Anyone who has tried to shop around for hospital services knows this: It’s hard to get prices in advance.

President Trump signed an executive order Monday that he says would make such comparisons easier, and make the pricing process more transparent.

The order directs agencies to draw up rules requiring hospitals and insurers to make public more information on the negotiated prices they hammer out in contract negotiations. Also, hospitals and insurers would have to give estimates on out-of-pocket costs to patients before they go in for nonemergency medical care.

“This will put American patients in control and address fundamental drivers of health care costs in a way no president has done before,” said Health and Human Services Secretary Alex Azar during a press briefing Monday.

But just how useful the effort will prove for consumers remains unclear.

If the executive order leads to finalized HHS rules, proponents say it could encourage competition and lower prices.

Other health care analysts say much depends on how the administration writes the rules over the next several months — rules that govern what information must be provided and in what format. Trump’s executive order already is running into opposition from some hospitals and insurers who say disclosing negotiated rates could drive up costs.

As health care consumers await more details on those rules, here’s what we know:

Q: What does the order do?

It may expand price information consumers receive.

The order directs agencies to develop rules to require hospitals and insurers to provide information “based on negotiated rates” to the public.

Currently, such rates are hard to get, even for patients, until after medical care is provided. That’s when insured patients get an “explanation of benefits,” which shows how much the hospital charged, how much of a discount their insurer received and the amount a patient may owe.

In addition to consumers being unable to get price information upfront in many cases, hospital list prices and negotiated discount rates vary widely by hospital and insurer, even within the same region. Uninsured patients often are charged the full amounts.

“People are sick and tired of hospitals playing these games with prices,” says George Nation, a business professor at Lehigh University who studies hospital contract law. “That’s what’s driving all of this.”

Some insurers and hospitals do provide online tools or apps that already can help individual patients estimate out-of-pocket costs for a service or procedure ahead of time. But research shows few patients use such tools. Also, many medical services are needed without much notice — think of a heart attack or a broken leg — so shopping for price simply isn’t possible.

Administration officials say they want patients to have access to more information, including “advance EOBs” that outline anticipated costs before patients get nonemergency medical care. In theory, that would allow consumers to shop around for lower cost care.

Q: Isn’t this information already available?

Not exactly. In January, new rules took effect under the Affordable Care Act that require hospitals to post online their “list prices.” These are prices hospitals set themselves, and have little relation to actual costs or what insurers actually pay.

What’s resulted are often confusing spreadsheets that contain thousands of a la carte charges — ranging from the price of medicines and sutures to room costs, among other things — that patients have to piece together (if they can) to estimate their total bill. Also, those list charges don’t reflect the discounted rates insurers have negotiated, so they are of little use to insured patients who might want to compare prices from hospital to hospital.

In theory, at least, the information that would result from Trump’s executive order would provide more detail based on negotiated, discounted rates.

A senior administration official at the press briefing said details about whether the rates would be aggregated or relate to individual hospitals would be spelled out only when the administration puts forward proposed rules to implement the order later this year. It also is still unclear how the administration would enforce the rules.

Another limitation to the executive order: It applies only to hospitals and the medical staff they employ. Many hospitals are staffed by doctors who are not directly employed, or rely on laboratories that are also separate. That means negotiated prices for services provided by such laboratories or physicians would not have to be disclosed.

Q: How could consumers use this information?

In theory, consumers could get information in advance that would allow them to compare prices for, say, a hip replacement or knee surgery.

But that could prove difficult if the rates are not fairly hospital-specific, or if they are not lumped in with all the care needed for a specific procedure or surgery.

“They could take the top 20 common procedures the hospital does, for example, and put negotiated prices on them,” says Nation. “It makes sense to do an average for that particular hospital, so I can see how much it’s going to cost to have my knee replaced at St. Joe’s versus St. Anne’s.”

Having advance notice of out-of-pocket costs could also help patients who have high-deductible plans.

“Patients are increasingly subject to insurance deductibles and other forms of substantial cost sharing. For a subset of so-called ‘shoppable services’, patients would benefit from price estimates in advance that allow them to compare options and plan financially for their care,” says John Rother, president and CEO at the advocacy group National Coalition on Health Care.

Q: Would the availability of this extra information push consumers to shop for health care?

