a minimum payment standard based on physicians races or billing arbitration process that requires the consideration of many factors. Finally, transparency in many forms is important. For example, all patients who knowingly choose to obtain scheduled Health Care Services from out of Network Services should be informed about their anticipated out of pocket costs. Regarding networked a question si. It is important to recognize that physicians very much want to be included in networks but want to be offered fair contracts. However, with nearly 57 of physicians in practices of ten or fewer physicians and with most Health Insurance markets highly concentrated, many physicians are in a weak position relative to commercial health insurers. Insurers need to be incentivized to offer fair contracts to physicians. And we recommend that congress recommend that congress facilitate this through the regulation of Provider Networks. To protect patients, Network Adequacy standards should include measurable on the front end before Insurance Products are brought to market. And factor in minimum time and distance requirements. Maximum ratios and maximum weightait times. The ama urges congress to avoid any solutions that set minimum payment standards for out of network care at noncompetitive rates. Any guidelines on out of Network Provider payment should reflect actual charge data for the same service in the same geographic area. Proposals that use inNetwork Rates as a benchmark for provider payments should be avoided. These rates are negotiated by physicians in plans during the contracting process. And fees are discounted in exchange for contracted benefits. Those companies that dont sit down to negotiate should not benefit from skipping that step. Sketing payments at these discounted rates favoring insurers. Its likely health plans would drop physicians from their networks knowing they could use our services for less when we are outside of their network. Payment benchmarks should not be based on medicare rates which do not reflect the costs of providing care. When you adjust for inflation and costs, medicare patient has declined 19 over the past 17 years. As such, linking rates to medicare would eliminate any incentive for insurers to build adequate networks or offer physicians fair contracts. Manipulation of insurer controlled data for these purposes have happened in the recent past resulting in real harm to patients and physicians. In conclusion, the ama looks forward to the opportunity to work with the committee to protect patients from unanticipated gaps in their coverage and to promote greater access to innetwork care. Thank you very much. Thank you, doctor. Miss thornton . Will you turn your microphone on there . Excuse me. Lets try this again. I am Jeanette Thornton senior Vice President of product employer and commercial policy for Americas Health Insurance Plans. I appreciate the opportunity to testify on solutions to protect the American People from Surprise Medical Bills. We want to end Surprise Medical Bills so that patients have the peace of mind in an emergency that they will not receive inflated bills from doctors it did not seek out for care and often never knew treated them. We have all heard personal stories that demonstrate the need for federal legislation to protect patients from Surprise Medical Bills. Theres a story from dr. Khan who had a balance bill of 44,000. Stacy shapiro, a first grade teacher in austin who faced a 700 bill after she felt ill following a morning run that she was unable to pay. This issue can even hit close to home for someone like myself who hack studying this issue. My focus was on getting better. It did not come across my mind in that time of great stress i should check the Network Status of all the doctors who entered my room. Luckily i am okay and the doctors were in my network. Many havent been so lucky. These stories make it clear that surprise mm bills are creating Financial Hardship for the American People and that federal legislative action is needed. We ask that federal legislation focus on four things. First, balance billing should be banned in situations where patients are involuntarily treated by an out of Network Provider. This includes Emergency Health services at any hospital, any Health Care Services or treatment performed at an out of Network Provider not sleblgted edselected by the patient. Health insurance provider should be required to imburse. States should be required to establish an independent dispute resolution process that works in tandem with the established benchmark. Fourth, hospitals or other Health Care Providers should be required to provide advanced notice to patients of Network Status of the treating providers. We would appreciate the Health Subcommittee chairman has introduced legislation and end surprise billing act. Which would establish a role for banning balance billing. Ahip supports this bill. As the Committee Consideration legislative options, we urge you to reject arbitration to out of Network Providers which would result in excessive payments and increased premiums. Our major concern is that it fails to address the root cause of Surprise Medical Bills. Exorbitant bills from certain specialty doctors. This approach gives equal weight to bill charges and negotiated rates. Even though bill charges from the specialists do represent a form of price gouging. We appreciate that some congressional proposals and the Trump Administration have rejected arbitration in favor of a marketbased approach to protecting the American People from Surprise Medical Bills. It is also important to look at the role of state laws addressing Surprise Medical Bills. Two states in familiar, california and texas, have enacted laws that take very different approaches. In california, a new law provides surprise medical billing detections and provides reimbursement based on market rates that similar providers routinely accept at payment in full. This does not increase Health Care Spending and encourages plans and providers to enter into mutually beneficial contracts. By contrast, the current state law in texas ties reimbursement for noncontracting providers to the 80th percentile. This approach has led to inflated payments with higher cost for consumers and one of the highest rates of surprise billing across the country. Thank you for this opportunity to testify. Ahip and our member plans stand ready to work with members of the committee to alleviate the Financial Burdens imposed on the American People by Surprise Medical Bills. Thank you. Thank you. Mr. Nichols . Thank you very much. My name is tom nichols. Im executive Vice President for the American Hospital association here today to represent our 5,000 hospitals and Health Systems members. I know the subject of todays hearing is very important to you, mr. Chairman. We applaud your long standing efforts to deal with this issue. The bottom line, we must protect patients. Congress must act to help 60 of american who have sponsored plans under arisa. Patients should not be subject to balance bills when they have access to Emergency Services outside their network or have acted in good faith to obtain innetwork care. They also shouldnt be surprised by coverage denials from insurers when they access any Emergency Services in network or out of network. Id like to outline elements that could be part of a legislative solution to surprise medical billing. First, congress should explicitly prohibit balance billing in the scenarios i just described and make sure they are kept out of process to determine reimbursement between the payer and the provider. Then congress should help improve standards for networks and ensure adequate oversight to prevent the incidence of out of network care. We encourage congress to allow providers and payers to determine fair and appropriate reimbursement. We reject a National Rate or benchmark for out of Network Services even if geographically adjusted, not able to capture the many things considered. Were a disincentive for insurers to maintain networks. We have seen an increase in the use of no Network Pricing models in the commercial market. This could accelerate should insurers have the ability to establish out of network rate. Including negotiating rates with providers. While the aha believes that hospitals and payers are able to negotiate reimbursement for out of Network Claims without government involvement, there may be a resolution process. The style of arbitration appears to be an efficient process that places the responsibility to initiate request with the insurer. And not the patient. Decisions have been split between the providers and payers. There has not been a notice nl impact on premium insurance rates. Commissioners has also put forward a model act to resolve disputes. Again, these are state level solutions. Do not resolve the surprise bills covered under arisa plans. Someone suggested the bundling of services would be the best way to reduce the medical bills. We disagree. While the aha supports bundle models this would be hard to apply to e. D. Services. As well as when a patient has a scheduled service that may require the input of providers some of whom are supplied by the hospital. Some of whom are not. More importantly the additional complexity of what and with whom to bundle would not prevent the issuance of bills. In certain settings moreover this would place hospitals in the role of what insurers should do. Negotiating with providers on behalf of their subscribers. Regarding proposals that would require hospitals and other providers to giver an estimate of out of pocket costs at the time of scheduling care, this is information our members are working towards providing though challenges exist. In order to generate accurate estimates, providers must obtain information from a health plan in order to understand the patients cost sharing responsibilities where an individual is with out of pocket minimums. We ask congress to provide health plans to continue to work toward this goal without including this component in a surprise billing package. Finally, all the discussions how to best serve patients must include increased efforts to navigate the Health Care System. Mr. Chairman, we have an opportunity to protect patients from surprise bills. As a consensus does appear to have developed among all parties. We should not risk moving forward by adding other policies that would put that passage at risk. Look forward to working with the subcommittee and appreciate this opportunity to appear. Thank you very much. Mr. Gelfin . Chairman doggett, Ranking Member nunes, and subcommittee, thank you for the opportunity to testify. Im senior Vice President for Health Policy at the arisa committee. A trade association representing Large Employer plan sponsors. Our Member Companies offer Health Benefits and selfinsured plans pay around 85 of Health Care Costs for our beneficiaries. About 181 million americans get insurance through their job and surprise billing fundamentally frustrated the goals of providing equality affordable sponsored coverage. Often our employees do everything right. They look up inNetwork Providers, they call ahead, they ask questions. Still they receive enormous unexpected bills. Many are afraid to go to the hospital even, a platinum plan. Theyre