Posting Patient Prices: Transparency Cure for Hospital Blank Checks

Posting Patient Prices: Transparency Cure for Hospital Blank Checks

Joe Selvaggi: [00:00:00] This is Hubwonk. I’m Joe Selvaggi. Welcome to Hubwonk, a podcast of Pioneer Institute, a think tank in Boston. Consider a policy shift that promises to enhance healthcare for Americans, extending their lifespans, and generating savings of up to a trillion dollars. Advocates for healthcare price transparency argue precisely this.

Their proposals hinge on the belief that clear pricing fosters competition, drives down costs, elevates quality, and ensures accountability in services rendered. This concept of transparency is commonplace in modern consumerism, from online groceries to international flights. However, healthcare, unlike retail, lacks upfront pricing, leading to unchecked expenses and errors.

The ramifications of this absence of market discipline are evident in the U. S., where healthcare expenditure per capita is double that of other affluent nations, despite similar or lower [00:01:00] life expectancies. How might price transparency reshape healthcare costs? What obstacles impede efforts to empower consumers with pricing information?

And how might individuals and organizations eager to realize savings seek value in the future? My guest today is Cynthia Fisher, an accomplished entrepreneur, philanthropist, and founder and CEO of PatientRightsAdvocate. org, a nonprofit dedicated to healthcare price transparency. Ms. Fisher, along with Dr.

Arthur Laffer has co-authored a new report titled “Healthcare Price Transparency and Competition, How Real Price Transparency Can Reduce American Healthcare Costs by Over a Trillion Dollars Annually, and Extend Life Expectancy.” This report argues that consumer choice and market discipline can realign healthcare costs with historical norms while delivering the quality and accountability consumers demand.

We will delve into the obstacles facing price transparency reform and examine the [00:02:00] efficacy of regulatory and legislative initiatives driving change. When I return, I’ll be joined by the founder and CEO of PatientRightsAdvocate. org, Cynthia Fisher. This is Hubwonk. I’m Joe Selvaggi, and I’m now pleased to be joined by the founder and CEO of PatientRightsAdvocate.org Cynthia Fisher. Welcome to Hubwonk, Cynthia.

Cynthia Fisher: Thank you, Joe. Pleasure to be here.

Joe Selvaggi: Okay, well, I’m thrilled to have you. today we’re going to drill down into the need and potential benefits of price transparency in healthcare. Very, interesting topic. But before we go into detail, you are a founder of an organization.

let’s start off by, learning a little bit more about the patient rights advocate that you started. what’s your, mission? Joan.

Cynthia Fisher: Yes, our mission is to have price transparency throughout our healthcare system and empower patients and all consumers of healthcare and coverage to be able to lower their costs.[00:03:00]

by benefiting from competition and consumer choice, and to be able to be protected from overcharges in medical billing and claims payments. So if you think about it, price transparency is truly transformative because it shifts power to the consumer to be protected from overcharges and to be able to greatly lower their costs.

Joe Selvaggi: Well, that’s a great summary. I enjoyed reading your most recent report. You wrote it with well-known economist, Dr. Arthur Laffer, Professor Laffer. It’s entitled, it’s a pretty bold title, “Healthcare Price Transparency and Competition How Real Price Transparency Can Reduce American Healthcare Costs More Than 1 Trillion Annually and Extend Life Expectancy.”

That’s a big claim. So it caught my attention. I found the piece to be a very persuasive read. our listeners, we talk about healthcare a lot on the podcast, and our listeners probably already know. We spend about $4 trillion a year. That’s T trillion. But t [00:04:00] in an economy that’s only $27 trillion large.

So we know that we spend a lot, but we also know about half of that is in the private sector. Half of that it’s public, Medicaid, and these kinds of things. But you’re gonna, out of that $4 trillion, you’re gonna save us. A trillion. At a high level, where does that number, that amount, come from?

