"Lowering Health Care Costs for All Americans: Examining Policies to Increase Health Care Transparency."
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House Energy and Commerce Subcommittee on Health U.S. House of Representatives
Follow its sittingsJune 22nd, 2025.
Without objection, so ordered.
Diana DeGette
Thanks. Now, so this is just all to the point. We saw this coming. We warned of it. We implored the majority not to go forward with this disastrous policy.
And the results are clear. The implementation of the Big Bad Bill contradicts how this majority attempted to sell it to the American people, and sick people, the ones I just mentioned, are going to be and more are going to be kicked off of care as a result. So just remember though, these paperwork requirements were never intended to make people healthier. What happened was these these cuts to Medicaid were made to give tax handouts to the wealthiest Americans and corporations. So they had to find the offset by cutting Medicaid, which cares for healthcare for poor and working Americans.
And this really ignores the reality that healthcare should not be a reward for working, but a prerequisite to being stable and productive and healthy so you can work. Now, so this year, since the majority passed through the Big Bad Bill and didn't work with us to expand the enhanced ACA subsidies, more Americans are losing insurance and they're seeing their costs go up. 80% of returning marketplace enrollees say they're seeing higher costs this year. 51% say these costs are, quote, a lot higher. And critically, as of March, 37% of marketplace enrollees were cutting back on necessities like food to afford health insurance.
And I talked to some of the insurance companies, they said that enrollment is way, way off this year. And so, Mr. Chairman, I agree with you, we need to pass legislation relating to transparency, but we need to sit down and work in a bipartisan way about how we can get affordable healthcare for all Americans, not just a few. I yield back.
H. Griffith
Gentlelady yields back. Now recognize the chairman of the full committee, Chairman Guthrie, for his five minutes for an opening statement.
Brett Guthrie
Thank you, Chairman Griffith, thank you for holding this hearing today and thanks for all of our witnesses being here. And today we're the hearing will examine several healthcare transparency policies and build on this committee's many years of bipartisan work to bring greater transparency to the sector, and we're continuing the committee's work this year to tackle healthcare affordability for the American people, again, committee's work this year to tackle it. We'll also consider legislation to build on the Trump administration's historic price transparency regulations by codifying a framework for hospital and insurer price transparency.
These policies will help provide actionable pricing information to patients and employers empowering them with the tools they need to get high quality care at the best price. This will ultimately bolster competition and improve American healthcare and affordability for American people. Further today's hearing will include new newer policies taking action on President Trump's great healthcare plan. We'll consider how to address concerns we've heard from patients and from providers about the burdens created by prior authorization and for improving transparency is transparency of insurers overhead costs. By providing this information to the American people in a consumer friendly way these policies can help consumers better shop for the healthcare plans and will increase competition in the marketplace.
We'll also consider a discussion draft that brings pricing information directly to patients when they are seeking care by requiring hospitals to publicly post on their walls the discounted cash price of shoppable services enabling consumers to make informed choices about where to lower where to find lower cost care. As I noted this committee has a long track record of working in a bipartisan way to bring greater transparency to the healthcare system. Shining a light on the cost of healthcare while equipping American patients and employers with the tools they need to lower healthcare costs. It is it was in this committee over three years ago when Congress had our first hearing working on price transparency legislation. Today's hearing will continue our leadership on this critical work to empower patients by improving healthcare transparency.
I thank the witnesses for being here and I yield back.
Speaker 6
Chairman yields back now recognize the ranking member of the full committee Mr. Pallone for his five minutes for an opening statement.
Frank Pallone
Thank you Mr. Chairman. Almost a year after passage of the Republicans' big ugly bill healthcare prices are skyrocketing hospitals and clinics are closing and healthcare workers are being laid off. Over 20 million Americans saw their healthcare premiums skyrocket at the beginning of this year because the Republicans' failure to extend the premium tax credits. And Republicans' big ugly bill cut Americans' healthcare by more than a trillion dollars and families across the country are facing the brunt of this healthcare crisis. Now doubling down on this chaos just last week the Trump administration issued a rule that will intentionally result in more people losing access to healthcare when they need it most.
And to make make no mistake this is by design and what congressional Republicans voted for. People with devastating illnesses including those with cancer Parkinson's and HIV will be forced to prove over and over again that they're in fact too sick to work in order to maintain their healthcare. And undoubtedly for many this will be a burdensome and complex reporting scheme that is impossible to navigate when they need the care most and for states a costly and inefficient mandate that will only result in fewer people having access to care. In fact according to the American Cancer Society these new restrictions are and I quote "unreasonably harsh and will be life threatening for cancer patients." And it could even get worse as Republicans are considering another budget reconciliation bill that would strip healthcare away from even more Americans than their big ugly bill.
Fortunately today we are considering bills that will actually improve Americans' healthcare by bringing more transparency to the healthcare system. And I want to thank the chair for recognizing the importance of this transparency effort. I heard Chairman Guthrie talk about the link between transparency and competition and I agree they are linked but it may be necessary also to create more competition even with increased transparency because if you know as we know the monopolization with regard to hospitals and so many healthcare interests exists and is getting worse as well. So let's not forget that in order to create in order to use transparency more effectively as many of these bills will we have to also look at the competitive environment to make sure it truly is competitive.
We'll also discuss a bill that will codify existing requirements for both hospitals and insurers to make healthcare pricing more transparent by requiring price information to be displayed publicly and in a standardized format. And lack of transparency into healthcare prices makes it difficult for consumers to make informed decisions, and it also makes it challenging for employers to negotiate more competitive prices. This bill represents work that this committee has been undertaking for several Congresses and that I worked on with the previous chair of this committee, Chair Rogers, and I look forward to our discussion on this bill today. We'll also discuss a bill that will bring more transparency to hospital ownership by requiring hospitals and physician practices to disclose ownership data, including for entities owned by private equity firms and venture capital firms. And I'm very concerned that private equity firms investing in healthcare are driving up healthcare costs for consumers while also reducing the quality of care for patients.
Recent studies have shown consumers receiving care at hospitals acquired by private equity saw an increase in their out-of-pocket costs. Billions of dollars are being invested into the healthcare system by private equity firms, many with unclear ownership structures, and our healthcare infrastructure is becoming increasingly unstable because of it. According to the Private Equity Stakeholder Project, at least 20% of healthcare companies that filed for bankruptcy in 2023 were owned by private equity firms. Policy makers and regulators need better visibility into these ownership structures, and this legislation gives us that visibility. We'll also discuss bills to increase transparency in the Medicare Advantage program to improve care.
More seniors with Medicare are now enrolled in MA plans than traditional Medicare, but there's limited data to conduct oversight and ensure that the program is providing good value. And I'm also concerned by reports of some MA plans' misuse of prior authorization requirements and the harmful impact these practices have on seniors' accessing timely care. And we'll also consider a bill that would increase transparency and accountability of broker compensation in the MA market. While agents and brokers can play an important role in helping seniors enroll in Medicare, they deserve access to unbiased and accurate information about coverage options that best serve their individual needs. And it's critical that we increase transparency and accountability of broker compensation in order to protect Medicare beneficiaries.
So I look forward to the discussion today. We can't have a comprehensive conversation about addressing healthcare affordability without acknowledging the ongoing harm of the Republicans' Big Ugly Bill, and I also hope that their efforts to try to improve or expand, I guess I should say, the Big Ugly Bill, hopefully they come to naught for the sake of our healthcare system. And with that, Mr. Chairman, I yield back.
H. Griffith
Chairman yields back. We now conclude with member opening statements. The chair would like to remind members that pursuant to committee rules, all members' opening statements will be made a part of the record. We want to thank our witnesses for taking their time to testify before our subcommittee today. Although it is not the practice of this subcommittee to swear in witnesses, I would remind our witnesses that knowingly and willfully making material false statements to the legislative branch is against the law under Title 18, Section 1001 of the United States Code.
You will have the opportunity to give an opening statement followed by questions from members. Our witnesses today are Ms. Carol Keese, who is the chief of staff at Turquoise Health. We also have Mr. Shawn Gremminger, who is president and chief executive officer for National Alliance of Healthcare Purchaser Coalitions. Mr. Benedict Ippolito is senior fellow at the American Enterprise Institute. Dr. Christopher Whaley is the associate director of the Center for Advanced Health Policy through Research and associate professor of health services, policy, and practice at Brown University School of Public Health, and Ms. Sophia Tripoli, who is the senior director of health policy at Families USA.
Per committee custom, each witness will have the opportunity for five minutes of opening statement, followed by a round of questions from the members. The light on the timer in front of you will turn from green to yellow when you have one minute left. I now recognize Ms. Carol Skeenes for her five minutes to give an opening statement. Welcome.
Carol Skeenes
Chairman Griffith and Guthrie and distinguished members of the subcommittee, thank you for the opportunity to be a witness today. My name is Carol Skeenes and I'm chief of staff at Turquoise, a healthcare pricing and transparency platform that partners with more than 300 hospitals, payers, employers, life sciences organizations and researchers to make price transparency data useful, reliable and actionable. I want to start with a simple observation. The transparency framework this subcommittee helped build is making an impact. When hospitals were first required to post machine-readable files in 2021, initial observations were that the data would be too complex or incomplete to use.
When payers followed in 2022, the files were so large that many doubted whether anyone could even parse them. We've come a long way since then, between iterative final rules and improved file quality, and at Turquoise, we see industry stakeholders, regulators and consumers deriving value from price transparency data every day. The transparency rules are creating competitive pressure and we see it in the market. Payers and providers are negotiating rates with more clarity and efficiency. Self-insured employers have better ownership of their fiduciary responsibilities by using price transparency data to find savings opportunities and shop smarter within their existing networks.
But MRF data alone does not answer the question patients and employers actually ask: how much is this going to cost me? Answering that question requires solving four problems. First, bundling individual billing codes into complete open-license procedure packages. Second, integrating benefits data so cost calculators reflect what a specific patient actually owes. Third, improving data quality because today there are known yet solvable gaps in the MRF data.
And lastly, targeting administrative waste in the healthcare transaction in areas besides pricing data. These include prior authorization, simplified modular contracts and streamlined claims processing. Turquoise has built more than 400 open-license standard service packages specifically to bridge that gap, and in February, we partnered with New York City to launch the first consumer price comparison tool in the country powered by MRF data. It reached 83,000 users in days. A colonoscopy in New York City ranges from $500 to $9,000 depending on a number of factors, including which door a patient chooses to walk through, and for the first time, patients can see the range before they walk through any specific door.
Scaling that nationally requires Congress to act. We urge this subcommittee to pass legislation that aligns with current final rules. Bills such as the Lower Costs, More Transparency Act and the Patients Deserve Price Tags Act have the opportunity to codify the existing MRF requirements in statute, extend them to non-hospital providers, mandate drug price reporting, self-pay and stop-loss rate disclosure and establish uniform schema standards.
We've entered a new before-and-after era of consumer activation and engagement with price transparency. Before, when the original final rules and laws were passed, our best bet was patient estimate tools and patient education. Now, AI has given us both an accelerant and a new era because it lowers the barrier to entry for consumers in an incredibly meaningful way. The data is ready, and innovators like the team here at Turquoise are ready. So now more than ever, we're at a critical moment where AI-enabled technology can give patients and employers the chance to utilize new tools for understanding the cost of care.
Our hope is that today we can discuss the legislative framework necessary to keep that momentum going. Thank you again for the opportunity to speak with you. I welcome your questions.
H. Griffith
Thank you very much. I now recognize Mr. Shawn Gremminger for his five minutes for an opening statement.
Shawn Gremminger
Thank you, Mr. Chairman, Ranking Member DeGette, and members of the subcommittee. Thank you for the opportunity to speak on behalf of America's employers and healthcare purchasers. I'm Shawn Gremminger, President and CEO of the National Alliance of Healthcare Purchaser Coalitions. We're a national trade association representing nearly more than 400 regional employer purchaser coalitions around the country. Our member coalitions represent employers of every size, from Fortune 500 companies to small businesses to public entities, providing healthcare coverage to roughly 90 million Americans.
These are the employers who write the checks. And I'm here to tell you what they're getting in return is not acceptable. The problem is simple, even if the solution is hard. Healthcare costs continue to outpace wages and inflation. A family health plan now approaches $30,000 per year, and healthcare inflation is rising at the fastest pace in at least 15 years.
Every dollar consumed by rising healthcare costs is a dollar not going to wages, retirement, or business growth. What makes this especially maddening is that higher prices don't mean better care. In my written comments, I highlight the lack of connection between cost and quality by hospitals in Virginia and Colorado. In the Commonwealth, my home state, the highest-priced hospital with more than 200 beds has negotiated rates at 327% of Medicare. It has a two-star quality rating by CMS.
Just 50 miles away, the lowest-priced hospital in the state with more than 200 beds has rates less than 200% of Medicare and boasts a five-star quality rating. Employers are often paying more and getting less. And as we know, and as has been discussed already, the system is deliberately opaque. Five years after the federal price transparency rules took effect, less than half of hospitals are fully compliant, though this stats depend on who you ask. When the data does exist, it's often too inconsistent and poorly standardized, and then it takes an army of data engineers just to make it usable.