skipping care. Theyre worried while at work. This has become a crisis. Now, the vast majority of providers never generate surprise bills. Its a small subset of the system that the patient cannot choose. Number one is when a patient receives care at an inNetwork Facility but is treated by an out of Network Provider. Number two, a patient requires Emergency Care but the providers, the facility, or the transportation are out of network. Number three is when a patient is transferred or handed off without sufficient information or alternatives. Employers believe that congress can and should solve this problem and that the best solutions will be simple, straightforward and common sense. Chairman doggett, thank you for your leadership on this issue. You introduced the end surprise billing act in 2014 which would hold the patients harmless. We believe ending surprise billing starts we the concepts you pioneered. Three core policy changes to end the surprise billing crisis. First, an innetwork matching rate guarantee. Its simple. If a patient goes to an inNetwork Facility, every provider they see should be required to accept inNetwork Rates. Second, an emergency last resort benchmark backstop. When plans and providers cannot agree on care, set a benchmark. The average privately contracted rate. Third, require informed consent. When a transfer or handoff takes place, inform the patient if the care will be out of network and offer an alternative when possible. These three policies would wipe out the vast majority of Surprise Medical Bills. There is more that congress should do including crack down on abusive behavior by outsourced medical Staffing Firms and banning certain kickback agreements. But this would already be an effective start. And the ways and Means Committee can make this happen by making these simple rules a condition to participate in medicare. No new taxes or spending needed. No complicated insurance rules. Just an opt in and let providers vote with their feet. Now, we know that congress is under immense pressure from certain providers, hospitals, and wall Street Investors to maintain the status quo. Theyre sending congress on a series of snipe hunts to derail legislation. For instance, the first snipe hunt is a call for mandatory binding arbitration. Playing on the fear that making changes to the Health Care System will cause changes. Some have urged congress not to specify how to solve the problem and instead to punt to arbitrators. Arbitration is a dodge to deflect tough decisions away from washington that will raise costs for parkttients. When the premium costs are decided, we have to pay facilities, pay arbitrators, pay for arbitration thresholds, and pay list prices demanded by providers. If providers can make more money by arbitration rather than by participating in networks, patients will pay a very heavy toll. Next, transparency alone will not solve this problem. We are dealing with a market failure and de facto monopolies. Informing a patient they will see the only anesthesiologist on duty who only accepts cash doesnt actually help the patient. Some have warned congress that if you legislate on surprise billing, you risk creating winners and losers. To this we respond, obviously. The Current System is not perfectly balanced. And the current losers are patients. The idea that the deep inequities in the Current System can be solved without changing anything is another snipe hunt. Others say that the free market will solve the problem. It wont. It hasnt. And surprise billing is getting worse and not better. They say that if congress creates a benchmark, its Big Government interfering in a free market. We disagree. Lastly, some have advocated deferring to the states. But many states have either not acted, enacted only half measures, or made things worse. Even if every state enacts a comprehensive solution, this still wont help the 100 million americans in selfinsured plans. In conclusion, thank you for this opportunity to share our views. Were eager to work with congress to work towards a bipartisan solutions. Im happy to answer any questions. Doctor, let me have you respond to his suggestion we have an innetwork matching guarantee. I think you referenced that. If you have an innetwork matching guarantee, isnt that sufficient . And if you permit charges above that, isnt it incentive to never join the network . Sure. So, yeah. I mean, it sounds easy to implement and it is. Just call everybody in network, right . But the reality of the situation is if im the only guy that can sew an ear back on when it gets cut off in a tragic lawn accident, and theres nobody else around for a hundred miles, is my fee should it not be different than in a place where theres ten people available to sew that ear back on . And i dont have any ability to negotiate that in this situation thats unique to my gee ogographygeography. I should be able to sit across from the insurer and say i know you usually only pay 200 for that. But im the only guy around that can do this. That i did last friday for mr. Jones and my fee is actually 400. I think we can work this out. But really 100 is not reasonable for that. And thats why setting everybody innetwork fees and eliminating the ability to sit across from an Insurance Company and negotiate those fees isnt a solution. Its an easy way out. But its not a fair solution. Ive seen at least one study that suggested that Emergency Physicians were charging three times the medicare rate if youre innetwork and eight times the medicare rate if you were out of network. Can you see any justification for that kind of action . So, you know, medicare is a program that exists to take care of our Elderly Population and our disabled population. I participate in it out of a sense of responsibility for my community. Sure. And i understand the dissatisfaction with medicare rates generally. What im referring to is the difference in charges and why one price for those in network and another for those that are out. Right. So there is a benefit for me to be in network with Blue Cross Blue Shield of michigan, for example. I get something from that. They sit with me, they show me their data. We Work Together on incentive programs to sort of curb costs. If theres an Insurance Company thats in town that does none of that activity to improve the care of the population in my town but yet wants to benefit from the same rate of compensation to me, theyre doing nothing to earn that discount. Blue cross sits across from me on a weekly or monthly basis to improve the care of my population. But golden rule insurance thats new in town, from ex, doesnt do any of that work. And yet wants to benefit with the same rates . No. I take the discount from blue cross who gives me something else. You should be expected to pay more for my services. I get something from blue cross. I get nothing from golden rule. Thank you. Mr. Gelfin, why wont the new york arbitration system work well . Unfortunately, our belief is that arbitration raises costs and it doesnt eliminate Surprise Medical Bills. What it does is rearrange the deck chairs on the titanic and send those surprise bills to somebody else to pay. Inevitably in new york what happens is when a provider does win the arbitration, the amount the insurer must pay is the billed charge. Which as you saw in the video, no reasonable company would ever agree to pay. My companies right now have the option of participating in certain state programs that would have arbitration and so far we have not heard from any company that has chosen to do that. Ms. Thornton, what has been the experience with your companies in new york state . And does this arbitration model provide a model that could help us resolve this problem . Ill get good at this in a second. Thank you for the question. So our plans have been working in the state of new york for many years and have a lot of experience with the arbitration approach. So as a starting point, when that law came into place, we were really starting from a broken system where the plans were required to pay the full bill charge amount. So the arbitration process was better than what they had in place before. But our perspective is that its really important to first have a payment benchmark that is really based on the amount of payment that similar providers are getting in the state. The challenge with arbitration is that its sort of a clunky and costly process. Its very difficult for plans to plan ahead and get that certainty when theyre setting their rates. It adds a lot of costs and a lot of burden for consumers to sort of wait and see whats going to happen throughout the process. We dont think it would work at the National Level as it hasnt worked in new york to the fullest extent possible. Whats the effect of having uncertainty on premiums . So a plan can estimate sort of when theyre setting their rates. Im going to have a certain number of out of Network Claims. Its really important that they can understand what theyll have to pay in those scenarios so they can accurately set their rates Going Forward. And finally, mr. Nichols. At least one of those who were with President Trump at his recent press conference, i believe a physician from Johns Hopkins suggested that bundling should occur. That we go to a hospital for services, why doesnt the hospital send us a single bill for all of the services that are rendered there. Why wont that approach solve this problem . Yeah. For a couple reasons, mr. Chairman. First of all, i think if we get the patient out of the middle of this and make sure that they are only paying their innetwork cost, that solves the problem. Going to bundling takes us to the issue of the potential disagreement between provider or insurer. It doesnt help the patient necessarily. We can help the patient in different ways. The problem with bundling is it puts us in the position, puts hospitals in the position of frankly what the insurer should be doing. Or in this case of medicare and medicaid, what the government should be doing. It makes us the negotiator, the in between the payer and whomever is working in the hospital. Many of these physicians are not employed by us. If they were, that would be an easier situation. But they are not. It puts us in a situation we have to negotiate with them. We could potentially be on the hook. We could be lench edveraged. I dont think its workable. Lets just take care of the patient. Mr. Nunes . Thank you. Americans ought to know what theyre going to owe out of pocket before they get that service. Today it costs a patient literally double to get chemotherapy in a hospital compared to a physicians office. My bill which became law as part of the 21 century cures act created a website to patients can compare their out of pocket costs for any given procedure in a hospital outpatient center. To add Services Performed in a physicians office. Mr. Nichols, i assume youre familiar with this and it would be nice if we could get the commitment from the Hospital Association to support legislation to expand transparency online with a tool that could include physician rates in order to empower patients with cost sharing information. Mr. Nunes, as you might imagine, i am familiar with that provision. And i think if were talking about transparency, what you describe is reasonable. I would