BACKGROUND PRESS CALL BY SENIOR ADMINISTRATION OFFICIALS ON THE PRESIDENT'S PRINCIPLES TO ADDRESS THE PROBLEM OF SURPRISE BILLING IN HEALTHCARE

Office of the Press Secretary FOR IMMEDIATE RELEASE May 9, 2019

BACKGROUND PRESS CALL BY SENIOR ADMINISTRATION OFFICIALS ON THE PRESIDENT'S PRINCIPLES TO ADDRESS THE PROBLEM OF SURPRISE BILLING IN HEALTHCARE Via Teleconference   11:05 A.M. EDT      MR. DEERE:  Thank you, Operator.  And good morning, everyone.  Thank you for joining us for today's call on the President's principles to address the problem of surprise billing in healthcare.      Before we get started, the call is embargoed until the top of the President's remarks, which are currently scheduled for 11:45.  But again, everything on the call is embargoed until he begins those remarks.      You'll be hearing today from our Director of the Domestic Policy Council, Joe Grogan, as well as [senior administration official].  Joe's remarks are on the record.  And then, when we go to Q&A at the conclusion of his remarks, that will be on background attributable to senior administration officials.      With that, I will turn it over to our Director of the Domestic Policy Council, Joe Grogan.      MR. GROGAN:  Thanks.  The President had a roundtable discussion here in the White House at the end of January in which he met with patients -- American citizens -- who had struggled with the issue of surprise billing.  There were a number of stories recounted to the President about outrageous billing practices for people confronted with bills that they had not consented to take on themselves.      The President, coming out of that meeting, directed his staff to work closely to figure out what, administratively and legislatively, could be done to increase transparency in the medical system and address, specifically, surprise billing.          We are continuing to work on our transparency efforts.  And we've done some things at CMS, like post hospital rates, and we will be doing more over the coming months on transparency. But today we are unveiling principles that will be sent to the Hill for a legislative package that we hope will be bipartisan, House and Senate, to address the problem of surprise medical billing.      Specifically, this occurs in two instances.  One is somebody is taken to the emergency room; they are not able to consent because obviously it's an emergency, so they don’t get to choose what emergency room they go to.  They're not able to choose the contractual relationship that they're going to enter into with a physician.  And after the fact, they can get surprised with a bill when they discover that they are being charged an out-of-network rate for this service.      So we want to get at that problem and make sure that these payments are -- while they need to be negotiated between providers and private insurance, the patients would be responsible for the co-insurance or co-payment that would've been applied had it been in network.  So they're not surprised because it's not their failure that the hospital is not in network.      The other situation is elective surgery, where you go in for surgery, you're under the impression everything is in network, you choose the hospital and the practice group that you're going with, based upon the fact that it's in network, and then another physician is brought in -- oftentimes an anesthesiologist or a radiologist -- and you get an out-of-network bill.  We are hoping to address that problem as well, where you wouldn’t get an out-of-network bill absent specific consent to that.  You would have to -- your portion would be limited to fees associated with in-network charges.      The other thing to keep in mind is that we want to make sure that federal expenditures should not increase when Congress does its work here.  We think that we can get at this problem without throwing additional taxpayer dollars into the problem.  And we also want to make sure that out-of-network providers cannot separately bill patients.  So if you go to the hospital, you're in network, you pay the hospital bill, and then suddenly, weeks later, sometimes months later, you get an out-of-network bill from somebody, and we want to prohibit that practice.  It should all be reflected in the one bill at the service where it was provided and not have an out-of-network provider seek to chase a patient down for that fee.      We are focused on this problem because some of the data here is pretty alarming, although the anecdotes are perhaps even more so.  Most people here on the White House staff and at HHS can recount stories from their personal lives or those of a family member.  We've had conversations with members of Congress that have dealt with surprise billing with no explanation as to why these bills are so big, and an intense amount of work to track down the source of these large bills.      Some research shows that 14 percent of out-patient emergency room visits, 20 percent of hospital admissions through the emergency room, and 9 percent of elective in-patient admissions generate surprise medical bills.      Also, it's important to understand that this problem could be localized or most egregious in a small number of providers.  Fifteen percent of hospitals have more than 80 percent of emergency department visits producing out-of-network bills.  