Though I agree with Ms. Skeens that the transparency rules have made meaningful improvements over the previous regime. But here's what I find most troubling: many employers can't even access their own claims data. In our 2025 survey of more than 300 purchasers, 42% said their vendors refuse to provide complete data access. More than half of smaller employers said they simply can't get it. Employers are all paying the claims.
They're bearing the financial risk, and someone else is deciding whether or not they get to see their bill. When employers do have access to their claims, the results speak for themselves. They're far more likely to implement direct contracting, centers of excellence, site-of-care programs that reduce costs and improve outcomes. Data access isn't just a compliance issue; it drives real, measurable savings. So what do we need from Congress?
Among the bills the committee has before it, I want to focus on the Patients Deserve Price Tags Act, particularly Section 7, which establishes once and for all that plan sponsors have a right to their own claims and encounter data. This should not be controversial. Employers fund these plans. They have fiduciary obligations to their workers. They need this information to do their jobs.
The legislation also codifies and strengthens the hospital and price transparency rules, requires disclosures of how prices are actually calculated, and creates meaningful enforcement mechanisms. It's the most comprehensive transparency bill before this body. I should note that we also support provisions from the CHECK Act, the Lower Costs, More Transparency Act, and others, but none go far enough without the employer access data provisions in Section 7. I also want to be clear about something: transparency alone will not solve this problem. In markets dominated by one, two, or three health systems, employers may gain visibility into prices but still have no leverage to negotiate.
Transparency is necessary, but it is not sufficient. This committee should also pursue site-neutral payment policies, restrictions on facility fees, and prohibitions on anti-competitive contracting practices that lock employers into overpriced networks. And in the most consolidated markets, policymakers should seriously consider reference-based pricing benchmarks tied to Medicare. States as diverse as Indiana, Vermont, Montana, and Washington have already gone in this direction. These are not radical policies.
They're rational responses to failed markets. Finally, I want to leave you with this: a poll conducted just last month by the United States of Care found that more than seven in 10 Americans believe healthcare costs are unaffordable, and nearly half have faced financial pressure from medical bills in the past two years. 69% of people believe Congress should act, including majorities of both Democrats and Republicans. The public's frustration matches what employers feel every day. The diagnosis is not in dispute.
What we need now is the will to act. If we do not give employers the tools to bring costs under control, the commercial market will buckle, and what replaces it will almost certainly be worse for American workers and their families. The moment for action is now. Thank you very much.
Speaker 10
Gentleman yields back. Now recognize Dr. Benedict Ippolito for his five-minute opening statement.
Benedict Ippolito
Thanks very much, Chairman Griffith and Ranking Member DeGette, members of the committee. My name is Benedict Ippolito. I'm an economist at the American Enterprise Institute. I'm also an incoming commissioner at MedPAC, and I believe that obliges me to say that these are my views and of course not theirs. Many, not all, but many of the challenges that healthcare markets face stem from, directly or indirectly, from a lack of transparency.
Either you have market actors who have to make decisions without all the relevant information in front of them, or you have policymakers like yourselves who are tasked with regulating or overseeing markets, yet you don't have all the relevant information to do so. And so today, I think you're considering several bills that illustrate the broad potential value of transparency. There's many of them, so I'm just going to focus on a couple that I think are notable. I'll start by saying, first, one of the most important ways that individuals influence healthcare markets is by the way they choose their insurance plan. When they do that, they make these tradeoffs between premiums and various measures of generosity on those plans: how broad is the network, how low is the cost-sharing, which hospitals are in and which hospitals are out.
Alright, when we are in a well-functioning market, those decisions reflect their preferences and they direct insurers how to design their markets and they influence hospitals and other market actors. If they are making those decisions without relevant information, there's no reason to think that the outcomes we observe actually reflect their preferences. So I really like the provision to start publishing greater information about prior authorization rates, denial rates, things of that nature. That is clearly something that consumers value. We see it in surveys.
I am sure you hear about it in your offices. It's also something that's opaque and it varies a lot across insurers. And so what you have are people or their employers picking between plans where there's big variation in this measure and yet they can't readily observe it.
So that strikes me as a very good idea. Um, second, I appreciate the proposal to increase reporting of ownership and merger information. This has been a, a sort of consistent frustration. As healthcare markets have evolved, we have seen a greater share of consolidation come in the form of serial acquisitions that are too small to require reporting to antitrust agencies or other regulators. That means that we've got a lot of sort of stealth consolidation that occurs particularly in markets like the physician market.
Um, this is a tactic that you often see private equity firms employ. It's very difficult to tell policymakers what you should do about this if we don't really have a good handle on what that consolidation looks like, um, and what the effects of it are. And so efforts to increase reporting of ownership, transactions, and update that every year seem like a very good idea to me. Um, I'll conclude with one, I guess maybe a little bit more nuanced point. Um, the committee is considering increasing transparency into broker fees in the MA program and, and considering restrictions on how large those fees can be.
I just want to flag that that does come with some complications. Trying to regulate financial transactions between private entities can be fraught. The bill includes a laundry list of fees that are included and tried to be captured in this, in this, um, limit. Uh, you know, it's transactions, payments, gifts, reimbursements for costs, all sorts of things that illustrates how hard it is to sort of encompass all potential transactions. I just highlight that it's possible that includes everything.
It's equally possible that we're going to find creative workarounds and that limit isn't really going to bind. I also want to say that I think that provision, I don't want to tell anyone what, what they think, but it strikes me that that really reflects a question about Medicare Advantage and how those payments work in the program. Um, if you think those payments are too high or you think those payments are otherwise inappropriate in some form, that seems to me to be the underlying issue. That's what's giving these plans a big incentive to pay large fees to brokers to encourage enrollment in those plans. And so it strikes me that the more direct thing to do is address the Medicare Advantage program directly.
That will come with important tradeoffs. You will hear about those tradeoffs from your constituents, but it strikes me that that's worth, uh, confronting directly rather than trying to do it through sort of broker fee restrictions and things like that. Um, that said, I think this strikes me as a constructive effort to improve transparency in the healthcare market. It reflects the broad value that transparency could have for consumers and for policymakers. And so I thank you for having me and I look forward to questions.
Speaker 12
Chairman yields back. Now recognize Dr. Christopher Whaley for his five-minute opening statement.
Christopher Whaley
Thank you, Chairman Guthrie and Griffin, Ranking Members Pallone and DeGette, and members of the subcommittee. Thank you for the opportunity to testify today. My name is Christopher Whaley. I'm a health economist and an associate professor at the Brown University School of Public Health. My research focuses on healthcare costs, price transparency, and the impacts of market consolidation on the employer-sponsored and Medicare markets.
Today, I want to make three core points. First, healthcare prices are high and I think broken. Second, transparency in both price and organizational structure is a necessary foundation to improve healthcare affordability. And finally, the bills before you this morning would take steps I believe to directly address the gaps that matter the most. The United States leads the world in healthcare spending.
High spending is driven by price, not sicker patients or better care. For a family of four with employer-sponsored insurance coverage, premiums are projected to exceed $37,000 per year. My work shows that private-insured hospital prices average 254% of what Medicare pays nationally, but in some states like West Virginia, Florida, and Georgia, prices exceed 300% of what Medicare pays.
Critically, these high prices are not linked to better quality. Several studies show that higher-priced hospitals and providers do not provide better quality of care. Instead, a major driver of high prices is consolidation. Over the last two decades, roughly 2,000 hospital mergers have produced massive health system conglomerates, increasing prices with no quality improvement. Beyond hospitals, over half of US physicians are now employed by a hospital or healthcare system, and private equity firms have deployed nearly a trillion dollars into healthcare markets over the last decade.
These new ownership models remain deeply opaque to patients, employers, and regulators alike. To improve the affordability of the US healthcare system, I think it's critical for Congress and policymakers to improve both price and organizational transparency. And I want to make one thing clear: transparency by itself is not a cure-all for the US healthcare system. Patient-facing price tools have largely not changed shopping behavior, and healthcare is far too complex for that alone. But I think transparency is foundational for everyone else who needs to act, whether it's employers negotiating on behalf of their workforce, researchers studying healthcare market dynamics such as myself, states designing price reforms, and federal regulators overseeing the Medicare program.
I think transparency is already working. Transparency data has allowed researchers like myself to document several things, including private equity-affiliated physician-charged prices that are 6 to 10% higher than prices that independent doctors charge. In addition, Medicare Advantage plans pay less than half what commercial plans pay, negotiated by the very same insurer. And finally, prices at ambulatory surgical centers are approximately 36% lower than hospitals in the same county, providing what I think is rigorous evidence for site-neutral payment reforms. Transparency data has also provided the evidence base for Oregon's hospital payment limits, which saved over $100 million in two years with no harm to quality or the workforce.
Purchasers like the 32BJ Health Fund have used their own claims data to generate $100 million in annual savings, money that went back directly to the workers in the largest pay increase in their union's history. To further these innovations and to fully understand evolving US healthcare ecosystem, I think it is critical for Congress to continue their existing efforts. As I discuss in more detail in my written testimony, the bills this subcommittee is considering have the potential to address some of the most consequential gaps in our current transparency framework. First, the Lower Cost, More Transparency Act and the Patients Deserve Price Truth Act would strengthen price disclosure and ensure that employers can actually access their own claims data, data that third-party administrators currently withhold despite clear fiduciary obligations that employers and purchasers have. I want to emphasize the importance of ensuring that employers have access to their own claims data, which is critical for them to fulfill their fiduciary obligations.
The CHECK Act would extend those protections to itemized billing and limit excuses about gag clauses and other provisions for not sharing data, and likewise, the ownership transparency data would create the national database we need to track organizational changes. And finally, the Medicare Advantage bills would bring long-overdue accountability to broker compensation and the MA encounter data. Both areas where my colleagues and I have documented serious problems. My colleagues found in a recent study that over $10 billion in payments to MA brokers from MA plans per year, raising what I think are concerns that the advice that Medicare Advantage beneficiaries use to select their plans might be conflicted by broker payments. In conclusion, Congress can help bring transparency into the increasingly complex US healthcare system, which I think will benefit patients, employers, and policymakers.
Thank you, and I look forward to questions.
Speaker 14
Gentleman yields back, and I will now recognize Ms. Sophia Tripoli for her five minutes' testimony.
Sophia Tripoli
Thank you. Chairman Guthrie and Griffith, Ranking Members Pallone and DeGette, and members of the committee, thank you for the opportunity to testify.
My name is Sophia Tripoli and I lead health policy at Families USA, the long-time voice for healthcare consumers. I want to start with a near universal truth. Healthcare affordability is the top issue for voters across the country, and 91% of Americans, including conservative Republicans and progressive Democrats, want Congress to lower their healthcare costs. A big part of why costs are out of control is because the system has been operating in the shadows, and the institutions profiting as a result have fought hard to keep it that way. For decades, hospitals, health plans, and drug companies have been allowed to quietly take over entire sectors of the American healthcare system, consolidating markets to drive up prices, aggressively billing patients, denying access to care, and hiding all of it behind layers of complexity designed to keep patients and lawmakers in the dark while maximizing their profits.
It may be tempting to chalk this up to just a broken system or to scapegoat vulnerable populations as the reason why healthcare costs too much, but that is a false representation of what's actually occurring. The US healthcare system is working very well, but just not for us. While families struggle to afford the care they need, corporate consolidation in healthcare is accelerating. Insurers grow larger and more dominant, hospital systems consolidate into powerful regional monopolies that charge any price they want, private equity has moved aggressively into care delivery, and drug companies still block lower-cost generic drugs from entering the market while drastically increasing drug prices almost entirely unchecked. Consider the example of CommonSpirit Health, the nation's largest non-profit health system which owns 158 hospitals and more than 2,000 healthcare centers across 21 states.
They charge more than three times what Medicare pays for the exact same hospital services, generating $17 million in net income per hospital per year. Or take the Medicare Advantage program, where 33 million of our nation's seniors get their care. Just five health insurance giants now control 80% of the market, where insurers abuse the billing system by making enrollees appear sicker than they are to generate higher payments from Medicare. This upcoding costs the Medicare program $40 billion each year. Or take that nearly 60% of doctors say their patients were delayed needed care because of prior authorization.
These are symptoms of a sickness spreading: the corporate capture of our healthcare system, all facilitated by a complete lack of transparency. Nowhere is this more alarming than in the case of hospitals. Over the last 25 years, unchecked hospital consolidation has driven up prices by over 220%, costing hardworking Americans nearly a trillion dollars in lost wages since 2012. Private equity has compounded the damage, becoming one of the largest investors in healthcare delivery over the past decade. PE firms increasingly buy up small healthcare providers in order to skirt antitrust oversight and enforcement, all while driving up prices and worsening access and outcomes for patients.
