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June 6, 2019

The Easy (Blue) Answer

Imagine I want to buy your house.  And pretend you want to sell it to me.  We sit down and discuss the price, but you just want more than I want to pay.  We can’t reach a deal. 

So, I go over to your next-door neighbors.  We sit down over an iced tea and talk turkey.  Maybe they are more motivated than you, maybe they are ready to move, but regardless of why, they agree to a much lower price.

Fine, you say, buy their house.

But I want your house; I just want it at their price.  Their house is in the same neighborhood and pretty similar to yours. Since you are being unreasonable, I should be able to just negotiate terms with them and then get your house for that price, right?

That is effectively how the Blue Cross Blue Shield plans would like to solve the thorny surprise billing issue. 

Their association, which represents 36 independent BCBS companies covering almost one in three Americans, recently sent a letter to Congress asking them to establish a benchmark for what out-of-network provides would be paid.  The answer, they pose, is simple – if someone is OON, they get paid Medicare or the in-network rate, whichever is higher.

How thoughtful that they threw in that last part.

They want the government to develop this ‘methodology’ so it is fair and standard (again, how nice), but that sort of glosses over the most salient input to the fair and unbiased methodology – which is the in-network rates THEY happen to have negotiated. 

Like a wolf wearing a wool coat, this is price-fixing dressed up in a thin disguise.  Take out the 117 million people covered by Medicare and Medicaid and the Blues have about half of everyone who remains…and a far greater percentage in many markets.  When you have that big a share, you set the market price.  The Feds, in this model, are just running the spreadsheet.

As we’ve discussed many times, this issue needs to be solved, is gaining political traction, and is complex and messy.  Which is why simplistic, one-sided solutions aren’t the answer.

How about an employer association propose that if they don’t like the premium increases offered to them by their carrier, they can just force the carrier to agree to pricing some other insurer offered them? 

Or that I can buy your house at the price I negotiated with your neighbor?

Same idea.

Tim Coan
Tim Coan

CEO and founder

Tim Coan, ALN’s CEO, writes an insightful and witty blog weekly about a variety of topics relevant to independent physician practices.