posted by AHIP
on January 14, 2020
AHIP President & CEO Matt Eyles sat down with Sen. Bill Frist on his “A Second Opinion” podcast to discuss the latest in health care, including how we improve affordability and enhance coverage for every American.
Matt Eyles: It is a very different model. Insurance protects against catastrophic risk. There are plenty of risks that we all face in health care, and it’s important to be protected against those.
I’d say the evolution in health insurance has really been from protecting against financial risk – that’s still a part – to providing coverage and making sure that people have access to care. The health insurance industry two decades ago was much more about paying claims, collecting premiums – not managing care as much. HMOs were just starting to take off, which are types of managed care plans.
Today, health plans are much more sophisticated and really trying to think about the total cost of care. How do we keep people out of the hospital, and how do we make sure they’re getting preventive care, treatment, and services?
Insurance plans are thinking about the whole person, including non-health factors like where you live, what you eat, and whether you’re able to get to the doctor. Plans are really thinking about the whole person in a way that didn’t exist two decades ago.
Matt Eyles: I think it’ really about taking care of people and recognizing that we need to meet people where they are to improve their health, to recognize the health conditions they have today, and to consider how you can prevent them from getting worse over time. You need to make investments up front to ensure that people are getting the care they need on a regular basis, whether it be with respect to primary care or if you have a chronic condition.
The downstream implications of not taking care of them – and you know this better than anyone as a physician – can be catastrophic. It can mean surgery; it can mean being debilitated and permanently disabled. So, it’s really important to invest in those activities up front, and health insurance plans really are at the forefront of recognizing that we need to focus on prevention and wellness.
I have been on the board of the Kaiser Family Foundation and they started with their series of articles on surprise bills about three years ago. It seems all of the sudden this has become a huge issue. So, what is surprise billing, and how are you and some of the plans addressing it?
Matt Eyles: So, a surprise medical bill happens when a patient goes into a facility like a hospital that is part of their insurance network. But when they go into that hospital, they get treated by certain medical professionals – and it tends to be limited to a certain number of medical specialties such as anesthesiologists, radiologists, and a couple of others – that the patient might not even remember having seen.
But they are billed from that provider because that provider doesn’t participate in their insurance network. They get surprised with a medical bill, and those can be staggering at times as we’ve seen from the reports in the media.
Matt Eyles: Most of it is through those acute episodes where someone walks through the front door of a hospital unplanned. I don’t want to say it never happens with planned procedures like knee replacement surgery, but if there’s an acute episode and you need to get to the hospital to get some treatment, that tends to be where the bigger part of the problem is.
We have data that shows 1 in 6 Americans has been hit by a surprise medical bill. It is worse in some part of the country than others.