Cynthia Fisher: Joe, there was an article in the Journal of American Medical Association about 25 percent of our healthcare costs are purely administrative waste. 25 percent of an over 4 trillion a year spend is a trillion dollars. And in today’s world, we have not had. a functional market in healthcare. It is extremely dysfunctional because the true purchasers of all of healthcare, which is the patient and the employer and union [00:05:00] plan, as well as the federal government, when we look at the purchasers have had no concept of actual prices that they would pay in advance of care, or to see what the competitive prices are, In a market economy, that has enabled both hospitals and insurance companies to keep hiding prices and many middle players in between those prices and bills that add administrative waste and administrative costs.

to procuring care. And what have we seen over the past couple of decades? If we’ve seen high single and double-digit increases in coverage costs and premiums that have increased so much when you look at the share of workers wages and employers’ growth or budgets, public sector budgets, they’ve been harmed by these runaway costs that have been [00:06:00] far greater, three to five times.

That’s higher than inflation. That’s ridiculous. So that’s a big part of it because it’s really quite simple. So the true purchasers haven’t seen any prices, but now we have that right by law, which is a really transformative change.

Joe Selvaggi: Some would push back and say, yeah, we spend a lot on healthcare, but we’re a wealthy nation.

We like healthcare. So we’re spending all this money and therefore we should be healthier. is there any evidence that all this extra spending we do, is improving our health?

Cynthia Fisher: Well, let’s look at the numbers on a macro level, Joe. If we look at the American spending on health care, we’re spending over two times more than any other developed nation.

And yet we’re dying four years earlier than the average life expectancy of other developed countries. That [00:07:00] says, if you look at the correlation of our death rate, that perhaps we are, quality of care isn’t as high as other nations as we’re dying earlier is one of the factors. But why? Why are we paying and why has it even been tolerable to pay over two times more?

And a lot of that is because as long as hospitals and insurance companies and all the middle players continue to hide prices, they can charge whatever they want. And quite frankly, it’s the industry. moving toward profits over patience and keeping the billing data and the prices away from the true purchasers.

the good news is, this is all starting to change. And that is because of the Implementation Bylaw of Price Transparency over three years ago. Look, Jeff, every one of us, everyone who [00:08:00] gets CARE, simply wants to know what are we going to get and what’s it going to cost. When we see prices and price transparency will clearly usher in the next question is what are you going to get for that price?

And that would be quality discovery as well.

Joe Selvaggi: I found your paper very persuasive. Some of the graphs very early on in the paper talk about this. LifeCross or HealthCross. It shows an inverse relationship between what we spend and our life expectancy. What we spend is consistently going up. Our life expectancy, relative to that, spending is going down.

clearly, we’re not getting good value. You also point to a historical trend that we, relative to our wealthy peers, again, if we’re talking about life expectancy, if we’re spending, if we’re dying earlier than our peers, We’re spending far more, I think, in some of your observations, nearly twice as much as our wealthy peers in this world.

Was this always the case? Has the U. S. always spent twice what our peers spend, or is this a recent phenomenon [00:09:00] with an inflection point?

Cynthia Fisher: This is more of a recent phenomenon over the past couple of decades, and a lot of it’s due to government policies, that have enabled a broken system, and the system’s broken as long as the consumer, who’s the patient, employers, and unions, as long as the consumer has been not able to have access to prices in it and actually also have accountability and integrity in the billing practices. none of us would tolerate that in any other facet of our lives. Every other facet, whether we go to the grocery store or the gas station or buy online retail, has prices and markets and then when we get the bills we check it to the price we agreed we thought we would pay and we have the ability to have remedy and recourse.

However, in healthcare, that’s been blocked because the information has been blocked all along, and that’s game over now. We’re in a new revolutionary time where now prices are beginning to be revealed by law by all [00:10:00] hospitals and insurance companies. And we’re finding substantial, interesting findings from all of this discovery.

Joe Selvaggi: So I want to go there, but I want, let’s, I want to drill down a little bit more. We’ve got, the provider, the doctors, and hospitals that are, curing us, and we’ve got our, us, but there’s so many people in between. we’ve talked in this, A lot about these intermediaries or these middlemen.

Of course, we have insurance companies. We don’t enter the healthcare system by ourselves. We seem to always be guided by our health, insurance. We have, intermediaries like pharmacy benefit managers who decide which drugs we can have and at what price. To what extent is this sort of, blurring of lines?

Let’s imagine in a brave new world where the hospital does offer prices. Aren’t all these intermediaries they say they represent us, but at some level they’re, shielding us from what we spend and the choices we make? Isn’t that part of the problem?

Cynthia Fisher: Absolutely. Absolutely. In fact, the first question you asked has this been the case over time.