For too long, healthcare corporations have been allowed to set prices in secret, hide their ownership structures behind layers of shell entities, and operate with almost no accountability. American families are not bargaining chips to be traded in the backroom deals between corporate giants and their lobbyists, and this Congress has the power and responsibility to end that game. This is why this hearing is so important. Our healthcare system is in desperate need of transparency of prices, ownership status, care denials, coding abuses, and the bad behavior of brokers and agents. Transparency is essential to any meaningful effort to hold corporate health systems accountable.
Just ask Jessica, an Arizona resident who waited months for a cancer screening she can't get a price on. Jessica needed a procedure to investigate her GI bleeding. With her history of cancer, every delay matters. Jessica lives paycheck to paycheck and cannot afford a big medical bill, so she spent weeks calling surgery centers, tracking down her doctors, calling her insurers to find out how much the procedure would cost her, all while her bleeding worsened. No one she talked to could give her an answer.
Jessica told us, "I still don't have a price, so I have to keep waiting."
These are practical, bipartisan solutions that are long overdue. As I wrap, I want to make one more point. As critical as transparency is, and we desperately need it, it will not be nearly enough to lower healthcare costs. It is an essential step, but not sufficient to solve the American affordability crisis. We implore you to ensure greater transparency in the system and to advance bold solutions that will fundamentally lower prices and bring down the cost of care.
Thank you, and I look forward to your questions.
Speaker 14
Thank you. Now we'll begin questioning, and I'd ask that members not begin a new question to our witnesses as their five minutes expire, but encourage members to submit written questions for the record. And I now recognize myself for five minutes. Dr. Whaley, your testimony notes that commercial hospital prices now average roughly 254% of Medicare nationally, with some states exceeding 300% of Medicare. So can you explain what's driving up those extreme price differences between markets and whether consolidation is a primary factor?
Christopher Whaley
Sure. So nationally, hospital prices average 250% of Medicare, and we see wide variation in what hospitals charge patients with commercial insurance. And what's really driving those prices is not due to difference in quality, not due to differences in, say, cost shifting, but a key driver is consolidation, where we've seen tremendous mergers and acquisitions within the hospital industry.
Speaker 14
Exactly. And I'd like to enter into the record an article from the Associated Press dated June 9th, 2026, highlighting the Trump administration's recent actions to ensure hospitals are complying with hospital price transparency rules and making available information about the prices they're charging to consumers. So without objection, so ordered. You know, it talks about they have warned more than 500 hospitals that are failing to provide the public with basic pricing information. So I'll continue with you, Dr. Whaley.
Your testimony highlights significant payment differences between hospital outpatient departments and ambulatory surgical centers for the exact same services. And as somebody who supports preserving access to independent community-based care, you know, my worry is that current payment incentives are pushing more care into higher-cost hospital-owned settings. Do you believe greater transparency around site-of-service pricing could help slow consolidation and encourage lower-cost community-based care options, sir?
Christopher Whaley
I do. I certainly think that transparency around site of care, as well as site-neutral payment policies, can help narrow those gaps.
Speaker 14
Great. Dr. Ippolito, in your testimony, you discuss the importance of ownership transparency and how complex ownership structures can obscure consolidation trends. We don't know who owns who. So it's difficult for policymakers and regulators to even understand who actually owns healthcare delivery assets in a local market. So would better ownership reporting from Congress and antitrust regulators identify anti-competitive behavior earlier before communities lose independent providers?
Speaker 14
Well, that's good. I got another question for you, sir. I think most Americans would be shocked to learn how little visibility patients have into claim denial rates and utilization management practices before enrolling in a plan. You mentioned that in your testimony. It's unbelievable when the only way you know it is when you get denied or when you're required to get a prior approval.
Do you believe consumers would make different plan choices and even private entities and health sponsors if denial rates and prior authorization practices were presented clearly and uniformly during the enrollment phase?
Benedict Ippolito
They certainly might. There's a tradeoff.
You tradeoff lower premiums for more, you know, oversight of services that you you you get. Let's let consumers choose what they prefer. I think that's the right way to do it. Transparency is perfect for that.
Speaker 14
I'm all about that, exactly. Because if you work in the healthcare industry, even as a pharmacist, and you're looking at these claims that are denied or these prescriptions, it's unbelievable what the process you have to go through. You have to have a dedicated person to do all these things. But if the plan sponsor knew ahead of time that this was going to cost their company money, I think they'd make a different choice. And it also put market pressure on insurers to change their behavior, don't you think?
Benedict Ippolito
Yeah, the whole point is that the insurer should be offering what customers actually want. This is an important amenity that they should be evaluating that that decision on. Yeah.
Speaker 14
Yeah. You know, I think Americans increasingly feel like healthcare pricing operates in a black box where nobody knows the price, nobody understands the billing, and patients, they don't have any leverage. Ms. Stripling, you said it. You've got patients who don't they can't get surgery because they don't know how much it's going to cost. If Congress could enact just one transparency reform this year that would most directly lower healthcare costs for patients and employers, what would it be quickly, Ms. Skeens?
Dr. Ippolito?
Dr. Whaley?
I think the Patients Desire Price Tax Act.
Ms. Stripling?
Agree, Patients Desire Price Tax Act.
Diana DeGette
Okay. Well, with that, I yield back. And now I recognize the ranking member, Representative DeGette, for her five minutes.
Thank you, Madam Chair. Well, I think it's great to hear all of our witnesses here today saying that addressing transparency and consolidation are really important towards beginning to understand the high prices of healthcare. And I was just recently at a conference with Dr. Ippolito where he explained in greater depth about his his views on this. And and there was a bipartisan attendance at this conference, and there was a lot of bipartisan agreement. So that was great.
But what I want to talk about is how transparency and also addressing consolidation could be first steps, but they're not the solution to the problem of high healthcare costs. So, Dr. Whaley, I I want to start with you with additional transparency. I'm going to give you an example. Do you think people would shop for MRIs in the same way they shop for cars? There's transparency, the MRI over here costs this and costs that over there.
Christopher Whaley
As currently constructed, patients would probably have a hard time shopping for MRIs the same way they do as a car.
Christopher Whaley
It it would help somewhat, but it wouldn't move us all the way there.
And why not?
Christopher Whaley
One one of the things that my research has shown is that when patients get even something we think is simple, like an MRI, it's not just their choice. It's the choice of the physician referring them. And if your say physician works for a hospital system or a private equity company, then they have incentives to refer you to higher priced provider despite what the patient might want.
Diana DeGette
Right. So so just because we have transparency doesn't necessarily mean the patient is going to get the cheapest MRI or, by the way, that the cost savings will inure to the patient.
Exactly.
Diana DeGette
So, who would really use the information that we would get from new transparency requirements?
Christopher Whaley
I think it's important for employers, such as the ones that Mr. Greminger represents, when they're designing networks, even upstream of the patients, to ensure that they have access to efficient providers who have lower costs or negotiate better prices. I think it's also very important for regulators, researchers such as myself, to use this type of data to understand the impacts of consolidation and design policy.
Diana DeGette
So it's really a good data point for everybody, but it doesn't necessarily mean it's going to solve the pricing issue.
Speaker 22
I think if it's used in ways to inform benefit design and to design networks and audit the plans that, or the prices that insurers negotiate on behalf of employers, it can certainly help.
Sophia Tripoli
Okay. So, Mr. Triplett, do you think that transparency in and of itself would bring prices down for the healthcare consumers?
I think I agree with Dr. Whaley that price transparency is absolutely essential in terms of unveiling how high and variable prices are so that we can target where there's low-value care and high-value care occurring in the healthcare system. There might be some cases where consumers can shop in certain circumstances and actually find a lower-cost service, but for the reasons that Dr. Whaley outlined, I agree it is most useful for employers to negotiate a better deal for workers and for themselves, as well as for researchers to help continue to study the markets.
So what would the next steps be if Congress were to enact transparency legislation?
I mean, I think once we, first of all, please enact the transparency legislation, it's desperately needed, as a number of bills on discussion for today are also needed. And then we'd have to have a real serious conversation of how do we directly intervene more directly on prices, site-neutral payments, addressing the anti-competitive marketing practices, contracting practices, and even, I would say at this point, some sort of intervention on the growth of hospital prices in particular will more directly bring down prices and lower healthcare costs for consumers.
Diana DeGette
Right. So just, what I'm trying to get at is just the transparency, it helps open it up and see better what's happening, but it doesn't necessarily in and of itself bring down prices.
Correct.
Diana DeGette
Okay. So, I look forward, Madam Chair, to working with you and all of our colleagues because I do think this first step is something that we can do, but we need to be clear we need to go further. And I yield back.
Speaker 21
Thank you, Ranking Member. Yields back, and I now recognize the Chairman of the full committee, Representative Guthrie, for his five minutes.
Brett Guthrie
Thank you. To Mr. Greminger, the price transparency rules that we have now been in effect for several years now, and we've seen updates made over time to improve the usability of this data for consumers and employers. Can you give us an example of how employers in your organization have leveraged these tools to lower costs for employees, and how would codifying price transparency framework strengthen these requirements?
Shawn Gremminger
Thank you for the question, Mr. Chairman. So, we have, I'd point to just a couple of quick things. First, the Purchaser Business Group on Health, one of our members, did a data demonstration project where they married claims data that employers have access to with the price transparency data as provided through Turquoise, and found that they were able to significantly better understand what they were paying, understand what plan designs would make a difference in terms of their ability to lower costs. What we've seen in the research that we've done in terms of researching with our employers, employers that have better access to data, both through the public, publicly available price transparency data, transparency in coverage rule, etc., and their own claims data, is they're more likely to engage in more innovative plan designs, including tiered networks, where you would say we're going to try to drive people to lower-cost, higher-quality settings, narrow networks where we're going to say we're going to exclude high-cost or overpriced places, working with centers of excellence. Codifying these rules, I think, will mean that providers will be more likely, first of all, to comply, we've seen not full compliance, but also more likely to lean in on this as a real reality of the future.
Brett Guthrie
Thanks. You know, and the things that we do here, Congress is trying to be, we want to be, make it for the consumer, for the patient to be friendly for them. And so there was a particular provision where rebates go to the customer. That's right, rebates go to the customer because we want the benefit to go to the consumer. Well, there was an insurance business that we had before us a few months back that created a group purchasing organization that was the customer.
And so if you're going to buy their insurance, you have to join their group purchasing organization. So guess where the rebate went? To the group purchasing organization. And so what it seems to me is every time we try to really tackle it so the American people benefit, it just seems to pop up somewhere else and the coverage is somewhere else. And so that's what we're trying to get is make it transparent so people can make informed decisions.
And I like what my friend from Colorado talked about with somebody out shopping for MRIs. You know, most people get their health insurance through their employer. So if every individual went out and shopped like that, that would be very, very beneficial and want to give them the information to be able to do that. But if employers shopped like that, it would really make a big difference when our major, major employers who have lots of covered lives can, and when you talk to them, it's what's frustrating. You'll talk to CEOs of the, you know, Fortune 50 companies.
As a matter of fact, I think even Jamie Dimon, who is a financial person, had the most sophisticated financial group around him, tried to get a handle on the information around his their employees' insurance and finally gave up because he said we can't get to this, too opaque and not clear. And I think it's that way for a reason. Then you have group purchasing organizations show up in Switzerland. That's where the money's going. That's what happened.
And so what do your employees need? We know that there are groups that buy pharmaceuticals at a discounted price and sell full price to employer plans. And so what do your employers need to say, we really need to sit down and, I talked to somebody in the automotive industry, my family's in the automotive business. I said, if we had a 700 percent markup on a product we sold you, what would you do? And he said, we'd fire your buyer.
You'd fire a buyer and then tell us what's the deal? What are you doing to get that kind of a markup? But there's some medicines that have that kind of a markup when you check the discounted price to what they're paying. What do you really need for your employers to be able to sit down with their insurance company and say, I'm getting a bad deal?
Shawn Gremminger
Yeah, I think it's, I mean, two things, particularly in the pharmaceutical side, but really also on the medical benefit. Having access to your own claims data so you know exactly what you're paying, not just what you should be paying, but literally what you have paid is extremely helpful because then you know whether or not you're getting a bad deal. You otherwise you're just sort of guessing. And then you need competition, right? You need to have multiple choices so that you can change direction.
If you have just one or two dominant hospital systems in an area, or if you only have just a couple of big PBMs that you're having to negotiate with, you may be just trading one bad deal for another bad deal. What really is going to make a difference is employers actually having both the transparency and then greater competition to be able to shop.
Brett Guthrie
There appear to be disruptors coming. I think the information and making it transparent means that they will come into the business place. But we had one in Ohio said you can go to any doctor that you want to and here's the number we'll pay and if you can get it cheaper you get the money. So the patient has some skin in the game on it. They get to keep money if they get it cheaper than what is listed.
But they can't get on the marketplace because they don't have a network. And but the network is every doctor in Ohio. But that's not a sufficient network. And which is frustrating when we do things like that that prevent people from being disruptors. And that's what we need, disruptor to bring lower price and better quality and better care is what I'm when I say disruptors what I mean.
