A bipartisan group of Texas lawmakers announced plans this week to address surprise medical bills in a way they believe would ease the burden on patients in the state.

During a news conference Thursday, state Sen. Kelly Hancock, a Republican from suburban Fort Worth, announced he had filed a bill in the Texas Legislature aimed at preventing medical providers from, among other things, balance billing patients — charging patients the difference between what the health care provider and the medical insurer think a medical service or procedure is worth. State Rep. Trey Martinez Fischer, a Democrat from San Antonio, is filing a similar bill in the House.

If passed, the legislation would force medical providers and health insurers to mediate payment disputes before they send bills to patients. Hancock said the point of SB 1264 is to take “the burden off of patients.”

“[It] takes it off of their plates completely,” Hancock said.

He highlighted the case of Drew Calver, a public school teacher in Austin whose six-figure hospital bill after a heart attack was featured in a “Bill of the Month” investigation last summer by NPR, Kaiser Health News and KUT, NPR’s member station in Austin. Hancock noted Calver’s bill was reduced after the media attention but said it shouldn’t take such attention for a patient to get a reasonable bill.

Under this legislation, both sides of the payment dispute would settle their issues through an existing balance bill mediation program. The Texas Department of Insurance program has been successful in lowering medical bills across the state.

The legislation would beef up the program, which addresses surprise balance bills greater than $500 from all emergency providers — including free-standing emergency departments and all out-of-network providers working at a network facility.

“This is designed to apply in situations where patients don’t have any choice which facility they go to or which physician is involved in their care,” Hancock said.

Historically, the Insurance Department’s mediation program had many loopholes, and few consumers qualified for help. It was expanded in 2017, though, and more patients have been filing complaints.

For example, in 2014, the department was asked to mediate 686 medical bills. During the 2018 fiscal year, it received 4,445 bills.

Hancock said the program, so far, has saved Texas patients $30 million.

Still, consumer advocates argue, the system works only when patients know mediation is an option.

Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities, said patients don’t always know help is available, or they find the process intimidating.

“The instructions for how to do it are on your medical bill and your explanation of benefits — the most indecipherable documents you are going to get,” she told KUT earlier this year.

She and others have argued Texas should adopt a program similar to those in other states like New York, California and Florida, whose systems are more consumer-friendly.

Martinez Fischer said it’s time Texas officials stepped in to help patients who are caught in the middle of disputes between medical providers and health insurers. “It has been an industry issue for a few years, I grant you that — the health plans and the providers fighting over their business interests,” he said. “And I respect that. But 10 years later, it is a consumer issue.”

Among other things, Hancock’s bill would allow people with federally regulated, self-funded health plans to opt into the state’s mediation program. According to Hancock, those plans make up about 40 percent of Texas’ insurance market, but those consumers are currently not able to take part in the program.

Hancock said this should provide relief to consumers while federal lawmakers weigh their own efforts to address surprise medical bills.

“Texas will send a loud and clear signal to D.C. that similar consumer protections need to be passed at the federal level,” Hancock said. “Until then, Texas … [is] committed to doing something about it.”

U.S. Rep. Lloyd Doggett, a Democrat who represents Austin in Congress, said he is encouraged by Texas’ efforts but called federal protections “essential.”

“Only approval in Congress of legislation like my End Surprise Billing Act can both protect those who work for large employers with self-funded, federally regulated ERISA plans and assure that patients across America are not forced to pay the price for conflicts between insurers and health care providers,” Doggett said in a written statement.

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

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State attorneys general and women’s health advocates who are hoping to block in court new Trump administration rules for Title X, the federal family planning program, face one major obstacle: The Supreme Court upheld very similar rules in 1991.

Those rules were summarily canceled after a change in administrations. But the court is arguably more conservative than it was 28 years ago.

Still, those who oppose the Trump administration’s rules say that the ground has shifted. They expect to succeed in court this time, they say — pointing to protections enacted in the 2010 Affordable Care Act and changes made by Congress in the mid-1990s in bills that fund Title X.

“I don’t file a lawsuit unless I’m confident we will prevail,” Washington state Attorney General Bob Ferguson said at a news conference Monday, as he announced his plans to sue the Trump administration over the changes to the program. “We’ve filed 17 cases against this administration,” Ferguson said. “We have not lost a case yet.”

The new rules for Title X, posted Friday by the Department of Health and Human Services, are aimed primarily at evicting Planned Parenthood from the program — a longtime goal of abortion opponents. Currently no Title X money can be used for abortions. But conservative groups argue that since many Planned Parenthood affiliates receiving Title X support also provide abortions, the federal family planning money could be improperly commingled with funds used for the procedure.

Planned Parenthood affiliates serve about 40 percent of the program’s 4 million patients.

