In his deluge of executive orders, Trump once again is focusing on health care cost transparency.
Efforts to open the lock on health care costs began in 2019 under the Trump administration with mandated publication of hospital price lists, called chargemasters. These price lists are arbitrary, as they have no relation to the contracted prices that hospitals and insurance companies negotiate. These negotiated prices were not available to the public but later were mandated to be published, despite lawsuits filed by hospitals.
Although the gates to the secretive world of health care costs are being hammered open with laws requiring price transparency, these data points have minimal utility to the average patient. Giving patients access to spreadsheets with up to fifty thousand rows of data that are organized by procedural code is not useful for practical price comparison. However, this data is undeniably useful for health care researchers and journalists. These published price lists revealed some interesting findings, including insurance prices oftentimes being more expensive than cash prices for certain services. This information further diminished trust in insurers, as their negotiations did not seem to save consumers money under the assumption they were buying services “in bulk” from hospitals.
We have technically already required the release of negotiated prices (and some hospitals still don’t comply). But does this translate to shifting the convoluted world of health care costs into something that resembles a free market with impactful participation from consumers? Price availability is one thing, but having services authorized in a timely manner by insurers is another.
We know insurance is guilty of systematically denying claims, creating bureaucratic roadblocks via prior authorizations, denying appropriate care to elderly post-acute populations, and making it difficult to appeal a denial. These tactics keep plunging Americans into debt, often impacting minorities and lower-income populations more than others.
What else can we do beyond requiring published prices? We can require quality reporting from insurance companies.
Quality reporting is a well-developed facet of health care. Hospitals report outcomes ranging from emergency room wait times, cataract surgery effectiveness, staff vaccination adherence, and colonoscopy follow-up. Surgical societies have also incorporated quality metrics into routine evaluations of patient care.
Quality reporting, although well-intended, takes an administrative toll on hospitals and physicians. So why would enforcing quality reporting on another element of health care—insurers—be useful? Quality reporting has taken on a complex and almost disorganized role when it comes to hospitals and physician groups. Learning from this, we can ask for simplistic quality data from insurers: denial rates, reason for denial, and outcomes of the appeals process.
Insurers have some required quality reporting, namely for marketplace plans on ACA.gov. However, this information is not audited and does not include employer-based health plans. Most denial estimates are collected from consumer surveys. In the same way prices were secretive, denial and appeal information still remains so.
Health insurance is a mandated product; therefore, it is inherently subject to oversight. Hospitals and physicians are required to report quality metrics, and this onus should be expected from insurers. In the continued spirit of transparency and protecting the sick and vulnerable from profiteering efforts, we must require insurer cooperation with transparency beyond price list publication. Doubling down on the publication of prices may be a part of the battle worth a repeat intervention from Donald Trump, but so is investigating insurance claims, denials, and the appeals process.
Christine Ward is a trauma and critical care fellow.