Patients soon will have an easier time dealing with health insurance-related problems, thanks to new laws. Two bills backed by the Texas Medical Association this legislative session — each of which passed and earned Gov. Greg Abbott’s signature into law — should give patients some relief from the headaches of surprise medical bills and unwarranted changes to their prescribed medication. The issues — surprise bills and “step-therapy protocol” — are just two of the ways in which health insurers make life difficult for Texas patients and the physicians who care for them.
Under Senate Bill 507 by Sen. Kelly Hancock (R-North Richland Hills), more patients can seek mediation after they receive balance bills for health care they thought their insurance covers but does not. The law broadens the scenarios for which patients can seek mediation, giving them much-needed recourse while preserving a physician’s right to be paid for his or her services. The other measure signed into law, Senate Bill 680 — also by Hancock — gives physicians greater authority to judge whether prescribed medication is working, and more quickly override a health plan’s efforts to change the medication.
Both measures, which take effect Sept. 1, are good examples of successful legislative changes to Texas’ health insurance policy, according to Beaumont anesthesiologist Ray Callas, MD, a member of TMA’s Board of Trustees. Dr. Callas gave medicine a high grade for its legislative work on insurance. “If you were going to score it [on] a zero-to-10 scoring system, I would give it probably an 8.5,” says Dr. Callas, the immediate past chair of TMA’s Council on Legislation. “I think we moved the needle forward in order to protect patients and to hold insurance companies accountable.”
SB 507 maintains the current $500 threshold, meaning a patient can seek mediation to settle bills higher than $500 after he or she has paid deductibles, copays, and out-of-pocket costs for treatment. This applies to care received at certain in-network facilities — namely, hospitals, birthing centers, ambulatory surgical centers, and freestanding emergency departments. The bill also expands mediation to all emergency care situations and requires health plans and practitioners who send a bill for out-of-network care to include a “conspicuous plain-language explanation of the mediation process.”
Dr. Callas says SB 507 protects patients from surprise billing and expands parts of the process that are successful. “Because mediation is working, we are happy to see the mediation process protected, as the initial informal [mediation] conference call is where 95 percent of disputes are resolved,” Callas says. “We feel maintaining this process is in the best interest of the patient to have a timely resolution of an out-of-network balance bill.”
Narrow or small insurance networks with too few physicians from which to choose pose problems for patients. Often confused by their health insurance coverage, patients sometimes seek care from a physician who is not in their plan’s insurance network. When that happens, insurance pays a fraction of the patient’s health care bill, and patients receive a bill for the unpaid balance. Mediation can help them resolve those financial circumstances.
The second insurance-revision law improves patient care, particularly for some patients such as cancer patients. The step-therapy override, authorized by SB 680, says a health plan’s protocols are no reason to switch a patient to another drug if a physician believes the initial medication is working. Currently, health plans institute step therapy to save costs; essentially mandating physicians first try prescribing a different, cheaper medication regardless of the doctor’s clinical preference. Instead, the bill shortens how quickly a physician can override an insurer’s step-therapy plan from the current 53 days to just three days, and it prevents patients from having to go through the step therapy process a second time if their coverage changes. Austin hematologist-oncologist Sylvia Jaramillo, MD, testified in support of SB 680 on TMA’s behalf at a Texas Senate Business and Commerce Committee hearing in March. She told lawmakers step therapy “can increase risk and expose patients to potentially ineffective treatments. This can cause delay in access to appropriate care, which ultimately affects patient outcomes.” Dr. Jaramillo also told the committee, “While sometimes step therapy sounds reasonable, it can be very dangerous.”
Dr. Callas says both bills are a victory for patient safety and transparency. “If patients are happy with the legislation and what it does for them, then physicians will be in a better position to build a tighter bond with their patients, without fear of some insurance-related process taking over.”
In the end, he says, physicians want to focus on where their attention should lie — providing the best care possible for patients. These bills help improve the health care system for patients and the doctors who treat them.
TMA is the largest state medical society in the nation, representing more than 50,000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMA’s key objective since 1853 is to improve the health of all Texans.