Specifically, Trump’s rules would forbid family planning providers in almost all cases from referring pregnant patients for abortion. It also would rescind previous regulations that require providers to give women with unintended pregnancies “nondirective” counseling about all their options. “Nondirective” counseling has meant that providers can neither encourage nor deter women from any specific action. Women’s health advocates, including Planned Parenthood, argue that changing that provision, as the Trump administration wants to, would hamper physicians and other providers from giving women unbiased advice, which they say is a violation of medical ethics.

The new regulations also would require any providers that also perform abortions to make those facilities physically and financially separate from their clinics that receive federal funds.

Planned Parenthood has not specifically announced that it will sue, but Dr. Leana Wen, the organization’s president, was clear last week in a call with reporters that “Planned Parenthood cannot participate in a program that would force our providers to compromise their ethics.”

And several other lawsuits are being lined up in anticipation of the rules’ formal publication in the Federal Register, expected next week.

The American Civil Liberties Union announced it will sue on behalf of the National Family Planning & Reproductive Health Association, which represents publicly funded family planning providers and administrators, as well as the Cedar River Clinics in Washington state. The Center for Reproductive Rights has said it will sue on behalf of family planning providers in Maine.

Several other state officials have said that they will sue, including officials in New York, Oregon and California.

Proponents of the administration’s move point to the 1991 Supreme Court case Rust v. Sullivan as proof that the rules are constitutional. In a 5-4 decision, the court said that very similar regulations issued by the Reagan administration in 1988 were an acceptable exercise of executive authority and did not violate the underlying law or the U.S. Constitution.

Although the rules were upheld, subsequent legal action meant they were in effect only for a month before again being blocked and then rescinded by President Bill Clinton in 1993.

Alliance Defending Freedom, a law firm that opposes abortion, released a statement regarding Trump’s new Title X rules that said, in part: “The Protect Life Rule, which the U.S. Supreme Court has upheld, will prevent organizations like the nation’s largest abortion business, Planned Parenthood, from funding their abortion activities through the Title X program.”

Opponents of the new rules, however, insist that the situation has changed in the years since that Supreme Court decision. For one thing, argued several members of Congress in a letter to HHS earlier this month, the department may have violated the federal Administrative Procedure Act that governs the crafting of regulations.

For example, the letter said, HHS “declined to deem the Title X rule economically significant — completely disregarding the considerable health-related costs the rule would impose — and failed to conduct a comprehensive regulatory impact analysis.”

And while the top court is more conservative than it was in 1991, “there are two new developments,” Washington Assistant Attorney General Jeff Sprung told reporters; “two statutes passed by Congress, that impose new requirements.”

One of those statutes involves language added to the spending bill that funded HHS in 1995 and was renewed in subsequent years. It restates the ban on using family planning funds for abortion, but also stipulates that “all pregnancy counseling be nondirective.”

In 2010, the Affordable Care Act added to that, with language that, among other things, bars HHS from issuing any regulation that “interferes with communications regarding a full range of treatment options between the patient and the provider” or that “restricts the ability of health care providers to provide full disclosure of all relevant information to patients making health care decisions.”

Leah Litman, an assistant professor of law at the University of California, Irvine, said the now more conservative Supreme Court might not necessarily accept those arguments, as well as others likely to be raised.

But there is no question, she said, that “the underlying scope of [the Title X program] has changed” since 1991.

Julie Rovner is chief Washington correspondent for Kaiser Health News, a nonprofit news service, which is an editorially independent program of the Kaiser Family Foundation and not affiliated with Kaiser Permanente.

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Surgeons are known for their busy schedules — so busy that they don’t just book surgeries back to back. Sometimes they’ll double-book, so one operation overlaps the next. A lead surgeon will perform the key elements, then move to the next room — leaving other, often junior surgeons, to open the procedure and finish it up.

A large study published Tuesday in JAMA suggests that this practice of overlapping surgeries is safe for most patients, with those undergoing overlapping surgeries faring the same as those who are the sole object of their surgeon’s attention.

But the study also identified a subset of vulnerable patients who might be bad candidates; the practice of double-booking the lead surgeon’s time seemed to put these patients at significantly higher risk of post-op complications, such as infections, pneumonia, heart attack or death.

Researchers say Tuesday’s study by a multidisciplinary research team from several universities is the most comprehensive analysis of the practice to date, delving into the outcomes of more than 60,000 knee, hip, spine, brain or heart surgeries among patients ages 18 to 90 at eight medical centers. The study compared the outcomes of procedures done in isolation with those that were scheduled to overlap by an hour or more.

Dr. Anupam Jena, a physician and health economist on the faculty of Harvard Medical School and senior author of the study, says his research team found overlapping surgeries to be “generally safe.” Overlapping surgeries were not significantly associated with difference in rates of death or post-op complications.