You go back earlier, [00:11:00] Singapore adopted our model from the 60s, and they’re only spending around 5 percent of gross domestic product on health care. And they’ve engaged also the consumer living a healthier life as part of a cash model as well, cutting out many of those middle players. and compared to the U.S., we’re approaching 20% Gross domestic product spend somewhere between 18 and a half, but it’s projected to be at 20 percent and even, and several years in the future, it’s even projected to be as high as 25%. But when you look at that, the American worker is working at 20 percent of gross domestic product spend.

That means we’re working one day a week just to pay for health care. One in five days is working just to pay for health care. compare that to Singapore, at 5 percent of gross domestic product, it actually harms the American workers, it harms the American [00:12:00] businesses on growth, because we’re hemorrhaging on overpaying for healthcare, which could otherwise go into wages, and otherwise go into school budgets, more teachers, better academic programs, and maybe infrastructure bill, bridges, road repair when we look at having opportunity cost of loss because we’re way overspending for healthcare.

And so this is a moment in time where we’re at this incredible inflection point, Joe, where price transparency is truly revolutionary because it enables all of us to be able to, for the first time, consider the ability to shop And the ability to put a halt and question our bills to make sure that they were charged at the right price and it wasn’t price gouged or an error or overcharge.

Joe Selvaggi: I want to take that, I like to use simple analogies that our listeners might understand. And I’d say, okay, I like to compare healthcare [00:13:00] maybe to a grocery store where we walk into a grocery store. None of us would walk into a grocery store. Where there were no prices, right? You want to know whether the Wheaties or the Weetabix are more expensive, ultimately, so that you can choose what you want to spend on, right?

You, maybe you want the premium product for this and not for that, or you may want something on sale, a lot more of it, or less of it if it’s not. say more about why price Whether it’s healthcare or anything else, why it’s so valuable for an individual consumer when they enter any market and then take it to healthcare.

Why is that information, I mean, can’t someone argue against this saying, look, I need what I need. I need new hips or a knee or a, MRI. I may have a choice in a grocery store. I don’t have a choice in healthcare. why is health, why is the price so valuable even in healthcare?

Cynthia Fisher: no matter what type of healthcare system we have, prices create a sense of fairness and allow for the consumer to have financial certainty. Think [00:14:00] about it. When anybody goes in to get care today, we have been, until we get these prices, across the country, and we see full compliance by hospitals and insurers, without the price, a patient and a consumer are blind to no prices and often surprised by bills blindsided far higher than they expected to pay. And then I question this, Joe, why do we all have to go in and pick up that electronic pen? and sign a blank check? Goodness, the healthcare system now that’s gone electronic doesn’t even show us what we’re signing anymore and allows us to read what we’re signing.

But we are signing that we will be financially responsible to pay whatever the hospital chooses to charge us. even beyond what our insurance coverage would carry. And so in the world where there [00:15:00] are high deductible health plans and co-pays and co-insurance and do know, the American worker pays for almost all of healthcare because we pay for out of wages automatically deducted as a portion of share with our employers.

And then we pay for the federal government and the state and local government. healthcare plans with our taxes. So we have to have these prices in order to benefit from competition and choice. And look, a simple example is an MRI. What is a fair market price for an MRI? And what we’re learning is that in stand-alone imaging centers, a cash price, all in, for the MRI, including the read, is around 300.

And yet, you could go to Mass General Brigham, and our Blue Cross plan, our charge in our insured [00:16:00] rate is over 7,000 for that same MRI.

Joe Selvaggi: Right.

Cynthia Fisher: I think this is a That’s a big difference.

Joe Selvaggi: This is a profound point because I think it when some of our listeners hear prices and they say look I need what I need What difference is the price?

that’s what they’re charging. But I think what you’re powerfully saying is you have a choice if you want to get an MRI, for instance, as you quote unquote need one. It’s not, where in Mass General I’ll go. It’s Mass General versus BU Medical or the MRI center down the street.

If you have the prices of all of them, you may still opt, just like you may fly first class or drive around a gold-plated Cadillac. But, ultimately it’s money spent. We all spend it. You can choose to be more efficient if you’re provided with the price. You can still disregard the price. It’s great, but you ultimately have an opportunity to save yourself, your plan, your deductible, all the way down the road, and collectively, all of us, a lot of money if you have at least the information to make an informed choice for a value.

Is that fair?