have to say its important for consumers to understand that there is a reason why prices are higher at Hospital Outpatient Department than they are in an asc or physician office. But providing that information to people is certainly appropriate. We have costs that physician offices and ascs do not have. We are open 24 7 mandated by this congress that we have to be available. We have overhead. We deal with emergencies. We deal with trauma. We deal with disasters, et cetera. There are costs associated with what hospitals have to provide that need to be built into those rates that are not usually reimbursable costs. So no problem with transparency, but it would be best people understood why those differences exist. Thank you. Im assuming that all of you are familiar with the greatest of three policy. The first being the median amount with inNetwork Providers for the emergency service. Number two, the amount of payments for out of Network Services such as the usual customary and reasonable amount. Or number three, the amount that would be paid under medicare for the emergency service. But i think most of you have problems with this policy. You think the payments are too high or too low depending on where you sit. So im going to go first to you, dr. Makamala. Which of these three are highest and whats the delta between that and what doctors collect . Sure. So given the choices of the three, medicare is usually sort of the Foundation Upon which the Insurance Companies tend to set their rates. So when i participate in network like with Blue Cross Blue Shield of michigan, its about 110 of medicare rate. Thats one step higher. If i dont participate with Blue Cross Blue Shield of michigan, then that rate is so i can get the assigned rate from them. Then i have a choice about what to do with the balance. Usually in my practice, i write that off. But Blue Cross Blue Shield sort of sets their rate and thats it. My point is that if and Blue Cross Blue Shield, i have a great relationship with. We do a lot of constructive Work Together. But if a Company Comes in town and markets their product saying come buy our policy. Then they get 15,000 patients to sign up but has never come to my door to say, you know, when they have an ear, nose, and throat problem wed like you to be in network and provide their care. Why should they get the benefit that Blue Cross Blue Shield gets . This out of Network Price for this new company that never sat down with me to sign a contract ought to be something that i negotiate with them. Not something thats dictated to me. Thank you. Thats helpful. Ms. Thornton, how do you see the issue . Gosh. So today the greatest of three methodology only applies to Emergency Services. Of the three options you mentioned, typically the usual and customary is the highest rate that applies. And as you noted, providers still are allowed to balance bill after the Health Plan Providers payment for those services. I should also note that a lot of the situations that were talking about today are not emergencies. And thus are not covered by the greatest of three. Say, for example, you have a surgery and the anesthesiologist is out of network and youre at an innetwork hospital. So somehow weve got to find Common Ground here. Mr. Nickellss, do hospitals charge the reasonable amount . If i could answer it differently, we dont support rate setting. We dont think thats the proper role of government. Lets take care of the patient, get them out of the middle of this. It should not be based on ucr or anything else. It should be a negotiation between the hospital and the insurer, the physician and the insurer. Thats how the system ought to work. Thank you. With that, im out of time. Thank you very much. Mr. Thompson . Thank you, mr. Chairman. Thank you for holding the hearing and all the witnesses. Thank you very much for being here. As you know and my colleagues have stated, there are a gazillion stories out there that i think reflect this situation. I had one just recently. A staff person of mine went to the emergency room. He has insurance. It included everything including a cat scan. But then he got bills from physicians he never saw and didnt ask to see. They reviewed some of his test results. And the bill for those two physicians was larger than the bill for his total e. R. Visit. Its also alarming that according to one study, 20 of hospital visits, one of every five of those visits began in the e. R. Resulted in a surprise bill. So im glad that we all agree that we need to fix it. Thats the easy thing. The hard part is to figure out what its going to be. Mr. Nickels in your testimony, you expressed support for insurance and providers. You also mentioned that fixed payment rates could undermine access to inNetwork Providers. You talk a little bit about how that might work. Why might a fixed rate approach lead to smaller, less Inclusive Networks . Yes. I think our concern there and by the way, your situation with your staff is i think what were all suggesting would hopefully solve that problem. They would not have gotten in terms of their obligations bills from those out of network doctors. I think for us our concern is if you set some sort of a rate, it becomes the default rate. And were already talking about inadequate networks. I think the ama has been particular on concerns about that. And networks are shrinking. If we have a default rate, theyre going to shrink some more. Because everybody will know, if i cant get what i want, im going to get the default rate. Thats not good for anybody. We need larger networks, more robust networks. Again, weve called for federal intervention and others have called for state intervention making sure there are adequate networks. We think it could do harm to that effort. One of you, i dont remember which, mentioned that my home state california put in place a fixed payment rate approach. Mr. Nickels, to your knowledge, have you seen networks begin to tighten in california because of that . Or do you expect that to happen . I believe im right on this. The California Law does not affect hospitals. It affects physicians. I think it is relatively new. It is in its first year. I dont believe the data is in yet to make that determination, but you can see where were coming from about that fear shrinking the network because they can default to an amount could have that effect. Thank you. Do you want to say something, doc . Yes, sir. So in answer to your question, there are multiple already cases documented of Insurance Companies shrinking their network in california because they can get that same rate with physicians outside of the network. Contracts are not being renewed for physicians that have had contracts for 20 years. Then they go to renew it and theyre dropped from the network. Miss thornton, you mentioned that arbitration doesnt work. And you argue that the arbitration system enable a form of price gouging by providers. Can you expand on that a little bit and why would an arbitration system lead to higher premiums . Thank you. Sure. Happy to expand on the reasons why we dont prefer an arbitration as an approach. One of the challenges with arbitration is that youre taking somebody whos sort of looking from the outside and youre having them to make a decision about what the appropriate payment should be. And a lot of times, some of the state laws have very narrow sort of things that the arbitrator can consider when they have to make their decision. Say what the Sticker Price was or the bill charge was or what the similar providers would be providing for that service. And so our concern is theres a very theres a likelihood theyre going to want to take the providers price as well as youre really sort of rewarding a provider from coming in with an overall higher price in the first place. So youre not really getting at the root cause. Youre not really looking at why are these high charges coming in in the first place. If that makes sense. Thank you. New yorks implemented a baseball style arbitration policy. To your knowledge, have you seen premiums go up since that policy was implemented . Do you expect premiums to go up in new york as a result of that law . So to my knowledge, a recent study did show that premiums have come down since that rule was put in place. However, as i mentioned before, there are a lot of other extenuating circumstances with the prior approach that may have led to that decrease. Thank you. Thank you have much. Mr. Buchanan . Thank you very much. I also want to thank our witnesses in florida. But grew up outside of flint area. Good to see you, doctor. Let me ask you in florida. I dont know if its the case in michigan and other states. But the idea of you see a lot of hospitals and others write off 40 of their receivables. So i guess you look at this surprise inflated billing, how do we get there and then seems like the lack of transparnency is a big concern. Ive done 80 town halls. We all do them. Those are the two biggest things. They get a bill for 50, medicare pays 10, they write off 40. Or just the lack of transparency. They have no idea what its going to cost and get a bill later. So i guess thats my two questions for all the panelists. But the other thing is, how do we change this behavior or this practice because it is especially i tell people i read something that was alarming to me. 62 of americans dont have 1,000 in the bank. So all of a sudden they get a bill for 3,000 or 4,000. They live paycheck to paycheck. It is a gigantic issue. And the costs have gone up so much in the last 20 years not because of democrats republicans. The costs have gone up. So doc, ill start with you. Just your thoughts. Why do we have this massive kind of in a sense surprise billing, the lack of transparency, and what do we do to change that . You know, my wife and i share an office. Shes an ob gyn. Im an ent. We have two people just to navigate billing. Were supposed to be experts at it. This is how complicated it is. Everybody you heard this afternoon is asking for transparency. And we need to work towards that. And that will come from you. Right . The requirement to be transparent. I mean, if you look at the contract languages, when i signed up for my own Health Insurance, i mean, i would need my lawyer sitting next to me to decipher it and im in the business. Absolutely that transparency is necessary. As to why so much gets written off, right . So when you go and get care and you end up paying 25 and 75 gets written off. My wife and i, we contract with my wife and i, we contract with probably about 30 Insurance Companies. Kidss when i take a tonsils out, one Insurance Company may pay me 250 and the other 400. I cant have a separate fee so , my fee is about 475 so when i do it, i know that the highest paying payer, im still theyre still within that threshold. Right . Because if i charge 400 theyre not going to send me 450. Theyre going to send me 400. Weve got limited time. Mr. Nickels, do you want to respond to that . Just the idea of the practices in florida thats not writing off 40 of their accounts receivable. Ive been in business 30 years before i got here. If i did that, id be broke. Id be out of business. Whats the rationale for that . They ask for a big number and they get what they can. I dont know if its just the canadians coming down, if