This year, the federal government ordered hospitals to begin publishing a prized secret: a complete list of the prices they negotiate with private insurers.
The insurers’ trade association had called the rule unconstitutional and said it would “undermine competitive negotiations.” Four hospital associations jointly sued the government to block it, and appealed when they lost.
They lost again, and seven months later, many hospitals are simply ignoring the requirement and posting nothing.
But data from the hospitals that have complied hints at why the powerful industries wanted this information to remain hidden.
It shows hospitals are charging patients wildly different amounts for the same basic services: procedures as simple as an X-ray or a pregnancy test.
And it provides numerous examples of major health insurers — some of the world’s largest companies, with billions in annual profits — negotiating surprisingly unfavorable rates for their customers. In many cases, insured patients are getting prices that are higher than they would if they pretended to have no coverage at all.
Until now, consumers had no way to know before they got the bill what prices they and their insurers would be paying. Some insurance companies have refused to provide the information when asked by patients and the employers that hired the companies to provide coverage.
This secrecy has allowed hospitals to tell patients that they are getting “steep” discounts, while still charging them many times what a public program like Medicare is willing to pay.
And it has left insurers with little incentive to negotiate well.
The peculiar economics of health insurance also help keep prices high.
Customers judge insurance plans based on whether their preferred doctors and hospitals are covered, making it hard for an insurer to walk away from a bad deal. The insurer also may not have a strong motivation to, given that the more that is spent on care, the more an insurance company can earn.
Federal regulations limit insurers’ profits to a percentage of the amount they spend on care. And in some plans involving large employers, insurers are not even using their own money. The employers pay the medical bills, and give insurers a cut of the costs in exchange for administering the plan.
A growing number of patients have reason to care when their insurer negotiates a bad deal. More Americans than ever are enrolled in high-deductible plans that leave them responsible for thousands of dollars in costs before coverage kicks in.
Patients often struggle to afford those bills. Sixteen percent of insured families currently have medical debt, with a median amount of $2,000.
Even when workers reach their deductible, they may have to pay a percentage of the cost. And in the long run, the high prices trickle down in the form of higher premiums, which across the nation are rising every year.
Insurers and hospitals say that looking at a handful of services doesn’t provide a full picture of their negotiations, and that the published data files don’t account for important aspects of their contracts, like bonuses for providing high-quality care.
“These rate sheets are not helpful to anyone,” said Molly Smith, vice president for public policy at the American Hospital Association. “It’s really hard to say that when a lot of hospitals are putting in a lot of effort to comply with the rule, but I would set them aside and avoid them.”
The trade association for insurers said it was “an anomaly” that some insured patients got worse prices than those paying cash.
“Insurers want to make sure they are negotiating the best deals they can for their members, to make sure their products have competitive premiums,” said Matt Eyles, chief executive of America’s Health Insurance Plans.
The five largest insurers — Aetna, Cigna, Humana, United and the Blue Cross Blue Shield Association — all declined requests for on-the-record interviews. Cigna, Humana and Blue Cross provided statements that said they support price transparency.
The requirement to publish prices is a rare bipartisan effort: a Trump-era initiative that the Biden administration supports. But the data has been difficult to draw meaning from, especially for consumers.
The New York Times partnered with two University of Maryland-Baltimore County researchers, Morgan Henderson and Morgane Mouslim, to turn the files into a database that showed how much basic medical care costs at 60 major hospitals.
The data doesn’t yet show any insurer always getting the best or worst prices. Small health plans with seemingly little leverage are sometimes out-negotiating the five insurers that dominate the U.S. market. And a single insurer can have a half-dozen different prices within the same facility, based on which plan was chosen at open enrollment, and whether it was bought as an individual or through work.
But the disclosures already upend the basic math that employers and customers have been using when they try to get a good deal.
People carefully weighing two plans — choosing a higher monthly cost or a larger deductible — have no idea that they may also be picking a much worse price when they later need care.
Even for simple procedures, the difference can be thousands of dollars, enough to erase any potential savings.
It’s not as if employers can share that information at open enrollment: They generally don’t know either.
“It’s not just individual patients who are in the dark,” said Martin Gaynor, a Carnegie Mellon economist who studies health pricing. “Employers are in the dark. Governments are in the dark. It’s just astonishing how deeply ignorant we are about these prices.”
A vital drug, a secret price
Take the problem Caroline Eichelberger faced after a stray dog bit her son Nathan at a Utah campsite last July.
Nathan’s pediatrician examined the wound and found it wasn’t serious. But within a week, Nathan needed a shot to prevent rabies that was available only in emergency rooms.
Ms. Eichelberger took Nathan to Layton Hospital in Layton, Utah, near her house. It hasn’t published price data for an emergency rabies vaccine, but the largest hospital in the same health system, Intermountain Medical Center, has.
Nathan, then 7 years old, received a child’s dose of two drugs to prevent rabies. The bill also included two drug administration fees and a charge for using the emergency room.
Intermountain owns a regional insurer called SelectHealth. It is currently paying the lowest price for those services: $1,284.
In the same emergency room, Regence BlueCross BlueShield pays $3,457.
Ms. Eichelberger’s insurer, Cigna, pays the most: $4,198.
For patients who pay cash, the charge is $3,704. Half of the insurers at Intermountain are paying rates higher than the “cash price” paid by people who either don’t have or aren’t using insurance.
This pattern occurs at other hospitals, sometimes with more drastic consequences for adults, who require a higher dosage.