Cynthia Fisher: That’s [00:17:00] absolutely fair, and I’ll tell you a funny story. My husband needed two MRIs, and in Massachusetts, It was a pretty high price if he stayed at Mass General. And then we started saying, what if we looked around Massachusetts as a market? What is the lowest price we could find?

And we found 950 is the lowest price. Woonsocket, Rhode Island, 250. So we happened to be on vacation in Florida, and I said, you know what? Let’s look for a cash price and why don’t you get your MRI nearby? We found one for 300 and a double read because a radiologist was going to provide two reads. My husband was very proud of his second MRI, he was able to lower that to another center and get it for 250.

So that case in point, you can’t teach an old dog a new trick, Joe.

Joe Selvaggi: Oh, no, that’s good. Good on you, husband. I also didn’t want to glide over the other point you made, which is accountability. Meaning, if I go in again, I’m stuck on this grocery store analogy. If I go into a grocery store, and [00:18:00] the Wheaties say, Hey, it’s me, Four bucks and ultimately I’m scanning through and it comes up eight bucks, I’ve got something, to go on I said look this the price shows there on the shelf for you just charge me You just overcharged me, if you don’t in a sense have information You are literally writing a blank check You have no idea what it should be costing you so you have no idea if you’ve been overcharged.

Is that a fair assessment?

Cynthia Fisher: Absolutely. And what if those charges when you went to the grocery store were thousands of dollars higher than you expected when you were thinking, I got two bags of groceries? Maybe it’s 120 a spend total. And then you get a 1,200 bill. If you went to the grocery store it would be, built like healthcare, right?

All the middle players in between, and then figuring out the maximum amount that you could be charged. think about it. Hospitals now have departments called Revenue Cycle Optimization, which to me is interpreted as charging whatever you can, as high as you can get away with at each patient encounter.

And then every middle player in between is looking at how can they profit from it. [00:19:00] Even more with additional modifiers or spread pricing on that patient encounter. And so the next thing you know, you’re paying thousands of dollars for something that should only be a couple of hundred. And so the other part on prices is Joe, now all of the hospitals are three years into having to show all of their actual prices and compare them by every insurance carrier and every plan as well as a discounted cash price. And we’ve learned a lot. Around the country, we do it every six months and a consumer-type report. And the last report we did, we showed that About 34. 5 percent of the nation’s hospitals are fully complying with the law where they’re showing all of their actual prices, so we could start to see tech developers, the more prices that are out there, We could see tech developers create, say, a Google [00:20:00] search engine for things like an MRI or a colonoscopy.

Joe Selvaggi: And Cynthia, I want to go, yeah, I’m glad you brought that up because, this is not a, an episode of despair. we’re not just going to throw up our arms and say that nothing good is happening, because as you say, some are complying with the CMS requirement. you, in your paper, mentioned an organization, a large organization.

I think one was a municipal, like a state, insurance for their employees. One was a union and the other was just a private insurer. They have used the power of price transparency to substantially save, in one case you say it saved them from insolvency, but it saved them a ton of money.

Share with our listeners at least, one of the examples of where price transfer transparency is actually working to inform large For instance,

Cynthia Fisher: we gave the example of S E I U 32 B J. 200, 000, workers in the New York, New Jersey area that are in real estate buildings. Janitors, doormen, and women that, tend to these buildings.

They were [00:21:00] able to save by getting the billing information and negotiating with hospitals that provided great care at reasonable prices. Looking at childbirth, hip replacements, those types of things. Cancer treatments are very expensive and find you where the same quality of care is better priced.

They save 33 million dollars a year for three years. And what did they do with that money? They increased wages to the highest wage increase ever and gave a 3,000 bonus to every employee.

Joe Selvaggi: That’s a small amount for someone who cleans office spaces. That’s a lot of money.

Cynthia Fisher: That’s a lot of money and a lot of happy people, a lot of happy workers that love their health plan.

And on top of it, the real estate building owners because this is a combined plan with the ability owners and the workers got to save a two-month premium each year of not having to pay for two [00:22:00] months because they saved so much money in addition to raising wages and bonuses. So this is a huge win. we’ve seen the states of Montana and Maryland Bartlett ran that health plan, and just by getting a hold of the numbers and running her health care plan by the numbers and creating pricing that was really What was a fair price for her state workers, 30,000 state workers?

