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A Rule-Based Solution to Opaque Medical Billing in the U.S.

Published online by Cambridge University Press:  31 May 2024

Christopher A. Bobier
Christopher A. Bobier*
Affiliation:
SAINT MARY’S UNIVERSITY OF MINNESOTA, WINONA, MINNESOTA, USA.
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Abstract

Patients and physicians do not know the cost of medical procedures. Opaque medical billing thus contributes to exorbitant, rising medical costs, burdening the healthcare system and individuals. After criticizing two proposed solutions to the problem of opaque medical billing, I argue that the Centers for Medicare and Medicaid Services should pursue a rule requiring that patients be informed by the physician of a reasonable out-of-pocket expense estimate for non-urgent procedures prior to services rendered.

Keywords

Informed ConsentAutonomyFinancial BurdenHealthcare Costs

Information

Type
Independent Articles
Information
Journal of Law, Medicine & Ethics , Volume 52 , Issue 1 , Spring 2024 , pp. 22 - 30
Copyright
© The Author(s), 2024. Published by Cambridge University Press on behalf of American Society of Law, Medicine & Ethics

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References

Epstein, W. N., “Price Transparency and Incomplete Contracts in Health Care,” Emory Law Journal 67, no. 1 (2017) 1–58; W. M. Sage, “Regulating through Information: Disclosure Laws and American Health Care,” Columbia Law Review 99, no. 7 (1999): 1701-1829; G. C. Alexander, et al., “Rethinking Professional Ethics in the Cost-Sharing Era,” The American Journal of Bioethics 6, no. 4 (2006): 17-22.Google Scholar
Hall, A., “Financial Side Effects: Why Patients Should Be Informed of Costs,” The Hastings Center Report 44, no. 3 (2014), 41–47, at 41; see also K. R. Riggs and P. Ubel, “Overcoming Barriers to Discussing Out-of-Pocket Costs With Patients,” JAMA Internal Medicine 174 (2014): at 849; P. A Ubel et al., “Full Disclosure-Out-of-Pocket Costs as Side Effects,” New England Journal of Medicine 369 (2013): 1484, at 1484.Google Scholar
White, A., “77% of Americans are Anxious about their Financial Situation — Here’s How to Take Control,” CNBC (July 21, 2021), available at <https://www.cnbc.com/select/how-to-take-control-of-your-finances/> (last visited February 12, 2024).+(last+visited+February+12,+2024).>Google Scholar
Ubel, P., Abernethy, A., and Zafar, S., “Full Disclosure — Out-of-Pocket Costs as Side Effects,” New England Journal of Medicine 369, no. 19 (2013): 1484–1486, at 1484.CrossRefGoogle ScholarPubMed
Dworkin, G., The Theory and Practice of Autonomy (New York: Cambridge University Press, 1988).Google Scholar
For overview of informed consent law, see L. S. Svitak, and M. Morin, “Consent to Medical Treatment: Informed or Misinformed?” William Mitchell Law Review 12, no. 3, (1986): 541-578; M. A. Hall and D. Orentlicher, D. Health Care Law and Ethics in a Nutshell (4th ed.) (St. Paul, MN: West Publishing Co, 2020); T. Paterick, et al., “Medical Informed Consent: General Considerations for Physicians,” Mayo Clinic Proceedings 83, no. 3 (2020): 313-319; C. Robertson, “Should Patient Responsibility for Costs Change the Doctor-Patient Relationship?” Wake Forest Law Review 50 (2015): 363-380; N. N. Sawicki, “Modernized Informed Consent: Expanding the Boundaries of Materiality,” University of Illinois Law Review 2016, no. 3 (2016): 821-871; M. D. Ginsberg, “Informed Consent: No Longer Just What the Doctor Ordered? Revisited,” Akron Law Review 59, no. 1 (2018): 49-196.Google Scholar
C. Robertson, “Should Patient Responsibility for Costs Change the Doctor-Patient Relationship?” Wake Forest Law Review 50 (2015): 363-380; N. N. Sawicki, “Modernized Informed Consent: Expanding the Boundaries of Materiality,” University of Illinois Law Review 2016, no. 3 (2016): 821-851; M. D. Ginsberg, “Informed Consent: No Longer Just What the Doctor Ordered? Revisited,” Akron Law Review 59 (2018): 49-196; T. S. Hall, “Bargaining with Hippocrates: Managed Care and the Doctor-Patient Relationship,” South Carolina Law Review 54 (2003): 689, 720–23.Google Scholar
Canterbury v. Spence, 464 F.2d at 787 (D.C. Cir. 1972).Google Scholar
