A bill awaiting Missouri Gov. Jay Nixon’s approval would require hospitals to disclose cost estimates to patients within three business days.
State Sen. David Sater, R-Cassville, sponsored the bill. It links hospital costs to 17 other measures related to healthcare, including a provision that would charge Medicaid patients for using the emergency room during a non-emergency. Another would allow doctors to charge those patients for missing an appointment. Patient advocates say the latter goes against federal law.
So-called “Christmas Tree” bills, which often combine several measures to garner support, can only be approved or vetoed in full by the governor.
“There are pieces in there that are good or benign, but we really feel that the harm from these Medicaid fees outweighs the goodness in the bill, so we’ll be asking the governor to veto it,” said Jen Bersdale, executive director of Missouri Health Care for All.
The parts of the bill that Bernsdale considers good include a provision to require hospitals and clinics to give patients an estimate for how much their care will cost if they ask for it.
Requiring such estimates could be a burden for smaller providers, Missouri Hospital Association spokesperson Dave Dillon said. He pointed to FocusOnHospitals.com, an MHA website where many hospitals in the state have already voluntarily post estimates online.
“It’s difficult for a single place to encapsulate all the information on healthcare pricing for all procedures,” Dillon said. “Your insurance may be different than your neighbor’s insurance.”
Legislative researchers estimated this provision would cost an average of $79,020 for 150 Missouri hospitals, but did not tally how much it may save Missouri patients.
Two provisions that concern Missourians with Medicaid coverage are far more controversial. One would require patients to pay an $8 co-pay if they use the emergency room for non-emergencies. Another would allow physicians to charge patients for missed appointments.
Rep. Sue Allen, R-Town and Country, who handled the bill in the House, said the co-pay is designed to reduce unneeded emergency room visits.
“The intent is to help, maybe, get some behavioral changes. Let people have some skin in the game,” Allen said. “It shouldn’t be a way of convenience; it needs to be the most accountable way.”
Bersdale, of Missouri Health Care for All, said she’s concerned a financial penalty would keep people away from the ER when they really need it. The missed appointment fees are even higher: $5 for the first, $10 for the second and $20 for the third.
“If you’re living a comfortable middle class life, those fees seem pretty reasonable, but in Missouri, Medicaid eligibility is really, really low,” Bersdale said. “Frankly, the way to keep people from using the emergency room for things that aren’t emergencies is to increase access to primary care, so they have other places they can go.”
Missouri’s Medicaid program covers adults with children if they make less than 18 percent of the federal poverty line, about $302 a month for a family of three. Children, pregnant women and people with disabilities can qualify for coverage with higher household income levels.
The Centers for Medicare and Medicaid Services does not allow physicians to bill patients for missed appointments, and considers them part of a provider's overall cost of doing business. Should Nixon sign the bill into law, the state likely would need to apply for a federal waiver.
Charging a missed appointment fee to someone living below the poverty line, who may not have transportation or reliable childcare is unfair, Bersdale said.
"When we put these kinds of fees on people, what happens is they end up delaying or avoiding healthcare that they really need," she said.
Nixon has until mid-July to sign or veto the bill.
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An earlier version of this article stated that Missouri hospitals oppose the cost transparency measure. The Missouri Hospital Association has not taken a formal stance on the matter.