So the data would seem to indicate that there are a small number of facilities that are taking advantage of this situation and taking advantage of patients, and not protecting the economic wellbeing of their patients.      And the last thing I'll say before we open it up to questions is this is an indication that the administration continues to work hard on healthcare issues that are important to the American people.  There are a number of things that we are addressing in Medicare, Medicaid -- the exchanges, rules, transparency.  There's a ton of work going on, and this proves that we can walk and chew gum at the same time, and we're not ignoring big problems that affect people and frustrate people that have lingered for too long. Q    Hi, this is Andrew Feinberg with Breakfast Media.  Thanks for doing this call.  Can you clarify something about what you're going to do to solve this problem with out-of-network billing for ER admissions and elective surgeries?  Are you going to mandate that hospitals or providers contract with all insurance companies?  And how are you going to do this?  Do you have any details to give?      SENIOR ADMINISTRATION OFFICIAL:  Yeah.  So for the emergency services, the principle is that patients cannot receive balance bills.  So the -- and this is just for out-of-network emergency services -- so that the co-payments, the cost sharing that the patient is responsible for, would be the same for an out-of-network emergency service as for an in-network emergency service.  The overall payments would be determined with negotiation between the provider and the private insurer.      Q    Yeah.  This is Alex Ruoff with Bloomberg Government.  I was wondering if you could just go over what other principles you'll be sending to the White House.  In particular, I think you just mentioned banning balance billing for emergency services.  Can you go over the full list here?  Like what exactly are the demands you're going to make of -- or, you know, the principles you want to see in a surprise billing, you know, bill?      SENIOR ADMINISTRATION OFFICIAL:  So we went through -- we just went through the ones for emergency services. For scheduled care, we think that much of this problem can be solved by upfront information.  So when you go to a scheduled care at a facility, they need to tell you, for reasonably expected services, if there's going to be care that's out of network.  They need to provide you with an estimate with the out-of-pocket costs.  They should provide you a written estimate in advance of the service.  And there should be no separate bills from out-of-network providers absent advance informed consent.  We want to take the surprise out of the care that people receive when they go to in-network facilities.      Q    Hi, this Ariel Cohen from Inside Health Policy.  Thanks for doing the call.  A lot of these principles that you mentioned have been discussed by senators on the Hill, House members, but a lot of it has been held up by disputes from insurers and providers.  And that's been holding up a lot of the legislation.      What exactly will you be directing members of Congress to do to sort of get around this in-fighting that's happening right now?      SENIOR ADMINISTRATION OFFICIAL:  I think you just hit on a lot of the problem.  Providers point figures at payers.  Payers point fingers at providers.  And the American people are left really getting the shaft.  So it's a cruel and indifferent process, and it needs to change.  So the President is going to put a bold call that we need to take legislative action along the lines that were outlined at the top of this call.      SENIOR ADMINISTRATION OFFICIAL:  And we definitely think that the time is right for presidential leadership here, and that with it, we'll get momentum.      We have had similar conversations that jived with what you just said, members saying, "Listen, we want to address this, but there are special interests that are prohibiting us from -- some members from getting behind it.  And we need the White House's help."  We've worked with staff and with members, and we think it's time for the President to (inaudible).      Q    Hi.  Thank you.  This is Susannah Luthi with Modern Healthcare.  Just getting back to the mechanism that you're discussing to ban balance billing, will it be something like addressing contract reform between providers and insurers?  Or are you not getting that specific?          SENIOR ADMINISTRATION OFFICIAL:  I mean, I think contracting reform is certainly part of it, right?  We don't think that there should be separate bills from out-of-network providers unless the patient has given their consent.  So if they're choosing an in-network facility, they should know exactly what they're going to be charged before they receive that service.      So, yeah, I mean, I think there's part of it here where there's got to be contracting reform between hospitals and the doctors that provide care in those hospitals.      SENIOR ADMINISTRATION OFFICIAL:  But we do want to see Congress step forward and provide more details underneath our principles.  And it will be an iterative process back and forth between us and Congress as they take steps forward in response to the President's call for action.      Q    Hi.  This is Rachel Roubein with Politico.  I was curious: So, you mentioned that overall payments would be determined with negotiations between the provider and the insurer.  