Quick hits: Congress revives surprise billing legislation; rural and urban Dems differ on Trump impeachment

Here's a roundup of stories with rural resonance; if you do or see similar work that should be shared on The Rural Blog, email us at heather.chapman@uky.edu.

Rural and urban Democrats show starkly different opinions on a possible Trump impeachment. An interesting read before Thanksgiving dinner political conversations. Read more here.

Volunteer firefighters want to spend Thanksgiving with their families too, so here are some tips on how not to burn your house down if you deep-fry your turkey. Read more here.

After months of inaction, House and Senate committees are once again negotiating on bills to address surprise medical billing. High air ambulance bills make this particularly germane in rural areas. Read more here.

Want a dirt-cheap live Christmas tree? All you need is a hacksaw and a Bureau of Land Management Permit. Read more here. Read more here.

Congress aims to curb surprise air ambulance bills

Use of air ambulances has declined over the past decade, and prices for their runs have soared, so many customers are stuck with massive, unexpected bills when their insurance fails to cover the ride. Complaints from constituents have prompted lawmakers at both the state and federal level to try to curb the surprise bills, Alma Almendrala reports for NPR.

An estimated one in six insured Americans are hit with surprise bills after a hospital stay, and air ambulances are a big offender. Tom Saputo, of Thousand Oaks, Calif., ended up paying more for a post-surgical ride back to the hospital than he did for the surgery itself, a double lung transplant. The air ambulance company, Mercy Air, charged his insurance company more than $51,000 for the 27-mile flight, leaving Saputo responsible for more than $11,000, Almendrala reports. Mercy Air blamed Saputo's insurer for not covering more of the bill, but forgave the bill after it caught the attention of ABC's "Good Morning America."

"The median cost of a helicopter air ambulance flight was $36,400 in 2017, an increase of more than 60 percent from the median price in 2012, according to a Government Accountability Office analysis. Two-thirds of the flights in 2017 were out of network, the report found," Almendrala reports. "The air ambulance industry justifies these charges by pointing out that the bulk of its business — transporting patients covered by the public insurance programs Medicare and Medicaid — is underfunded by the government."

Critics argue that market saturation is the real reason behind increasing air ambulance prices. "While the number of air ambulance helicopters in the U.S. has increased — rising more than 10% from 2010 to 2014 — the number of flights hasn't, which means air ambulance companies seek to raise prices on each ride," Almendrala reports.

State-level efforts to eliminate or limit surprise "balance billing," as it is called, have been generally unsuccessful; federal judges usually strike down such laws because they violate the Airline Deregulation Act of 1978, which prohibits states from regulating air traffic. Congress is considering several bills to limit or ban balance bills. "One measure by Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., would ban balance bills from air ambulance companies," Almendrala reports. "The bill passed committee and is now headed to the Senate floor for a vote, pending approval from Senate Majority Leader Mitch McConnell of Kentucky."

Air ambulances offer rural residents iffy memberships

Rural residents rely disproportionately on air ambulances to reach distant medical care in emergencies, but many have been hit with huge, unexpected bills since many such services aren't in insurance networks. To combat fears about such bills, ambulance services have been increasingly advertising prepaid subscriptions that promise patients free use of their helicopters in an emergency. 

"Nationwide, though, state insurance leaders, politicians and even one of the nation's largest air ambulance companies have raised concerns about the slickly marketed membership campaigns," Sarah Tribble reports for NPR. "The memberships often don't include every ambulance company in an area, and the choice of which medevac service answers a call is out of a consumer's hands."

Meanwhile, the cost of air ambulance services has soared in recent years. The median price for an air ambulance trip increased from $22,100 in 2012 to $36,400 in 2017—a 65 percent jump. Medicare and Medicaid patients pay lower fees or even nothing for such trips, but those with private insurance often find their plans don't cover the entire cost of the service, leaving them saddled with "balance bills" for the uncovered portion, Tribble reports.

States can't regulate air ambulance rates, routes or services, but several, including North Dakota and Montana, have introduced or passed bills to limit air ambulance memberships or decrease the likelihood that subscribers would get stuck with balance bills, Tribble reports.

The federal government does have the power to regulate air travel, though; Congress formed a committee last year to look into air ambulance bills. Air ambulance lobbyists blamed inadequate Medicare and Medicaid reimbursement for the high rates and asked that the federal government reimburse them more, Harris Meyer reports for Modern Healthcare.

Study that showed increasing air-ambulance charges may bolster Senate bill that cracks down on surprise medical bills

In 2016, nationwide median charges for air ambulance services, which are used disproportionately in rural areas, were 4.1 to 9.5 times what Medicare paid for the same services, according to a recently published study. The billing disparity is much higher than for physicians or ground ambulance services. "Median charges for air ambulance services compared to Medicare rates soared by 46% to 61% from 2012 to 2016," Harris Meyer reports for Modern Healthcare. "For Medicare patients, the median charge per trip increased from $24,000 to $39,000."