they can get full retail, they take it. Whats your thoughts . Youre absolutely right. And what happens is, again, like physicians we are required to charge people the same amount. Its actually required in the medicare statute. And what happens is that charge is an amount and then we negotiate with insurers and we work out some amount. Its usually less, but you write off some of it. With medicare, you mentioned earlier. Thats a fixed rate. We have no control whatsoever on that amount. And med pack and others, independent sources talk about how poor the payments are, well below our costs not to mention , our charges. Thats the reason that gets written off. I think to take care of the patients you referred to earlier, we just need to get them out of the middle of that when they see that bill, what those charges are. Whatever it says, it doesnt affect them personally. They pay their innetwork amount. Miss thornton, you want to add your thoughts to it, please . We agree that the patient should be taken out of the middle. None of the stories youve all mentioned should happen again if we really take the patient out. Theyre not receiving these bills. Then its left between the plan and the provider to work it out. I wanted to comment on transparency that you mentioned. I think thats important in a lot of the situations. We do think more transparency about what networks a provider accepts is really important at the time of care. But this really only works in sort of elective care or planned surgery. During an emergency or when youre having that anesthesiologist behind the scenes, transparency isnt going to help you. Because youre not in a position to make a choice. And i think thats why we also need to think about the transparency from that perspective. Thank you, mr. Chairman. I yield back. Thank you. Mr. Kind. Thank you, mr. Chairman. Thanks for holding the hearing. Want to thank all the witnesses today. All of us can come up with our own stories of surprise billing in our respective districts and states. I represent a large rural western wisconsin district. So emergency ambulance, Emergency Air service is one that i hear constantly. But has anyone here maybe ms. Thornton can put this in context. How extensive is this problem of surprise billing in the overall medical billing world . Do you have a percentage on it . A given year . So we have heard that one in five emergency room visits result in a surprise medical bill. And when you talk about ambulance care, both ground ambulance and air ambulance, its even higher. About 51 of ambulance rides resulted in out of network bill. And thats even higher for air ambulance. So we definitely think that needs to be part of any discussion on this issue. I would agree. Weve had legislation in the past to address quality access issue with the Ambulance Services and that. But this is something that we have to address. But overall with the overall medical billing in a year, what percentage would you say is surprise billing to the patient . So its very interesting. What weve seen when it comes from a hospital perspective, its maybe only 15 of the hospitals nationwide that are causing this issue that results 80 is one statistic that has been cited that results in a surprise medical bill. This is not every doctor. This is not every hospital that are resulting in these Surprise Medical Bills. Its really more of a targeted problem. And thats why were supporting federal legislation to address it. Mr. Gelfin, let me ask you. You mentioned the importance of informed consent as one of the options in the world of price transparency. But if youre seriously injured or sick and got to get to the hospital right away, i dont care how much informed consent there is or how much price transparency, from the Patient Perspective thats not going to , work well is it . It is also not reasonable to expect the patient to ask those questions in an ambulance. One thing we havent mentioned yet is almost all of the providers generating these balance bills are providers that you dont have a choice of whether or not to see. We use the acronym pear which stands for pathology, emergency, anesthesiology and radiology. And the side car is makeybe ambulance and air ambulance. Its not a huge problem many are causing. It is really those providers who you are stuck. Youre going to see this person or nobody. Ive got patients going to minnesota, iowa, illinois. Minnesota and illinois have passed legislation already. Have dones total comprehensive, i think 16 have done partial. 25 hasnt done anything. Does that speak to the need of some federal standard instead of the patch work that were seeing out there right now . We absolutely believe a federal standard is needed if for nothing else because of the 100 Million People who cannot be helped by state law. Is everyone in agreement with that, mr. Nickels . I saw you nodding your head. Yes, sir. There are some states that acted. 60 Million People covered states , cant help them. They need to be helped here. And also the people who are in states that havent done anything. I think there also needs to be action for them. If i could comment on one of your other questions, if you dont mind. In terms of how much of this is really going on, i think theres a certain level of frustration. I dont know that we all know with certainty. The only federal study that ive seen that weve seen is from the federal trade commission which basically said they studied ambulances going to hospital Emergency Departments. 99 of hospital Emergency Departments were in network. So its not the hospital itself that is out of new york. It is people, physicians who practice in our institutions. That does not absolve us of responsibility. But i think and they are the physicians that were just described, thats where the issue is. Just staying with you for a second. You talked about the need for maybe expanding networks, robust functioning networks. Are we going to run into any kickback law problems if we go down that path . We have all kinds of stark and antikickback problems that i could go on forever on. But yeah. I think that is an issue in terms of our relationships with physicians, our ability to work with them, Work Together with them, have some sort of, you know, financial arrangements. I think that is an issue that would certainly help this issue in encouraging physicians to be in network. We cannot require physicians who dont work for us to do that. But it would be it would certainly be an encouragement. Ms. Thornton, federal action needed from your perspective . Certainly. We do have a patchwork of provisions across the country. Some cover e. R. Others cover other things in addition to e. R. I think having a federal floor would be very important. Great. Thank you. Yield back. Thank you very much. Mr. Smith . Thank you, mr. Chairman. Thank you to our witnesses here today. I appreciate your unique perspectives and there are probably even more perspectives out there when you think about how much input is required for health care. Certainly challenging and i admire your pursuit. In my district, the Third District of nebraska, 75 county counties counties. Many critical access hospitals. Some of which have one doctor. And so we have rural and we have remote and various dynamics associated. And i want to make sure that if and when there is federal action taken that we dont have unintended consequences and just overall that we know this is not a uniform problem across the country or even from one provider to the next. From one plan to the next. One patient to the next. And so i just hope that we can move cautiously even though we know that there is a huge problem that we are currently facing. That is the common thing. There is the problem of surprise billing. Can you perhaps touch on what concerns there would be in rural areas . I know doctor, you mentioned that pricing would be different given kind of supply and demand i think is what i heard you say. What other things should we keep in mind in terms of challenges facing rural areas where there tends to be probably more out of Network Dynamics in play and fewer choices for patients and yet, you know, the mere access to one provider is considered to be positive in many cases. Absolutely. And so everything that weve talked about is magnified in the situation youre talking about. And for the one physician thats in that Community Hospital thats taking care of patients in the middle of the night, you know, they shouldnt be subject to the same sort of negotiation or same contract that would be given to somebody at creighton, for example. Where they have multiple physicians that are going to care for the patient. Its a unique situation. That physician should have every opportunity to sit across the table from the insurer in that area and say, look. Im happy to take care of these patients. Lets work out a contract. Right . To bypass that and just sort of give them a contract thats based on x percentage of medicare and not take into consideration the uniqueness of that practice environment goes counter to any negotiation between any parties in any type of contract. But that would currently i mean, they would have the opportunity, right . To opt into a network. Correct . The provider. If given, yep. There are lots of examples of, again, if youre out of network and youre forced to sign this sort of contract, theres no incentive for an Insurance Company to bring you into network. The Insurance Company is happy to have dr. Smith in the town youre describing be out of network because theyre getting him for inNetwork Prices. Thats what we want to avoid by putting them at a table together to work out a more appropriate contract. Anyone else wishing to respond . I couldnt agree more on that one. If you talk about unintended consequences, again, were all trying to get the patient out of the middle of this. And i think theres a consensus here. But the notion that some sort of a benchmark, a National Rate, something that is an average would work in Rural America i think is one of those unintended consequences youre referring to. That physician, that hospital should be negotiating with that insurer. Should not be based on some number that somebody comes up with arbitrarily. I think as i mentioned earlier will actually result in fewer physicians and hospitals being in network because it can default to that particular rate. So i think that would be a serious unintended consequence we need to avoid. Okay. Overall, any other unintended consequences we should be concerned about . Ms. Thornton . The one thing i will say is that health plans are strictry regulated on Network Adequacy. They would be required to contract with that hospital anyway. So i think its more important. We see surprise billing happen either in Large Networks and small networks. I really dont think its a Network Adequacy issue at play here. Its other dynamics. I would just say that the situation you described where theres little choice of provider is a recipe for price gouging. The patients that are going to be seen in that environment are probably in need of the most protection from these surprise bills. There is no incentive to participate in a network if youre the only game in town. I might add theres probably more Community Accountability as well where there are a lot of eyes on