She saved 121 million in 18 months for the state plan and put money back into the tax coffers, into reserves.

Joe Selvaggi: That’s your money, that’s my money. It’s people’s hard-earned pay that’s otherwise wasted. you, we’re, I love the success stories, but again, we’re going to focus on the success and then talk about where we still have to go.

We’re talking about the sort of fruit of the rule that was put in by CMS. This is, as you say, it came into effect, on January 1st, 2021. I think it was two parts. It required that all hospitals [00:23:00] post a machine-readable file with prices for all services and items they offer.

And they also had to have a cost estimator tool for the 300 most shoppable services. Say more about the rule and, what your thoughts are on it. is this the answer or, a hell of a start?

Cynthia Fisher: the true, important part of this rule is, that machine-readable file that posts all of the actual prices by every service and every code and code name and code, across every insurance carrier and plan that the hospital offers. And you can compare that to the discounted cash price if you just want to pay cash. So being able to have every hospital post those files in standard format, allows a tech economy to create mobile shopping tools.

And the whole goal here, think about what we have in the airlines, for instance. We can go and we can trust when we buy an airline ticket and we have [00:24:00] choices to be able to purchase. And just like healthcare, airlines have wide variation, look right now, we’re in storms, we have weather that might cause more turbulence or delayed flights, whatever, but we know that the airline prices have wind to deal with, fuel costs differ, wide variation, however they’re able to price.

And price, prices in airlines since the deregulation back in the 70s, when prices weren’t known for airlines, only by the travel industry, and once prices became transparent, And we purchased them directly, you cut out the middle player, which was the travel agent, right? And we went directly online, directly accessing prices for airlines, and what happened is that the real value of pricing of airlines in real dollars is now half of what it was in the 70s. And hundreds of millions of [00:25:00] people are flying, and planes are safer. And this is competition, this is choice, and it is readily available access to the consumers. And you have trust and accountability in those billings. The same can happen for health care with these hospital files being unleashed.

And you can imagine even an Uber platform. Let’s go back to the MRI. I would love to see an Uber-type platform for you, Joe, or me. If we needed an ACL looked at for our knees for an MRI image, why not allow a platform like an Uber type of platform to let the healthcare sector bid on our business at a time that we could go get that care and show us at what price and what quality of service that they would choose to provide us.

So you can imagine that.

Joe Selvaggi: You make a great point. You actually wrote an, I’m referencing one paper, but I’m now going to reference another paper by PRA that I think is also compelling. You took that [00:26:00] information again, now some of it’s online, not all of it, not as much as you want, but you looked at. In the information that’s provided, you found huge discrepancies.

Call it MRI. I don’t remember which procedure was in your paper, but you saw not just, again, we use BU and Mass General as a sort of, okay, I would rather go to one than the other. But even within, let’s say, Mass General, again, I’m using that just because that’s our local hospital.

For the same procedure, a difference of 10 times, 20 times, for the same exact procedure based on who it is. again, to use my crazy grocery store analogy, can you imagine, one customer being charged 10 times more for Wheaties than another customer? It would be absurd, and yet, it’s going on all the time.

Say more about your observations about the range of prices, intra-hospital and inter-hospital.

Cynthia Fisher: Well said. Intrahospital, what we were finding is that on average that is a ten times difference for the same service by the same providers for different patients. As you said, [00:27:00] none of us would tolerate that in a grocery store to see someone pay 5 for a half gallon of milk and another person pay 50.

Worse, let’s look at the gas station. I like to think about if I pulled up to pump my gas and got 15 gallons of gas, say it was 50, and you got the same gas right behind me, filled up your tank for the same exact amount of gas, and you were charged 500. In using the same gas station, you would be outraged.

I would even get out of my car to help you to get the appropriate price. That’s what we’re finding, right? All of us want each other to be treated fairly. None of us want to have a ten times difference in pricing, than the next person for the same service with the same surgical team, for instance. And it’s happening every day because we have been blind to know this.

And, [00:28:00] once it’s really wide scale known among patients, they have the right to see these prices and among employers and unions as they compare, what is that third party insurance carrier negotiating on their behalf? And why is the carrier allowing gouging at 10 times more? Because there’s certainly profit in the lowest price.

