Advocating for Better Mental Health Services and Fairer Billing Practices on the Hill

By Alison Smith, MD, MPH

Studies conducted by lobbyist groups show that the single most impactful way to make change as a constituent of a U.S. legislator is to show up in person to the legislator’s office with well-researched data, a personal story, and a specific proposal.

ACEP’s 2019 Leadership and Advocacy Conference (LAC) was held in Washington, DC from May 5-8th and provided that opportunity for three Utah emergency physicians. UCEP President David Mabey, University of Utah Emergency Medicine first-year resident James Fierbaugh, and I (UCEP Secretary/Treasurer) attended on behalf of Utah and were among nearly 500 emergency physicians who came together for the annual conference.

For three days, we attended sessions on how to be effective physician leaders and advocates. We heard excellent lectures on current contentious issues in emergency medicine affecting our patients, our livelihoods, and our practice. Finally, we were educated on the topics about which we would be talking to our leaders on the Hill.

On the day of our visits to the U.S. Senate and House Congressional offices, we had the opportunity to meet with legislative aides and staffers for Senators Mike Lee and Mitt Romney and for Representatives Chris Stewart and Ben McAdams. We had two “asks” of our Utah legislators.

First, we urged lawmakers to co-sponsor the “The Improving Mental Health from the Emergency Department Act” (HR2519 and S1334 sponsored by Senator Shelly Capito of West Virginia). This bill would create a grant program to supply funds for communities to do the following:

  • Expedite transport to post-emergency care through expanded coordination with regional service providers, assessment, peer navigators, bed availability tracking and management, transfer protocol development, networking infrastructure development, and transportation services;
  • Increase the supply of inpatient psychiatric beds and alternative care settings such as regional emergency psychiatric units; and
  • Expand approaches to providing psychiatric care in the emergency department, including tele-psychiatric support and other remote psychiatric consultations, peak period crisis clinics, or through creation of dedicated psychiatric emergency service units.

We argued that more connected, collaborative care improves treatment options, avoids delays in care, and better supports our mental health patients in their recovery. We shared personal stories from our experiences in the ED to shed light on the daily issues we face around the state related to long psychiatric boarding times and lack of both inpatient and outpatient mental health services for patients.

Second, we raised the issue of surprise (i.e., balanced) billing. In an emergency, getting treatment as quickly as possible is the top priority—not having to worry about where one is in-network, how much a deductible will be, or how much treatment will cost. Unlike other physicians, emergency physicians are actually prohibited by law from discussing any potential costs of care or insurance details with patients until they are medically screened and stabilized, according to the Emergency Medicine Treatment and Labor Act (EMTALA). This ensures that care is given to all regardless of ability to pay, but it can also translate to patients not fully understanding the potential costs that could result from their care or the limitations of their health insurance until they receive a bill (or multiple bills, as the facility, ED physician, consultants, lab, OR, and other fees can all result in separate bills to the patient).

Insurance companies pay out an “allowed amount,” often a seemingly arbitrary number they decide they are willing to reimburse for a patient’s care. The patient is then sent the remainder of the balance, in addition to their copay and deductible costs charged by their insurance company. We explained to our captive audience of legislative aides that this ends up making physicians look like the “bad guys” who are requesting the extra payment from the patient’s pocket.

What we proposed is to take patients out of the middle. We explained that this could be achieved by Congress adopting a proven process that encourages insurers and providers to negotiate fairly. This is a “baseball style” arbitration, a model that has already been effective in several states and provides an evidence-based template to federally protect patients from surprise medical bills. Briefly, this is a process whereby if an insurer underpays the physician and both sides cannot agree on a fair payment, the physician can take the insurance company to arbitration. An impartial arbitrator reviews both the insurer’s and physician’s claims and picks one of the amounts charged. The “loser” must pay for the arbitration fee and, if the amount was determined to be underpaid, the difference in the claim. This process encourages fair claims and payments by both insurance and physician groups from the start.

The key principles of such an approach are as follows:

  • Protect patients. ACEP supports a prohibition of “balance billing” of a patient provided there is a corresponding fair and independent mechanism to resolve provider-insurer billing disputes.
  • Level the playing field. An independent, “baseball-style” arbitration process is a simple and efficient solution that incentivizes providers to charge reasonable rates, and insurers to pay appropriate amounts. In New York, this model has almost eliminated surprise bills; meanwhile, insurance premiums and health care costs in the state have grown more slowly than those in the rest of the nation.
  • Improve transparency. To ensure patients better understand the limits of their insurance coverage and all potential out-of-pocket costs every time they seek care, insurers should provide the deductible amount on the policyholder’s insurance cards.
    • Patients should also not have to pay any more out-of-pocket costs for emergency care than they would have paid if it was in-network. Under current law, this patient protection does not apply to deductibles, only to coinsurance and copays for emergency care.
    • Lastly, policyholders should be provided with clear, concise, and meaningful explanations of their plans’ emergency service benefits, a current list of in- and out-of-network providers, and their rights under EMTALA.

Our visit to the Hill felt invigorating and productive, and we are hopeful that it will make a difference for our patients and our fellow Utah emergency physicians. We encourage each of you to reach out to your representatives in Congress to support these and other measures you feel are important. What you do in the emergency department matters, but so does what you do outside the department. I encourage you to use your voice. It is the best weapon you have to promote the change you want to see.