the billing and neighbors having to answer to neighbors. So thank you. I yield back. Thank you. And to maintain balance as we traditionally do, im going to go two to one and call on mr. Blumenauer. Thank you. I appreciate your focusing on this like a laser. Having the hearing so we have an opportunity to weigh the alternatives. I think its clear mr. Gelfand, you are talking about people who are stuck. The opportunity of people who need protection the most are most are most at risk. I have no doubt that there are rationales for various approaches. But i want for us to end up with something that protects those who are at risk and that deals with the notion that theres a relatively if i understand the problem correctly, there are a relatively small number of providers that are creating most of the problems in terms of significant surprise billings. In my state, we recently passed a law of about 15 months ago in oregon that banning out of Network Billing, the law requires that patients who receive care at innetwork facilities will only receive bills at inNetwork Rates. While the Insurance Companies and the Health Care Providers work out the remainder of the reimbursement. I wonder if i could ask you to comment on your perception of the oregon approach and anything youve heard about whether or not its working. Start with you and go down the line quickly because id like to hear from everybody. Yes. Thank you, sir. We couldnt agree more with what youre working the proposal that youve come up with in oregon. Where the patient isnt responsible. They have know idea that when they went in there with their bleeding finger that they were going to be taken care of by a surgeon that was out of network. Thats not the patients responsibility. At that point, monday morning the physician should be on the phone with the Insurance Company saying i took care of one of your subscribers and that should be negotiated. Ms. Thornton . Agree that in oregon consumers were taken out of the middle. Thats what were talking about here. No more balance bills. They can have the peace of mind if they have an emergency, theyre not going to receive those bills. Thats so important. As to the benchmark, i understand that they do allow a reasonable payment rate from the plan process. Thats the type of approach that we support. Mr. Nickels . Yes, agree. I understand the oregon law. You do touch on the issue weve been talking mostly about Emergency Care. But the issue which oregon covers where the patient comes into an inNetwork Facility knowingly and intended to do that but gets billed by an out of Network Physician. Not in emergency necessarily and that oregon takes care of that. That patient should pay their in network insurance. Thats what were all recommending at the federal level, too. Our view is it is best those negotiations for the other part, the difference between what the insurer wants to pay, the provider wants to get should be worked out between the insurer and the provider. Mr. Gelfand. We agree taking the patient out of the middle is the first step that has to be done. We would caution someone eventually does have to pay the bill. If that has to be paid by an Insurance Company or an employer, what happens is if we dont address the underlying issue that is causing the generation of those bills, then the prices will just be spread throughout the premiums. Instead of one person receiving a surprise bill, every enrollee is going to be paying for that surprise bill. Any other comments . Thank you very much. Thank you. Ms. Sewell. Thank you. Thanks to all of you for being here today. Two thirds of bankruptcies in the United States are linked to medical debt, making medical debt the leading cause of bankruptcy in our country. When they are at their sickest, patients and their families are often left with no support. While they fight for their lives, they spend countless hours on the phone serving as intermediaries between Insurance Companies and providers. Weve all taubldlked about that we have all talked about that today. Id like to ask for submission an article, mr. Chairman, an npr article about recent polling in a report entitled life in Rural America. So ordered. The article shows that 40 of Rural Americans struggle with routine medical bills, food, and housing. Over a quarter of the respondents say they have not been able to get health care when they need it at some critical point. The article tells a story of a 72yearold retired caregiver in rural kentucky. When asked if she could afford an unexpected 1,000 expense, she resoundingly said no. An urban a recent study by the urban institute shows that eight of the ten states with the highest rate of pastdue medical debt are in the south. Alabamas one of them. There are lots of stories like that. And i would guess that my witnesses all the witnesses here today would agree with me that a person should never face financial ruins because they cant pay their medical bills. We must recognize that our reimbursement system both public and private has created a scenario in which safety net and rural hospitals have to garnish a sick persons wages or tax returns in order to keep their doors open. When medicaid reimburses some Emergency Rooms at 10 of cost and medicare, not much more than that in alabama. Rural hospitals are having to make up for those low reimbursements in every way they can. Id like to ask mr. Nickels, what more can we do to help hospitals with bad debt so they dont have to send debt collectors after some of our most vulnerable constituents just to keep its doors open . Thank you. I agree with everything you said. And i think that the Health Care Crisis in Rural America is one i hope that the congress would take a serious look at this year. I guess my first thing and i cant resist is perhaps medicaid expansion. Well, some of us werent fortunate enough to have a state that expanded medicaid. I couldnt resist. You know. That would be one place to go. I mean, the federal government i would agree with you. I bet. The federal government needs to acknowledge that they underpay i mean, med pack and others acknowledge this. This isnt just industries talking about ourselves. Ama has said the same on the physician side. But i think the federal government and state governments have a responsibility to pay more adequately. The truth of the matter is and we havent even talked about this is a cost shift. Private insurers pay more and Insurance Companies pay less. That should end. Ms. Thornton, how important are medicaid, bad debt and low payments helping hospitals make up for inadequate reimbursements . Well, im not an expert in medicaid policy, so unfortunately i cant get into too many details on that question. Very important. Mr. Nickels, i know you know a lot about that. I was trying to coach the witness here. Very important. As you know, there are medicaid dish cuts on the horizon being in october this year we have to stop 4 billion this year. 8 billion the year after that. Same with bad debt and those other programs. I mean, the Medicaid Program notwithstanding my complaining about inadequate payment along with the Medicare Program do have subsidies for certain kinds of hospitals, dish being a classic example of it. Very important for our continued ability to provide services. But its not something we can do to scale so we all have to Work Together. Both the practitioners, hospitals, Insurance Companies state and local governments. , when we have states like alabama that havent expanded medicaid, that have the lowest reimbursement rates for medicaid, that is really problematic for the people that i represent. People of the seventh Congressional District that i represent, which is my home district includes birmingham, but also my hometown of selma, alabama. Everybody knows of it because of the civil rights and Voting Rights history. But its a town of 19,000. Its actually unacceptable that we have so many rural hospitals throughout this nation that are closing. And these are the most vulnerable. And sometimes the bad debt reimbursements are just as painful for folks who are struggling to receive those calls day in and day out. I hope we as folks who work in this industry both policy makers and practitioners will figure out a way to do better. Thank you, mr. Chairman. Thank you. Mr. Marchant. Thank you. I would like to associate myself with the remarks made in the beginning. I think it is our responsibility to address this surprise billing issue. I would, however, note that throughout this testimony, theres been a general complaint and i hear it all the time that medicare is a very, very artificially low reimbursement rate. So i would just caution us to in trying to fix this problem not to add too much more government regulation to the fix that might end up actually just exasperating the situation. I have a large medicare population. And am blessed with the situation where within 30 miles of my district there are probably dallas, ft. Worth, probably 50 different hospitals or clinics that any medicare patient could go to. Situation where medicare patient goes in for a routine colonoscopy. They found out theres a polyp. Its removed. A few weeks later, they get this letter that says the amount you may owe the provider. Thats a dreaded letter usually. Its the precursor usually to a surprise billing. You may get the surprise billing earlier than that. Should we involve medicare in this whole discussion about should we be protecting these medicare patients from surprise billing . Id like to have your comments about that. Sure. Thank you for the question. So, 93 of physicians in this country participate in medicare. They accept what medicare pays. Right . So the question is relevant to a very small percentage of physicians that are participating with medicare that are accepting medicare patients but not accepting payments that are nonpar with medicare. But they are still subject to medicare rates and then they have the option to balance bill the patient if they would like. But again, its a very small fraction that were talking about that go that route. 