So I wanted to clarify if you were talking about an arbitration process similar to what some other states like New York have done.          SENIOR ADMINISTRATION OFFICIAL:  So I don't think that's necessarily the way this needs to go.  There are a number of different models that have been tried in states, as you've noted.  And we're not specifically endorsing arbitration in this approach.      Q    Hey.  Thank you.  This is Jon Healey with the LA Times.  Appreciate you doing the call.  Just to be clear, I take it you're not including in the proposal any requirement for ensuring network adequacy?  There's going to be no guarantee that somebody have access to an in-network anesthesiologist or whatever when they go to an in-network facility?  And also, just on top of that, how do you feel about (inaudible) of the state laws that already exist on this issue?          SENIOR ADMINISTRATION OFFICIAL:  Well, as we said a little bit earlier, the important thing here is the President stepping forward and calling for action.  Congress needs to react to that call and move forward.      I'm not going to necessarily negotiate through this call and through the press with Congress here this morning.  We want to see them take action.  There are a lot of Americans, lots of families, who need Congress to step forward and actually react and serve to respond to significant challenges that families and individual Americans face when these surprise bills pop forward.      And so we're hopeful that Congress will actually react to the President here.  We expect Congress to react to the President here.  And then we will work with Congress on the details so, at the end, we can deliver a bipartisan, bicameral reaction that ensures that patients and Americans are protected from surprise medical billing.      Q    Thank you for holding this call.  This is Tami Luhby with CNN.  My question is, you know, Congress has been looking at this.  So, under what authority or effort do you think either the President or lawmakers can do to actually, you know, bridge the gap between -- or bridge the differences between all of the players here?          SENIOR ADMINISTRATION OFFICIAL:  Well, listen, I mean, anytime you have a legislative effort -- and certainly in healthcare is no exception, or perhaps the best example: there has to be tradeoffs.  The key thing here is that people have thrown up their hands for far too long and said, "Nothing can be done about this."      We have had very fruitful conversations with members and staff.  There are a number of different legislative options here to get at this problem.  And we look forward to working with the Hill -- as I said, both Democrats and Republicans -- in order to get a bill that will provide the (inaudible).      Q    Hi.  This Sarah Kliff with Vox.  Thanks for doing this call.  I was curious -- you know, there's obviously a lot of things the President can focus his time on, even within the healthcare space.  What is it about surprise medical bills that has gotten the President interested?  You know, why this issue, of all the issues he could work on?          SENIOR ADMINISTRATION OFFICIAL:  I think it's a good question.  I mean, it goes to the types of things that animate the President.  I can tell you, as somebody who's been in Washington, D.C. for a long time, there are -- you know, in the previous administration, there were a number of issues that were left to fester and linger and grow into bigger problems because they were so focused on the ACA.  They had complete and total tunnel vision.  And we've been working on Medicare, Medicaid, and a whole host of other issues and improving health outcomes.      We've got a robust HIV elimination project, pediatric cancer initiative -- a number of things ongoing.  And this is an example of something where the President was presented with real human beings who were getting screwed over by the system because people have been too indifferent for far too long to their plight.      This is something that should get fixed.  On its face, this is a simple problem.  And while there needs to be some tradeoffs in finding the right legislative solution, and we have to make sure we don't have unintended consequences, Republicans and Democrats should be able to figure this out so the American people aren't getting screwed.  And you’ll hear from people today that will be with the President, talking about examples of their surprise bills. You know, we’ve heard in the past about people getting diagnostic tests that cost $18,000 and they had -- and they get the bill three months after the fact and they had no idea.  And of course, at this point, they have no recollection of having consented to or what the urine test was for in the first place.      So this is just right up the President’s alley.  Something that can be fixed, should be fixed.  And he’s excited to wade into it.          SENIOR ADMINISTRATION OFFICIAL:  And, Sarah, thank you for your reporting in this area.  I think you’ve done as effective job as anyone at highlighting many of the more egregious problems.  And just to, you know, echo what my colleague said, this is an area where there should be bipartisan agreement.      If you look at surveys, it’s one of the main concerns, if not the main concern, that people have about the healthcare system, is getting one of these surprise bills. And we know that at a majority of hospitals, this isn’t a problem.  