The short answer is maybe.

“The evidence to date shows patients aren’t necessarily the best shoppers, but we haven’t given them the best tools to be shoppers,” says Lovisa Gustafsson, assistant vice president at the Commonwealth Fund.

Posting negotiated rates might be a step forward, she says, but only if the information is easily understandable.

It’s also possible that insurers, physician offices, consumer groups or online businesses would find ways to help direct patients to the most cost-effective locations for surgeries, tests or other procedures based on the information.

“Institutions like Consumer Reports or Consumer Checkbook could do some kind of high-level comparison between facilities or doctors,” says Tim Jost, a professor emeritus at the Washington and Lee University School of Law.

But some hospitals and insurers maintain that disclosing specific rates could backfire.

Hospitals charging lower rates, for example, might raise them if they see competitors are getting higher reimbursement from insurers. And insurers say they might be hampered in their ability to negotiate if rivals all know what they each pay.

“We also agree that patients should have accurate, real-time information about costs so they can make the best, most informed decisions about their care,” said the lobbying group America’s Health Insurance Plans, in a written statement. “But publicly disclosing competitively negotiated, proprietary rates will reduce competition and push prices higher — not lower — for consumers, patients and taxpayers.”

Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation, and is not affiliated with Kaiser Permanente.

Let’s block ads! (Why?)

Updated 4:03 p.m.

President Trump signed an executive order Monday on price transparency in health care that aims to lower rising health care costs by showing prices to patients. The idea is that if people can shop around, market forces may drive down costs.

“Hospitals will be required to publish prices that reflect what people pay for services,” said President Trump at a White House event. “You will get great pricing. Prices will come down by numbers that you wouldn’t believe. The cost of healthcare will go way, way down.”

Like several of President Trump’s other health policy-related announcements, today’s executive order doesn’t spell out specific actions, but directs the department of Health and Human Services to develop a policy and then undertake a lengthy rule-making process.

“The president knows the best way to lower costs in health care is to put patients in control by increasing choice and competition,” HHS Secretary Alex Azar said at a phone briefing for reporters Monday morning.

Azar outlined five parts of the executive order, two of which are directly related to price transparency.

It directs the agency to draft a new rule that would require hospitals to disclose the prices that patients and insurers actually pay in “an easy-to-read, patient-friendly format,” Azar said.

The new rule should also “require health care providers and insurers to provide patients with information about the out-of-pocket costs they’ll face before they receive health care services,” he added.

The idea is simple. Health care is an industry where consumers don’t have access to the kind of information they have when making other purchasing decisions. The executive order could — if it leads to finalized, HHS rules — pressure the industry to function more like a normal market, where quality and price drive consumer behavior. Some consumer advocates welcomed the move.

“Today patients don’t have access to prices or choices or even ability to see quality,” said Cynthia Fisher, founder of a group called Patient Rights Advocate. “I think the exciting part of this executive order is the President and administration are really moving to put the patient in the driver’s seat and be empowered for the first time with knowledge and information.”

Exactly how the rules the executive order calls for would work is still to be determined, administration officials said.

Push back from various corners of the healthcare industry came quickly, with hospital and health plan lobbying organizations arguing this transparency requirement would have the unintended consequence of pushing prices up, rather than down.

“Publicly disclosing competitively negotiated, proprietary rates will reduce competition and push prices higher — not lower — for consumers, patients, and taxpayers,” said Matt Eyles, CEO of America’s Health Insurance Plans in a statement. He says it will perpetuate “the old days of the American health care system paying for volume over value. We know that is a formula for higher costs and worse care for everyone.”

Some health economists and industry observers without a vested interest expressed a similar view. Larry Levitt, senior vice president for health reform the Kaiser Family Foundation, tweeted that although the idea of greater price transparency makes sense from the perspective of consumer protection, it doesn’t guarantee lower prices.

“I’m skeptical that disclosure of health care prices will drive prices down, and could even increase prices once hospitals and doctors know what their competitors down the street are getting paid,” Levitt wrote.

This executive order is the latest in a series of moves from the Trump administration on health care price transparency recently. As NPR reported, just last month the White House announced its legislative priorities for ending surprise medical bills, which included patients receiving a “clear and honest bill upfront” before scheduled care. That same week, HHS announced a final rule requiring drugmakers to display list prices of their drugs in TV ads.