Joe Selvaggi: I want, yeah, of course, that’s right, they, nobody’s providing services at law, so you, you’re 100 percent you’re not eliminating. Profit or reasonable profit, I want to push back. There’s one thing that I think was missing in my, layperson observation of this phenomenon.

To me, again, to use my grocery store analogy again, let’s imagine the grocery store. It’s just like you want it. Everybody, all the prices are posted and they’re all fair and they’re all the same for all of us. Okay, we’ve gotten there. But I go to the checkout and all I do, regardless of how much is in my cart and what I’ve chosen, I pay a hundred-dollar copay and the rest goes to my insurance company.

What then, in that sort of. that’s me making an analogy to an insurance company. Once I get to my. Limits of [00:29:00] my copay, my incentive to shop has gone away. You don’t really address that in any of your papers. What would you say to those people? Again, you, I’m old enough to remember when medical insurance used terms like major medical, meaning, yeah, if you got really sick, we cover it.

But, you’re on your own for the basic stuff. We’ve gone to now almost the first dollar payment. Doesn’t that make the consumer and those of us who might benefit from prices indifferent to the difference in what we pay?

Cynthia Fisher: you raise a good point, Cho, and it can, absolutely, but where we’re not indifferent is what we make in our jobs and what we have in our savings and take-home pay, so when we can see actual prices and price comparisons, the real world.

Inflection to change is going to be coming from the employer and the unions as groups, as a collective with, for instance, SEIU 32BJ, 200,000 employees. And so when they were able to save [00:30:00] a hundred million dollars, that’s real money, and they’re able to be able to lower everyone’s cost of what comes out of their paycheck.

Joe Selvaggi: And when the consumer is exposed to the prices, again, they make better choices. Of course, we have all kinds of studies, like LASIK studies, where if insurance doesn’t cover it and you’ve got to shop around, magically, LASIK prices have come down, 95%, because you’ve got to pay it. you can’t just push that off.

I think, at least having the information, it’s going to govern prices. And of course, we all know, as amateur economists, that prices are determined at the margin. There’s some people who never buy something, some people will buy at any price. Prices are determined by the person at the margin, just someone who is influenced by price.

And if it’s the SEIU, great, they’re going to influence price, even if I, as Joe Consumer, might not have an interest. it will work even if I don’t care.

Cynthia Fisher: exactly. And, what’s really amazing is, look, it’s a lot of large employers too, and medium and small employers are [00:31:00] starting to get ahold of these numbers.

And they also need access to control the checkbook because when the employers share in our billing and charges, they need to make sure they’re accurate. And, look, there are some provisions in a lot of insurance contracts that shouldn’t be signed, like anti-audit provisions. Can you believe that?

Many of the insurance, big insurance companies say you can’t audit what you’re deciding with the hospitals we’re going to charge you. that’s, crazy. The employers that are actually saving 30 to 46 percent for all of their workers on what they were paying for coverage costs get a hold of the billing and they look at those charges before they’re paid to make sure they’re not being overcharged.

And the other part of it is to make sure the prices are right. Let me give you an example. Rosencare down in Orlando, Florida, Harris Rosen, 6, 000 employees, [00:32:00] pays less than half of the national average. for coverage for all of his workers. And how did they do that? For all of their families, they were front-loaded with great primary care and access to physical therapy, occupational therapy, and training, readily available to their employees, and they got a hold of the prices.

and they directly contracted and cut out many middle players with many of the hospitals. So they have been able to save over decades and put that into higher wages and growth for their hotel chains.

Joe Selvaggi: So we agree that, okay, I hope our listeners are excited about this, brave new world of, price transparency.

But yeah, you’ve, and your analysis is, this is a three-year-old law, we only get 30 to 36 percent compliance, and actually, your analysis suggests some hospitals are slipping backward, meaning, they don’t voluntarily choose to make less money, so surprise, surprise, if nobody’s [00:33:00] watching, they become less transparent.

What else is going on beyond the CMS rule? I’ve read something about something going on in the Senate, which is going to, rather than an executive oversight, executive branch oversight of CMS, we’re talking about the legislative branch passing laws that will actually have some teeth that might influence price transparency.

What can you tell us about what’s going on in Congress?

Cynthia Fisher: Yes, in Congress, it’s, this is such a bipartisan issue, and first of all, the polling for across the country, time after time, is over 90 percent of Americans want prices in healthcare, because they believe, very firmly, they will lower their costs when they have the ability to choose where to go, and at what price.