Since many air ambulance providers aren't in insurance networks, patients get stuck with unexpected "balance bills" for thousands (or tens of thousands) of dollars for services they believed were in-network. The study may bolster a new Senate bill that would crack down on surprise bills. "Last month, the Senate health committee shocked the air ambulance industry, which is made up heavily of private equity-owned companies, by including a balance-billing ban for air ambulance services in its broader legislation to regulate surprise out-of-network billing," Meyer reports.

Because of a federal law that governs air carriers, courts have blocked states from regulating air ambulances, so experts say only the federal government can address the problem. "Congress last year ordered creation of an advisory committee of stakeholders to examine air ambulance price-transparency measures and consumer protections against excessive charges," Meyer reports.

"The Association of Air Medical Services, the industry's lobbying group, blamed inadequate Medicare and Medicaid payment rates for the out-of-network billing controversy," Meyer reports. "It said air ambulance services are essential for Americans, particularly in rural areas, and that the federal government needs to conduct a study to develop rates that cover actual costs in order to preserve these services."

Air ambulances are a boon to rural areas, but they can leave patients holding the bag

Trudy Lieberman

By Trudy Lieberman
Rural Health News Service

Not many of us think about needing air ambulances. We don’t dwell on that possibility, but for people hurt in car accidents or who live in smaller or rural communities without medical care at hand, being airlifted to a hospital can mean the difference between life and death.

Increasingly, the service also can mean the difference between getting well at a price you can afford or at a price that could push you over a financial cliff.

Air ambulances have become the centerpiece of a nationwide dispute over balance billing, a practice that requires unsuspecting families, even those with good insurance, to pay a large part of the bill.

In Nebraska a woman who was injured when her van rolled on a gravel road found herself with a $44,000 air ambulance bill. Her insurance paid most of the bill. A North Dakota man who got a $67,300 bill from a company that transported his wife to the Mayo Clinic had to pay more than $50,000 out of pocket. In Ohio, a man filed for bankruptcy because he owed $22,000 to an air ambulance company, which had placed a lien on his home.

And so it goes in other states where patients have complained about balance billing, this particularly dark side of the medical marketplace, which affects all health-care services, not just air ambulances. It works like this: You have health coverage, incur a medical bill, and assume the service is covered by your insurance, Medicare, or Medicaid. Then comes the surprise! The bill isn’t covered because the provider is not in your insurer’s network. You’re on the hook for the entire amount.

Sometimes it’s impossible to tell if a provider belongs to a network or not. When you are wheeled into the operating room, are you going to ask the anesthesiologist if he or she belongs to the hospital’s network? How many accident victims suffering from trauma are going to direct EMS workers to check if the air service is in or out of network before they’re lifted to a hospital?

You can also get stuck even if the ambulance company is in the network. An insurance payment may not come close to covering the cost. “Rates ambulance companies charge private patients are much more than they are charging to Medicare or Medicaid patients,” says Chuck Bell, programs director at Consumers Union, the non-profit publisher of Consumer Reports.

The industry argues that Medicare rates are too low and some patients have no insurance so only by charging insured patients higher fees can they stay in business, Bell told me. “The air ambulance industry has grown rapidly, and prices have shot up a lot with some companies trying to make a quick buck.” For one large company the average bill went from about $17,200 in 2009 to $40,000 in 2014.

The problem with air ambulances is an example of the disorderly introduction of medical technology without any planning or regulation. Patients are trapped in the middle of a tug of war between insurers that want to keep payments low and air ambulance companies that are eager for profits.

To collect more revenue from privately insured patients, ambulance companies sometimes resort to aggressive collection practices, asking for financial information from privately insured patients to assess which ones have assets they can go after, Bell explained.

One solution is to ban balance billing for the air-ambulance industry and create a fee schedule for the entire marketplace, but that seems unlikely because of a 1978 federal law that deregulated the airlines and prohibited the federal government from regulating prices and schedules in the states.

North Dakota passed a law requiring those needing air ambulances to use a list of providers that are part of insurers’ networks. One company sued, and the issue is tied up in court. Other federal laws may also inadvertently prevent a national solution that would apply to all consumers no matter what kind of insurance they had.

The usual shopping advice doesn’t apply here. But you can check your insurance benefits and at least know if you are covered for these services. You can look at a chart from the Kaiser Family Foundation that offers guidance about your state’s rules on balanced billing. And, you can make a lot of noise with state officials if you face one of these bills.

Some companies offer membership programs for a nominal fee that will pay some portion of the bills. These cards, which are not insurance, may not cover the full cost, and you may be picked up by a service that doesn’t honor your card. And in an emergency, are you going to look for your card and tell the EMS worker, “Hey, call this one?”

Have you had experience with balance billing? Write to Trudy at trudy.lieberman@gmail.com.