Canterbury v. Spence, 464 F.2d at 786-787.Google Scholar
See Largey v. Rothman, 540 A.2d 504, 508-09 (N.J. 1988); Wheeldon v. Madison, 374 N.W.2d 367, 374 (S.D. 1985); Cross v. Trapp, 294 S.E.2d 446, 455 (W. Va. 1982); Wilkinson V. Vesey, 295 A.2d676,689 (R.I. 1972); Duffy V. Flagg, 905 A.2d 15, 20 (Conn. 2006); Howard v. Univ. of Med. & Dentistry of N.J., 800 A.2d, 73,79 (N.J. 2002).Google Scholar
Johnson v. Kokemoor, 545 N.W.2d 495, 497 (Wis. 1996); DeGenarro v. Tandon, 873 A.2d 191, 200 (Conn. App. Ct. 2005); Barriocanal v. Gibbs, 697 A.2d 1169, 1172 (Del. 1997).Google Scholar
Moore v. Regents of the Univ. of Cal., 793 P.2D 479,483 (Cal. 1990).Google Scholar
Faya v. Almaraz, 620 A.2d 327 (Md. 1993).Google Scholar
Redford v. United Stated, Civ. No. 89-2324 (CRR), 1992 WL 84898 (D.D.C. Apr. 10 1992).Google Scholar
Hartke v. McKelway, 707 F.2d 1544 (D.C. Cir. 1983).Google Scholar
Hartman v. D’Ambrosia, 665 So. 2d.1206 (La. Ct. App. 1995).Google Scholar
S.D. CODIFIED LAWS § 34-23A-10.1; KAN. STAT. ANN. §§ 65-6709(b)(5), 65-6710; N.D. CENT. CODE ANN. § 14-02.1-02; Planned Parenthood Minn. v. Rounds, 375 F. Supp. 2d 881, 887 (D.S.D. 2005).Google Scholar
Planned Parenthood of Se. Pa. v. Casey, 505 U.S. 833, 882 (1992).Google Scholar
Ginsberg, supra note 6.Google Scholar
Sawicki, supra note 6, at 869.Google Scholar
Sawicki, supra note 6, 826.Google Scholar
Robertson, supra note 6, at 373.Google Scholar
Levinson, W., Kao, A., Kuby, A., and Thisted, R.A., “Not all Patients want to Participate in Decision Making,” Journal of General Internal Medicine 15, no. 1 (2013): 46–50.Google Scholar
Gatter, R., “Informed Consent Law and the Forgotten Duty of Physician Inquiry,” Loyola University Chicago Law Journal 31 (2000): 557, 579.Google ScholarPubMed
Id.Google Scholar
Id.Google Scholar
Sawicki observes that legal scholars have “concluded that, with very rare exceptions, the physician’s duty only extends to disclosure of medically material facts” (833); and Robertson writes that the courts have largely “focused on the risks of treatment.” (371)Google Scholar
Canterbury, 464 F.2d at 787.Google Scholar
Areto v. Avedon, 858 P.2d 609.Google Scholar
State v. Presidential Women’s Center 937 SO.2w 114 (Fla. 2006).Google Scholar
Whiteside v. Lukson, 947 P.2d 1263, 1265 (Wash. Ct. App. 1997).Google Scholar
Felton v. Lovett, 388 S.W.3d 656, 662 (Tex. 2012).Google Scholar
Kaskie v. Wright, 589 A.2d.Google Scholar
Epstein, supra note 1, at 58; see also J. H. Krause, “Reconceptualizing Informed Consent in an Era of Health Care Cost Containment,” Iowa Law Review 85 (1999): 261, 317.Google Scholar
Minnesota Statute 144.651Google Scholar
Department of Public Health and Environment, Standards for Hospitals and Health Facilities, 6 CCR 1011-1, 6.6.1b2.Google Scholar
Code of Medical Ethics Opinion 2.1.1Google Scholar
American College of Surgeons’ Statements on Principles II.a., available at <https://www.facs.org/about-acs/statements/statements-on-principles/> (last visited april 9, 2024).+(last+visited+april+9,+2024).>Google Scholar
American Academy of Orthopedic Surgeons, Position Statement: Shared Physician-Patient Responsibilities, available at <https://www.aaos.org/globalassets/about/position-statements/1182-shared-physician-patient-communication.pdf> (last visited February 12, 2024).+(last+visited+February+12,+2024).>Google Scholar
See ARIZ. REV. STAT. ANN. § 36-125.05 (2016); ARK. CODE ANN. §§ 20-7-301–07 (West 2011); CAL. HEALTH & SAFETY CODE §§ 1339.55,.< /font>56, .58, .585 (West 2016); COLO. REV. STAT. ANN. § 6-20-101 (West 2016); DEL. CODE ANN. tit. 16, §§ 2001–2009 (West 2013); FLA. STAT. § 381.026 (West Supp. 2017); 20 ILL. COMP. STAT. ANN. 2215/4-2(d)(6)&(7) (West 2015).56,+.58,+.585+(West+2016);+COLO.+REV.+STAT.+ANN.+§+6-20-101+(West+2016);+DEL.+CODE+ANN.+tit.+16,+§§+2001–2009+(West+2013);+FLA.+STAT.+§+381.026+(West+Supp.+2017);+20+ILL.+COMP.+STAT.+ANN.+2215/4-2(d)(6)&(7)+(West+2015).>Google Scholar
Federal Register (2019) Improving Price and Quality Transparency in American Healthcare To Put Patients First Sect. 3b, available at <https://www.federalregister.gov/documents/2019/06/27/2019-13945/improving-price-and-quality-transparency-in-american-healthcare-to-put-patients-first> (last visited February 12, 2024).+(last+visited+February+12,+2024).>Google Scholar
