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Loren Adler Profile picture
Loren Adler
@LorenAdler
Fellow and Associate Director, Brookings Schaeffer Initiative for Health Policy | mostly health econ, occasionally budgets or Knicks | he/him
Jul 19, 2023 • 7 tweets • 3 min read
New paper in @Health_Affairs Scholar

Through painstaking work (thanks @ctmilhaupt), we mapped every EM & anesthesia clinician to their parent company & its ownership structure from 2009-19

We find that private equity's growth coincided w/ surprise billing driving headlines Image Private equity & publicly traded medical groups grew from 3.2% & 8.6% of the national anesthesia and EM markets in 2009, respectively, to about 20% of each by 2019.

This data is calculated solely based on the Medicare market. Their role appears even larger in employer market. Image
Dec 9, 2021 • 4 tweets • 2 min read
Hospital & doctor groups continue their anti-consumer lawsuits in pursuit of greater government intervention to guarantee more generous price supports for a subset of their members

(OON payment minimums through arbitration are fundamentally a form of government price support) Despite consistently fighting against patient & consumer interests in the surprise billing debate and doubling down with legal action against the No Surprises Act, hospital & doctor lobbies have done a sensational job of both-sides'ing the coverage of the debate.
Oct 1, 2021 • 17 tweets • 7 min read
Yesterday afternoon, the Biden Administration released Part 2 of their Interim Final Rules implementing the No Surprises Act.

cms.gov/newsroom/fact-…

Here’s what you need to know about the No Surprises Act now that we have clarity on its implementation.

A thread First and foremost, starting 3 months from today (on 1/1/2021), patients will be protected from surprise out-of-network bills for all emergency medical care & involuntary OON non-emergency care at in-network facilities. Same for air ambulances but not ground ambulances.
Sep 30, 2021 • 4 tweets • 1 min read
Still digesting, but the Administration has released its interim final rule implementing the No Surprises Act, including details on the arbitration process.

Summary: cms.gov/newsroom/fact-…

IFR: cms.gov/files/document… Judging by the rule's summary, it appears to delineate a coherent framework to adjudicate OON payment disputes in arbitration, starting w/ the presumption that the median in-network price is appropriate & deviating only when clear evidence to justify doing so is presented.
Sep 14, 2021 • 8 tweets • 3 min read
(1/7)

Even if political constraints keep drug savings to $150-$200B over 10 yrs, Dems have other big-ticket offsets available:

~$150B from site-neutral Medicare payments

~$200B from reducing MA overpayments

~$80B from reducing PAC overpayments

+ ~$150B from rebate rule (2/7)

The Trump Administration (following MedPAC recs) laid out a path forward to pay the same price for physician services that can be performed safely in the office setting even if they take place in a hospital outpatient department or hospital-owned physician’s office.
Sep 14, 2021 • 6 tweets • 2 min read
I similarly found this confusing.

From US perspective, the evidence to date makes it pretty clear the benefits of boosters now outweigh costs.

The parameter I don't have a good sense of is to what degree a trade-off exists in practice bet boosters & doses to other countries. Given the "why not both" option if the US were willing to pay high prices for doses then donated to other countries & US-first focus of US policy, I'm skeptical the practical effect on doses donated to other countries is large.

But curious how others think about this ...
Jan 5, 2021 • 6 tweets • 3 min read
New paper in @Health_Affairs looking at arbitration over surprise bills in NJ, w/ @BenChartock, Bich Ly, @ErinLDuffy1, & Erin Trish.

It's not good.

Arbitration awards appear to be based on charges, averaging *5.7 times* prevailing in-network prices.

healthaffairs.org/doi/full/10.13… Moreover, arbitration awards >25x median in-network prices were not uncommon.

New Jersey, similar to New York, illustrates the danger of basing an arbitration system on unilaterally-set provider charges.

Such an approach is destined to unnecessarily increase health costs.
Dec 21, 2020 • 17 tweets • 5 min read
(1/17)

Today’s surprise billing fix is a huge win for consumers!

As of 1/1/2022, it will be illegal nationwide for an out-of-network provider to surprise bill a patient for more than their standard in-network cost-sharing obligations.

THREAD based on the final language (2/17)

The protections from surprise billing will apply in all emergency situations (w/ lone exception of ground ambulance rides) & for non-emergency out-of-network physician services received at in-network facilities.

Helpful rundown of the protections: healthaffairs.org/do/10.1377/hbl…
Dec 16, 2020 • 4 tweets • 2 min read
27 Senators sign a bipartisan letter supporting inclusion of the recently-announced surprise billing agreement in the year-end spending legislation: cassidy.senate.gov/imo/media/doc/… Unfortunately, the AMA is opposing the bipartisan surprise billing legislation.

Interestingly, they previously seemed to support the Neal/Brady bill (left), and the new bill is identical other than a couple concessions to provider lobbying.

searchlf.ama-assn.org/letter/documen…
Dec 12, 2020 • 16 tweets • 5 min read
THREAD

Today's bipartisan, bicameral surprise billing legislation isn't perfect, but it's a clear improvement over the status quo

Leg text: energycommerce.house.gov/sites/democrat…

Section-by-section: energycommerce.house.gov/sites/democrat… Surprise billing would be prohibited for all OON emergency services (& post-stabilization), much OON care at in-network facilities, & air ambulances.

Out-of-network payment can be challenged to an arbitration process that's instructed to mainly consider median in-network rates.
Dec 11, 2020 • 10 tweets • 3 min read
While the debate has largely broken down as benchmark vs. arbitration, much more important is how generous the out-of-network payment mandate ends up being.

E.g., arbitration based on Medicare rates would be more consumer-friendly than a benchmark based on charges. Or to take concrete state examples, CT's surprise billing law that uses an OON benchmark payment mandate at the 80th percentile of charges for emergency services is just as bad for consumers as NY's that relies on arbitration to get to the same end state.

brookings.edu/blog/usc-brook…
Jul 24, 2020 • 12 tweets • 5 min read
1/
Quick thread re: @gottliebecon’s paper presentation that sparked some debate last night (and @Jabaluck’s livetweeting thread)

conference.nber.org/conf_papers/f1…

2/
First, the paper itself provides some great new descriptive work on physician salaries that should prove valuable for future research, but I don’t think it tells us much about the normative question of whether doctor pay is too high/too low.