Transforming Health Care Through Evidence and Collaboration
Transforming Health Care Through Evidence and Collaboration
The NIHCM Foundation is a nonprofit, nonpartisan organization dedicated to improving the effectiveness, efficiency and quality of America's health care system.
  • Data Insights

    Mental illness has become more common over the last decade, particularly among 18- to 25-year-olds. This Data Insights looks at trends in mental health and their implications for the future.

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  • Briefing

    NIHCM Foundation led a briefing on Capitol Hill to discuss social determinants of health and the opioid crisis with Founding President and CEO Nancy Chockley, former CMS Administrator Don Berwick, Curtis Barnett of Arkansas Blue Cross Blue Shield, Craig Samitt of Blue Cross and Blue Shield of Minnesota, and Grant Baldwin from the CDC.

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  • Data Insights

    As urbanization increases, an older, sicker and poorer population remains in rural America. Despite the health care challenges posed by these changes, promising initiatives can improve rural health.

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  • Advisory Board

    NIHCM Foundation is pleased to welcome Dr. Scott Gottlieb, Sherry Glied, PhD, and Katherine Baicker, PhD, to its distinguished Advisory Board. Their ideas and insights will advance NIHCM's mission to improve health care for millions of Americans.

    Press Release Advisory Board
  • Awards

    NIHCM Foundation hosted the 25th Annual NIHCM Awards at the Organization of American States in Washington, D.C. to recognize outstanding health care research and journalism.

    Press Release Winners Finalists
  • News

    NIHCM welcomed Secretary Azar to a meeting in March to discuss efforts by the Department of Health and Human Services to transform health care by lowering costs and improving value for patients.

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Events

November 18, 2019
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Part of the Beyond the Beltway: Health Policy Webinars for Journalists series, this webinar will explore the current landscape of the long-term care delivery system.

November 13, 2019
Rural-Health-Webinar-Graphic

This webinar explored how leaders are leveraging the unique strengths of rural communities to develop and implement promising solutions.

In the News

November 2019
Population Health Spotlight
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How Common and Costly Are Surprise Bills for Emergency Department Physician Services?

Why This Study Is Important

Surprise medical bills are a major source of financial hardship for patients. These bills occur when patients unexpectedly receive care from providers who are outside of their insurance network, despite seeking care from in-network providers. Providers who are out of network often charge well above market rates, leaving patients exposed to potentially large out-of-pocket costs.

This study begins to supplement anecdotal reports of surprise billing with national data on the prevalence, geographic variation and cost implications of surprise billing by emergency department (ED) physicians for privately insured patients. Surprise billing by ED physicians provides a snapshot of the wider problem also being reported for anesthesiologists, pathologists, radiologists and assistant surgeons.

What This Study Found

  • While virtually all of the more than 2.2 million ED visits analyzed took place at in-network hospitals, 22 percent of these in-network visits generated a surprise bill from an out-of-network ED physician.
  • This national average masks significant geographic variation: some markets had almost no surprise billing, while one had a 97 percent surprise billing rate.
  • ED physicians do not face the same price competition that other physicians face when treating privately insured patients because patients don’t have a choice of emergency physician.
  • On average, charges by out-of-network ED physicians were about eight times higher than the rates paid by Medicare, and more than 2.6 times higher than commercial reimbursement for in-network ED physicians. This difference implies an average potential out-of-pocket cost of $623 for patients receiving a surprise ED physician bill, with wide variation.

What These Findings Mean

  • The fact that some markets experience almost no surprise billing suggests that this problem is solvable, but appropriate policy must be carefully designed to avoid unintended consequences.
  • “Hold harmless” provisions that require insurers to pay the out-of-network billed rate – such as have been adopted in some states – are misguided because they significantly weaken providers’ incentives to negotiate more competitive rates and ultimately hurt consumers when insurance premiums rise for all subscribers.
  • Requiring hospitals to offer a bundled ED care package reflecting in-network rates for both the facility and ED physicians holds more promise for improving market competition while still protecting consumers.

More About This Study

This study examined insurance claims from across the nation for privately insured individuals receiving hospital-based ED care between January 2014 and September 2015. Indicators on the claims identified the network participation status of facilities and physicians. The potential out-of-pocket cost for a patient treated by an out-of-network ED physician was computed as the difference between actual charges by the physician and the average commercial reimbursement for in-network services, calculated as 297 percent of the Medicare rate.

Full Citation

Cooper Z and Scott Morton F. “Out-of-Network Emergency-Physician Bills – An Unwelcome Surprise.” New England Journal of Medicine, NEJM 375(20):1915-18, November 17, 2016.

For more information about this study, contact Dr. Zack Cooper at zack.cooper[at]yale.edu.
For more information about the NIHCM Foundation Investigator-Initiated Research Grant Program, contact Julie Schoenman at 202-296-4426.

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This Research Insights pulls out the key findings and policy recommendation on unexpected medical bills as published in the New England Journal of Medicine.

Events

November 18, 2019
alliance-image-111819

Part of the Beyond the Beltway: Health Policy Webinars for Journalists series, this webinar will explore the current landscape of the long-term care delivery system.

November 13, 2019
Rural-Health-Webinar-Graphic

This webinar explored how leaders are leveraging the unique strengths of rural communities to develop and implement promising solutions.

In the News

November 2019
Population Health Spotlight
aces-in-the-news 4

Grants

Journalism GrantsJournalism Grant Program

We are no longer accepting letters of inquiry for the 2019-2020 round of grantmaking. NIHCM will notify grant winners in November 2019.

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Investigator-Initiated Research Grant Program

We are no longer accepting letters of inquiry for the 2019-2020 round of grantmaking. A small number of applicants will be invited to submit a full proposal in September.

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Awards

Winners Named in the 25th Annual Research and Journalism Awards

Winners Announcment 2018 1

Congratulations to all of the winners of the 25th Annual NIHCM Foundation Research and Journalism Awards! The winners and finalists were honored at a banquet in Washington, DC, in May.

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