‘The game’s over’ — Trump administration pushes for more health care price transparency

Employers that pay for their workers’ health care have long bought insurance networks without seeing the prices inside them. New federal transparency rules aim to change that, experts in health benefits purchasing said.

Some large employers already are mining the data to find hospitals that charge far more than their peers with no better outcomes. But the biggest shift may come for smaller employers that have long depended on brokers and consultants to tell them whether they’re getting a good deal.

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS) and with the departments of Labor and the Treasury, on Oct. 5 finalized updates to the Transparency in Coverage (TiC) rules first established during President Donald J. Trump’s first term. The rules require health plans and insurers to publish more reliable pricing data and to give patients personalized cost-sharing information by phone as well as online.

“At the heart of this rule is a simple idea: People should know what their health insurance will cover and what they will need to pay before receiving medical care, not after the bill arrives,” CMS Administrator Mehmet Oz, M.D., MBA, said in a news release.

The same day, four experts discussed what the data mean for employers during a panel at the HHS rollout for the new rules on health care price transparency. Daniel Aronowitz, assistant secretary of Labor and leader of the department’s Employee Benefits Security Administration, moderated. The panelists were James Gelfand, president and CEO of the ERISA Industry Committee (ERIC); Elizabeth Mitchell, president and CEO of the Purchaser Business Group on Health (PBGH); Chris DeCou, Ph.D., director of health benefits at Amazon and a clinical psychologist; and Chris Deacon, J.D., author of “The Great American Healthcare Heist: Why We’re Paying More and Getting Less.”

For most employers, health care is the second-biggest operating expense after wages, Aronowitz said. Employers that sponsor health plans have a fiduciary duty to act in their employees’ best interest, he said, but they can’t do that without knowing the rates.

“Every dollar in excess health care is $1 that can go into wages for American workers,” Aronowitz said. “This is an American worker issue.”

What do the new rules change?

The rules target the machine-readable files plans must post, which are large data files listing the prices plans have negotiated with providers. According to the HHS release, the rules:

• Cut duplicative information.
• Add context about in-network prices.
• Expand out-of-network pricing information.
• Strengthen accountability for accurate data.
• Reporting will move from monthly to quarterly to lower administrative burden.

An HHS fact sheet lists further changes:

• Reporting moves from the plan level to the network level, reducing duplicate files.
• Plans must drop provider-rate combinations that are unlikely based on a provider’s specialty and post a taxonomy file explaining those exclusions.
• A new utilization file will show which providers actually were paid for claims in the past year.
• The claims threshold for reporting out-of-network pricing drops from 20 to 11, and plans must attest that their files are accurate and complete.

The rules take effect 60 days after publication in the Federal Register. Updated in-network and out-of-network files are due five months after publication, new contextual files are due after 11 months, and the phone requirement begins Jan. 1, 2027. Plans will be expected to publish a new Prescription Drug File starting in December 2027.

The rules support Executive Order 14221 on health care pricing. The release cited data showing that prices for the most expensive 25% of health care services have dropped 6.3% per year since transparency requirements first took effect for hospitals and health plans.

For independent physician practices, the rules matter on two fronts. The files show the rates plans negotiate with physicians and other providers, which employers increasingly use to judge value. And practices that offer health benefits to their own staff are employers, too, facing the same question of whether their plans pay fair prices.

Who is using the data now?

ERIC is a national nonprofit organization that represents the largest U.S. employers as sponsors of employee benefit plans, operating under the Employee Retirement Income Security Act (ERISA). Right now, the most sophisticated employers and those with specialized big-data consultants are the main users of the TiC files, Gelfand said. The data are hard to use, and not by accident, because some carriers and third-party administrators (TPAs) have gone out of their way to make them tough to work with, he said.

Still, those employers can compare prices in any market for the first time and shape networks around actual value rather than “ethereal concepts” such as a provider’s reputation, Gelfand said. Outlier providers will face questions about why their prices don’t match their outcomes.

Employers also can compare TiC data with hospital price data to judge whether their TPA is getting a good deal, he said. Gelfand called it a wake-up call when it emerged that carriers might be agreeing to higher rates for self-insured employers, which pay workers’ claims directly, in exchange for lower rates in their fully insured business.

“But ultimately, the TiC data gives us the opportunity to ask one simple question: Is the design of our plan operating in the best interests of our workers and their families? If the answer is no, then we have to change it,” Gelfand said.

What happens when employers follow the money?

Employers need three numbers to manage plan dollars well, Gelfand said:

• The negotiated rate, which the TiC files provide
• The provider’s billed charge
• The amount the TPA actually took out of the employer’s bank account

“There’s a reason why this has been almost impossible to achieve up until now, and that’s because the health care industrial complex absolutely thrives on opacity,” he said. “There are literally tens of billions of dollars at stake.”

