Counterpoint
Hal Andrews | December 6, 2023Adam and Eve colluded in the first recorded cover-up in human history, and the White House has been implicated in numerous examples over the years: Teapot Dome, Watergate, Iran-Contra, etc. Historically, the reputation of the White House was damaged as much by the cover-up as by the collusion itself. Health plan price transparency offers perhaps the first opportunity for the White House to enhance its reputation from collusion by openly endorsing it.
In June, I suggested that health plan price transparency would require every stakeholder to defend their rate because of what it reveals about the lack of correlation between price and quality. In every market, there are examples of inexplicable rates being paid for average or below-average quality. Adam and Eve were ashamed of and tried to hide their nakedness from the sustainer of their life. Given what health plan price transparency exposes, many payers and providers are well-advised to imitate Adam and Eve and fervently try to cover up what they have done to employers, the lifeblood of every commercial payer and provider.
Here are just a few of many examples:
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Note: Analysis was conducted using health plan price transparency negotiated rates (CMS definition) for UnitedHealthcare. (September 2023 file)
Source: Health Plan Price Transparency and Trilliant Health’s Provider Directory, and analysis of Hospital Readmissions Reduction Program (HRRP) data.
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Note: Analysis was conducted using health plan price transparency negotiated rates (CMS definition) for UnitedHealthcare. (September 2023 file)
Source: Health Plan Price Transparency and Trilliant Health’s Provider Directory, and analysis of Hospital Readmissions Reduction Program (HRRP) data.
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Note: Analysis was conducted using health plan price transparency Health Care Service Corporation negotiated rates (CMS definition) for surgery centers who billed code 45380 >250 times in 2022. (October 2023 file)
Source: Health Plan Price Transparency and Trilliant Health’s Provider Directory, and analysis of Ambulatory Surgical Center Quality Reporting (ASCQR) Program data.
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I will leave it to the reader to contemplate the fact that the BCBS TX in-network ASC provider with the combination of highest price and lowest quality is a subsidiary of UnitedHealth Group. Why should the White House want payers and providers to collude with respect to the revelations from health plan price transparency? The White House, aka the Executive Branch, controls CMS, DOJ and FTC. Through CMS, the White House implemented Transparency in Coverage. Through DOJ and FTC, the White House controls antitrust policy and enforcement, including the 1996 Statements of Antitrust Enforcement in Health Care that the DOJ withdrew in February 2023.1 Ironically, health plan price transparency reveals that the DOJ’s enforcement of antitrust policy for the past 27 years has harmed employers and consumers alike by concealing numerous egregious examples of payers richly reimbursing providers for poor quality care. In defense of payers and providers, the Sherman Act’s threat of a $1M fine and 10 years in Federal prison has been a strong deterrent for most healthcare executives to discuss price. And, in fairness to providers, only a provider who retained a consultant to conduct a DOJ-defined “safety zone” analysis could possibly discover that its reimbursement was the highest in a market. On the other hand, every payer knows – and has known for years – about the extreme reimbursement outliers in every market. Historically, payers and providers have engaged in a routine like the Looney Tunes characters Ralph Wolf and Sam Sheepdog, clocking in at the same time every day, trying to beat the hell out of each other all day long, and then shaking hands when clocking out at the end of the day. With health plan price transparency, employers will soon realize that payers and providers are like two other cartoon characters:
In contrast to the Sherman Act, CMS’s Transparency in Coverage initiative is designed to promote price transparency and enable price discovery for any healthcare service in any market. Having through the DOJ implemented and enforced a regulatory framework that enshrined price opacity for decades, the White House can make amends to the American public by encouraging payers and providers to use CMS’s Transparency in Coverage initiative to collude to reduce the cost of healthcare, especially premium reimbursements for poor clinical quality. |