90 of physicians out there are on the par side of medicare meaning they do participate. It is not an issue for the majority. Is there a when the medicare patient goes in, are they told that up front that youre going to be seen by a doctor or in a setting where were not going to accept the rate . Yes. So the very small percentage of physicians offices that arent on par with medicare and not participating status, that is something the patients are told up front when they present with their Medicare Card and id filling out the paperwork. Well courtesy bill medicare on your behalf but there may be a balance afterwards. You know, that works in the situation where theres an elective procedure or an elective appointment. But what were talking about in this room today is the surprise situation where, you know, the patients being taken care of by somebody thats nonpar with medicare. Thats the issue that needs to be resolved here in this room today. And i think the point is that that should be a negotiation between the payer and the physician to find out where that payment is going to land. Mr. Nickels . If i could first associate myself with your comment about unintended consequences in government intrusion. I think we figured out a way to help the patient. We are wary of government setting rates, having benchmarks, having numbers whether theyre associated with medicare, whether theyre associated with the private sector. We think thats the wrong way to go. That would really create unintended consequences we need to avoid. In your medicare example, i believe thats a change that needs to be made in medicare law that would probably not occur to someone with private insurance. I think that is i dont want to call it a glitch, but thats something the medicare statute needs to be amended to fix. Thank you. Any other comments . Thank you, mr. Chairman. Thank you. Ms. Chu. Yes. Even though my state of california does have a surprise medical billing law, it addresses only part of the problem. For instance, it doesnt cover arisa employer plans. And it doesnt cover a particularly egregious case of surprise billing that happened in Zuckerberg San Francisco General Hospital in San Francisco. And i wanted to draw your attention to this as has been detailed by a vox reporters investigations. This is the largest Public Hospital in San Francisco and it was out of network for all private insurers. And the reason for this is that up through the beginning of 2019, it didnt participate in the networks of any private insurers. Thats right. Every single private insurer in the city was out of network for this hospital. And so id like to submit this vox article for the record. So ordered. And it points out that this resulted in abnormally high surprise bills for the patients. And so an e. R. Visit for a bike crash cost 20,000. An e. R. Visit for a migraine cost 10,000. It was 31,000 for a broken ankle. Now, since then Zuckerberg San Francisco general has since come out and changed its policies after a lot of public pressure. But im concerned about why this was an acceptable and Legal Business practice at all. So mr. Nickells and ms. Thornton, how common are practices like those carried out there and how often do major hospitals exclude or even most private insurers in order to subsidize their patients on Public Programs and does this happen in certain areas of country more than others . Ms. Chu, i read the same stuff you produced. I am familiar with that situation and i know the California Legislature has prevented that from happening in the future as well they should. I know of no other hospital in america theres probably one out there but i dont know of it that was out of network for every insurer in that area. Now, theres a negotiation involved here. And hospitals and physicians need to have the ability to be in network and not in network depending on the negotiation. If theyre in not in network, it shouldnt impact the patient. It should impact the negotiation between the hospital and the plan. But in that case, it affected everybody for everything. And was frankly inexcusable. I dont know of any other instance like that. And ms. Thornton . We agree this was just a horrible situation. If you dont have any choice when youre hit by a bike and where you are taken to the hospital. It would have been our preference that the hospital would have joined health plan networks. This is why we need a federal legislation to step in in those situations where there isnt a network for that person. And they can still be protected and not have to get worried about going on a bike ride. And to anyone on the panel, i want to ask about what would happen if we pass a federal law to address surprise billing that differs from state laws that are currently operating . Do you believe that federal law should supersede the state laws and if not, what would the impacts be to providers, patients, and plans in states with different surprise billing laws . If i could just speak to it from perspective of National Employers that run plans for employees in every single state, it would be important for us that there is one standard that applies to all of our beneficiaries no matter where they live, work, or receive medical care. That being said, those are only for those selfinsured large plans for a fully insured plan that is already on the state level, it would make sense for state law to govern unless there is no state law. I would fundamentally agree with that. I think we have to have maximum flexibility to allow states that have made these changes such as your own to allow that to continue to be the law of the state. But to this point made, and i think again i think its 60 Million People, states cant touch because theyre under erisa. There should be a standard for those folks and then states should be given maximum flexibility to do their own thing. For states that dont do anything and have any law, i think the federal statutes should apply. Anybody else . We agree. States should be the premare the primary regulators of their plans and their state. This is starting with a state issue where the federal government comes into play as the erisa plans that james mentioned as well as states that have enacted comprehensive protections. Thank you. I yield back. Thank you very much. Mr. Evans . Thank you, mr. Chairman. I thank you for your leadership on this particular issue. I also thank the witnesses. Im from the city of philadelphia and we have a number of leading Health Facilities in the city i represent. Childrens hospital. University of pennsylvania. Temple university hospital. Einstein Medical Center in jefferson. And its not often that representatives from different institutions will come to meet with me to speak on the same exact issues. Given the diversity of specialties among practitioners , Health Care Professionals from across the city have come to the office to discuss the need to end surprise medical billing. Currently as we know, pennsylvania has a partial legislation relating to medical billing. I want to go to mr. Gelfand to ask the question relating to some examples you can give me. Where have you seen the most surprising billings for your members . Hospitals, ambulance, and where the Patients Experience the highest balancing bills . So those balance bills are very heavily focused on providers that are ancillary, that are at the hospital. That once you go to the hospital, whether its in network or not, you dont have a choice. You dont get to choose your anesthesiologist or who operates on you in the emergency room. Especially when talking about transportation, air ambulance. Ms. Thornton, ive heard a lot about the increase of Narrow Networks and how they contribute to the issues were seeing with surprise billing. Can you explain what Narrow Networks are and how they contribute to the issue of unexpected medical bills . Thank you for the question. A network is a really important part of a Health Insurance design. Its a way to improve quality, manage care as the doctor mentioned. Its a way that we Work Together to improve care. Frankly, i dont think the issue surprise billing occurs more or less whether the network is big or small. We see equal numbers whether its a Large Employer plan that has a Broad Network as well as plans that have a smaller network. Another important thing that has been mentioned is that these are often providers that someone doesnt choose. So you dont go searching for the perfect anesthesiologist. Right . There are providers that do Service Often without you choosing. Let me follow up to you then. In your testimony you stated that a balance budgeting should be banned in situations where patients are involuntarily treated by out of network doctors. How are they allowed to be treated by out of Network Providers they do not select in the first place . Thats a great question. It gets to the heart of this issue, right . Is a complicated process. You could be at a hospital and you expect that every provider thats going to treat you is going to be in those same networks. And unfortunately that isnt the case today. Which is why were so supportive of federal action in this area. Then that leads the followup to mr. Nickels relating to hospitals then. The question is why cant hospitals require all providers that patients cannot choose themselves . Yes. A couple things. I just cant resist, im also from the great city of philadelphia. From your district actually. So nothing goes wrong there, i know. So the issue, we cannot force by law physicians who are not employed by us to in Network Rates. That is if we did that, we would be sued. It would be restraint of trade. However what we are trying to suggest and the other panelists are trying to suggest is we have a way to protect the patient from the surprise bill. To your question about who are the physicians you dont know about who are treating if you come in emergency you dont know whats going on. You need to be taken care of and whoever is there is taking care of you. And the other situation is when you come into a in Network Facility you did all the right things but an out of Network Physician, anesthesiologist, radiologist takes care of you and thats where the bill is generated from. You cant make people do that. We try to get physicians to be in our networks in the same networks. But, again, this is an issue of private contracting. Thank you, mr. Chairman. You yield back the balance of my time. Thank you. Mr. Kelly. Thank you, mr. Chairman. Thank you all for being here. I dont know if there is anything more complicated than trying to understand how people get billed for medical procedures. Im in the automobile business and people say dont try to , compare it with automobiles. But we repair a lot of cars. Both in the mechanical end and body shop end of the business we use a labor time guide to be the it could be the mitchells manual. It could be the chilton manual, the manufacturers manual that actually they have run time studies on how to do all the different procedures. Now, i know there is a difference. I know there is a difference. But im trying, to say, doctor when you were talking about when youre going to enter into an agreement with an insurer how do , you determine or how do they determine what should be the fair price to do whatever it is . I think you used what an appendectomy. There are variations. No two models are the same. There is wear and tear that enter into it. How do you come up with a fair price to do the operation or the procedure youre asked to do. Right, so im from flint, michigan. Automobile town. Im a car guy, too. Let me start by rephrasing it back to you. You presumably do a great job servicing the automobiles you service. You provide youre doing the same transmission swap in a in an impala. Before we go any farther thats not what we do because depending on what region of the country youre in there is different procedures and it takes different times to do different operations. There is taken into consideration the age of the car mileage of the car where the car , has been operated same as a human person. But apples to apples if youre doing the same job as somebody else you may charge a certain amount because you are the only one around and you do a great job. In the same way the reason the negotiation comes into play if im the only person for 100 miles that can sew this finger back on that has that skill, that is something i should be able to sit across from the person paying the bill to say this is the situation nobody , else can do this. This is my fee. This