Sweeping Senate healthcare proposal would address surprise billing, transparency

Surprise bills
A proposal with nearly three dozen specific bipartisan healthcare provisions, including several aimed at surprise billing, was sponsored by the Senate Health, Education, Labor and Pensions Committee's top-ranking members Thursday. (Callie Richmond for KHN)

Senate lawmakers released a draft package of legislation Thursday aimed at curbing healthcare costs, starting with topics like surprise billing and drug prices. They said they believe they can pass the bills on a bipartisan basis.

Introduced by Senate health committee Chairman Lamar Alexander, R-Tenn., and ranking member Patty Murray, D-Wash., the proposal includes nearly three dozen specific bipartisan provisions. Alexander said in a statement they hope to move it through the health committee in June and put it to the Senate floor as early as July. The Senate health committee is accepting comments on the discussion draft until June 5. 

RELATED: Providers, insurers parse what they could support—and what they won't—in surprise billing solution

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“These are common sense steps we can take, and every single one of them has the objective of reducing the healthcare costs that you pay for out of your own pocket," Alexander said.

That could be a lofty goal with its ambitious number of proposals, including a number of provisions that will please and disappoint different segments of the healthcare industry.

For instance, when it comes to surprise billing, the proposal would require that every practitioner at an in-network hospital will also take a patient's insurance. For providers, that means they can choose to join the insurance networks that cover that hospital or they can choose to send the bill through the hospital rather than sending separate bills to the patient or insurer. 

The bill also calls for insurers to pay providers the median contracted rate for the same services provided in a geographic area and calls for binding arbitration between payers and providers for surprise bills over $750.

RELATED: Industry experts weigh in on slew of bills aimed at drug price transparency at hearing

In addition, the bill calls for blocking brand-name drug makers from blocking generics or biosimilars, banning gag clauses that prevent employers and patients from knowing the price and quality of healthcare services and banning anticompetitive terms in health insurance contracts with hospital systems that prevent patients from seeing other lower-cost, higher-quality providers.  

The proposal

Here's a breakdown of what the committee is considering: 

Surprise bills

  • The proposal would require that every practitioner at an in-network hospital will also take a patient's insurance. For providers, that means they can choose to join the insurance networks that cover that hospital or they can choose to send the bill through the hospital rather than sending separate bills to the patient or insurer. 
  • The bill also calls for insurers to pay providers the median contracted rate for the same services provided in a geographic area.
  • It would also require insurers or providers initiate an independent dispute resolution process, or arbitration, for surprise bills over $750. For surprise bills less than $750, the insurer will pay the provider the median contracted rate.

Drug costs

  • The proposal would change policy to stop drugmakers of brand-name drugs, including insulin makers, from "gaming the system" to prevent new, lower cost generics or biosimilars from entering the market.
  • Prevent the abuse of citizen petitions to unnecessarily delay drug approvals.
  • Eliminate a loophole where the first generic drug to submit an application to the Food and Drug Administration (FDA) can block other generic drugs from being approved.
  • Educate healthcare providers and patients on biological products and biosimilars, which are the lower-cost version of biological products
  • Help generic drug and biosimilar companies speed drug development and avoid patent infringement through transparent, modernized and searchable patent databases.

Transparency

  • The proposal would designate a nongovernmental, nonprofit entity to use de-identified patient healthcare data so patients, states and employers are able to better understand their healthcare costs and take steps to reduce those costs.
  • It would also ban gag clauses that prevent employers and patients from knowing the price and quality of healthcare services while maintaining all privacy and security protections on patient data.
  • It would ban anti-competitive terms in health insurance contracts with hospital systems that prevent patients from seeing other lower-cost, higher-quality providers.  
  • It would require healthcare facilities provide a summary of services when a patient is discharged from a hospital to make it easier to track bills and require hospitals to send all bills within 30 business days to prevent unexpected bills many months aftercare.
  • It would require providers and insurers to give patients price quotes on expected patient out-of-pocket costs for care so patients are able to shop around.
  • It would require insurance companies to keep up-to-date provider directories so patients can easily know if a provider is in-network.
  • It would ban pharmacy benefit managers (PBMs) from charging employers, health insurance plans and patients more for a drug than the PBM paid to acquire the drug, what is known as “spread pricing.”

Prevention

  • The proposal would aim to increase vaccination rates by allocating funding for a national, evidence-based campaign to combat the spread of vaccine-related misinformation, including online and make grants available to support community vaccination and awareness campaigns. 
  • It would expand the use of technology-based healthcare models to help patients in rural and underserved areas access specialized healthcare.  
  • It would provide states, tribes, and communities with an evidence-based guide to developing programs to prevent obesity and other associated health conditions.  
  • It would address efforts to reduce maternal mortality by authorizing grants for states to collaborate to improve the quality of care for mothers and infants, allocate funding for innovative programs that provide integrated care to moms and for training healthcare providers to improve healthcare and reduce health disparities. It would also require a study to make recommendations for best practices for preventing maternal mortality.

EHR access

  • The proposal would aim to give patients full electronic access to their own health claims information to help them pick the best health insurance plan for their family.
  • Ensure the Department of Health and Human Services (HHS) can successfully implement interoperability provisions of the 21st Century Cures Act.
  • Incentivize healthcare systems to keep your personal health information private and secure. For starters, it would encourage HHS to consider whether providers are following best security practices before issuing audits or fines related to violations of the Health Insurance Portability and Accountability Act. It would also support a study about privacy protections that apply to third-party mobile applications and what protections exist when patients share their protected health information on them.

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