I will yield back.
Frank Pallone
Gentleman yields back and I now recognize the ranking member of the full committee, Representative Pallone.
Meanwhile, health care consolidation and private equity's increased role in our health care system is driving up the prices of health care services for families. So, I'm concerned about the growing influence of private equity and its impact on costs and patient care and health outcomes. I have three questions, so I'm going to ask each person to maybe spend a minute or so in answering the question. Let me start with Dr. Whaley. In your testimony, you discussed how private equity firms have been driving consolidation.
Thank you, Madam Chair. About half of Americans have reported difficulty affording health care and too many families have to delay or forgo necessary care due to rising costs.
Could you briefly, in a minute or so, discuss how private equity arrangements can impact health care costs and patient access to care, if you will.
Christopher Whaley
Sure. I think there are two main ways. So, the first is the roll-ups strategy, if you will, where private equity slowly accumulates market power within a given market in a way that each individual transaction evades regulatory scrutiny, but cumulatively leaves the private equity company with lots of bargaining power that they can use to negotiate higher prices. And we've seen in our own work that that leads to considerably higher prices. The second way is what happens to the firm that they acquire.
And in many cases, they either saddle the firm with bad debt, engage what's often referred to as a sale-leaseback, or charge high and excessive management fees that allow the private equity company to make money off the firm.
Frank Pallone
All right, thank you. Then let me go to Ms. Tripoli. Can you discuss the impact of private equity acquisitions on our overall health care system?
Sophia Tripoli
Absolutely. I mean, I think private equity by definition is incompatible with making sure that patients have health care they need at a price that they can afford. The whole business model is you come in, you buy up the competition, you cut off service lines so you get you remove access to care, you increase prices, you lay off workers, you you make the the business look profitable in the short term, you saddle them with bad debt. And we know that the result of private equity in the markets, they're increasing competition, they're driving up prices, reducing access to care, and in many of the private equity or venture capital-backed health care institutions have much worse quality, higher fall rates for seniors. So we know that it's higher cost care and lower quality care for the American people.
Frank Pallone
No, I appreciate that and what you say certainly makes sense. There's a lot of evidence that private equity's investments in health care result in price increases for families without and also reduce the quality of care. But despite billions of dollars being invested into the health care system by these private equity firms, the ownership arrangements remain totally opaque to patients and policy makers and regulators. That's part of the problem. So let me go back to Dr. Whaley.
You can you briefly elaborate why transparency in the ownership structure is important? What kind of data elements would be helpful for hospitals and providers to disclose regarding ownership? And this goes back to my thing is, you know, all for transparency, but if there's no competition, what's the point? But if you could answer that with regard to the data or some suggestion.
Christopher Whaley
Most of these transactions are incredibly opaque, which makes it hard for researchers, policy makers, and patients to know who employs a given doctor. And I I think it's critical that we have transparency around these efforts to actually make sure that we're monitoring these markets and ensuring competition. And we've seen several examples of this at the state level where they actually require, I think, meaningful ownership disclosure.
Frank Pallone
No, I agree and I appreciate. I just think that transparency is important. Without transparent ownership data, health care consolidation is going to continue unchecked. I mean, you know, in my state, we have basically two large systems now, maybe a few others, but there's not really, you know, the competition is is not really there anymore in my opinion. And given the impact of health care costs and patient outcomes, I mean, policy makers and regulators need a better need visibility into the ownership structure.
And I support obviously efforts to to strengthen price transparency, but we're not going to be able to achieve it without ownership transparency. I mean, that's that's the key. So thank you. I appreciate the comments from both of you.
Speaker 1
Thank you, gentleman yields back. And appreciate my vice chair taking over while I had to go to another committee where my vote was needed. So I do apologize to the witnesses and the members as well. There you go. So now I'll begin my questioning, I yield to myself the five minutes that I am allotted.
Let's try to get things straightened out, Ms. Skeens, for folks back home, can you briefly explain how hospital prices are set with all the different insurance plans that individuals have and if these are the prices that the hospitals post?
Carol Skeenes
Yeah, thank you for the question. A number of different ways, through negotiated rates that may be straightforward dollar values, something like a case rate, or based on a specific fee schedule. And then you get into more nuanced options, maybe it's a percentage based on the claim-specific total charge, or a per diem rate depending on the number of days the patient is in the hospital. Then there's additional exceptions for high-acuity care known as stop-loss or outlier clauses. All of these percentages of Medicare, you know, percentages of statewide fee schedules, any number of these, one, two, or all of them could exist in these payer-provider negotiated rate contracts.
And so what you see in the files is both a list of the charges but also those negotiated rates. So, you know, for a consumer, the ability to download that information and understand meaningfully what does that mean based on your own cost-sharing amount is quite difficult. That's a high barrier to entry.
Speaker 1
So there's not a standard price that each hospital and insurance company plans start their negotiations from, or is there a price they start from and then they negotiate from there?
Carol Skeenes
Yeah, there's typically, particularly if the hospital is already in-network with the payer, they'll renegotiate based off of the rates that are currently in existence. And that's a lot of what the rate data has been used for is understanding what a fair rate is in comparison to the market, whether it's in the state or maybe it's other hospitals that offer similar treatment options. That's where their ability is to look for what the appropriate rate is for the services.
Speaker 1
And you, I think you've already answered that it's, that makes it all the different things that go on make it difficult for hospitals to post these prices because of the variables, is that accurate?
Carol Skeenes
Most of them are posting the rates, and the challenge then for groups like us and like Mr. Grimeger shared is taking that information which is accurate at that granular level and then translating that into, so what does it mean for an employer who's looking for care? What does it mean for a patient who's looking for care? And that's where I think that translation layer of taking something that's inherently machine-readable and making it more consumer-friendly, particularly if the underlying data is accurate, which we're seeing, then we have a better chance of helping patients understand what it costs.
H. Griffith
So what we need to do is get that, that standard price out there so then people can have some idea. Now I just have to bring this up, my team back here is rolling their eyes because we've talked about it before. I pulled into the gas station at Raphine, Virginia, there's about five or six of them, they have their price posted, but then there's a touchscreen. And when I pulled into this week I chose the Shell, they had one of the lowest prices, and then they gave me like four or five different rewards programs I could be a part of, and I chose the Kroger program and got ten cents a gallon off. Can we not create something, I know the competition is more complicated than the four or five options that Shell offered me as to, you know, their own program, the Kroger program that they're affiliated with or others, but can we not with, and you mentioned AI in your opening statement, can we not use AI so that me as the consumer who's not as familiar with purchasing something that I may need in the future, God forbid, a knee transplant or knee replacement or something, can we not have it so that, you know, I plug in that I'm with Anthem Blue Cross Blue Shield Covacare and have a price pop up so I can see what's going on?
Speaker 26
Yeah I mean first and foremost Kroger doesn't exist in South Carolina so I'm jealous that you had that discount at the gas station but secondly I think you're exactly right.
Carol Skeenes
Oh and they all have them Sheetz and Circle K I mean I've got all kinds of memberships.
Yeah and I think secondly to your point the idea is the clinical complexity that goes into all these underlying different data points tied to what is actually on a claim is not a level of information that a patient is going to have access to. You go to the gas station you know which of the two types of gases you're going to get and then you get to pick a rewards program. So from our perspective the onus is on the industry to create open license and more patient-friendly service packages so they can say I need a knee replacement I have Anthem. That's what our consumer cost tools do and not go through all the machinations of what are the specific codes behind that and making the patients just end at just I need a knee replacement I have this insurance.
Speaker 24
And my time is just about up but don't you think AI can help us with that?
Absolutely.
Speaker 1
So we're right around the corner from being able to do this so everybody can know what's going on I have to yield back I apologize and I may have questions for the record.
Raul Ruiz
Thank you Mr. Chairman. The majority has called yet another hearing to present their ideas to lower costs for patients. Well here's the thought. If you really want to make healthcare more affordable and more accessible for people you don't cut a trillion dollars from Medicaid. You don't impose more red tape paperwork and make sick people jump through even more hoops.
And you don't negligently let the premium subsidies people rely on to afford coverage expire. You just don't. The title of this hearing boasts "Lowering Health Care Costs" but the nine bills under consideration today miss the mark. Transparency is greatly needed but requiring hospitals and insurance companies to publicly display just how much patients are getting ripped off isn't going to stop patients from being ripped off. In fact competition thrives when there's a choice and in a lot of healthcare systems there is no choice.
You have to go to the hospital that your insurance company requires you to or see the doctors that they require you to and as an emergency physician I can tell you that when you're in an emergency somewhere you have no choice. You come into the emergency department you get that MRI that CAT scan you're not choosing when they're trying to provide you that kind of emergency care. Publicly disclosing prices isn't going to keep safety net hospitals from shutting their doors because they can't afford the latest Republican cuts over six hundred billion dollars of decreased revenues to hospitals. More than four hundred rural hospitals across the country are at risk of closure now including several in the congressional district I represent. So where's the choice when your only hospital in a rural area has closed and now you have to drive even further during an emergency?
Suddenly your risk of permanent injury or death from stroke or heart attacks has skyrocketed. So we all agree that healthcare has become unaffordable and less accessible but we need to dig deeper to address that growing problem especially since it has been exacerbated by Republicans' fabricated healthcare crisis driven by that one big beautiful bill better known as the big ugly law. Ms. Tripoli which would have a more direct impact on healthcare access and affordability making prices public or restoring ACA enhanced premium tax credits for millions of Americans?
Sophia Tripoli
Thank you for the question. Without question, restoring the enhanced premium tax credits would bring affordability immediately to millions of Americans who need a short-term fix. And also price transparency is critical, as is ownership transparency, because in addition to providing out-of-pocket protection for consumers, we also have to address the root drivers of why premiums are so high in the first first place.
Raul Ruiz
So again, I liken this to the patient that comes into the emergency department with multi-organ failure and a rash, right? Like let's say a diabetic coming in in a coma. You have to treat the emergency first. And the emergency is the ACA tax credits expiring and the near trillion dollars cuts to Medicaid. You have to deal with that, otherwise you're only dealing with the rash.
Yeah, we have to deal with the rash at some point, but you have to save the patient's life first. Okay. This hearing is about dealing with the rash and ignoring that the patient is dying because of the crisis that they created. So again, Ms. Tripoli, which would have a more direct impact on health care access and affordability, making prices public or reversing the one trillion dollar Medicaid cuts?
Sophia Tripoli
We absolutely have to reverse the trillions of cuts to health care, including the disproportionate impact it has had and will continue to have on Medicaid. At the same time, we do need price transparency to address the root drivers of the affordability crisis.
Raul Ruiz
So with the near one trillion dollar Medicaid cuts, that's going to lead with and the ACA tax credits expiring, that's going to leave 15 million people uninsured. They're going to be uncompensated care. And we heard from insurance company CEOs in this hearing, in this hearing room, that the hospitals are going to renegotiate their prices to cover the uncompensated care. They're going to pay those prices. And so they're going to and they already have increased premiums for everybody.
I yield back.
H. Griffith
Gentleman yields back. Now recognize the gentleman from Ohio, Mr. Balderson, for his five minutes of questioning.
Troy Balderson
Thank you, Mr. Chairman, and thank you all for being here this morning, this afternoon. My first question is for Ms. Skeens. Thank you for being here. As machine-readable files for hospital and insurance prices have continued to improve, can you give us an example of how your company has been able to leverage this more actionable data to improve market competition and help consumers and employers shop for care?
Carol Skeenes
Thank you for the question. To your first part, that's right. We primarily see the accuracy of the data play out in the elimination of needing to go back and forth to verify what the correct rate is when payers and providers are negotiating for a fair market value rate. From an employer perspective, alongside other data sets like claims data, it allows them to see the different scenarios that their specific employee group is high utilization and, you know, essentially adding the ability to look at the price data, weigh it alongside quality data, and ensure that they are upholding their fiduciary responsibilities to providing that care.
And then from a consumer perspective, I would touch just briefly on this recent boon in the way patients are engaging with AI to ask what the cost of their care is. We've started to see that feeding through, for example, with our work with New York City, where the machine-readable file data itself powers the prices that patients are receiving when they use our cost comparison tool alongside the ability to input which insurance they have, so that they don't have to actually go through the files. They can see one rate, an accurate rate, and then with the understanding of their own cost-sharing, see what it costs them. The idea is then that could scale if that underlying data is accurate in AI uses that patients will have access.
Troy Balderson
Okay. Thank you. Follow-up to that, as Congress looks to strengthen price transparency requirements, what concrete steps should we consider to improve the usability of this data?
Carol Skeenes
Thank you for the question. There's a number of things that are currently not available in the data that we think are crucial for understanding the full cost of care. The first of that is either stop-loss or outlier reimbursement. This is, you know, upwards of a hundred billion dollars worth of cost every year for patients who are extremely sick or needing high-acuity services. That's not currently a requirement in either the hospital or the payer machine-readable files, but particularly for employers, matters significantly for understanding how to best cover their employees.
