Mattke Soeren, White Chapin, Hanson Mark, Kotzias Virginia I
Rand Health Q. 2017 Jan 1;6(4):7. eCollection 2017 Jan.
Policymakers must balance the complex and sometimes conflicting objectives of ensuring access to care, limiting the financial burden on patients, and controlling overall costs. States differ in how they handle involuntary out-of-network charges-i.e., payment for care when a patient does not have the option of selecting a hospital in his or her health plan's network. New Jersey's current regulations emphasize patient protection, in that patients are only responsible for the portion of the cost that they would have incurred for in-network care, and health plans must pay the remainder of the provider's charges. This policy is seen as contentious by health plans, who argue that they have been made responsible for paying whatever charges a hospital submits, and proposals to limit payments for involuntary out-of-network care are being debated in the state legislature. This study seeks to inform the current debate (as of October 2016) by analyzing the role of out-of-network payments in New Jersey hospitals' financial performance and simulating the effect of policies to limit charges for involuntary out-of-network care. The authors' estimates suggest that implementing New Jersey Bill A1952, which proposes a limit of between 90 and 200 percent of Medicare rates for involuntary out-of-network hospital care, would have reduced payments for hospital care by commercial plans by between 6 and 10 percent during 2010 through 2014. Assuming no change in operating expenses and no recoupment of lost out-of-network revenues, the cap would have led to an operating loss at between 48 and 70 percent of hospitals.
政策制定者必须平衡一系列复杂且有时相互冲突的目标，即确保医疗服务的可及性、限制患者的经济负担以及控制总体成本。各州在处理非自愿的网络外费用方面存在差异，也就是说，当患者没有选择其健康计划网络内医院的选项时，如何支付医疗费用。新泽西州目前的法规强调对患者的保护，即患者仅需承担其在网络内就医本应产生的费用部分，而健康计划必须支付医疗机构收费的其余部分。健康计划认为这项政策颇具争议，他们辩称自己要负责支付医院提交的任何费用，而限制非自愿网络外医疗费用支付的提案正在该州立法机构进行辩论。本研究旨在通过分析网络外支付在新泽西州医院财务表现中的作用，并模拟限制非自愿网络外医疗费用政策的效果，为当前（截至2016年10月）的辩论提供参考依据。作者的估计表明，实施新泽西州A1952号法案（该法案提议将非自愿网络外医院医疗费用限制在医疗保险费率的90%至200%之间），在2010年至2014年期间，商业保险计划支付的医院医疗费用将减少6%至10%。假设运营费用不变且无法弥补网络外收入损失，这一上限将导致48%至70%的医院出现运营亏损。