The Trump administration opened the door by requiring disclosure of negotiated rates, but it may take another act of Congress to reveal how much vendors take out of employers’ accounts, Gelfand said.

“But once you know how much was supposed to go to the provider, and how much was actually taken out of the account, the game’s over, right? You know exactly how much vendors are paying themselves with your money, and you’re going to find some uncomfortable stuff, right?” he said.

What did employers find in the data?

Employers and employees have asked for pricing information for decades, but the industry was not responsive, Mitchell said. Once the data became available, five PBGH members ran it against their own claims. One member in the Puget Sound area believed it had the absolute best deal because its plan and consultant had told it so.

“Turned out they were paying 30% more for one facility,” Mitchell said about the example.

That employer used the information to negotiate lower rates, she said. Another member, the City and County of Denver, found it was paying twice as much for emergency care at one facility as at others, with no difference in outcomes, which allowed it to change its contracts and where employees received care.

“We learned that one of the most expensive hospitals in California actually had the lowest quality scores,” she said. “That makes a huge difference, not just for the employer but for employees, where they are getting the right care.

“Affordability in the commercial market is at a crisis level,” Mitchell added. “This will give self-insured employers the information they need to reduce costs on behalf of American workers.”

Can transparency lower what workers pay?

Aronowitz said Amazon in 2026 cut the cost of its basic health plan to $5 a week with $5 copays. The plan, now called the essential plan, charges a $5 weekly contribution and a $5 copay for mental health, primary care and other office visits, DeCou said. It came from thinking about coverage the way a consumer would: how much it costs and how much it costs to see the doctor.

For primary care physicians, the design is notable because one of the nation’s largest employers built its basic plan around low-cost office visits.

“Where the transparency data fits in, it allows us to say what is going to be the financially sustainable version of this. How do we appreciate what the costs actually are? Make apples-to-apples comparisons,” DeCou said.

Amazon uses TiC files with other transparency and quality data both when sourcing benefits and on an ongoing basis, aiming for care that is safe, timely, effective, efficient, accessible and patient-centered, DeCou said.

What does it mean to be a fiduciary?

Aronowitz introduced Deacon, a former assistant director of the division of pensions and benefits in the New Jersey Department of Treasury, as a fiduciary expert who held insurers accountable when she led New Jersey’s health plan. A plan fiduciary must act solely in the interest of plan participants, act prudently, pay only reasonable expenses, follow plan documents and prudently select and monitor service providers, Deacon said.

Self-funded employers long have chosen networks based on size, disruption, discounts and administrative costs because they couldn’t see behind them, she said.

“What we are able to do is really move from buying a network as a product to looking behind the network and seeing the prices, you know, in that product,” Deacon said.

With TiC data, an employer can see what its plan would have spent last year with one network, perhaps $30 million, compared with $25 million under another, she said. Without the data, the two might look comparable, and administrative fees could even push the employer toward the more expensive option.

Can small employers use the data, too?

Much of the focus has been on large employers that can hire actuaries, economists and data analysts, Deacon said. But she sees the greatest value elsewhere.

“I think the promise of transparency data and this increasing availability of it is really most valuable to the smaller employer market,” she said.

Small employers may not be able to analyze their own claims, but they can compare regional network prices for a basket of services, such as emergency room care, labor and delivery, and musculoskeletal imaging, and document that process, Deacon said. The bigger change is a shift in power from dependence on consultants, brokers and vendors toward what she called “an informed oversight relationship.”

“They can do evaluations themselves. They can ask smarter questions. They can ask better questions,” Deacon said.

That approach could serve independent physician practices that sponsor health benefits for their own employees.

What should employers do now?

In a closing lightning round, Aronowitz asked each panelist for the one thing every employer should do with TiC data now.

“I would recommend demanding complete and total transparency from all of your vendors,” Gelfand said. “And if they don’t comply, then tell them what the president would say: You’re fired.”

DeCou encouraged employers to bring the data into the employee experience, not just contract negotiations.

Mitchell said PBGH will scale its project with the Peterson Center on Healthcare to more employers, including small and midsize ones.

“The more employers that use this data, the more pressure to bring prices down,” Mitchell said.

Deacon advised employers to match what comes out of their bank account for each claim against the published network price and look into any differences.

“I’m not saying it’s necessarily paid erroneously or wrongly, but it is cause to investigate and look at that exception, understand those variances, and that variance itself can begin to become a component of your evaluation of your network and vendors,” Deacon said.