is what you usually pay. Lets work out a number reasonable for both of us. And thats the difference between one geographic location where there are multiple options and another geographic location where there is a pausety of providers. I think im like ms. Sewell. I come from an area that is largely agricultural. Youre in the finding a lot of the providers in the areas. You dont have the specialist. You have to go someplace else. I am wondering, because i think mr. Doggett is onto something. There shouldnt be the surprise at the end of it, especially in different situations, Emergency Rooms will be the one i think would be the one thats most prevalent that happens the most in. So there is a difference between being in a metropolitan area, being in an urban area, a suburban area, agricultural area. How do we solve the problem . I do agree with you. If there is limited talent to take carry of that specific problem there has to be a way of compensating because at the end of the day it is a business. The solution is if an Insurance Company is going to come into flint, michigan, and sell insurance they know eventually they need a hand surgeon. How do they sell insurance to a town thats an industrial based town with a lot of hand injuries and not have any hand surgeons in the network. When they pup put up the billboard saying we are selling insurance, they should at the same time say we are missing an orthopedic hand surgeon lets find one and get him or her in network. Thats a skipped step routinely. They will sell the product for years and fill in this way with lack of a good Provider Network by trying to negotiate out of Network Rates the same as in network because they skip the first step. Maintain a Network Adequacy. Establish the adequacy before you sell your product. My chief of staff we were out somewhere and he had a skiing accident. He is out of state, he is out of network. One of the things he kept doing is well i better call and check , to see if i i have coverage if there is going to be a surprise billing at the end of this. But not everybody has the situation where you can sit back and make some of the decisions. Mr. Nickels you seem to have a great depth of experience with this. I dont know how we approach this because certainly its got to be more expensive to run a big hospital in philadelphia than a small in a rural part of one pennsylvania and again not having the talent onboard to handle different situations. A couple of comments on that. First is keep in mind that half of our payments are dictated by government. There is no variation other than wages that are paid in that particular area of the country. So, we are not billing for that. Government has decided the feds or the states over half in some parts of this country. Half on average. Thats the first thing. On the rural issue there is no question that this is a perfect example of an issue only exasser only exacerbated in Rural America because of the pausity of physicians, lack of choice, et cetera. But its really a problem. If we get the patient out of the middle it we solve the biggest part of the problem and we need. Need to negotiate the rest. Thank you for being here mr. Doggett thanks for bringing it up. We have to find a way to get through the problem. There is nothing worse than some of the folks than the surprise bill because it shocks them. Thanks for being here. Thank you very much. Mr. Schneider. Thank you mr. Chairman and i agree thank you for holding this critically important hearing and to the witnesses, thank you for sharing your perspectives your expertise. According to the Kaiser Family foundation, Surprise Medical Bills are the top financial concern for americans above transportation costs, utility bills, rent and mortgages even above food. Two thirds of americans say they are worried about an unexpected medical bill and they should be. According to the university of chicago my state, illinois, nearly 60 of americans have been surprised by a medical bill. Some of the stories are actually heart breaking. One story, a recent example, a family witting in a hospital parking lot for hours after their twoyearold child accidentally ingested an entire bottle of overthecounter medication. Instead of going inside because they were too fearful of the andey would incur thats serious often times you hear stories that are absurd. All of these are problems. As i think about this thank you for sharing for perspectives. One of you used the term were talking about cost shifting. And there are so many moving parts in our Health Care System, there are so many stakeholders but as a patient if i go to a hospital i will use the example of a ski accident. If i have a ski accident and need to be air lifted because im out in back country to the hospital, and from where i am i cant get a helicopter so its a plane. I take a plane and land at the airport and ambulance to the hospital. I have the emergency surgery. On and on. What i am hearing is the biggest source well what is the most likely source going to be in that case of the potential surprise bills that are coming my way . Anyone . So, i mean, naturally there is going to be the emergency room visit. Trip to the operating room. Surgeon does the procedure, fixing the arm. Anesthesioligist puts the patient to sleep wakes the patient up, recovery afterwards and go home. But the air ambulance and the regular ambulance. The trip to the hospital as well. The fact that some of these physician groups like the anesthesiologists for example, if they are not in network, that is the root of the problem. The question is, why are they not in network . Im out of state. Im using the example of someone out of state. Than it is out of network. Naturally, there has to be a solution. That is not a problem that can be prevented by contract youre , going to be in vacation in a random place and obviously the Insurance Company doesnt have a contract with the local facility. That is for those people that produce that bill that provided that service to have a conversation with the Insurance Company and instead of having some assigned random number, right. I just want to pull it back just because of time. I get all these bills in we have heard the stories. Insurance pays for some. I get threatened by others. Say thely, lets patient at the end of the day is held harmless. It all gets taken care of. But in the system there seems to me to be a lot of wind falls a lot of short falls to the patient. The hospital, potentially the Insurance Company. Is there a wind fall, is someone in the system making a wind fall in the dilemma we are talking about . If i could interject, for one thing we will do a disservice to patients if we protect them from hospital bills but theyre already bankrupt just from the trip to get there. And thats why ambulance and air ambulance has to be included. I dont think we mentioned yesterday today that many of the hospitals are not the doing what zuckerberg hospital was doing. The hospital will be in network but they will have outsourced their emergency room to a wall street owned private company. The company wont take insurance. Those guys are definitely making enough profits that wall street is suggesting that people should invest in the companies because of the relationships they have with the in Network Hospitals and the out of network Emergency Rooms. Anyone else . I would say that that that mother sitting in the parking lot is not only concerned about what her out of pocket costs would be for the visit but also her premiums. So its really important that we think about when we think about to solve this issue, we are not doing it in a way thats going to raise premiums Going Forward. Thats where i went with the idea of short falls. If we dont address this issue its costing all of us in the and. Exactly. We have to find a way to address it. I am out of time. I thank you and yield back. And if any of you have suggestions about the air ambulance issue, its not really been addressed in any of the proposals and we could use your specific recommendations by a complex but serious problem. Mr. Gomez. Thank you, mr. Chairman. Thank you for having this hearing. I was in the California Legislature when the bill passed, ab 72. Ite get into that in a little bit. When it comes to health care this is of an idea that ive had discussions with. Most americans want to be health care secure. What does that mean . I think it means that, you know, they understand they have to pay for premiums. They have to pay deductionables. Deductibles. But they dont want to be that scenario where they cant get the care they want and need, the best care possible, they want to be able to make sure they can afford it and make sure the Insurance Plans includes real benefits. And especially they dont want to end up in a situation where they get a bill, you know, sometimes days or weks or months after a procedure that they didnt know that they were going to get. It is something that keeps up a lot of americans at night. I believe its unacceptable. And i think that its a problem that well be dealing with in our Health Care System. And i think its true no matter whether a patient researches their options for in network care ahead of time. They end up in the emergency room or they lack the resources , time and Language Skills to navigate some of the most complex Health Care Systems in the world. My father died of pancreatic cancer. He didnt speak the language well. And i had to help him deal with a lot of those issues. And its difficult. And when you deal with the stressful situation of life and death, its even more difficult. So its something that i think that its not going to be easy, right . On ab 72, there was a negotiated agreement between the plans, the hospitals and the docs. The docs ended up going neutral on the bill and it passed unanimously, 72 to i think two people. A bunch of abstentions. You can say those are nos or didnt want to take a position. It was pretty much unanimous. I want to ask, how is the California Law working . And what are some of the short falls . I understand the big shortfall is it doesnt deal with a big chunk. But how is it working in the field . We can go down the line. Yes, so the my understanding of the aftermath of the California Law is that if an Insurance Company can get the care for their subscribers from an out of Network Physician at, lets say 125 of medicare and , theyre currently paying the in Network Physicians 140 of medicare whats likely to , happen . Its exactly what happened. They dont renew the contracts for physicians in network and make them out of network. It solves one problem and creates a massive other problem. So groups that were working in a hospital for 19 years go to renew the contract for the 20th time and doesnt get renewed because it is cheaper for the Insurance Company to knock them in out of Network Status. There is aftermath to these things if theyre not thought out properly. So as you mentioned, ab 72 was passed with bipartisan support. Consumer groups supported it our Industry Health plan supported it. The regulations really just went into effect in january as was mentioned. But our plans have thought that its really starting to work really well. We feel like consumers are protected and like i mentioned before, it addresses the new in the issue in