These findings, says Jena, are in line with all but one of several such studies conducted since 2015, when an investigative team at the Boston Globe first turned searing attention on Harvard’s Massachusetts General Hospital. There, at one of the nation’s premier teaching hospitals, reporters highlighted a practice that at that point was little-studied and not widely discussed outside hospitals. In extreme cases, the surgeries were essentially concurrent, with the multi-tasking lead surgeon moving back and forth between ORs.

Within a year, the Senate Finance Committee jumped in with a report detailing lawmakers’ safety concerns about little-studied practice. And the American College of Surgeons updated its guidelines, adding that juggling “critical” parts of a surgery was “inappropriate.”

However, the less extreme practice of letting the beginning and end of surgeries overlap is still viewed by hospitals as an efficient means of deploying the skillful hands of their top surgeons. Mass General, which has continued the practice, is in the company of teaching hospitals nationwide. Overlapping surgeries in this way “offers greater and more timely access to certain surgical specialties,” Mass General says in an FAQ on the topic, “many of them high-demand, high-volume elective procedures.”

Jena says this is the first study to show that certain types of patients might particularly be at risk.

“This is the only [study] that breaks out and finds in certain high-risk groups, we might have worse outcomes”— namely, in older patients, those with pre-existing medical conditions, and those undergoing coronary artery bypass graft surgery, where blood flow is restored to the heart.

When the researchers homed in on these high-risk patients, they found slightly higher mortality rates among the patients who had undergone overlapping surgeries and were older or had underlying medical conditions — 5.8 percent compared with 4.7 percent for patients who had the lead surgeon’s full attention.

The scientists found a similar discrepancy in complication rates — 29.2 percent of high-risk patients experienced post-surgical complications when subject to overlapping surgery, compared to 27 percent of patients whose procedure was done in isolation. (The “complications” recorded in the study ranged from minor infections at the surgical site to heart attack or stroke.)

This discrepancy, says Jena, “could occur because a surgeon is separating their mental effort between two cases or [from] literally being [in] two places at once. Those kinds of problems would have a measurable effect on high-risk patients.”

The study also found that surgeries booked to overlap lasted a half-hour longer, on average, than those done in isolation.

Dr. Robert Harbaugh, former president of the American Association of Neurological Surgeons and current chair of the department of neurosurgery at Penn State’s Milton S. Hershey Medical Center, was not involved in the study, but says he was not surprised to see the findings show a “modest but real” risk posed to high-risk patients.

“In my practice, if I know someone is a very high-risk patient, you’re much less likely to (schedule) that patient for an overlapping surgery,” says Harbaugh. Surgical patients who have multiple underlying conditions, such as diabetes or hypertension, he says, require his full attention.

This study, he says, supports his sense that there is “a specific group of patients that probably has to be monitored more closely.”

However, Harbaugh says, overlapping surgeries are crucial “to make the operating room run more efficiently.” Surgeons are fully booked two or three months in advance in his department at Penn State, he says. Allowing four surgeries a day lets patients be treated that much sooner — as well as providing “the next generation of surgeons” much-needed training time.

The leading surgeon is always scrubbed-in for the “dangerous part of the surgery,” Harbaugh notes, and only leaves the patient with residents who are “competent to open or close a case.”

“If you’re finishing an operation and you tell your resident, ‘you can you go ahead and close the incision,’ they’re more than competent enough to do that,” he says. “Then you leave, go to another room where a [surgical] fellow has started a case. That’s an efficient use of time.” Harbaugh estimates 15 percent of the surgeries done by doctors in his department overlap.

Harbaugh also notes that his surgical department at Penn State requires surgeons to explain to patients when they sign the consent form that that they will be stepping out for parts of the surgery. But he doubts that policy of transparency is universal, he says.

Jena says there is “little information about what patients know” when it comes to the practice of overlapping surgeries. A 2017 study found few people had ever heard of the practice.

He says he and the study’s lead author, Dr. Eric Sun, an anesthesiologist and assistant professor at Stanford University, “both would agree that doctors should be telling patients about this practice.” Jena recommends patients ask, ahead of the operation, if their surgeon will be dividing their time.

If they don’t like the answer, Jena says, “At any point, the patient could say, “I don’t want care provided to me.”

Diana Zuckerman, a policy analyst and president of the National Center for Health Research, is doubtful many such conversations are likely to occur. “Most patients wouldn’t know to ask,” she says.

“The good news is, for an an individual patient, they shouldn’t worry,” Zuckerman says, pointing to the fact that the study found no significant increase in post-op problems or deaths overall.

However, she says, questions linger over whether patients should be informed about a surgeon’s other commitments, even if the risks of complications are low.

“I think it’s safe to say if patients were told, nobody would like it,” Zuckerman says. “Nobody wants to feel like the doctor is going in and out their surgery.

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