The last polling came in at 94%. Bipartisan. for Americans wanting health care price transparency. Congress has been frustrated that the Health and Human Services has not robustly enforced the law. [00:34:00] However, President Biden did increase the fines to over two million dollars. And when he did, they fined two hospitals.

Look, nearly two-thirds are yet to show all of their prices. Most of the hospitals in the country do have pricing files, but if they’re missing swaths of pricing data, then we can’t have a functional competitive market yet, right? but we did find that when the Biden administration fined two hospitals over a million dollars, It worked.

That higher fine worked because those two hospitals came into compliance within weeks. And today, they still have exemplary files, and that was two years ago. However, we have not seen that level of fining and rapid enforcement. I think they’ve only looked at around 20 hospitals, but having de minimis fines, and so it’s been slow walked.

So Congress has come [00:35:00] forward to put forth two bills. And the House passed a bipartisan bill for lowering costs through more transparency. And the Senate, Senator Braun from Indiana, and Bernie Sanders, who’s chairman of the Senate Health Committee, came together and even went further to create a better bill that allows for all actual prices to have to be, provided by hospitals and insurance companies and much higher fines, as well as a daily feed of the billing information and claims and electronic funds so that the industry has wanted to give estimates.

And why the Senate bill is so important is the Senate bill has actual prices and we just saw Health and Human Services roll back actual prices to being able to be [00:36:00] substituted with an estimate. Estimates have no accountability, Joe. Estimates do not allow for a true market or market forces. And so that’s why the Sanders Braun bill is so critical because it says actual prices.

So we have an actual market and when patients are given an estimate, I’ll give you an example. Cindy Reddy in Colorado came forward and testified. She was given an estimate for 5,000 and her actual bill came at 74,000. The insurance company that told her in advance the estimate and that they would cover denied her care after the fact.

So the hospital put a lien on her home for 74,000. She came to us, and [00:37:00] we have all of the country’s hospitals’ prices online. And fortunately, the hospital had complied and had her plan and those prices. And line item by line item, when she compared her bill, it should have been around 8,000 by the plan with an 800 copay.

She was able to prove to the insurance company and the hospital that they way overcharged her. It took seven months. But she finally got them to release the lien on her home, and the insurance company did cover at the prices they negotiated with the hospital.

Joe Selvaggi: I think that’s an interesting point, a very salient point, because, again, an estimate is by all rights, nonbinding.

You, if I estimate you change the oil in your car, it would be 25 bucks and now it’s 250 bucks. I’m like, what do you say? Oh, I gave you an estimate. That’s no promise. If the price is the price, that’s a contract. It’s saying, I will do this for that. so you’re saying with [00:38:00] the Senate, bill, you can’t slip in estimates and as a sort of, a catch-all phrase to say, and by the way, whatever we charge.

Regardless if it’s, as you described, 15 times more than the estimate, sorry, it was a bad estimate, but it was an estimate, so you don’t have that sort of escape hatch in the new bill.

Cynthia Fisher: That’s correct. And the other part of it is that prices, actual prices, are negotiated. And so we find those actual prices today in the insurance part of the insurance companies have to post all of their prices.

And so when we don’t see them missing in the hospitals, why then should the hospital be able to, in the new rule change in 2025, be able to substitute an actual price with an estimate? That’s a rollback, that’s harmful, and that’s what the Biden administration just did in their latest rule, is they allowed for [00:39:00] an estimate substitute.

Cynthia Fisher: That would throw a big wrench. in all of the progress that’s been made thus far. And for people like Cindy Reddy, who because she saw the actual prices, was able to prove that she was overcharged and that the estimate was meaningless.

Joe Selvaggi: Yeah. so what you’re saying is CMS did a little bit of backsliding by allowing estimates and I think it’s important for our listeners, you know, again, I don’t know, we know what we say, but we don’t know how it’s heard. It’s not that we’re price fixing. We’re saying, look. charge what you want, just let everybody know, and let, then they have, of course, the right of exit, they can go somewhere else, or not do the procedure at all, or go to a neighboring hospital.

we’re not looking for some philosopher king to determine what things should cost, we’re just saying, tell us what you plan to charge us, and give us a choice of, you Choosing where we want to go, right? I mean, this isn’t a command economy. This is a market economy that we’re advocating for.