However, several of President Trump’s past health care announcements have gotten tied up before the promises to lower costs could be realized.

For instance, in May 2018, Trump rolled out a Blueprint To Lower Drug Prices which included a variety of proposals intended to reduce pharmaceutical costs to individuals, the industry and the economy as a whole, as NPR reported.

In October of last year, the Centers for Medicare and Medicaid Services proposed an international pricing model for setting what Medicare Part B would pay for certain drugs. This is the closest the Trump administration has come to Trump’s campaign promise to have Medicare negotiate with drug companies.

The proposal was put out for public comment with a December 2018 deadline. Thousands of comments came in, including a lot of pushback from the pharmaceutical industry and the proposed rule has not yet been finalized and it’s not clear it ever will be.

Let’s block ads! (Why?)

Across the country, surgeons are learning to use more than just scalpels and forceps. In the past decade, a growing number of medical institutions have invested in the da Vinci robot, the most common device used to perform robot-assisted, or robotic, surgery.

Compared to traditional open surgery, robotic surgery is minimally invasive and recovery time is often shorter, making the technology attractive to patients and doctors. But the da Vinci surgical system is expensive, costing as much as $2 million, and recent studies show that for certain procedures it can sometimes lead to worse long-term outcomes than other types of surgery.

Even so, the robot has become common practice in some specialties, such as urology and gynecology, and that growth is expected to continue, which means more surgeons are learning to use the device.

“It’s not necessarily, ‘Is robot better?’ ” says Dr. Kenneth Kim, director of the robotic training program at UAB Hospital in Birmingham, Alabama. “Robot is just another tool that they need to master just like any other surgical tool.”

But “mastering the robot” can be a challenge.

“It never was an issue because open surgery, like scissors — like everyone learns how to use scissors in kindergarten,” Kim says. “Everyone knows, functionally, how to use a knife. But with the robot, it’s a totally different, new tool and it’s more complex, so now that has a separate learning curve.”

The da Vinci robot is not self-operating, at least not yet. Instead, it works almost like a big video game. The surgeon sits at a console station and uses hand and feet controls to manipulate a separate surgical part attached to the patient.

Operating in virtual reality

One way students get comfortable with the device is by operating in virtual reality. At training institutions like UAB, surgical residents use a simulator to complete monthly tasks and practice common procedures.

OBGYN resident Teresa Boitano says the exercises help develop skills that are directly applicable to the operating room. During one of these tasks, Boitano moves the robot arms to precisely place colorful rings onto corresponding spikes.

“And so I’m going now to grab this first ring and at the same time I’m thinking, ‘OK now where do I need to go to get the next one?’ ” Boitano says. “You’re always trying to stay ahead of the game but then also, making sure you’re not doing any errors at the same time.”

If she does make a mistake, the machine will tell her. Kim says the latest simulators come equipped with advanced motion-tracking technology. So while Boitano’s practicing a task or doing a run through a hysterectomy in virtual reality, the simulator records her movement – how accurately she uses the robot arms or how fast she completes the exercise. It provides objective data about surgical performance.

Dr. Khurshid Guru, director of robotic surgery at Roswell Park Comprehensive Cancer Center in New York, says this simulator technology helps standardize the training process.

“The analogy is that now you don’t have to worry about learning how to drive a car because everybody could get onto the street, they are taught the basic principles of driving a car,” Guru says. “The million-dollar question now is, ‘When would you allow them to get onto the expressway?’ “

Guru says that is the next step, when surgeons specialize in different procedures.

Robot-assisted surgery not for every patient

Dr. Monica Hagan Vetter, of The Ohio State University, has studied robotic training programs across the country. She says using a simulator to measure surgical ability helps ensure surgeons have a certain level of skill before they actually operate on people.

“You can learn the steps of the procedure,” Vetter says, “but if you don’t know how the robot works, if you don’t know how to troubleshoot the robot or what to do in an emergency, then even if you can perform the world’s best hysterectomy and you know all the steps and all the instruments, you are not safe to do that.”

