The Truven Health Blog

The latest healthcare topics from a trusted, proven, and unbiased source.

By Truven Staff

The Cost of Out of Network Care

Bill Bithoney imageThe issue of extremely high variation between in- and out-of-network fees is highly significant and not adequately addressed in the ACA.  Private physicians who remain out-of-network can charge insured patients and their insurance companies exorbitant fees for out-of-network care.  An excellent example is an anesthesia group that practices in an in-network hospital working with in-network surgeons.  Patients actively choose their surgeon but rarely choose an anesthesiologist, trusting their surgeon or assuming the hospital will do so. Patients in this situation can be hit with a surprisingly large anesthesia services bill. The anesthesia group does extremely well; however, the hospital that uses this group doesn’t benefit and may well lose business in the long run because of their sky-high fees.

In elective surgical cases and in most medical cases, price transparency is the answer.  Research has suggested that substantial savings are possible if consumers shop on line using price calculators such as the one available at Dartmouth Hitchcock Medical Center and the one being introduced by Harvard Pilgrim.  Such on line price calculators are currently most useful in employer based health plans where patients are incented in various ways, often financially, if they pick low cost, high quality physicians and hospitals.  Many insurers and employers are pushing for the use of such calculators and they are becoming more prevalent especially in states where legislation is clearing away obstacles to such information sharing.

It would not be politically feasible in my opinion to force physicians to accept all insurance types.  We must use price transparency and financial incentives for patients to drive health care business to the most cost effective providers.

Bill Bithoney, MD