The North Carolina House and Senate have each put forward budget proposals, and both would make major changes to healthcare in our state.
Here are the some of the reforms you need to know about.
Prior Authorization
Each budget proposal would make significant changes to the prior authorization process.
There are some similarities between the two.
Both include measures to increase transparency.
Both require insurers to clearly disclose and communicate prior authorization policies.
And both tighten turnaround times that are already required by law.
There are also substantial differences.
Most notably, while the Senate proposal focuses on improving the process for patients, the House appears to be more concerned with easing “administrative burdens” for provider practices, even if that comes at the expense of the patient.
For example, the House bill exempts providers from prior authorization, even if they have an up-to-20 percent failure rate on claims.
North Carolinians should not be comfortable with a one-out-of-five failure rate from their doctors, especially if you are the patient whose care was inappropriate, excessively expensive, or dangerous. As a state, we should also not accept up to 20 percent opioid or fentanyl prescriptions to not meet established medical standards, for example.
This exemption threshold is dangerously low for patients.
It is also costly. A fiscal analysis for the General Assembly found this provision alone could cost taxpayers and the State Health Plan up to $76 million a year by 2027. Extrapolate that to all North Carolinians and we are talking hundreds of millions of dollars in added healthcare costs for patients and employers.
The House prior authorization proposal also adds administrative requirements and restrictions that will put patients at risk for increased cost and safety gaps.
On costs, if it is not confirmed that care is covered before it is administered, then patients are left vulnerable to high surprise bills. Or if a provider sends a test to an out-of-network lab, then patients are left responsible for the excess cost.
On safety, prior authorization could not be used to help enforce prescribing limits on opioids, or protect patients from being targeted by fraudulent addiction treatment facilities.
Facility Fees
The Senate budget proposal eliminates hospital facility fees from being charged at non-hospital settings.
Major hospital systems are charging patients what is known as a hospital ‘facility fee’ even if the patient never steps foot in the actual the hospital.
These fees drive up healthcare costs by hundreds of millions of dollars.
The Senate proposal, if passed, will ensure that patients are not charged hospital fees unless they actually use the hospital.
It would save patients upwards of $200 million a year in unnecessary tack-on fees.
The House proposal does not address facility fees.
Billing Transparency
The Senate budget allows patients to get an accurate estimate of any charges they will be obligated to pay before receiving care. Under the legislation, the patient’s bill cannot exceed 5 percent of that estimate.
It also requires patients be notified if anyone on their care team is out-of-network, and if they may receive a separate bill.
The House budget does not address healthcare billing transparency.
Mandates
The House budget proposal includes a mandate dealing with advanced diagnostic breast imaging.
The mandate attempts to make highly expensive tests like MRIs and ultrasounds more affordable for patients, but, unfortunately, does not actually address the cost.
Instead, it mandates that the cost is shifted into the amount you contribute out of your paycheck every month for health insurance.
The problem of affordability is real. North Carolina is the most expensive state for healthcare in the country. By lowering the amount that can be charged for advanced imaging tests, lawmakers can make sure cost is not a barrier, and that women can afford the care they need.
The Senate budget does not include any healthcare mandates.
If the final budget passed by the General Assembly is mandate-free, increases transparency, ends facility fees, and includes patient-focused prior authorizations reforms, it will be a big win for healthcare in North Carolina.
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