There's also a gap in drug coverage reporting that would be helpful to add, and then ensuring anything specifically tied to non-dollar value rates, so percentage-based reimbursement, algorithm-based reimbursement. We want to make sure that however that is codified in the rules that pass, that information is required, the calculus is required, so that we understand the dollar value of the rate.
Troy Balderson
All right. Thank you very much. Well done. Mr. Grimmenger, as Congress looks to ways to strengthen healthcare price transparency, can you explain how employers are already using this data? First question.
For example, how are they using it to steer employees towards higher-quality providers, pursue direct contracting arrangements, or build tiered provider networks, and what does that ultimately mean for the cost of their employer's care? Thank you very much. Bunch of questions right there, but if you could do your best. Thank you.
Shawn Gremminger
Sure. So we've seen in the research that we've done as we've surveyed employers that folks that have better access to the data are in fact using it in meaningful ways. So give you one of the things that you mentioned, sort of steering toward higher-quality, lower-cost providers. If you are able to look at and and really be able to digest and understand the data that we come at that comes out of Turquoise, you can see where just within your own insurance network, which hospitals are priced lower than maybe the ones that you currently have or that you see most of your patients going to. Then you can direct patients using usually cost-sharing changes to say, instead of going to hospital X for your knee replacement, we want to encourage you to go to hospital Y because we know that the negotiated prices are substantially lower.
You can look and say, wow, we've seen a hospital that has really high quality and relatively low cost. Let's see if we could create a center of excellence program where we actually provide meaningful direction for employees to go to that specific hospital to receive care. The end result is we are seeing lower overall trend for those those employers that are able to engage in those kinds of practices. But I also want to be clear, that is sort of a marginal one or two percent trend change off of some of the highest healthcare trend that we're seeing in the United States today. These changes are important, but in the end, being able to make those things are still somewhat at the margins.
Okay. Thank you very much. Mr. Chairman, I yield back.
Debbie Dingell
Gentleman yields back. Now recognize the gentlelady from Michigan, Ms. Dingell, for her five minutes of questioning.
Thank you, Mr. Chair, and thanks to both you and Ranking Member DeGette for holding this important hearing, because healthcare cost transparency is really important. Patients are navigating an unreasonably complicated system and paying outrageous bills that don't seem to reflect the level of care they receive.
Total healthcare spending and insurance premiums continue to increase at rates much faster than the economy, the rest of the economy. Families are then left to face impossible decisions between care and other household necessities. While patients struggle, major companies are buying up various entities in the healthcare supply chain, consolidating power, gaming our broken system to inflate costs, deny care, and pad their bottom lines. You know that this is called vertical integration. Vertical integration allows companies to enrich themselves with taxpayer money, evade laws meant to hold companies accountable.
I've seen too many examples of this in recent months. And point-blank, vertical integration harms patients, taxpayers, and independent doctors and pharmacists who cannot compete with massive consolidated companies. We need meaningful reforms to address this, not the half-baked plans and secret deals with drug companies that we've heard about recently, all with few substantive details that explain how they will tangibly benefit patients. So, Mr. Balu, let me start with you. In your testimony, you mentioned the need for greater transparency around health-related ownership information, which I agree with you.
What gaps currently exist in oversight and reporting requirements for ownership across the healthcare industry, and how could stronger disclosure requirements improve accountability, patient care outcomes, and the costs for consumers?
Sophia Tripoli
Thank you so much for the question. I think by and large, there's so much consolidation happening in the system, horizontal, vertical integration as well, but it is essentially a giant black box. We actually don't, we have very, very little information into these smaller transactions that are not raising to the level where they would trigger federal oversight and antitrust enforcement and laws. And so they're flying underneath the hood. I think Dr. Ippolito called them stealth mergers and acquisitions, which I love that term because that's exactly what they are.
So we actually need the legislative discussion draft that is for today's hearing on ownership transparency. That is a piece of legislation that would help to break that wide open and give us very critical information about how these mergers and acquisitions are actually occurring, who owns the care. And then we would have much greater information at scale for federal and state regulators to actually intervene on these healthcare transactions.
Debbie Dingell
Thank you. I just, I don't think people, I had a sister who was hospitalized, and people don't understand that even the medical practices are being bought up by the hospital and it's impacting patient care. So I would like to ask you, how does the lack of transparency surrounding ownership among all the entities impact the quality of patient care? Specifically, I mean, it is, I can give you some examples, but I'd like you to give it to me. And how does it make it easier for providers to jack up prices and for some of these corporate entities to deny care or say you don't need it, and how do patients dispute these decisions?
Sophia Tripoli
Absolutely. Because it's a black box and because we don't actually have this information, there's actually not a ton of oversight, federal or at the state level, oversight or regulation about these types of transactions to flag them and to investigate them about whether there's going to be a benefit to the community or whether it is in fact just going to increase prices and reduce access to care. And in some cases, as the case with private equity and venture-backed capital-backed purchases, the real estate that the facility is sitting on is more profitable than the business itself, and so they close it down and they sell off, they can sell off the property itself.
So we need the transparency data so we can know what's happening under the hood and then we can allow federal and state regulators to intervene and analyze what's happening in these markets and address the very deep consolidation that's occurring and driving up the cost of care.
Debbie Dingell
So I'm down to 28 seconds so I'm going to ask you in writing what more does Congress need to do to tackle the negative impacts. But not only when you talk when cap private capital fund are taking over they are telling how long a doctor can spend time with they're telling whether they can give them further care they are making medical decisions and people do not know that it's venture capitalists that are making medical decisions. Thank you thank you for your work on this and I yield back Mr. Chair.
H. Griffith
Appreciate the gentlelady yielding back and now recognize Dr. Mariannette Miller-Meeks for her five minutes.
Mariannette Miller-Meeks
Thank you very much Mr. Chairman for holding this extremely important hearing and I want to thank our witnesses for being here today. Healthcare costs continue to place significant financial strain on American families employers and taxpayers. It's why I introduced and the House passed the Lower Healthcare Premiums for All Americans Act to address these issues and why one of the bills we're considering is Lower Cost More Transparency Act of 2026 which this committee has previously passed. While patients are often encouraged to shop for care and make informed decisions too many still lack access to clear timely and usable information about the cost of services. I look forward to discussing these proposals that aim to improve transparency across the healthcare system and strengthen accountability for providers and insurers and most importantly empower consumers with the information they need to make informed choices.
Dr. Ippolito did the Affordable Care Act or Obamacare hasten and promote consolidation and vertical integration that my colleague just mentioned?
Benedict Ippolito
Um I think it probably weakly encouraged it through things like coordinated care and the emphasis on that that was seen at that time as as beneficial for coordinating and improving provision.
Hospital outpatient departments did that increase cost of care?
Speaker 30
Under there are many of us who predicted that this would occur and it's occurred at an accelerated pace and rate.
Mariannette Miller-Meeks
Dr. Whaley and Dr. Greminger um you each noted how employers can leverage price transparency data along with their own claims data to ultimately make healthcare cost more affordable for their employers. Should employers have access to um covered employees claims data to help employers to better negotiate premiums from insurance companies?
Christopher Whaley
Absolutely and it's necessary for them to be responsible fiduciaries.
Mariannette Miller-Meeks
And how um how have you seen employers shift care to lower cost settings or providers using price transparency data?
Christopher Whaley
I provide several examples in my testimony. One example comes from the 32BJ Health Fund which used their own data to recognize that a single provider was charging prices that were excessive and they used their own data to exclude that provider from their network saving their plan over a hundred million dollars.
And Mr. Greminger?
Shawn Gremminger
The example that that Dr. Whaley provided is an excellent one. We've seen smaller employers uh do similar things. There's a belief sometimes that only large employers have sort of market uh you know are be able to be market movers. But we've found that in smaller locations we've even seen employers engage in sort of tiered pricing strategies in which you'll say with keeping the open network saying we've found that this hospital is overpriced in this particular service and we're going to use a tiered copay to try to drive people to a lower cost setting that's equally high quality.
Mariannette Miller-Meeks
Ms. Gaines as price transparency data usability and machine readable files improve how can innovators leverage artificial intelligence or I'd prefer to call it augmented intelligence to help consumers or employers find insights from this data to lower their healthcare costs?
Carol Skeenes
Thank you for the question. I think it's about meeting consumers where they are, which is understanding a data set that's machine-readable is inherently not where consumers are going to find the answers to their questions. So can we take it a step further and bundle all of the known clinical policies, procedures, code sets that flow into the data in the machine-readable files and create open-license bundled service packages whereby a patient can say, "I need an MRI," and then they can get accurate pricing data flowing into the conversation they're having with whatever AI agent of their choosing.
Mariannette Miller-Meeks
Mr. Grimmer, as a physician, I've seen firsthand my arch-nemesis, the challenges prior authorizations can create throughout our insurance companies, be they private or public. And today we're considering discussion drafts that would require commercial health plans to provide greater transparency into prior authorization and claim denial rates, which we know about 90% of those are approved after the first review, as well as the plan's overhead cost. How would this additional data benefit the employers you represent?
Shawn Gremminger
So first I'd just say we very much support the discussion draft. You know, I think the employer perspective on prior authorization utilization management is a nuanced one, right? We have seen too often where physicians may inadvertently or potentially intentionally prescribe drugs that are higher priced than what's otherwise necessary, or try to do services that are unnecessary and may actually be harmful to patients. That's a rarity, but we think it's important that there is actually an opportunity to say, "Time out, let's look at something else." That being said, we do believe that the significant use of prior auth is often simply to just delay care, create float for the insurance plan, and then ultimately they're going to 90% of the time say yes.
Understanding how often prior auth is being used, not just by the carriers that we may be contracted with, but by other carriers, will then provide more information for employers to say, "You know, I don't like the way that we're doing it internally. We found there's this other carrier over here, we have their data, we want to shift to them because we think that they're doing this better."
Speaker 35
And or claims denial, I'll add that in as well. Thank you very much, I yield back.
Speaker 33
Gentlelady yields back, and now recognize gentlelady from California, Ms. Barragán, for her five minutes.
Nanette Barragán
Thank you, Mr. Chairman. I think this is an important hearing and I appreciate that we're doing it today. Ms. Tripoli, do you think it's important for patients to have timely and accurate access to information about their own health and medical records?
Sophia Tripoli
Absolutely. I think one of the challenges right now in the health care system is that the data doesn't follow the patient. So you show up in the MedStar hospital system and your data sits there, but if you see a primary care doctor at the GW facility a couple weeks later, your data is in two different places, and so it makes it much more difficult for the providers to coordinate your care and make sure that they can meet your health needs.
Speaker 36
Do you think there's any connection or tie to that and cost of health care or transparency?
Sophia Tripoli
I think in general there's absolutely a need for, for a lot of different areas in the health care system where we need greater transparency over prices, over ownership data. We also do need a lot more work on sort of the back-end complexity of the system, making sure that there's data sharing across providers, interoperability standards so that data can flow, with patient privacy protections, of course. All of those tools together help to streamline and improve the experience of the health care system for the American people, lower health care costs, make sure they can get the care that they need.
Speaker 37
Do you have any idea why a, why somebody like a doctor or a provider would not want to provide timely access to a patient, their health care file and the notes?
Sophia Tripoli
Off the top of my head, I'm not sure. What I do know is that there are data vendors that block data from flowing to providers. That is a business practice that's a huge problem in terms of data access. My understanding and experience is by and large providers want to be able to leverage the data about their patient population to deliver the care that they need, but there might be other challenges, right, about the different data systems and that they're using across provider practices that make it very difficult for them to be able to do that.
And I think that is an actual challenge of data sharing and interoperability of the system.
Speaker 37
So the reason I'm asking is I had an experience recently where I was trying to get access to my mother's hospice file, her medical records, to consider whether to move her to another hospice program. But for whatever reason, I was told that it would take a long time if I wanted to get her medical file. But if I transferred her, the other company that would take over could get it immediately. And I've heard some theories on why that's the case. And this company called Compassus, I wouldn't say has a stellar record.
But does anybody here want to opine on why that may be the case, that it's hard for a patient to get their medical file?
Sophia Tripoli
I mean, the one thing, and then of course other witnesses should respond too, but I think the one thing of course is if the patient stays in that practice, that is volume that they can then bill for. So I think there is a financial incentive to keep patients with the providers that they're seeing. And there are hurdles in terms of getting providers to share data. Some of that is the complexity of the system in itself.
Nanette Barragán
Do you think that Congress should pass legislation to ensure that all Americans have access to their comprehensive digital health records in real time?
Absolutely.
Nanette Barragán
Well, thank you. This is National Health Data Week, and it's a week of action focused on demonstrating the power of health data to drive positive outcomes for patients. As the owners of their healthcare information, patients, I think, should have access, timely access, to their medical records and any notes about them without unnecessary administrative or financial burdens. I can tell you I was shocked when I had heard about, oh, well, we've got to go through legal and this and that. But if I give it to another hospice company right away, they can get it right away.