Cynthia Fisher: Absolutely. let’s let the market [00:40:00] forces work. And instead of after the fact, the prices are known by the insurers in the hospitals, and they have traditionally not let us know until after the fact. It’s about moving those prices to the front. And 90 percent of care is planned. And even in emergent care, when you have prices, you normalize and have market forces work, right?

So, this is to pull back the curtains, let the market forces work, and restore trust and accountability in our healthcare system.

Joe Selvaggi: Yes, of course, it’s strange bedfellows when you have Bernie Sanders and a Republican Senator agreeing, but I think, again, from my perch, I see, People presented with the same exact facts that you and I have discussed and seeing two different worlds.

You know, my friends who are market-oriented understand prices are what constrain all producers, right? the Wheaties aren’t six dollars instead of four dollars because you buy something else. You can choose, choice is what [00:41:00] constrains prices in markets. We don’t have prices in healthcare, so it’s not constraining.

So, this is market dynamics going out the window, and essentially hospitals can charge whatever they can get away with. Your price strategy, and transparency, will impose the same market discipline on hospitals that are imposed on every other producer. On the left, I think they think, Someone like a Bernie Sanders I can imagine seeing this as a really good idea, largely because they imagine all markets to be, or capitalism itself, to be predatory in a sense to, the rich and powerful preying on the weak and powerless.

And in his mind, I imagine price transparency offers an opportunity to expose and shame, people who are rent-seekers, all the way, all the middlemen who are making quote-unquote too much money. If you have price transparency, there’s no normative, element here. Sure, you charge as much as you can get away with, and the consumer goes somewhere else.

you don’t need someone to police the system if you have price transparency. You’ve got markets. You’ve got, the discipline of markets. Do I have it about right, or do you see this sort of [00:42:00] seeing your advocacy for transparency seen through two different lenses, but at the end of the day, it doesn’t matter?

It works for both sides.

Cynthia Fisher: It does work for both sides. And, you mentioned, Bernie Sanders. He’s been very advocating to have the government pay for most of healthcare, and he advocates very strongly for price transparency because he doesn’t want the government to overpay when you get to see prices and markets come and function because they are functional, that the purchaser, the true purchaser, is the patient and the American worker and employers.

When we are able to see prices have choices and have competition, then we benefit. Competition benefits us all. And when markets are consolidated too, then oftentimes prices get higher. because it comes to be about, but without knowing the prices at all, you could almost say it’s extortion. Making every consumer sign a blank check, that they will open [00:43:00] up their checkbooks and their family savings and be responsible with all their assets to pay for that health care without having a price.

Joe Selvaggi: Well, we’re running out of time. I’ve enjoyed our conversation. I’m sure we’ve piqued the interest of our listeners. They might be interested to read this report that we cited and several of the others that talk about the range of prices and the lack of transparency in your analysis of how hospitals’ prices differ.

All that’s a really valuable resource. Where can listeners go to read more about a patient rights advocate?

Cynthia Fisher: Yes, they can go to our website at PatientRightsAdvocate. org, and they can see how to shop in these new times, by getting prices, and how to be protected from overcharges on our site, and also become an advocate.

And we encourage the Senate bill, anyone who wants to go to their senator and write their senator, encouraging them to sign on the bill and see these two bills come together to allow for price transparency [00:44:00] everywhere. True price transparency is a great way to take action, and it is effective.

Joe Selvaggi: That trillion dollars could be better spent elsewhere.

Again, the entire defense budget is, 800 billion. So this is, every year we spend, 25 percent more than the entire, we waste, not spend, waste more than the entire defense budget. Plus 25%. So that’s a lot of money. That’s a real dollar. It’s a trillion here, trillion dollars there. You got real money. So I’m very excited about the upside potential.

we’re on our way and I think you’ve, your advocacy is, helping to move the ball, and who knows, we may, I’ll invite you back in the future and you can see, tell us that we’ve succeeded. Now we know exactly how much we’re going to pay before we walk through the hospital’s front door.

So thank you very much for joining me today, Cynthia. You’ve been a really great guest. Thanks so much, Joe. This has been another episode of Hubwonk. If you enjoyed today’s show, there are several ways to support Hubwonk and Pioneer Institute. It would be easier for you and better for us if you subscribe to Hubwonk on your iTunes Podcatcher.

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