In a recent Health Affairs article, the Commonwealth Foundation conducted their periodic survey of eleven countries to see how access issues might have improved or worsened. Even with the passage of the Affordable Care Act, more people in the United States had a cost-related barrier to accessing care in the United States than any other comparable country. About a third of Americans, many of whom had insurance, avoided doctor visits, didn't fill prescriptions, or didn't get a test that was ordered because of the cost of that care.

Even though health care costs have been increasing more slowly in recent years than in the past, people are feeling that cost more than ever. The number of people who are underinsured, who still have high deductibles or other out-of-pocket costs even after paying for insurance through premiums, is still alarming. Even those with employer-sponsored private insurance have seen their cost sharing go up in recent years, often to the point of it causing difficulty for the rest of their lives. The same Health Affairs study found that a greater percentage of Americans are worried about having enough money to pay the rent or mortgage than in the other ten countries as well.

One way that insurance companies try to reduce how much it costs them to cover the care of their beneficiaries is to make deals with certain doctors or hospitals to provide care at reduced rates. These are known as networks. Then, insurance companies steer their customers to these networks by charging them less for care within the network than without. Some plans, like HMOs, provide very little coverage at all when patients receive care from out-of-network hospitals or physicians.

To be honest, I've never liked narrow networks. As someone who is very knowledgeable about the local medical environment, I have always opted for plans from my employer that allow me greater latitude in where we get our care. My GI physician and my primary care physician work for one large system. My children's pediatrician is part of another. We get to see both because I have a plan with a wide network. I've always been willing to pay a bit more for that privilege.

Others, however, make different calculations. Such options are, perhaps, out of reach. They choose plans with narrower networks and then make sure that they stay in those networks to avoid out-of-pocket payments. Too often, even these people find costs spiraling out of their control.

In the last year or so, the news periodically covers people who have gone to in-network facilities for care, but wound up experiencing huge bills because they were cared for by out-of-network physicians in those hospitals. Sometimes, it's an out-of-network surgeon who does part of a procedure in an in-network hospital. People try to do the right thing, and play by the rules, and still they get hit with extremely high, and surprising, bills.

These stories were mostly anecdote, however. The true incidence of these issues was unknown. Until now, that is. A recent Perspectives published in the NEJM looked at data from emergency rooms across the country. Many hospitals contract with physician groups to provide the care received there. Physician groups, on the other hand, often contract directly with insurance companies to get their services paid for. If the hospitals and the physicain groups don't contract with the same insurance company, it's possible for people who go to an in-network emergency room to receive care from out-of-network physicians.

Patients, of course, may be able to tell what emergency rooms are in-network when they need care. But there's almost no way they would know who is staffing the ED when they need care. Moreover, it's somewhat ridiculous to think that they could check and see who's working, and whether they are in-network, when they need emergent care. It's also possible that the physicians groups working in an emergency room could change over the course of a year without patients knowing. Finally, it's possible that in some areas the only in-network facilities only have out-of-network doctors, leaving no good options for care.

The research covered in the NEJM showed that of the 99.35% of emergency department visits which occurred at in-network facilities, 22% wound up involving an out-of-network physician. There was also a lot of variation. In some of the highest areas, upwards of 89% of in-network visits could involve out-of-network doctors. Other areas had close to zero such visits.

That last statistic shows that things can be better. We want to use cost sharing to help drive people to make better decisions about where and when they get care. Surprising them with bills they didn't expect and couldn't avoid serves no one. Regardless of who is in power, this is an aspect of health care reform that deserves attention.