It is a Holy Grail of Health: forcing the industry to reveal the prices being negotiated between health and hospitals – information that has long been treated as a commercial secret. And between the turmoil of the executive orders, President Donald Trump signed during his first five weeks back to office was a promise to “make America healthy again” giving patients accurate healthcare prices.
The aim is to force hospitals and health insurance companies to facilitate consumers to compare the actual prices of medical procedures and prescription drugs. Trump gave his administration by the end of May to find a model and a mechanism to make sure the healthcare industry is complying.
But Trump’s 2025 command is also a symbol of the small progress the country has made since it issued a similar directive about six years ago. Consumers only find it partially useful and the quality of the information is spotty.
A first step “bold” that disappeared
The 2019 mandate was “quite bold”, said Gary Claxton, KFF’s senior vice president, a non -profit health organization for the KFF Health News. “Basically they went to the providers and the plans and said,” All the facts you think are confidential that we are not going to do confidential anymore. ”
What followed was, in the consumer defense groups, a disappointment. Hospitals and insurers are published on massive, complex, and confusing data on their prices. The information was a challenge for even the experts in pricing in healthcare, let alone consumers. Some members of Congress have laid down legislation to put the power of the law behind the claims of transparency. These accounts died. And President Joe Biden’s administration was criticized that it does not strictly impose regulations, with a consumer defense team buying even a Super Bowl ad with rapper Fat Joe claiming that “hospitals and insurers hide their prices”.
Trump’s new mandate, signed in February, said that hospitals and health plans “were not sufficiently detained to account when their transparency data was incomplete or not published at all”.
The Government Bureau said in October that Medicare & Medicaid services did not know if the prices reported by the healthcare industry were correct or complete. But the CMS, which regulates hospitals, now plans to “systematically monitor compliance” and help institutions understand the requirements, said Catherine Howden, a spokesman for the service.
Howden did not answer questions about whether CMS employees who oversee compliance with prices transparency have been fired as part of Trump’s widespread effort to reduce the federal workforce.
Zombies’ prices and other inconsistencies
In the meantime, independent researchers have found many problems with the quality of price data, both hospitals and health insurers share with consumers.
A recent exhibition by System Health System Peterson-Kff found that data reported by four health insurers in New York often included prices that say they pay hospitals for services that health providers are not or cannot. These are called “ghost” or “zombie” values. For example, the health plans reported dentists, optometrics, and acuologists who received knee replacements, gastrointestinal examinations and other procedures that are not related to their specialties.
In other cases, the data included different values for the same service paid by the same insurer in the same hospital. Unitedhealthcare, for example, said it pays the New York Medical Center-Presbyterian/Weill Cornell three prices-$ 47,000, $ 64,000 and $ 70,000-for the treatment of a heart attack.
Or, insurers said they pay the same price for very different services. Aetna, for example, stated that it paid exactly $ 6,292 to Mount Sinai Beth Israel Hospital for the treatment of respiratory infections, heart attacks, digestive tract cancers, kidney infections and urinary tract infections.
Neither UnitedhealthCare nor Aetna were about the divergences in the data. Cole Manbeck, a spokesman for Unitedhealthcare, said the insurer responded to price transparency requirements and urged members “to use our tools for the exact costs based on their specific health plan”. Aetna Shelly Bendit spokesman reported questions to AHIP, an insurance and trade association for insurers.
Health insurers have “strongly supported” the transparency of prices, said Chris Bond, a spokesman for AHIP. The team will work with the Trump administration to provide transparency “in a way that makes sense for the end user, while promoting a competitive private market,” Bond said.
What should a consumer do?
Estimates and overall prices are not very useful for consumers, who are mainly interested in what they will ultimately have to pay out of pocket, said David Cutler, a professor of applied finances at Harvard University. This can vary depending on the health plan, depending on discounts, copayments and other fees.
“Most price transparency information doesn’t have that,” he said.
It also does not provide information on consumers about the quality of care, Cutler added, which can lead to an old bias. “It’s like wine when you go to the restaurant,” he said. “People assume that the most expensive wine is better.”
Cutler said it is skeptical that price transparency will reduce the cost for patients. However, he said he could provide information on hospitals and health plans on what their competitors are charging and paying for services – knowledge that could inadvertently lead to price increases if hospitals receiving lower interest rate from the competitor require higher compensation.
Trump’s recent executive mandate notes that the top quarter of the most expensive health prices decreased by 6.3% per year since the 2019 mandate.
However, the same survey reported in the executive order showed that the minimum quarter of services became more expensive, with about 3.4% per year, according to the analysis by Turquoise Health, a healthcare prices that examined rates in more than 200 hospitals in the 10 largest US markets.
Some patients say that with research and perseverance, they have managed to do transparency work for them.
Theresa Schmotzer, 50 -year -old, of Goodyear, Arizona, said she used hospital prices to save about $ 3,000 on outpatient surgery to remove a fibrous last year.
Schmotzer, who has health insurance, said her hospital for the first time told her to owe $ 3,700 to the process and wanted to pay in advance. But it was skeptical.
She said that her health insurer was unable to report a price for the procedure or determine how much she would owe. On the morning of surgery, Schmotzer said, he found a computer sheet online at PatientRightsadvocate.org which included different prices paid by insurers, including her own. The mentioned price for the process was closer to $ 700, he said.
Schmotzer said it received a printing of the computing sheet in the hospital and presented it during the rehearsal. She pays $ 300 discount and told the hospital to charge her for the rest.
A few months later, he said, the bill arrived at the mail for the remaining $ 400, which he paid.
When people go for surgery and are not clear in advance what the cost will be, it is fear, he said. “Because they go to the blind.”
Subsequent steps
Hospitals say they want to work with federal regulatory authorities and comply with reports of reports, said Ariel Levin, Director of Political Coverage for the US Hospital Union, who represents about 5,000 institutions. Levin said consumers should have the price of services and “a more complete estimate” that represents an entire episode of care and the amount they owe out of pocket, based on their health plan.
The CMS has developed rules since Trump’s 2019 mandate to make hospitals and health plans easier and the organization has imposed a fine on more than twelve hospitals for receipt to comply.
Federal rules allow hospitals to report an estimate, a price range or a historical interest rate for their services, while health plans can adjust prices based on factors such as the severity of the case, the duration of the treatment and the age of a patient.
KFF’s claxton has said that this flexibility does not allow for “apple comparisons-apples” and that the data must be reliable before researchers can use it to better understand healthcare costs. “It doesn’t seem to be this yet,” he said.
Much remains to be made before the prices transparency meets expectations that it will increase competition and lower costs, said Katie Martin, chief executive of the Institute of Health Costs, a non -profit research team.
The transparency of prices alone is not a silver sphere, Martin said. It is “a crucial first step” for employers, legislators, regulators and others to better understand how money flows through the healthcare system and how to make it more effective, he said. “It’s not the whole thing.”
