Out of Control: Patients Are Unwittingly Subjected to Enormous, Unfair, Out-of-Network "Balance Bills"

Excessive medical debt resulting from the provision of health care can cause families and individuals to spend down their savings, forego medical treatment, and even go without paying for food and heat. In the United States, medical bills are the leading cause of individual and family bankruptcy. In 1981, only 8 percent of families filing for bankruptcy protection did so in the aftermath of receiving medical care.However, by 2007, more than 62 percent of all bankruptcies were linked to a medical event, according to a study published in the American Journal of Medicine. And bankruptcy was not limited to the uninsured. To the contrary, the study reported that more than 75 percent of filers had health insurance.One driver of excessive health care bills is a practice known as "balance billing," which refers to bills for the difference between the amount that an insurance company is willing to pay for treatment and a provider's total charges. Providers who are not members of a patient's insurance network have charged patients as much as 9,000 percent of what Medicare would have paid for the same procedure.In contrast, payment for in-network medical services is on average 123 percent of Medicare.Patients can be subjected to balance bills despite making their best efforts to avoid them. For instance, they might receive care at an in-network facility, only to find out later that an out-of-network doctor also provided medical services. This is because many doctors work at hospitals rather than for hospitals, and are not members of the same insurance network as the hospital.Solutions are possible at both the federal and state levels that would protect consumers from balance bills without unduly burdening providers or insurers, or upsetting the existing system of insurance networks. This paper outlines policies that have been implemented at each of these levels and proposes additional protections at the federal level

Simplifying Administration of Health Insurance

Reviews definitions and estimates of the insurance system's administrative costs and efforts to reduce them. Examines the potential of various reform proposals to simplify or further complicate the system. Includes data on estimated administrative costs

Value Creation in Health Care: The Case of the Princesse Grace Hospital (CHPG) Monaco

Health care has to make transitions to be truly effective in the modern world. A change in paradigm is needed. This requires that value - defined as the health outcome for a particular medical condition per unit of cost expended - must be applied and added to health care, and health care itself must be treated as a business that performs in a competitive environment to ultimately provide client or customer satisfaction. Health care today is typically service specific, necessitating that the client or patient visits different medical or clinical departments to get the range of treatment prescribed for his/her condition. We argue – following Porter and Teisberg - that health care should be patient-centric and that organization and treatment should be planned accordingly. Such planning must take into account the provision of a range of services directly accessible or networked regionally taking full advantage of technological advances in the field of medical technology and informational systems. We examine whether such principles are currently being applied in Monaco (specifically in the Centre Hospitalier Princesse Grace) taking into account both Monaco’s unique positioning and its geographical context in relation to the French health system as well as the resulting interaction in networking relationships. We explore how value in healthcare is currently being added and investigate plans for augmenting such efforts. Aspects of preventative and innovative initiatives are also discussed as a means of enhancing value. Finally, we offer a set of recommendations that in the context of the local situation might be successfully applied. Continuous review of performance and the application of best practice and technologies are proposed to ensure that the provision of health care services can compete with the best in the world.Health care; value creation in health care; Monaco; Southern France

Health Care’s Other “Big Deal”: Direct Primary Care Regulation in Contemporary American Health Law

Direct primary care is a promising, market-based alternative to the fee-for-service payment structure that shapes doctor–patient relationships in America. Instead of billing patients and insurers service by service, direct primary care doctors charge their patients a periodic, prenegotiated fee in exchange for providing a wide range of healthcare services and increased availability compared to traditional practices. This “subscription” model is intended to eliminate the administrative burdens associated with insurer interaction, which, in theory, allows doctors to spend more time with their patients and less time doing paperwork. Direct practices have become increasingly popular since Congress passed the Affordable Care Act (ACA). This growth has been driven by legislation in several states that resolves a number of legal questions that slowed the model’s growth and by the ACA’s recognition of the model as a permissible way to cover primary care in “approved” health plans. Yet legal scholars have hardly focused on direct primary care. Given the model’s growth, however, the time is ripe for a more focused legal inquiry. This Note begins that inquiry. After tracing the model’s evolution and its core components, this Note substantively examines the laws in states that regulate direct practices and analyzes how those laws address a number of potential policy concerns. It then analyzes direct primary care’s broader role in the contemporary American healthcare marketplace. Based upon that analysis, this Note concludes that direct primary care is a beneficial innovation that harmonizes well with a cooperative-federalism-based healthcare policy model