Ms. Triplett, I want to ask you, it's been touched upon a little bit. In your testimony, you point out that a colonoscopy can range at the University of Mississippi Medical Center from $782 to $2,144 depending on insurance. And I recently heard a story about a colonoscopy procedure that was affected by differences in reimbursement across care settings. Why is it that patients sometimes pay almost three times as much for the same procedure? And how would greater price transparency help families avoid these unnecessary costs?
Sophia Tripoli
Absolutely. I mean, the biggest predictor is consolidation. These prices are set based on who has more, which institution has more market power, the hospital system or their insurer. And the reality is that the vast majority of hospital markets are highly consolidated. And so that is a major reason why we're seeing not only that prices are so high, but we see for a single service like a colonoscopy or knee surgery, incredible variation across the country, across the state, within a particular plan.
Great. Thank you. I yield back.
H. Griffith
Gentlelady yields back. And I now recognize the gentleman from Pennsylvania, Mr. Joyce. And if you would take, and we're going to give you an extra 15 to 30 seconds to talk about sunscreen for a quick second.
John Joyce
Well, thank you, Mr. Chairman. And thank you to this committee. I am pleased to report that the FDA's approval of bemotrizinol, the first new sunscreen ingredient in over 20 years in America. This came out of this committee with bipartisan support. Mr. Chairman, it shows what we can do when we work together.
And I'm proud as a board-certified dermatologist to report how important new sunscreens are in preventing skin cancers, something that we've seen over the last decades, the rise in skin cancers in young individuals. Talking about working together, I would like to continue for talking about what we're doing and we're doing together with increasing transparency in healthcare.
For far too long, patients and purchasers of insurance products have been kept in the dark about the true cost of medical care. While we have made important strides both administratively through legislation and passed in this committee, we know that much more needs to be done. In November of 2019, HHS issued rulemaking that requires hospitals to publish prices as of January 2021. Hospitals are required to publish a machine-readable file of five types of standard charges for all items and services. They are also required to create a consumer-friendly shoppable list of 300 items and services, including 70 identified by CMS.
While I'm pleased to see data from my home state of Pennsylvania indicates that over 90% of Pennsylvania hospitals are in compliance with key components of this rules, a November 2024 report issued by HHS estimated that 46% of all eligible US hospitals were not complying with the HPT rule requirements. Less than 50%, that's unacceptable. I was further concerned to see the announcement from Secretary Kennedy and Administrator Oz that there are over 500 hospitals still out of compliance. Mr. Whaley, do you feel that the current transparency requirements are sufficient and being adequately enforced to give patients an accurate view to enable them to shop effectively for care when possible?
Christopher Whaley
I think they are a good start, but not sufficient and, as you noted, not being sufficiently enforced.
Speaker 39
Ms. Tripoli, do you concur with that assessment? It's not an adequate amount. Do you agree?
Speaker 40
Absolutely. It's why we need the codification of the legislation being considered today.
John Joyce
And I think that is important legislation again that we can consider and implement in a bipartisan fashion. Ms. Tripoli, you also cited hospital consolidation of independent physician practices as a key driver of increasing healthcare costs. Would you view policies that incentivize independent practices as an important safeguard against the rising healthcare costs that we continue to see throughout America?
Sophia Tripoli
I think absolutely we want to address that incentive for big systems to buy up physician practices. The best policy solution to address that is to advance this comprehensive site-neutral payment policy.
John Joyce
Mr. Whaley, in your testimony, you described physician-owned hospitals showing a substantial reduction in outpatient costs when compared to their non-physician-owned counterparts. Would repealing the prohibition of physician-owned hospitals be a good initial step to stop that rising cost?
Christopher Whaley
I think it would be a good step to improve affordability and add competition.
John Joyce
Finally, I'm pleased to see provisions of the Seniors' Timely Access to Care Act surrounding prior authorization denial rates included in this hearing today. While I urge passage of this critical legislation overall, Mr. Ippolito, can you elaborate on why public disclosure of denial rates is a benefit to the American patient?
Benedict Ippolito
Sure. I mean, surveys have shown clearly people care a lot about denial rates, they care a lot about prior authorization rates, yet they can't really observe that. So it would be a natural feature to make clear to people when they actually choose a plan so they can tell us how much are they willing to pay to have less denials, less prior authorization.
John Joyce
When you have the input from the patient, does that allow you to provide better coverage, better insight, and better education of the patient of what policies cover?
Benedict Ippolito
Well sure, as a first order thing, it tells the insurance companies how to design plans that people actually want. And that strikes me as a first order importance.
John Joyce
I think that first order of importance, that message is not lost on us here today in the committee. Mr. Chairman, I thank you for the additional time and I yield back.
Speaker 41
Gentleman yields back. Now recognize Ms. Kelly of Illinois for her five minutes of questioning.
Robin Kelly
Thank you Chair Griffith and Ranking Member DeGette for holding today's hearing. Lowering healthcare costs and improving healthcare access for all Americans is something everyone, excuse me, should be able to get behind. Yet this administration has been misleading the public about their work to make healthcare less accessible and more expensive. A great example is passing the one big ugly bill taking away one trillion, nearly one trillion in funding from Medicaid under the false narrative of fraud, waste, and abuse. Dr. Whaley, for a family wanting to get an MRI or life-saving procedure, for example, the current price transparency posting can be difficult to navigate and understand what the out-of-costs will be.
What policies would you recommend to close that gap?
Christopher Whaley
As I highlight my testimony, it's important to not just think of price transparency as a way to inform patients making decisions, but actually how networks are designed and choices are made upstream of the patient. So the patient's insurance plan or employer can actually exclude high-priced and low-quality providers from the network.
Speaker 44
Thank you. Ms. Tripoli, my district encompasses urban, suburban, and rural communities, and we are seeing significant financial strain on rural critical access hospitals and a loss of services in these areas. How might hospital and physician price transparency reforms affect rural hospitals and their patients?
Sophia Tripoli
I think price transparency, when we get it right, is a benefit to consumers across the country, including rural residents living in your district. And I think will provide a great value. I think rural hospitals should be able to comply, many of them are. And I think the main question here is like if these hospitals can generate a bill and send it to a patient, then they should be able to tell us what the price is before the patient gets the care.
Robin Kelly
And I was just saying to someone that I had, it wasn't a rural hospital, but a procedure and I didn't realize until I went there and they said, oh you owe this amount of money right before I had the procedure. So yeah, I was quite shocked. But thank you to the witnesses and for being here. But in order to improve the lives and health of all Americans, we need to build on the bipartisan work we've accomplished with the No Surprises Act and the previous iteration of the Lower Costs, More Transparency Act. Not defunding, not dismantling more of the healthcare system, but putting people over profits is the only way forward.
And I yield back. Thank you.
John James
Gentlelady yields back and now recognizes the gentleman from Michigan, Mr. James, for his five minutes of questioning.
Well thank you, Mr. Chairman. I appreciate you holding this hearing today and a special thank you to our hardworking staff working on getting this to a position where we can get it to the people, getting a hearing today. Congress is now not doing enough to lower the cost of healthcare. We can help people save money by passing my bipartisan and bicameral Patients Deserve Price Tags legislation. The idea behind this legislation is simple.
It will make it easier for patients to price compare when getting medical treatment so they can pick the lowest cost option, just like they do in every other aspect of their lives. People drive out of their way to fill up on cheaper gas. They check different websites for the best price before making an online purchase. They price compare before buying a flight. They get an estimate before making house repairs.
So why can't the people price compare before getting a medical procedure?
As a result, patients end up paying hundreds of thousands of dollars more for the exact same services and the same level of care with the same billing codes. Patients Deserve Price Tags was part of a bipartisan lower cost, more transparency legislation the House approved last term. It's not controversial. It passed the committee under suspension. The ranking member supported it and then passed the House 320 to 71.
But the Senate under Chuck Schumer let the bill die. This term, Senators Marshall and Hickenlooper are working on an identical version of this bill. They have 10 Democrats and 10 Republican senators as co-sponsors. That's one-fifth of the entire Senate already on board. In 2025, President Trump issued an executive order to make America healthy again, which included an April 1 deadline for healthcare providers to comply with existing but unenforced price transparency laws.
Yesterday, HHS Secretary Kennedy announced that the grace period had ended and that the Trump administration is enforcing hospital price transparency. I applaud that leadership from the President and from the Secretary, and I applaud that action. My Patients Deserve Price Tags bill will make that change permanent and provide stronger enforcement for that mechanism for the American people. The Senate has members from both parties on board. My bill has members of both parties on board.
The White House supports this. HHS and RFK Jr. support this. Passing this bill again in the House should be a no-brainer. We can and we must get this done for the American people. The great healthcare plan that President Trump put out in January has four main tenets: lower drug prices, lower premiums, hold big insurance companies accountable, and maximize price transparency.
My Price Transparency Act, again, is bipartisan and bicameral. This legislation bolsters each of those pillars. Patients Deserve Price Tags will lower healthcare costs by requiring hospitals to clearly label prices so that patients can make informed decisions about where they get treated to save money, increase quality of care. I urge the committee to pass this popular, bipartisan, bicameral bill that will lower healthcare costs for everyone. Thank you all for being here today.
My first question is for Ms. Triplett. From the patient perspective, what happens to a working family that cannot see the price of their care prior to receiving it? How does this opacity feed the medical debt crisis that's affecting an estimated 100 million Americans?
Sophia Tripoli
In my oral testimony and in my written testimony, I shared some examples of consumers who have serious medical conditions, are living paycheck to paycheck, and needed the opportunity to shop around for certain services and basically find a dead end. They talk to insurers, to doctors, they talk to everybody, no one could tell them how much something costs. The result for Jessica, one of the storytellers that we share her story of, is that she had to delay her care for months, maybe even years, before she was actually able to get the service, all because she couldn't find the price.
John James
That's unacceptable. We have a sick care cartel problem in the country, and we have to tear down the sick care cartels to make sure that we are fighting for the people. I'm excited for the support and the momentum behind this bill, and I'm looking forward to getting this across the finish line. Again, Mr. Chairman, thank you for your leadership on this matter. I yield.
Speaker 46
Gentleman yields back. Now recognize the gentlelady from Washington, Dr. Schrier.
Kim Schrier
Thank you, Mr. Chairman. Thank you, Ranking Member DeGette, and thank you to our witnesses for being here today.
I have a constituent named Lawrence. He's from Granite Falls, Washington, which is a rural town in my district. He and his wife are super studious and diligent, and when they qualified for Medicare, they did their homework and they reviewed all the plans available to make sure that they would find the best one with the coverage that they need. And they settled on a Humana Medicare Advantage plan and eventually found a medical home at a clinic 40 minutes away. That's just when you live in a rural area, that's how far away it is.
And Lawrence's doctor's clinic is owned by Optum, which is a subsidiary of UnitedHealth Group. Last year, Optum announced that it would no longer be in network with Humana starting January 1st of this year. So Lawrence would not be able to see his doctor. Faced with having to either find a new provider or find new insurance, he ended up having to switch to a United Medicare Advantage plan to just stay in network with his doc. Mr. Whaley, when United, a health insurance company and the owner of its own clinics and providers, pulls Optum clinics out of competing insurance networks, how does United benefit from that?
Christopher Whaley
I think that's a clear concern of the payvider-type model, where an insurer, in particular Medicare Advantage insurer, can acquire a physician practice and essentially say to that physician, you can only treat my patients. And so if you're a patient on, say, a rival insurance plan, then you either have to change your doctor or lose access to your care, or switch to a plan which maybe is more expensive.
Kim Schrier
And so this behemoth just keeps growing. Like, it's already a monopoly and it becomes more of a monopoly. UnitedHealth Group CEO Stephen Hemsley, when he came before this committee, he told us that United's vertical integration, the ownership of the clinics, the doctors, the pharmacy benefit managers, the pharmacy, he told us that it drives down prices. Is that true?
Kim Schrier
Nobody else has seen evidence of that either. Thank you. This is a gigantic problem with our healthcare system. UnitedHealth Group is the poster child. It is a company with more than 400 billion dollars in annual revenue.
It owns one in 10 physicians in this country. It is the company that is the poster child, the biggest abuser of prior authorization that delays or denies care, frankly, as part of its business model. And this company is gobbling up the healthcare system and jacking up prices for all of us. Not only can they force beneficiaries into their own plans, they also get paid based on how sick they say a patient is. And they purposely make patients look sicker in order to pad their pockets even further.
And it's a lot easier to exaggerate how sick somebody is if you own the doctor and the medical record system and the way that a problem list is generated and add sometimes meaningless diagnoses that just sound really bad. Research shows that patients are labeled as sicker when the insurance company also owns the provider. This is the definition of a monopoly and market manipulation. And this is what consolidation looks like, and it's a huge part of what is driving up cost for patients. My constituents are sick of it.
