The effect of new price disclosure rules for health insurers remains to be seen.


Article Content

The Centers for Medicare and Medicaid Services (CMS) is now requiring insurers and self-insured employers to publicly disclose what they pay hospitals, physicians, and others for services and supplies. The so-called transparency rules, which eventually will result in public access to price and benefit information, aim to help consumers make cost-conscious decisions, reduce "surprise billing," and put downward pressure on prices.

Figure. Reprinted fr... - Click to enlarge in new windowFigure. Reprinted from the Henry J. Kaiser Family Foundation. Visualizing health policy: US statistics on surprise medical billing. 2020 Feb 11;

But the impact won't be immediate. The rules took effect July 1 but online posting of specific price data for public use isn't required until January 2023. And even this implementation schedule may be optimistic, based on the CMS's experience with similar price disclosure rules for hospitals. Those rules set January 2021 as the target date for posting prices on the web, but a February 2022 review of 1,000 hospitals by the group http://PatientRightsAdvocate.org found that only 14.3% of hospitals had fully complied while 37.9% were in partial compliance. Of hospitals owned by the three largest U.S. hospital systems-HCA Healthcare, CommonSpirit Health, and Ascension-a mere 0.5% were found to be in compliance.


The mandate for insurers and self-insured companies requires them to immediately make available so-called machine-readable files of their in-network rates for all covered items and services, the amounts allowed toward charges from out-of-network providers, and the cost of drugs administered in the hospital or in medical offices-and to update these prices monthly. Machine-readable files are large data caches containing literally trillions of records. These are intended primarily for app developers and researchers who are able to manipulate the data into useful forms. The expectation is that the app developers will create user-friendly tools for consumers to access and manage pertinent information.


Beginning in January 2023, insurers must provide an internet-based price-comparison tool (available on paper if requested) for 500 services and items that beneficiaries might want to "shop for" in advance. This requirement will be broadened in January 2024 to cover all health care items and services.


The impact of these mandates on prices specifically and the U.S. health care market in general is difficult to predict. Posted prices might eventually tame the huge variations that currently exist in prices for the same services. The information might also give employers leverage to demand that their insurers match better rates offered to other companies. At the same time, insurance premiums could increase to cover the cost of uploading and updating these large data files. It's also possible that patients won't use the tools, opting instead to follow their providers' advice about where to go for services.-Betsy Todd, MPH, RN