Dr. Kenneth Kim says simulators and the data they provide help streamline the teaching process and offer the opportunity to give students more objective feedback. It is a way for surgeons to learn to use the da Vinci robot as a tool, but Kim says they still have to watch and learn.

“The simulator’s good, but it can only simulate so much,” he says.

In the real world, Kim says robot-assisted surgery is not right for every patient. A surgeon needs to know when to use it and when not to use it, and those decisions can change as researchers continue to study patient outcomes from robotic surgery.

Let’s block ads! (Why?)

In Florida, Gov. Ron DeSantis signed a bill last week that, if federal authorities give it their go-ahead — still a very big if — would allow his state to import prescription drugs from Canada. That makes Florida the third state to pass such a law, joining Vermont and Colorado. More such legislative attempts are in the works.

“There have been 27 different bills proposed across the country this year,” says Trish Riley, the executive director of the National Academy for State Health Policy. “I think that it’s an approach that makes sense to states. It’s something they can do now to help their citizens.”

The Trump administration has made bringing down the price of prescription drugs a priority, and politicians at every level are looking for ways to make that happen.

Riley says her group didn’t help write the Florida plan, although it met with staff and provided resources and model legislation.

“States are very much frustrated by the incredibly high costs of drugs,” she says. “When you’re a state and you have to balance a budget and you pay for so much prescription drugs through your state employee plan, your municipal workers [and] through Medicaid, the cost of drugs really is front and center. So I think this is very much a bipartisan issue of urgency at the state level.”

Prescription drugs are often significantly cheaper outside the United States.

“Canada negotiates drug prices just like many other countries around the world,” explains Rachel Sachs, a law professor at Washington University in St. Louis who studies prescription drug pricing. “In the U.S., we’ve constructed a system where pharmaceutical companies are able to charge far higher prices because there’s no mechanism to push back — there’s no way to say, ‘We’re not going to pay for that drug unless we get it at a better price.’ “

So what exactly is Florida’s plan to import certain drugs from Canada, and how would it work?

The Florida law imagines negotiating with the federal Department of Health and Human Services to establish a pilot program to buy these medications from Canada in bulk. “The state would contract with a wholesaler in Canada, who would provide certain high-cost drugs that the state identifies to a wholesaler in Florida,” Riley explains.

So Floridian patients who have a prescription for one of those drugs would just go to their pharmacy and pick up their medicine as usual — all the importing from Canada would be happening in the background.

The law wouldn’t set up a way for Floridians to order medicines from Canadian online pharmacies themselves or enable them to drive north across the border to get a deal on the drugs. Rather, it’s a big-scale, institutional kind of plan.

Would Floridians even notice that their drugs were coming from Canada under this plan?

“It’s possible that the ability to purchase drugs for lower prices at the wholesale level translates into lower premiums overall for particular classes of patients or lower prices at the pharmacy for other patients,” says Sachs. “But without more details about the plan, it’s hard to know.”

And before Florida’s plan can become a reality, it still needs to clear some major hurdles.

First, the state needs to work out a lot of details — such as which Floridians and which drugs the plan would apply to.

The next hurdle is a big one: The plan needs to get approved by the federal secretary of health and human services, Alex Azar. Though the authority of the secretary to make such an approval has existed since 2003, no secretary has ever exercised that right. To win approval, Florida needs to show that the drugs it wants to import are safe and that the plan will save the state money.

On the safety front, Azar last year cited safety concerns when he, at least initially, dismissed the idea of importing drugs from Canada as a “gimmick,” in a meeting at HHS headquarters with the media and others.

“The last four FDA commissioners have said there is no effective way to ensure drugs coming from Canada really are coming from Canada, rather than being routed from, say, a counterfeit factory in China,” Azar said. “The United States has the safest regulatory system in the world. The last thing we need is [to have] open borders for unsafe drugs, in search of savings that cannot be safely achieved.”

A pharmaceutical industry group also has been running ads in Florida recently, talking about the dangers of counterfeit drugs. Riley, of the National Academy for State Health Policy, says those sorts of ads are misleading.

“I’ve seen those in every state we’re working in,” Riley says. “In fact, this program follows current FDA rules. It will use FDA-registered wholesalers. It will simply follow that same supply chain, those same protections, those same assurances of safety.”