I'm sick of it. I think I can speak for every doctor in Congress who's sick of it. And this committee needs to take even bolder and more meaningful steps to stop this. So, Mr. Whaley and Ms. Tripoli, why is transparent ownership reporting important for healthcare entities, and what should this committee be doing to go further to break up UnitedHealth and other healthcare monopolies?
Christopher Whaley
So for the example you raised, it's very likely that the patient in your district had no idea that their doctor had been acquired by an insurance company, and likewise the state of Washington probably didn't know, and Medicare through CMS also probably didn't know. And so if we are going to design policies to address this type of consolidation, we need to know actually who owns any individual doctor.
Sophia Tripoli
To start with transparency and knowledge. Ms. Tripoli.
I would just add that one of the things we're also seeing in these vertically integrated plans, and UnitedHealth is a perfect example, is that they're actually financially, like, offering bonuses to their providers to upcode, to make their patients appear sicker, and there's documentation and evidence of that. And in these vertical, this vertical integration, they're also able to pay above market rates to their provider to the parent entities and keep the delta so that they can actually appear on paper that they're meeting medical loss ratio requirements, but in fact they're actually subverting the federal requirement and putting those to profits instead of to patient care. So I think some of the legislation for consideration today, strengthening encounter data, more transparency over medical loss ratio requirements and how plans in the MA program are spending their premium dollars, all incredibly tools to help us understand what's happening as the effects of consolidation for better intervention.
Speaker 51
And insistence that consumer dollars be spent on healthcare has been absolutely abused and perverted by insurance companies who are now controlling doctors. Thank you, I yield back.
Speaker 58
Gentlelady yields back, now recognizes gentlelady from Florida, Ms. Cammack, for her five minutes.
Kat Cammack
Well thank you, Mr. Chairman, thank you to our witnesses for appearing before us here today. I think we're all on the same page, which is rare in Congress. Both Republicans and Democrats, we all agree the system's broken. So I think that's a great starting place for all of us here today, because I think we all agree that patients deserve to know what healthcare costs are before they receive care. Not weeks later, not when the bill arrives.
And of course over the last several years, Congress and multiple administrations have enacted transparency requirements intended to give patients, employers, and policymakers a clear picture of those costs. Yet every day, Americans, heck, colleagues on this panel here, we've all talked about this. We still struggle to understand the prices, the coverage, and ultimately what we will owe for any procedure. Transparency, however, should not be the end goal. It's a part of it, yes, but the goal should be a more affordable, competitive, and accountable healthcare system, not a sick care system.
As we consider additional transparency policies today, I am very interested in whether the information being disclosed is actually useful to patients and employers, and whether it helps identify the drivers of rising healthcare costs, and if it can empower consumers to make better decisions without adding unnecessary burdens that increase costs elsewhere. So, we're going to do a quick round robin down the panel, starting with the first question, and I am going to ask you to be super brief and just give the name of the bill. Of all the proposals before us today that have been listed, which one is most likely to lower costs for patients and employers rather than simply produce more data? And I'll start with you, Ms. Tripoli.
Patients Deserve Price Tags and Ownership Transparency.
Great, good deal.
The Patients Deserve Price Tags Act.
Excellent.
I'll take Ownership Transparency.
Okay.
Okay, excellent.
Speaker 56
Patients Deserve Price Tags Act, specifically the element around algorithm and percentage-based reporting in machine-readable files.
Speaker 54
Excellent. You guys did so good on that one, thank you. All right, second question, round the panel again. Congress has enacted hospital transparency requirements, insurer transparency requirements, and transparency in coverage rules. Yet healthcare costs, they continue to rise.
So from your perspective, what is the single biggest reason that transparency has not translated into greater affordability for patients and employers?
Speaker 52
Transparency alone is not going to bring down prices, you also need to target high hospital prices, high drug prices.
Excellent.
Employers and purchasers need access to their own claims data.
Christopher Whaley
We have heavily subsidized purchasers buying in very consolidated markets.
Speaker 63
Market consolidation and anti-competitive practices by providers and health plans.
Carol Skeenes
There's a missing but necessary translation layer to take the data from those machine-readable files and get them into a more usable, palatable format for consumers and employers.
Kat Cammack
Mhm, I have something for the record that I'm going to submit on that. So hang on to that. But again, down the panel one more time. So do we have an information problem or do we have an accountability problem?
We have both.
Okay.
Yeah, both.
Both.
Both, okay.
Both.
Kat Cammack
Okay. The whole system sucks. Got it. Now, what information, since you all answered both, is missing that would help negotiate better prices?
Sophia Tripoli
Fundamentally, the negotiated rates, the actual price of healthcare is the most important piece of information to unveil for us to know how to better regulate.
Okay.
Christopher Whaley
Employers and purchasers need to have data on prices that are negotiated on their behalf and be held accountable for those prices.
Okay.
Speaker 67
Yeah, the most important is that employers who are the real decision-makers in that market have to have the information they need.
Okay.
Shawn Gremminger
As a guy representing employers, I agree. We need access to claims data, but we do need to be able to go further because we actually have to be purchasing in a competitive marketplace, which we don't have today.
Carol Skeenes
I think there's a focus on the few data elements that are currently missing that need to be codified. So stop-loss and outlier reporting. We haven't mentioned it briefly, but non-hospital entities should also be required to post their rates, drug prescription rates as well, and then self-pay cash prices for those non-hospital entities.
Kat Cammack
Excellent. And you gave me the perfect segue. In my remaining 30 seconds, want to talk about the medical loss ratio. If consumers are paying premiums, most of the money should be going towards patient care. That would be common sense.
We know common sense is not common, particularly on Capitol Hill. But as insurers have vertically integrated and acquired PBMs, pharmacies, provider groups, and other entities throughout the healthcare system, concerns have been raised that companies can satisfy the medical loss ratio requirements on paper while moving money within the same corporate family. So again, down the panel. Do consumers today have enough transparency to know whether their premium dollars are funding care or simply being transferred between affiliated entities? Yes, no.
Not at all.
Consumers, no.
Speaker 61
Gentlelady yields back. Now recognize the gentlelady of Massachusetts, Ms. Trahan, for her five minutes.
Lori Trahan
Thank you, Mr. Chairman. A little over two years ago, Steward Health Care declared bankruptcy. Steward was the largest private for-profit hospital chain in the country. When it collapsed, it was over a billion dollars in debt. Meanwhile, Steward executives walked away with hundreds of millions of dollars and left communities holding the bag.
Hospitals closed overnight. Patients were turned away. In the district that I represent, Nashoba Valley Medical Center closed, eliminating nearly 500 jobs and leaving a healthcare vacuum. Emergency transport times spiked from an average of 12 minutes to nearly a half an hour. Looking back, it's clear that this wasn't bad luck.
It was the predictable result of a business model designed to extract value, not deliver care, and regulators who didn't have the tools to see it coming. Dr. Whaley, why was it so difficult for regulators to identify these risks sooner?
Christopher Whaley
I think in the case of Steward specifically, regulators in the state of Massachusetts really had no idea until it was too late, until the hospitals were already under distress.
And so if they knew about the agreement prior, they could have potentially regulated the transaction. And we've seen similar lessons in other states where they're actually trying to get ahead of what might be the next Stewart.
Lori Trahan
Thank you. I mean, following up on that, ownership transparency is important, but only if we're connecting it to the real impacts that it has on patients. Dr. Whaley, briefly, would the transparency measures we're discussing help researchers and policymakers better link ownership models to patient outcomes, higher prices, and hospital closures?
Absolutely.
Lori Trahan
It's been two years since Stewart's collapse, and it's long overdue that we give regulators the tools to identify risks before communities lose essential healthcare providers. But the thing is, transparency can only take us so far. In Massachusetts, Stewart appeared at first to be swooping in to save community hospitals that were financially underwater. Destabilized by years of chronic underinvestment, these facilities were struggling to keep the doors open. And that's exactly the opening predatory investors look for.
Ms. Tripoli, in your experience, what are the conditions that make a hospital vulnerable to this kind of acquisition?
Sophia Tripoli
There are a variety of factors, but I think obviously the financial status of the hospital, the volume of services that they're seeing, the payer mix are all factors. And I would just say this business practice in itself that you're referring to, right, is these are small transactions that are happening. The whole purpose of private equity in this case, their whole business model is to target vulnerable hospitals and to target as many of them as they possibly can in a region so they can get the market control and increase, you know, for short-term profit, increasing the bad debt for those hospitals. So it is incompatible with making sure that you're keeping access to care that patients can afford in their communities.
Lori Trahan
Yeah, it sounds like exactly the conditions that Democrats on this committee were sounding the alarm about as Republicans passed the Big Ugly Bill, the largest cut to healthcare spending in history, followed up by refusing to extend the ACA tax credits that families need to keep their healthcare coverage. In Massachusetts, over 27,000 people have already dropped coverage through the Health Connector because they simply can't afford their premiums. And as coverage losses grow, hospitals face more uncompensated care while also absorbing substantial funding reductions. All that adds up to a massive destabilization of hospitals, especially safety net hospitals with the most strained margins. And they're already starting to feel the pressure.
Ms. Tripoli, are you concerned that the massive cuts facing hospitals right now are creating the conditions for more Stewart-like failures?
Sophia Tripoli
I think the hospitals that are most vulnerable, financially vulnerable, are these independent, particularly rural independent hospitals, those that are not associated or affiliated with these big systems. And so they have smaller financial margins. And so when a cut happens or a change happens, they are not able to absorb the impact as well as these big systems. So those rural independents, independent hospitals, are financially vulnerable right now.
Lori Trahan
Yep. So transparency is an important step. Let's be honest, but what's keeping my constituents up at night isn't who owns the hospital. It's whether the care is going to be there when they need it. And it's whether their next prescription, premium, or copay is going to break the bank.
So I'm all for giving regulators more line of sight into healthcare ownership and more tools to protect patients, but we can't lose sight of the immediate challenge, which is ensuring that hospitals remain financially stable and that patients can afford care in the first place. So thank you for your testimony, and I yield back.
Nicholas Langworthy
Gentlelady yields back. Now recognize the gentleman from New York, Mr. Langworthy, for his five minutes.
Thank you very much, Mr. Chairman, and I want to thank the committee for including my legislation, H.R. 9117, the Clear Healthcare Expense Cost Knowledge, or CHECK Act, as part of today's discussion.
In every other part of our economy, consumers can see prices before making a purchase. When you go to a restaurant, you get a menu, there's prices on it. When you walk through a grocery store, there's prices on every shelf. Healthcare should be no different. There should not be a surprise when you get a letter in the mail a month later.
But with that, Ms. Tripoli, for the average patient trying to navigate the healthcare system today, what information is most often missing when they're trying to understand the cost of their care?
Sophia Tripoli
I think just that, the cost of their care, their out-of-pocket costs, like what are they actually paying out of pocket? As well as other information about what is the type of care that I'm going to get from this plan when I'm selecting a plan, what are the prior authorization care denial rates, what's the quality of care that I'm going to get, can I see the doctor that I'm currently seeing? I think those are all very challenging data points for consumers to have as they navigate the healthcare system.
Nicholas Langworthy
Thank you. Too often patients open a bill and they're left with way more questions than answers. And one of the goals of the CHECK Act is to ensure that patients receive clear explanations of benefits and itemized medical bills so that they can better understand what they're actually being charged for, what their insurance actually covered, and what they owe. Ms. Tripoli, how important is that type of transparency for patients trying to make informed decisions about their care and their finances?
Sophia Tripoli
Very important. Having an itemized bill on the back end helps patients to double check, right, with their EOB and what they've been, what they're being charged. So it is an important tool that consumers can use. But I would say that that in and of itself is not going to be sufficient. We still need broader price transparency across the system, unveil prices overall, and to bring down healthcare costs by directly addressing the root drivers of what's driving up premiums in the first place.
Nicholas Langworthy
Thank you. And I think that's exactly why this matters. When prices remain hidden throughout the system, no matter which leg of the stool within our healthcare system they are, it becomes much harder to understand who is being paid for what services and at what cost. And when healthcare costs go up, every part of the system seems to blame a different leg of the stool. In hospitals, they point to insurers.
Insurers point to hospitals. PBMs point to manufacturers. Manufacturers point right back to the PBMs. And maybe everybody's right. Maybe everyone is right, and maybe they're all wrong.
But the only way to know is for everyone to flip their cards over, because if no one can follow the money, no one can figure out why the costs are skyrocketing to the level they are. Mr. Greminger, the CHECK Act includes enforcement provisions intended to help ensure compliance with transparency requirements and provide employers and health plans with access to information that they're entitled to receive. From your perspective, have existing transparency requirements been consistently enforced, and how important is enforcement in ensuring that those requirements produce actual meaningful results?
Shawn Gremminger
Thank you for the question. Unfortunately, I think they have not been consistently enforced. As we've seen, only a couple dozen hospitals have been, had penalties against them for non-compliance with the hospital price transparency rule. I understand President Trump just suggested that they would fine up to 500 hospitals for lack of compliance. We think that stronger enforcement is necessary, and we very strongly endorse legislation to codify these rules and increase enforcement action.
