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GOP Lawmakers May Oppose Legislation to Cap Out-of-Network Healthcare Costs

Munoz worries that if state moves to cap reimbursements, doctors may decide to give Garden State a wide berth

singleton and munoz
Assemblyman Troy Singleton (D-Burlington) and Assemblywoman Nancy F. Munoz (R-Morris, Somerset and Union).

A key Republican legislator on healthcare issues says that it’s unlikely members of her caucus will support a complex Democratic bill aimed at tackling healthcare prices, but instead will work to create an alternative.

Assemblywoman Nancy F. Munoz (R-Morris, Somerset, and Union), a nurse by training, said it’s important to consider the surprise bills charged by providers who are outside of a patient’s insurance network, but that Republicans don’t want to see the state set limits on healthcare prices.

While she didn’t provide details of what the Republicans are planning, Munoz said it might include an arbitration component.

The Democratic bill, which had been in the works for years, may be a central point of differentiation between the two parties. The measure seeks to make the amount that providers bill to patients and insurers more transparent, and to limit these payments to no more than two-and-a-half times the median amount paid by commercial insurers.

While Republicans can’t block bills in the Democratic-controlled Legislature, Gov. Chris Christie may be unlikely to sign such a major piece of legislation if Republicans are strongly opposed to it. That’s why the position staked out by Munoz -- a leading Republican on healthcare issues with a history of working with Democrats on significant bills -- is important.

Munoz predicted that some highly skilled doctors would choose not to practice in the state if they faced legally capped reimbursements.

“We don’t want to lose the best and brightest from the state of New Jersey,” she said.

The Democratic sponsors of the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act, A-4444/S-20, have indicated a willingness to work with the various healthcare stakeholders on the bill.

But a major stakeholder group -- the organizations representing doctors -- have come out forcefully against the key pieces of the bill. Another group -- the New Jersey Hospital Association -- is raising concerns that legislators want to pass the bill too quickly.

The bill would:

  • require providers to notify patients whether they are inside the patient’s insurance network and give an estimated out-of-pocket cost at least 30 days before a nonemergency or elective procedure;

  • establish a publicly available healthcare price index that lists the median price by in-network commercial insurers and limits out-of-network payments to a range between 75 percent and 250 percent of the median;

  • allow out-of-network providers or insurers, it they don’t reach agreement on a price within 30 days after a bill is sent, to request binding arbitration, with the arbitrator choosing one side’s proposed price, subject to the payment range;

  • and bar providers from waiving a patient’s out-of-pocket costs -- which bill sponsors say is used by providers to attract patients -- unless it would be a hardship for the patient.

“I think we would all agree that there are some outliers who are really giving this a bad name,” Munoz said of out-of-network bills. “Charging $120,000 for an arthroscopic knee exam is pretty ridiculous.”

She made the remarks as part of a panel discussion at a healthcare summit hosted on Saturday by the New Leaders Council, a nonprofit that seeks to recruit and train progressive political leaders.

Munoz said it’s inappropriate to set legal limits on what doctors can be paid based on median payments, since some doctors have unique, lifesaving skills. Munoz has worked as a nurse and her late husband, Assemblyman Eric Munoz, was a trauma surgeon.

Bill sponsor and fellow panelist Assemblyman Troy Singleton (D-Burlington) said he comes at the issue from a payer perspective, having worked on healthcare costs as a member of the United Brotherhood of Carpenters union.

“Some of the pricing that we got for some of the things (carpenters) do when a mishap happens truly shocks the conscience,” he said. “I think what we’re trying to do (with the bill) is create a sense of reasonableness and balance.”

He said that he thinks “everyone agrees” that it’s wrong that some providers rely on high out-of-network bills as a business model.

Singleton promoted the healthcare price index as a way to bring transparency to costs and make it easier for businesses and other payers to understand what they’re getting for their payments. In addition, it would benefit some doctors to know what’s the going rate that insurers are paying other providers.

“The thing I feel is the most important part (of the bill) is creating this air of transparency,” Singleton said.

“There is a common consensus that something needs to be done. Now, will it be what we introduced the other day? You know, no one knows,” he said. “But we wanted to at least start a dialogue and start a real conversation … and try to figure out a way to get us all to the finish line.”

Neil Eicher, top lobbyist for the hospital association, noted that his association hasn’t taken an official position on the bill, allowing “every single department in every single hospital” to digest its provisions.

“I think at the end of the day, we have to make sure that patients are protected from inadvertent or surprise medical bills. I believe that hospitals do play a role in that,” Eicher said.

But Eicher added that hospital officials are concerned about “the speed with which this bill may move through the Legislature. I’ll say that -- for a bill that turns the delivery system on its head in many ways, I think we do need to really take time to analyze the effectiveness of the bill and its impact” on hospitals, nursing homes, rehabilitation facilities, assisted-living facilities and healthcare professionals.

The insurance industry has been warmer in its response to the bill. Sarah M. Adelman, lobbyist for the New Jersey Association of Health Plans, said New Jersey insurers spent more than $1 billion on out-of-network costs last year, and that consumers would benefit if these costs were reined in.

While state law requires insurers in some cases to pay patients’ out-of-network bills, the health plans, employer groups, and consumer advocates note that these costs lead insurers to increase the premiums paid by all people with health insurance.

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