Azar also said in that May 2018 speech that he doubted that importing Canadian drugs would save U.S. states or patients money.

“[This idea] has been assessed multiple times by the Congressional Budget Office, and CBO has said it would have no meaningful effect,” he said. “One of the main reasons is that Canada’s drug market is simply too small to bring down prices here. They are a lovely neighbor to the north, but they’re a small one. Canada simply doesn’t have enough drugs to sell them to us for less money, and drug companies won’t sell Canada or Europe more, just to have them imported here.”

Since those remarks last year, President Trump has urged Azar to work with Florida on its plan.

“President Trump and Secretary Azar are firmly committed to getting drug prices down,” HHS spokesperson Caitlin Oakley told NPR in a written statement. “They are both very open to the importation of prescription drugs as long as it can be done safely and can deliver real results for American patients.”

Of course, even if Azar has a change of heart, Florida would face another potential obstacle: getting Canadians and pharmaceutical companies to go along with the plan.

“They need to find willing suppliers for each of the drugs they’re aiming to import, and that may be more of a challenge than they anticipate right now,” says Sachs, the law professor.

Pharmaceutical companies won’t be inclined to cooperate, she says.

“They’ll lose money — if it works,” explains Sachs. “There are many things they could do all along the supply chain to ensure that drugs aren’t diverted to the U.S. in the way that Florida wants.”

Canada isn’t enthused about the idea either, Sachs says, because Florida’s laws could indirectly drive up the price of some drugs in Canada.

When you talk about importing “Canadian drugs,” points out Steve Morgan, a professor of health policy at the University of British Columbia, you’re not actually talking about drugs made in Canada or otherwise especially Canadian. “They’re not actually Canadian drugs,” he says. “They are just international medicines, manufactured typically at one or two plants worldwide to supply the entire market with a particular drug.”

If Florida’s Canadian drug importation plan were in place, Morgan says, “given the scale of manufacturing in the United States, if you were buying a drug made by and sold by an American pharmaceutical company, it’s likely you’re literally buying the same product shipped to Canada and then shipped back into the United States.”

So are Canadians worried that all 21.3 million Floridians are coming for their cheaper drugs? Not really, according to Morgan.

“Canadians feel that the policy is probably not going to result in millions and millions of Americans suddenly getting their drugs from Canada,” he says.

“As a consequence of the money to be made by way of being a middleman in the United States, I don’t think you’re going to see institutional purchasers suddenly shopping in Canada,” Morgan adds. “They will be able to get better prices by negotiating continuous discounts right there in the United States.”

And maybe that’s the point.

Just before Florida’s governor signed the bill last week at The Villages, a large retirement community outside Orlando, he said the law was already making a difference.

“It’s interesting,” DeSantis told a room full of Florida seniors who had been invited to witness the signing of the drug bill. “Since we’ve passed this bill, some of the American companies have already come to us saying, ‘Hey, we’re willing to deal and give you better prices’ — already, just for the fact that we have this.”

The room broke into applause.

Let’s block ads! (Why?)

Texas is now among more than a dozen states that have cracked down on the practice of surprise medical billing.

Texas Gov. Greg Abbott, a Republican, signed legislation Friday shielding patients from getting a huge bill when their insurance company and medical provider can’t agree on payment.

Senate Bill 1264 is bipartisan legislation that removes patients from the middle of disputes between a health insurance company and a hospital or other medical provider.

“We wanted to try to take the patients — get them out of the middle of it — because really it’s not their fight,” says Republican state Sen. Kelly Hancock, the bill’s author.

Under the new law, insurance companies and medical providers can enter into arbitration to negotiate a payment — and state officials would oversee that process.

Surprise medical billing typically happens when someone with health insurance goes to a hospital during an emergency and that hospital is out of network. It also happens if a patient goes to an in-network hospital and the patient’s doctors or medical providers are not in network. Sometimes insurance companies and medical providers won’t agree on what’s a fair price for that care, and patients end up with a hefty medical bill.

Consumer advocates in the state have been urging lawmakers to do more to help Texans saddled with surprise medical bills.

Drew Calver is among the many Texans who have dealt with a surprise bill in the past few years. Calver, a high school history teacher in Austin, had a heart attack in 2017. He was rushed to the closest hospital by a friend that day, and doctors implanted stents to save his life.