a way that doesnt raise overall Health Care Costs which i think is important. My understanding of the California Law is that the benchmark doesnt affect hospitals. I know that is being debated in the state legislature as we peek about whether they want to extend it, but it wasnt. What we fear was what happened with the physicians. If you set a rate especially if based on medicare which everybody understands underpays for both physicians and hospitals. It does lends itself to our fear that you have a benchmark and we get fewer people in network, that insurers resort to the benchmark because its cheaper than they have to pay otherwise. And its our understanding that california took bold steps to solve the problem and we have not seen borne out some of the warnings given about various solutions. There has not been a mass migration of physicians out of the state of california. People are not losing access to care. Surprise bills are being stopped. Well i have a lot of questions. California is a very unique place. I have a lot of questions. But i know this is an issue that we just dont want to see that the patients continue to be the losers in the situation. And we will be asking for advice and input as we move forward. So thank you so much. Mr. Horsford. Thank you, chairman doggett. I am glad we are addressing this issue that has plagued people across the country far too long. I know we talked a lot today about kind of the different players. But i really want to focus on costs, not just shifting the responsibility of who pays at the end. One las vegas family experienced the shock and stresses of soaring hospital bills earlier this year in my district. Michael took his wife marta to the emergency room in january, after she fainted and appeared to have having a seizure. Despite having Health Insurance, the two selfemployed musicians were stuck with more than a 5,700 hospital and doctor bills after an hour and a half visit. 5,700. Now, 39 of insured adults under age 65 said they received an unanticipated medical bill within the last year that they thought would be covered by their insurance or that was higher than they anticipated. Half of the people said the bill was less than 500. But nearly one in eight said that they were on the hook for 2,000 or more. This represents a large concern for many americans, not only fears about unexpected medical bills but also seeing costs of the bills much higher than they could have ever anticipated. And that is a legitimate concern. Reports show that out of Network Providers are charging an average of 150 more for than in Network Providers. And i think we really have to drill down to the question, why . Now luckily in my home state of nevada, just last week governor steve cisilak sign into law a bill which represents the culmination of years of work. This compromise bill ensures that patient haves more protections in medical emergency situations. The final proposal signed in law holds patients harmless by requiring them to only pay whatever copay, coinsurance or deductable that they would have been responsible for at an in Network Facility for Emergency Care. Under the legislation if a hospital and insurer were recently in network the insurer would be required to pay 108 or 115 of the previously contracted rates, depending on how long they were out of network, and if they never had a contract or were out of network more than two years, the two parties, not the patient, would be allowed to make initial offers to each other before going to arbitration. So this bill represents every part of the system. Insurance companies, providers and Patient Advocates coming together to find a solution. And im very proud of nevadas leadership on this national problem. And i hope that it can be a guide for federal policy as we have done in other issues like drug cost transparency. So my question, mr. Nickels, dr. Mukkamala. Why are my constituents being charged many times the cost of care they need and how can we correct for the . For that . Let me begin by agreeing on the nevada law. Our members are supportive of that. Thats a good solution. If you come into the Emergency Department or inNetwork Facility you pay your out of Network Physicians you pay your innetwork coinsurance , period. Thats the way it ought to be. Thats the way it ought to have been for the couple you mentioned earlier. If it had happened to them henceforth it would be the way , it should be which is they pay the in network coinsurance. That takes the patient out of the middle of it. And thats the way it should be. The way nevada is looking at it is also reasonable because it gives the opportunity for the provider and the insurer to negotiate to come with up with the right price between themselves. That negotiation can occur with patients out of it, and it represents a model we ought to be looking at. Thank you. What about the cost . How can we drill down in what the bill looks like when you get it at the end of the day . When you get the bill, the bill is based on an amount that could be based oh charges, hospital charges et cetera. What are important to the patient is what the patient has to pay. But if the bill is still exorbitant and the patient has to pay 10 of the bill that is way more than it should be they , do still care about what the bill looks like. But that amount was negotiated between that patients insurer and the hospital. And the insurer im sure goot got as good a deal as they could. The original charge, the thing you see when you get the this is not a pill from a hospital, physician or anyone else is not what the insurer paid the hospital and what the subscriber pays is a percentage of what the insurer negotiated for that subscriber. Okay. I know my time is up, mr. Chairman. I appreciate this hearing. I look forward to us continuing to take action on this very important issue. Thank you. And i appreciate all our members and their cooperation here today. And particularly thank our witnesses and repipelined them that members have two weeks in which to submit written questions to be answered later in writing. I welcome you supplementing your presentation today with anything in writing you may want to add for the record. Your questions the questions and all the answers will be made part of our formal hearing record. With that, thank you for your time this afternoon. And hope we can continue working together to try to resolve this problem. The committee stands adjourned. Thank you, sir. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] [captions Copyright National cable satellite corp. 2019] announcer 1 join us later today houseoad for the white programming. The california democrat will host a town hall meeting in iowa, which you can see live tonight staring at 6 45 eastern. Formercomments from Trump Administration National Security advisor who recently joined the Hoover Institution to discuss threats to free and open society. Other panelists include historian Neil Ferguson and his wife, a Muslim Womans right activist. It airs tonight at 8 00 eastern on cspan. One question i want to ask you about nonviolent extremism is how important the internet is in the process of radicalization. One reads usually after a terrorist attack that the perpetrator was radicalized online. Is that actually what happens . A number of people believe if we shut off all of their social and media, radicalization would be minimized. I tend to disagree. By the time and individual goes to his smart phone or laptop to access any of these social media tools, they have already been inspired. At a minimum, they have been inspired to think things. They are looking forsome kind o. When you think about morality and you are 15, 16, 17, often outside of the west, 90 of people will think about going to their religion. You can go to your local imam, but most of those local imams have been displaced. Countries like saudi arabia have put a lot of money into putting their own imams and messages and infrastructure in place that has displaced that local islam that was established in most places world. So you are a young person, you live here, in the u. K. , bangladesh or sri lanka. You are thinking about the difference between right and wrong. You go to the mosque and you listen to a sermon. They tell you about this worldview that is so coherent, with the rewards in the hereafter and the sacrifices to make. And it is only because it is so complex that i think many individuals think, well, they give you preferences. At the end of my talk, i say why dont you go to the hoover website . Or the Classical Liberal website, this that and the other . They do the same thing. That is what people do on cyber. People come to these references and think i will get more information, and they get sucked in. But cyber is only part of the story when it is used that way. Announcer that is just a short portion of the discretion discussion on threats to free and open societys. See the entire program tonight at 8 00 p. M. Eastern here on cspan. Announcer this Independence Day on cspan, we are live with former Vice President joe biden and jill biden at 2 30 p. M. Eastern for their july 4 president ial Campaign Stop in marshalltown, iowa. Than at 6 00 p. M. , President Trump at the Lincoln Memorial for the fourth of july celebration. At 8 00, former speechwriters for president bill clinton, george w. Bush, and former First Lady Michelle Obama discuss their work and white House Stories at the university of Chicago Institute. Of politics watch this fourth of july. On cspan. University of Chicago Institute of politics. Watch this fourth of july on cspan. There has been discussion that any testimony might go beyond our report. It contains findings and analysis for the reasons for the decisions we made. We chose those words carefully and the word speaks for itself. The report is my testimony. I would not provide information beyond that which is already public in any appearance before congress. Announcer former special Counsel Robert Mueller is set to appear before two committees of congress on wednesday, july 17 at 9 00 a. M. Eastern to the house judiciary committee. Later in the day, he will take questions from the house intelligence committee, both open sessions. His report into russian interference in the 2016 election will air live on cspan. Org,ine at or listen with the free cspan radio app. Next, pete buttigieg, democratic president ial candidate and mayor of south bend, indiana addresses the innbow Push Coalition chicago. He talks briefly about her recent Police Shooting in his city and more broadly about his campaign for president. This is about 25 minutes. Mayor buttigieg good morning, and thank you. Thank you mr. Jackson. Thank you for the work of the rainbow coalition. And thank you for this morning, an opportunity for me to become better educated not only about the challenges but about the extraordinary capacities of minority contractors in this area that reflect on the challenges and capacities for minority enterprise across the country. It is educational and will inform my work Going Forward and im grateful for im delighted to be. Im grateful for it. Im related to be in the city of lori lightfoot, a trailblazer, and i congratulate her. I am honored to be in the presence of james clyburn, who clearly has a kind of biblical favor upon him bec