Centers for Medicare & Medicaid Services (CMS) (2022d) Affordable Care Act Implementation FAQs – Set 15, available at <https://www.cms.gov/CCIIO/Resources/Fact-Sheets andFAQs/aca_implementation_faqs15#:~:text=Section%202715A%20of%20the%20PHS,through%2Oan%20Exchange%20shall%20only> (last visited February 12, 2024).+(last+visited+February+12,+2024).>Google Scholar
Social Security Act, 1890(b)(7)(B), available at <https://www.ssa.gov/OP_Home/ssact/title18/1890.htm> (last visited February 12, 2024).+(last+visited+February+12,+2024).>Google Scholar
Kullgren, J. T., et al., “Consumer Behaviors Among Individuals Enrolled in High-Deductible Health Plans in the United States,” JAMA Internal Medicine 178, no. 3 (2018): 424–426.Google ScholarPubMed
Desai, S. et al., “Association Between Availability of a Price Transparency Tool and Outpatient Spending,” JAMA 315, no. 17 (2016):1874–1881; S. Desai, et al., “Offering a Price Transparency Tool did not Reduce Overall Spending Among California Public Employees and Retirees,” Health Affairs (Millwood) 36, no. 8 (2017): 1401-1407.CrossRefGoogle Scholar
Kullgren, J. and Fendrick, M., “The Price Will Be Right—How to Help Patients and Providers Benefit from the New CMS Transparency Rule,” JAMA Health Forum 2, no. 2 (2021): e210102; S. M. Desai, S. Shambhu, and A. Mehrotra, “Online Advertising Increased New Hampshire Residents’ Use of Provider Price Tool But Not Use of Lower-Price Providers,” Health Affairs (Millwood) 40, no. 3 (2021): 521-528.Google Scholar
Glied, S. “Price Transparency — Promise and Peril,” JAMA 325, no. 15 (2021):1496–1497.Google Scholar
Henderson, M. and Mouslim, M., “Low Compliance From Big Hospitals On CMS’s Hospital Price Transparency Rule,” Health Affairs Blog (2021), https://doi.org/10.1377/hblog20210311.899634.CrossRefGoogle Scholar
Gustafsson, L. and Bishop, S. “Hospital Price Transparency: Making It Useful for Patients,” To the Point (blog), Commonwealth Fund, https://doi.org/10.26099/qacm-j392.Google Scholar
Horný, M., Shafer, P.R., and Dusetzina, S. B., “Concordance of Disclosed Hospital Prices With Total Reimbursements for Hospital-Based Care Among Commercially Insured Patients in the US,” JAMA Network Open 4, no. 12 (2021): e2137390.CrossRefGoogle ScholarPubMed
Emanuel, E. J. and Diana, A., “Considering the Future of Price Transparency Initiatives — Information Alone is not Sufficient,” JAMA Network Open 4, no. 12 (2021): e2137566.CrossRefGoogle Scholar
Kullgren and Fendrick, supra note 46.Google Scholar
Federal Register, “Improving Price and Quality Transparency in American Healthcare To Put Patients First” (2019), Sect. 3b, available at <https://www.federalregister.gov/documents/2019/06/27/2019-13945/improving-price-and-quality-transparency-in-american-healthcare-to-put-patients-first> (last visited February 12, 2024).+(last+visited+February+12,+2024).>Google Scholar
See <https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/CMS-Transparency-in-Coverage-9915F.pdf> (last visited February 12, 2024).+(last+visited+February+12,+2024).>Google Scholar
Centers for Medicare & Medicaid Services (CMS) “No Surprises: Understand your Rights Against Surprise Medical Bills,” (2022), available at <https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills> (last visited February 12, 2024); Kaiser Family Foundation (KFF) “Surprise Medical Bills: New Protections for Consumers Take Effect in 2022,” (2021), available at <https://www.kff.org/private-insurance/fact-sheet/surprise-medical-bills-new-protections-for-consumers-take-effect-in-2022/> (last visited February 12, 2024).+(last+visited+February+12,+2024);+Kaiser+Family+Foundation+(KFF)+“Surprise+Medical+Bills:+New+Protections+for+Consumers+Take+Effect+in+2022,”+(2021),+available+at++(last+visited+February+12,+2024).>Google Scholar
Centers for Medicare & Medicaid Services (CMS), “Surprise Billing & Protecting Consumers,” available at <https://www.cms.gov/nosurprises/Ending-Surprise-Medical-Bills> (last visited February 12, 2024).+(last+visited+February+12,+2024).>Google Scholar
Epstein, supra note 1, at 7.Google Scholar