Even though he had health insurance that paid the hospital more than $55,000 for his care, Calver ended up with a bill for $108,951.

Calver and his wife, Erin, fought with the hospital and the insurance company for months with little success.

The Calvers eventually turned to the media. Last summer, Drew Calver told his story to the Bill of the Month investigation from NPR and Kaiser Health News. Shortly afterward, his bill was slashed to just $332. Erin Calver says she has seen her family’s story strike a chord.

“For whatever reason, people could relate to us — and be scared that maybe it could happen to them,” she says.

Drew Calver says it’s something lots of people worry about.

“The doctor that put my stents in — he either just had a baby or is about to have a baby — and he was saying that, ‘Yeah, that could happen to me too!’ ” Drew Calver says.

In fact, getting a steep hospital bill is something more Americans say is their biggest financial fear.

“Polling shows us that the top household pocketbook concern for consumers is a surprise medical bill,” says Stacey Pogue of the Center for Public Policy Priorities, a think tank that analyzes health and economic issues in Texas. “And that’s actually pretty shocking that consumers will say they are more worried about their ability to afford a surprise medical bill than their health insurance premiums [and] their really high deductibles.”

Last year, a Kaiser Family Foundation poll found that 67% of people worry about unexpected medical bills — more than the percentage who worry about prescription drug costs or basic necessities such as rent, food and gas.

Pogue says that’s a big reason lawmakers in the state took the issue seriously and passed legislation that she says is now one of the strongest state protections she has seen.

“It is as strong or stronger than any of the protections in the country,” Pogue says.

In addition to Texas, nearby states Colorado and New Mexico also passed legislation this year to address the problem of surprise out-of-network bills. The Commonwealth Fund’s most recent report on the issue found that about half of states offer some legal protections from surprise bills, but only six states had laws that provide “comprehensive” consumer protections, similar to those just passed in Texas.

Texas’s new surprise-bill law officially goes into effect on Sept. 1, 2020.

Hancock, the state senator, says the fight over who pays disputed bills will be back where it belongs: with insurance companies and the hospitals, doctors and labs providing medical care.

When a hospital and insurer can’t agree on a price, the two parties will have to work it out — without ever billing the patient.

“There is still the ability to negotiate,” Hancock says. “You didn’t have government determining what the price was or determining what the settlement was.”

But not all Texans will be protected by the new law, which does not apply to people who have federally regulated plans. In Texas, federally regulated plans account for roughly 40% of the state’s health insurance market.

In fact, Drew Calver would have been exempt from the state’s protections because until recently he had a self-funded health plan regulated by the federal government. However, the family switched to his wife Erin’s health plan, which will be subject to these new protections.

Pogue says people around the U.S. who have federally regulated health plans will be protected only if Congress acts. She thinks the state action will spur federal lawmakers.

“And I think Texas passing a bill will really help on that front,” she says, nothing that several other states have created similar laws. “Every nudge like that is going to help Congress move.”

Texas lawmakers did, however, pass separate legislation that could help Texans with federally regulated plans. Senate Bill 1037 prevents a surprise medical bill from affecting someone’s credit, regardless of whatever health insurance plan the person has.

Congressional leaders have said they are working on coming up with a fix for people across the country with federally regulated plans. Also, President Trump recently held an event at the White House, with Drew and Erin Calver standing by his side, announcing his administration’s support for banning surprise medical billing throughout the country.

During a U.S. House Ways and Means health subcommittee meeting in May, members discussed ways to ban the practice of surprise medical billing.

The subcommittee’s chairman, Austin Democrat Lloyd Doggett, said that “federal action is essential” to addressing the issue for many Americans with federally regulated plans. He said he plans to continue to push for legislation that will “finally offer some relief to patients.” However, no legislation has been passed yet.

During his opening statements, Doggett said there is a bipartisan desire to shield patients from surprise bills, but “conflict remains over how to resolve insurer-provider disputes.”

This story is part of NPR’s reporting partnership with KUT and Kaiser Health News, an editorially independent news service of the Kaiser Family Foundation. You can follow Ashley Lopez on Twitter: @AshLopezRadio.

Let’s block ads! (Why?)