But at a minority of them, it is a real big problem.  An opportunity here to advance good healthcare policy and protect patients from being bankrupt by these outrageous medical costs. SENIOR ADMINISTRATION OFFICIAL:  Okay, one last thing to be reminded about: I mean, I’d mentioned the roundtable but I did forget to mention he called for this in the State of the Union Address too, at the beginning of the year.  So he’s been focused on it for some time. Q    Hi, this is Evan Brown from Fox News.  Speaking as a patient who has had to navigate the financial waters of the healthcare system for both me and my wife and my child, I can tell you the biggest frustration I have isn’t so much the surprise or sticker shock, but it’s the fact that accounting is horrible in the healthcare industry. Oftentimes, I’m finding that people who have trained to be nurses or medical technicians are left to do medical billing in the doctor’s office and they often don’t know what they’re doing. And between that and insurance companies not really updating their publicly available records to the doctor or to the patient about whether or not deductibles have been met or how close you are to reaching your out-of-pocket care maximums, has left to a lot of confusion.  And often, the doctor -- when you’re going in for elective or routine care -- the doctor’s office will charge you what they’re told based on records which are not up to date.  So if you’ve already actually satisfied your deductible but it’s not reflecting on the record, you’re still getting charged a higher amount than what you should be. And to get a refund, you have to fight like heck.  And there’s really not a lot of recourse.  And oftentimes the doctors don’t tell you that you have a credit balance and they sit and hold on to your money.  Now, if you owed them money, they'd, of course, be knocking down your door every day. So how can a patient actually, with what the President is planning to do -- how can the patient have some recourse and some help?  Because there’s nobody out of the state attorney general’s office to help you with this.  There’s no real advocate for you at the insurance company.  They say they’re an advocate but you’re going to be sitting on hold, you know, when you’re at work.  And that’s just unacceptable.  If I sound like I’m a little passionate about it, it’s because I’ve been fighting an insurance company lately.      SENIOR ADMINISTRATION OFFICIAL:  So, first off, thanks for that.  I think your remarks are really -- speak to the visceral nature of a lot of this and why we’re so focused on it.  I will say that this proposal is not meant to solve every problem in the healthcare system.  But the President does have a comprehensive approach and there are steps being taken on a number of different areas -- protecting Medicare, on Medicaid as well -- where we want to make progress.      In this part, the thing that I think is most relevant to your question is that we do really want to have one price and that estimate up front so that there’s no sticker shock surprises coming at you.  And that’s the element that we really think that is important to highlight here.      MR. DEERE:  Operator, we’ll take one last question.      Q    Hi, this is Caitlin Owens with Axios.  I just wanted to follow up.  I know you said that you are not endorsing arbitration specifically.  Is that kind of a mechanism for figuring out, you know, how much the insurer will pay the provider in an out-of-network situation?      Another solution that has been talked about pretty frequently is creating some kind of bundle payment where, instead of the hospital and the doctor getting paid separately, there’s just one bill to kind of clean up this issue of surprise medical bills.  Are you supportive of that as a solution?  Or are you not endorsing any solution at all?      SENIOR ADMINISTRATION OFFICIAL:  Hey, Caitlin, thanks for the question.  Appreciate it very much.  Yes, as you picked up earlier, we do not have a lot of enthusiasm for arbitration.  We believe that that would be disruptive.  We believe that that would get in the way of solving this problem.  And we believe it would be an unnecessary distraction that insurers -- the end of the day, a lot of potential abuses disguised in a different form would nevertheless still be inflicted against patients and Americans.      Your observation about bundling is of interest.  Again, we’re not going to negotiate through the media.  We’re going to be working directly with Congress.  Fruitful, profitable ideas such as that, and others, I’m sure will be on the table.  And we’ll work through those in the upcoming months as Congress responds to the President’s call.      SENIOR ADMINISTRATION OFFICIAL:  And I would just add to what my colleague said.  We will -- I mean, one of the principles the President is going to put out is that there are no separate bills from out-of-network providers absent advance informed consent.      MR. DEERE:  Operator, that will conclude today’s call.      I do want to thanks our subject matter experts for joining us.  Just a reminder that Joe Grogan’s opening remarks were on the record.  The Q&A was on background attributable to senior administration officials.  And the call is embargoed until the President begins his remarks shortly.                                    END                11:29 A.M. EDT