AUSTIN, Texas - El problema creciente de los sorpresivos cobros médicos en Texas capturó la atención de grupos de consumidores y legisladores, quienes impulsan una legislación para terminar con la práctica llamada "cuenta de balance."
La iniciativa está en el capitolio estatal y se propone poner fin a estas cuentas médicas sorpresa, que están poniendo a cada vez más tejanos ante una crisis financiera mientras tratan de recuperarse de la crisis de salud para la que creían tener cobertura.
Trey Berndt, director estatal asociado de comunicación y defensoría en la AARP Texas, dice que el problema se da en muchos hospitales que están dentro de la red de las principales aseguradoras de salud del estado, pero usan médicos que están fuera de esa red, sin que los pacientes lo sepan.
"La mayoría de los consumidores pagan sus primas -comenta- y ven su tarjeta del seguro, que usualmente menciona el 'co-aseguro' o el 'co-pago,' y esperan pagar sólo esto. Sin embargo regresan a casa y reciben recibir cuentas a veces por miles de dólares más."
Una propuesta que espera la audiencia de un comité en el Congreso de Texas, acabaría con tales cobros médicos sorpresa limitando el desembolso del paciente a no más de lo que hubiera pagado dentro de la red.
Berndt comenta que la legislación también liberaría completamente a los consumidores de cualquier disputa por cobros que haya entre las aseguradoras y los proveedores.
"Cuando alguien está en la sala de urgencias -dice-, lo último en lo que quiere estar pensando es en la red y espera que los proveedores se entiendan con su aseguradora, y eso no está pasando y es lo que absolutamente necesita ser corregido."
Entre los tejanos que, encima de sus heridas han recibido insultos con una cuenta médica sorpresa, está Hugh Smith de Cypress. Su esposa se rompió la espalda hace tres años y mientras estuvo en el hospital, ellos explícitamente pidieron sólo médicos incluidos en la red de su seguro.
"Y pagué los deducibles y todos los co-pagos y todo -explica-, y luego de repente hubo un doctor que nos mandó una cuenta por el total, y no quiso hablar sobre el tema y dice que él está exento del proceso porque no es un médico que nosotros pedimos ni que nosotros lo usamos. Era un asesor del jefe de cirugía del hospital."
Luego de batallar con esa cuenta sorpresa durante dos años, los Smith consiguieron que se redujera el monto, pero aún así acabaron teniendo que pagar tres mil dólares. Aunque la práctica del cobro de la cuenta de balance es legal, Berndt dice que la AARP considera que actualmente es una de las más injustas prácticas de los seguros de salud.
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A recent report examined how some rural Tennessee hospitals have managed to stay afloat despite financial challenges.
The report includes interviews from staff at five different rural hospitals, which range in size from 25 to 125 beds.
Judy Roitman, executive director of the Tennessee Health Care Campaign, said some of the hospitals are drowning in uncompensated care. She explained as part of their research, they did an interview with a CEO from a rural hospital in Kentucky who expressed the importance of Medicaid expansion.
"Kentucky has expanded its Medicaid program and Tennessee has not," Roitman pointed out. "He said that's the key to our stability is actually having the funds coming in to treat these patients. And the CEOs and others in Tennessee hospitals said it would make a huge difference to have that federal funding."
Roitman added the federal government is offering Tennessee a nine-to-one match. If Tennessee were to expand Medicaid, at least 330,000 people would gain access to coverage.
Roitman pointed out the report suggested further steps hospitals could take, including examining how they are reimbursed for services provided. She noted private insurance plans tend to provide the highest reimbursement rates, and said more funding is needed to support TennCare, which does not cover enough of the cost.
"TennCare is all managed by managed-care organizations," Roitman explained. "They negotiate with every hospital about how they're going to reimburse and the big hospitals have some leverage to demand better payment and the smaller hospitals are just, they're just not getting paid."
Roitman added the report credited strong community engagement and effective hospital leadership as key factors in staff retention. Robust management and maintaining an engaged workforce significantly affect a hospital's viability, according to the report.
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Medicare and Medicaid are key sources of health coverage for many Americans and some people qualify for assistance under both programs. With lagging enrollment for the unique plans, outreach efforts are underway.
According to KFF Health News, only about three in 10 people who qualify for Dual-Eligible Special Needs Plans were enrolled in 2021. Experts said the option is designed for people who need additional help because of disabilities, certain health conditions or their age.
Dr. Gina Williams, associate medical director for UnitedHealthcare, said the plans try to take a dynamic approach to serving those eligible.
"Everything from managing your wellness to managing your behavioral health needs and then everyday needs," Williams outlined. "It's kind of a more comprehensive package for people who need a little bit more support."
Everyday needs include meal benefits and bathroom safety devices. The National Council on Aging said D-SNPs aim to provide a more streamlined coordination of care because there is assistance in arranging the services. Wisconsin's enrollment numbers are similar to the national rate, at 28%.
Christine Huberty, lead benefit specialist and northern region supervising attorney for the Greater Wisconsin Agency on Aging Resources, said a tricky component of the plans is navigating provider network restrictions. A rural resident might have to travel farther to see a doctor covered under the plan and she cautioned it warrants careful research when enrolling.
"I would say first and foremost, look at the provider network restrictions," Huberty advised. "Look at what's available in your area."
Meanwhile, Williams noted the push to get more eligible people to sign up coincides with more awareness around preventive care in a post-pandemic world.
"Everybody's kind of going into a phase where they're not only thinking about acute illness, but they're thinking about overall care," Williams observed. "What was the impact of the pandemic from a psychological standpoint? Do you need more support and then you also need more coordination of benefits?"
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In Mississippi and across the country, Community Health Centers are getting a funding increase, thanks to Congress passing a bipartisan spending package.
Community Health Centers in Mississippi serve patients without regard to their insurance status or ability to pay. More than 20 locations in the state provide medical care to more than more than 380,000 people.
Joe Dunn, senior vice president of public policy and advocacy for the National Association of Community Health Centers, said roughly one in 11 Americans gets their care from this type of clinic.
"Community Health Centers are the largest primary care network in the nation, providing care for 31 million Americans," Dunn pointed out. "This network is critically important, because they provide primary care, behavioral health, dental; just an array of services that are so critically needed."
Dunn emphasized more can be done. Research shows more than 100 million Americans need better access to primary care. Community Health Centers in Mississippi also support more than 4,000 jobs and about $678 million dollars in economic activity in the communities where they're located.
Dunn noted the increased funding from Congress will help the clinics provide more comprehensive care and reach more underserved patients, especially in rural communities, which ends up saving the state money.
"By incentivizing people to go get primary care, you alleviate more downstream costs," Dunn emphasized. "There's fewer hospitalizations and complications from chronic conditions, based on preventive screening and care at the outset."
The Congressional Budget Office reports the increase in funding for Community Health Centers just through the end of this year will reduce federal spending on public health insurance programs by more than $700 million.
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