July 19, 2017
Patients soon will have an easier time dealing with
health insurance-related problems, thanks to new laws. Two bills backed by the Texas
Medical Association (TMA) this legislative session — each of which passed and
earned Gov. Greg Abbott’s signature into law — should give patients some relief
from the headaches of surprise medical bills and unwarranted changes to their
prescribed medication. The issues — surprise bills and “step-therapy protocol” —
are just two of the ways in which health insurers make life difficult for Texas
patients and the physicians who care for them.
Under Senate Bill 507 by Sen.
Kelly Hancock (R-North Richland Hills), more patients can seek mediation after they receive balance bills for health care they thought their insurance covers
but does not. The law broadens the scenarios for which patients can seek
mediation, giving them much-needed recourse while preserving a physician’s
right to be paid for his or her services. The other measure signed into law, Senate Bill 680 — also by Senator Hancock — gives physicians greater authority to judge
whether prescribed medication is working, and more quickly override a health
plan’s efforts to change the medication.
Both measures, which take effect Sept. 1, are good
examples of successful legislative changes to Texas’ health insurance policy,
according to Beaumont anesthesiologist Ray Callas, MD, a member of TMA’s
Board of Trustees. Dr. Callas gave medicine a high grade for its
legislative work on insurance. “If you were going to score it [on] a zero-to-10
scoring system, I would give it probably an 8.5,” said Dr. Callas, the
immediate past chair of TMA’s Council on Legislation. “I think we moved the
needle forward in order to protect patients and to hold insurance companies
accountable.”
Expanded Mediation
SB 507
maintains the current $500 threshold, meaning a patient can seek mediation to
settle bills higher than $500 after he or she has paid deductibles, copays, and
out-of-pocket costs for treatment. This applies to care received at certain in-network facilities — namely,
hospitals, birthing centers, ambulatory surgical centers, and freestanding
emergency departments. The bill also expands mediation to all emergency care
situations and requires health plans and practitioners who send a bill for
out-of-network care to include a “conspicuous plain-language explanation of the
mediation process.”
Dr. Callas said SB 507 protects patients from surprise
billing and expands parts of the process that are successful. “Because
mediation is working, we are happy to see the mediation process protected, as
the initial informal [mediation] conference call is where 95 percent of
disputes are resolved,” Dr. Callas said. “We feel maintaining this process is
in the best interest of the patient to have a timely resolution of an
out-of-network balance bill.”
Narrow or small insurance networks with too few
physicians from which to choose pose problems for patients. Often confused by
their health insurance coverage, patients sometimes seek care from a physician
who is not in their plan’s insurance network. When that happens, insurance pays
a fraction of the patient’s health care bill, and patients receive a bill for
the unpaid balance. Mediation can help them resolve those financial
circumstances.
Step-Therapy
Override
The second insurance-revision law improves patient care,
particularly for some patients such as cancer patients. The step-therapy override,
authorized by SB 680, says a health plan’s protocols are no reason to switch a
patient to another drug if a physician believes the initial medication is
working. Currently, health plans institute step therapy to save costs;
essentially mandating physicians first try prescribing a different, cheaper
medication regardless of the doctor’s clinical preference. Instead, the bill
shortens how quickly a physician can override an insurer's step-therapy plan
from the current 53 days to just three days, and it prevents patients from
having to go through the step therapy process a second time if their coverage
changes. Austin hematologist-oncologist Sylvia
Jaramillo, MD, testified in support of SB 680 on TMA’s behalf at a Texas Senate
Business and Commerce Committee hearing in March. She told lawmakers step therapy “can increase
risk and expose patients to potentially ineffective treatments. This can cause
delay in access to appropriate care, which ultimately affects patient outcomes.”
Dr. Jaramillo also told the committee, “While sometimes step therapy sounds
reasonable, it can be very dangerous.”
Dr. Callas said
both bills are a victory for patient safety and transparency. “If patients are
happy with the legislation and what it does for them, then physicians will be
in a better position to build a tighter bond with their patients, without fear
of some insurance-related process taking over.”
In the end, he
said, physicians want to focus on where their attention should lie — providing
the best care possible for patients. These bills help improve the health care
system for patients and the doctors who treat them.
TMA is the largest state medical society in the nation,
representing more than 50,000 physician and medical student members. It is
located in Austin and has 110 component county medical societies around the
state. TMA’s key objective since 1853 is to improve the health of all Texans.
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Contact: Brent Annear (512) 370-1381; cell: (512) 656-7320; email: brent.annear[at]texmed[dot]org
Marcus Cooper (512)
370-1382; cell: (512) 650-5336; email: marcus.cooper[at]texmed[dot]org
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