This brief highlights key findings of a RAND survey of providers in New York State regarding the preparedness of community providers (i.e., not affiliated with the Department of Veterans Affairs) to treat veterans.

Patients treated at in-network facilities can involuntarily receive services from out-of-network professionals, which may result in a "surprise bill." As of June 2019, fewer than half of states protect patients from surprise out-of-network medical bills, and there are no federal policies enacted to protect patients. Moreover, payment for out-of-network medical services contribute to rising health care costs in the United States. This dissertation is comprised of three essays addressing surprise out-of-network medical bills and out-of-network health care provider payment. The first essay quantifies the prevalence and magnitude of potential surprise medical bills in ambulatory surgery centers (ASCs) and describes the characteristics of providers and health plans involved. This observational study of commercial claims identifies possible surprise out-of-network bills in one-in-twelve ASC episodes. These potential bills average $1,100 per episode and are predominately generated by anesthesiologists, registered nurse anesthetists, and independent laboratories. These findings indicate that consumer protection policies are needed to address surprise out-of-network billing in ASCs. The second essay examines the early effects of California's recent policy addressing surprise medical billing (AB-72) on the dynamics among physician, hospital, and insurer stakeholders. This case study identifies that an out-of-network payment standard set at payer-specific local average commercial negotiated rates has changed the negotiation dynamics between hospital-based physicians and payers. Leverage has shifted in favor of payers, and physicians reported that this experience of decreased leverage is exacerbating provider consolidation. Thus, this study finds that out-of-network payment limits can influence payer-provider bargaining. The third essay projects the potential impacts of an out-of-network hospital payment limit on negotiated in-network payments by private health plans. This study estimates the effects of three proposed out-of-network payment limits for hospital care - 80% of billed charges, average private prices, and 125% of Medicare - on negotiated in-network prices and total payments for hospital care in 2017. The results suggest that a strict out-of-network payment limit set at 125% of Medicare could achieve reductions in hospital payments similar to more drastic reforms, such as Medicare for All and public plan buy-in programs. This dissertation demonstrates that policies to address surprise out-of-network billing must be comprehensive in the scope of services, settings, and patient populations they cover to effectively protect patients. It also demonstrates that policies to address out-of-network billing impact the underlying contracting dynamics of the health care market and can influence the amount paid to providers both out-of-network and in-network.

An integrated approach to purchasing health care for U.S. Department of Defense and U.S. Department of Veterans Affairs could have important implications for access, quality, and costs but could face legislative, policy, or contractual challenges.

Massachusetts veterans have unmet needs for education, employment, health care, housing, financial, and legal services. A better understanding of these needs can inform investments in services and guide efforts to remedy barriers to access.

In response to the Patient Protection and Affordable Care Act, health care organizations have sought ways to increase efficiency quickly, improve their ability to coordinate care, and enhance patient outcomes as reflected in publicly available performance measures. One such response has been the emergence of the clinically integrated network (CIN), commonly defined as a group of health care providers that join together to improve patient care, reduce costs, and demonstrate market value. The Federal Trade Commission (FTC) and U.S. Department of Justice have jointly provided guidance for CINs to determine whether cooperation among these otherwise competing organizations to jointly negotiate fees runs afoul of antitrust law. However, little is known about whether CINs conform to FTC guidance. The FTC does not formally monitor CINs, and health systems wanting to establish a CIN are not required to seek FTC approval. As a result, CINs are basically invisible to regulators and health services researchers, although CINs have the potential to produce negative market effects, such as increasing prices without a corresponding increase in quality. In this report, the authors offer an initial assessment of CINs based on interviews with health system executives, describe how health systems (large and small) are using CINs strategically to compete in crowded health care markets, and identify why CINs bear watching by the FTC and the larger health care community.

A bipartisan consensus has emerged around the need to address "surprise medical bills," and policymakers have shown a growing interest in using out-of-network payment limits as a tool to control rising health care spending in the United States. Such policies cap the total amount that hospitals and physicians can be paid when they are not in network and prohibit providers from billing patients for an excess balance. Medicare Advantage currently limits payments to out-of-network providers at traditional Medicare payment rates, and the state of Oregon has recently enacted an out-of-network payment limit for its public employee insurance plans. In addition, limits on out-of-network payments to hospitals have been proposed by U.S. senators and 2020 presidential candidates. However, there is a lack of information about the potential impacts of applying such payment limits broadly to hospital services. This lack of information is complicated by the nuanced role that out-of-network limits play in the negotiation process for in-network prices. To fill this gap, RAND researchers estimated the effects that four proposed out-of-network payment limits for hospital care-125 percent of Medicare payments (a strict limit), 200 percent of Medicare payments (a moderate limit), state average payment by private plans (a moderate limit), and 80 percent of average billed charges (a loose limit)-would have on negotiated in-network prices and total payments for hospital care. These four scenarios reflect the variation in base measure (traditional Medicare, market price, and charges) and payment generosity among existing policy proposals.