It’s too soon to know what will be altered in the health insurance industry during the next legislative term, but some troubling trends are brewing.

We lived through reductions in fees. Thirty years ago, Medicare bureaucrats put out memos stating that they felt cataract surgery was overvalued and that fees should slim down — at one time the agency suggested $300. Knowing CMS’s game plan years in advance gave us plenty of time to adjust our office overhead to compensate. And so we did.

We lived through bundling of procedures. Some I understand, like bundling unexpected vitrectomy with cataract surgery on the grounds that CMS should not pay extra for a surgical complication. Some I do not understand, like prohibiting payment for an optic nerve photograph and a retinal nerve fiber layer OCT on the same day. While they test the same area, they do so differently and give us two distinct bits of information.

More recently, we have seen the prohibition of performing a blepharoplasty (unless donated gratis) when performing a ptosis operation. The cosmetic bleph’s purpose is to prevent a patient from looking like a Shar-Pei after the ptosis repair. The logic behind prohibiting a patient from electively deciding to have one done escapes me.

The surprise could be yours

The latest trend I find worrisome is a movement among some states regarding out-of-network payments. Until now physicians had the choice of belonging to a network and accepting its fees or not belonging to the network and not accepting its fees — and risk not seeing the patients, too. Our choice. Our freedom.

However, it is not as simple in world-real. Patients are sent to emergency rooms, where they have surgery requiring anesthesia, only to learn later that their PCP and their surgeon are truly in-network but the ER doctor and the anesthesiologist are not. They end up getting a “surprise bill” and realize, post-procedure and treatment, that their insurance coverage was limited.

Five states have now passed laws to protect against or prohibit surprise medical bills. Some laws just require that patients are warned, but some actually forbid charging more than the insurance company’s rate. In other words, even if you have no legal connection with the insurer, you have to accept its fee schedule and cannot charge your usual fare.

Practice under the Politburo

What comes next is uncertain, but one can picture an insurer that drops its premiums in half to attract subscribers and simultaneously drops its reimbursements to providers knowing the law prohibits every doctor from charging the patient extra. Doctors could not avoid the problem by remaining out-of-network, so the only solution would be to refuse to see any patient on that plan. But, what if we do?

All a state has to do is declare that not seeing a patient on a state-approved insurance plan to be unprofessional conduct, and poof! See not the patient; have not the license.

This wicket can become very sticky very quickly. Let’s hope the incoming “health planners” recognize us as critical resources and not disposable commodities. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, R.I. His e-mail is pskoch@clarisvision.com.