Nicholas Langworthy
Well, thank you very much, and I appreciate all of the witnesses' testimony here today and for this discussion. And I want to thank the committee for including my legislation, the CHECK Act, as part of today's hearing. And with that, I will yield back.
Speaker 69
Gentleman yields back. Now recognize the gentleman from Texas, Mr. Veasey, for his five minutes of questioning.
Marc Veasey
Thank you, Mr. Chairman.
I'm really glad that we're here today to talk about something that I think everyone feels that we should be discussing, and that's healthcare transparency. I know that everyone wants to know why we have to pay so much money for our healthcare. And one thing that I can tell you for sure, as much as we already pay for healthcare in this country, those costs are going to go up. As we all know, last year Republicans gutted nearly one trillion dollars out of the American healthcare system. And no matter what insurance you have, where you live, or who you are, we're all going to pay the costs for that.
Because the money has to be made up somewhere, and hospitals, particularly rural hospitals and safety net hospitals and providers, they're all going to bear the greatest brunt of those cuts. Gutting a trillion dollars out of our healthcare systems means that hospitals have to figure out how they're going to absorb those levels of uncompensated care, tighter margins, growing financial pressure. And that's really where private equity comes into the conversation. Over the last two decades, private equity, or PE, they've invested roughly five billion in 2000 to more than 100 billion dollars in 2024. And I want to explain a second, or I just really want to take a quick second to explain exactly what private equity is.
These are the PE firms are investment partnerships that buy companies and they restructure them to increase revenue and then sell them for a profit. And usually it's between three to seven years. And this business model is centered on maximizing returns for investors. And I want to be clear, it's not always black and white. PE firms can provide capital to struggling hospitals, improve operations, manage administrative functions, and in some cases help avoid closure for these facilities.
If the choice is a hospital shutting its doors or someone stepping in to keep it operating, hospitals are going to make the decision they believe keeps care available in their community. That math is not hard to understand. But we also can't ignore what the evidence tells us. Studies consistently show that private equity ownership in healthcare means higher prices, it means reduced staffing, it means worse patient outcomes, and fewer essential services. Again, these people are in the business of making money.
And some firms load hospitals up with debt. Others strip assets through sale-leaseback management arrangements, and they force hospitals to pay rent on buildings they once owned. And because many of these arrangements are incredibly opaque, patients often have no idea who actually owns the facility that they're walking into. And so as Republicans tout their healthcare cuts that will push more hospitals towards private investment, Congress should at least know who owns what, how these deals are structured, and what impact they are having on cost and quality. That's why I think transparency is critical.
As we consider ways to improve ownership transparency, we should be reporting, we should make these reporting requirements pose as little burden as possible to hospitals. And the last thing we should do is pile new administrative burdens onto providers that are already struggling to keep the doors open. And I wanted to ask Dr. Whaley, your research found that PE acquisitions are associated with higher provider prices, particularly when firms buy up practices within the same market. Can you explain how these roll-up strategies increase healthcare costs for patients?
Speaker 72
Sure. So prices between hospitals and physicians and insurers are typically negotiated, and the way you negotiate better prices is you just get bigger and have better negotiation power. And so what happens in many cases with private equity is there is a single transaction that might be too small to be scrutinized regulatorily, and then there's a second one that adds on top of that, and by and by it essentially adds cumulative market power that leads to higher prices and is passed on to patients through higher out-of-pocket costs.
Marc Veasey
Wow. Wow. I also wanted to ask, would you agree that ownership transparency is the first step in understanding when private equity is stabilizing care and when it may be making healthcare more expensive and less safe?
Sophia Tripoli
Absolutely, ownership transparency is critical. It's a giant black box right now. We need that data so that we can not only understand what's happening in terms of these transactions, the effects on communities, but that also so federal and state regulators can actually intervene and evaluate and investigate these transactions before they happen.
Yeah. Thank you. Thank you very much. Mr. Chairman, I yield back.
H. Griffith
I thank the gentleman for yielding back. Just trying to figure out the right order here, but according to my team, it's the gentleman from Ohio, Mr. Landsman, is up for his five minutes of questioning.
Greg Landsman
Thank you, Mr. Chairman. Thank you all for being here. Ms. Tripoli, you talked about the corporate takeover of healthcare in your testimony and made a really compelling argument that part of fixing this is the transparency question or issue, meaning that if there was full transparency on benefits and costs and prior authorization, everything, that we would be able to address this as a country, as a Congress, in ways that we currently aren't. Part of where this is playing out is Medicare Advantage, and so I wanted to get into that with you. In general, though, would you say that this corporate takeover of healthcare is increasing costs?
Speaker 75
What about care? Is care getting better? Is it the same? Is it getting worse?
Sophia Tripoli
It is in some places staying stagnant, but on many key indicators, it's getting worse.
Sophia Tripoli
Yes, these corporate institutions, whether it's plans, systems, drug companies, are making profit.
Speaker 77
Let's get into Medicare Advantage because the transparency piece should be much easier for us with Medicare Advantage. They're using, it is private health insurance, correct?
Speaker 76
Do you think, based on all your research, that everybody who enrolls understands that it's private health insurance?
Sophia Tripoli
I think there's some probably some level of understanding, but what that means in terms of the comparisons, I think there's an overwhelming number of choices for seniors when they go to enroll on the Medicare Advantage side and on the traditional Medicare side. And so it is a lot to navigate through for seniors and to make a choice that's going to make sense for them.
Greg Landsman
Do you think there's sufficient understanding as to, based on your research, what they're getting from Medicare Advantage versus what they could be getting if they actually had Medicare, which is, you know, not private health insurance, it's Medicare? Do you think there's full understanding? Maybe they understand that it's private insurance, but do they understand the differences in terms of benefits, in terms of the network, in terms of prior authorization rates? I mean, are those comparisons provided to seniors?
Sophia Tripoli
I think the comparisons provided are very challenging to navigate. Plus, if you bring in agents and brokers who have a financial incentive to steer patients and seniors into certain MA plans for their own financial gain, it complicates the issue. And so we do have many examples of seniors who think they're getting a supplemental benefit and enroll into an MA plan and get there only to find out that, in fact, that supplemental benefit doesn't exist.
So it is the reason we need a lot of transparency over MA in a whole variety of data points so that consumers and seniors when they're going to shop, they actually can make a much more informed decision and are not only steered by agents and brokers' financial incentives.
Greg Landsman
I would think that the American people would not only understand but expect the federal government to require a private insurer who's using the name Medicare to provide all of the data necessary so that seniors have a full understanding of what they're buying, which is full transparency in terms of costs, full transparency in terms of benefits, what benefits actually get used versus the amount of money they're spending on the marketing of these benefits, the comparative advantage when it comes to the networks, pre-authorization rates, those kinds of things should be immediately available to seniors. That would make a big difference in terms of them deciding what's best for them, correct?
Correct.
Greg Landsman
How do you think this committee, we've there's a whole host of bills, what do you think the most important thing this committee should do as it relates to Medicare Advantage and this issue of transparency?
Speaker 78
There's a couple things that are being some of the discussion drafts, all of the discussion drafts actually on Medicare Advantage that are for today are would be incredibly important. More transparency information around care denials, better and stronger encounter data, and I would recommend including an enforcement mechanism to apply financial penalties on MA plans who don't comply with who are already required to report encounter data. That helps crack down on the coding abuses and helps to get to a much more sane MA payment, accurate payment system, as well as I think increased transparency over medical loss ratio and how MA plans are spending their premium requirements, all very important.
Sophia Tripoli
Super helpful. Before I yield back, our bill, Medicare Advantage Consumer Protection Transparency Act, would require MA plans to be transparent, submit detailed information to CMS about the supplemental benefits usage offered, usage of supplemental benefits, number of patients covered, denials and pre-authorization requests. I think you spoke to those. With that, I yield back.
Greg Landsman
Appreciated. And now recognize the gentleman from Florida, Mr. Bilirakis, for his five minutes of questioning.
Thank you, Mr. Chairman. Appreciate it very much. Healthcare affordability remains one of the biggest challenges facing patients in the state of Florida and across the country. I think all of you know that. Every year, families face high premiums, higher deductibles, and higher out-of-pocket costs, while employers struggle to keep coverage affordable for their workers.
At the same time, our healthcare system has become increasingly complex. Patients often have little visibility into the cost of care before they receive it, and employers often lack access to the information they need to evaluate the cost and quality of the coverage they provide. I think we can all agree on that. These challenges can be especially difficult for communities like those I represent in Florida, Florida's 12th Congressional District, which includes the Nature Coast and the Tampa Bay area, as well as again as healthcare markets become more concentrated, patients in suburban and rural communities can face fewer choices, higher costs, and greater challenges accessing care close to home. It's a big issue, transportation issue, it's a huge issue in Florida.
At the same time, independent physicians, community providers, and smaller healthcare facilities often struggle to compete against larger systems. For Congress to address these challenges effectively, we need a clear understanding of how prices are set, how healthcare markets are changing, and how those changes affect affordability and access to care. So I want to thank all the presenters today. And thank you, Mr. Chairman, for holding this hearing. And I have a question for Dr. Whaley.
Gus Bilirakis
So I want to thank all the presenters today, and thank you, Mr. Chairman, for holding this hearing. And I have a question for Dr. Whaley. Your testimony notes that higher prices are often not associated with better quality outcomes. If quality is not the primary driver, what factors are contributing to higher prices in many markets?
Christopher Whaley
We know that prices are highly variable and are not linked to quality or not linked to things like cost-shifting, but instead a key contributor is consolidation and market power.
Speaker 84
Yeah. Okay, the follow-up is, how can more transparent pricing information help employers direct their employees toward high-quality, lower-cost providers, and do you have any examples you can share from your research where employers have been able to leverage this data?
Christopher Whaley
One example comes from the 32BJ Health Fund, which was able to get access to their own claims data. And when they looked at their data, they realized that there was one hospital in the network that was particularly and excessively higher priced. And so they used their data and actually decided to exclude that hospital in favor of other hospitals in their market. And as a result, they saved $100 million, which they passed on to their workers and their families.
Gus Bilirakis
Thank you. Next question is for Mr. Greminger. I hope I got that right. Your testimony notes that many employers lack access to complete information about the health plans they fund. And the question is, what barriers are preventing employers from obtaining that information?
Shawn Gremminger
Thank you very much, Congressman. You got the name right. In general, what we see is that the health plans themselves or their TPAs just simply refuse to provide access, or if they do, they will often put up other significant barriers. They'll say, we can only provide kind of a higher level of access at sort of an aggregate level, or we're going to charge you a substantial amount of money if you want to have full access to your own claims data. Rarely is it just a straight-up no.
It's often a, you know, here's what we can provide, and if you want to pay more or you want to sue us, we'll provide more than that. This is why we're so supportive of the Patients Before Price Tags Act, because we think it would finally get rid of the game that employers themselves have to play.
Speaker 83
Gentleman yields back. Now recognize the gentlelady from New York, Ms. Ocasio-Cortez, for her five minutes of questioning.
Alexandria Ocasio-Cortez
Thank you so much, Madam Chairman. Just one moment. Okay, thank you. I also want to thank the committee leadership for including my bill in today's hearing as well. And I want to talk about an aspect of Medicare Advantage today that we actually haven't focused on much this Congress, and that's on the agents and brokers who sell Medicare Advantage plans.
Now, Dr. Whaley, when someone turns 65, they're often inundated with all sorts of information about the different Medicare Advantage plans available to them, correct?
That's correct.
Speaker 85
And so people, I mean, you turn on daytime television and you've got all these celebrities, you've got Joe Namath and William Shatner talking to you about Medicare Advantage plans. You get lots of mail. People really start getting tons of marketing about these plans. And because of the money, the amount of money that these for-profit insurers invest in marketing, many people don't understand, to my colleague from Ohio's point, that Medicare Advantage is not Medicare.
Correct.
Speaker 81
Now, Dr. Whaley, if I'm turning 65 and I don't know the difference between Medicare and Medicare Advantage, I'm faced with sorting through dozens of these plans and marketing. And that's where we encounter this issue of agents and brokers. Dr. Whaley, in theory, agents and brokers work with everyday people enrolling in a Medicare plan that are there to help them pick the best plan for their health, right? Ostensibly.
I think that's how we'd like it to work.
Speaker 85
Ostensibly, that is how it's supposed to be set up. What gets complicated is that the agents and brokers are paid by the health insurers for enrolling individuals in specific plans. That means that their decision-making could potentially be clouded by compensation offered by these for-profit health insurers. And in fact, some of these individual companies, say you have a Blue Cross Blue Shield Medicare Advantage plan, or any other kind of company, United Healthcare managed MA plan, they often will provide these kinds of kickbacks to the brokers that enroll people in their preferred plan, right?
That's correct.
Speaker 85
And what are some examples of the compensation provided to these agents and brokers when they enroll individuals in any given Medicare Advantage plan?
Speaker 88
They can include direct fees of up to hundreds of dollars, or they can include things like conferences at ski trips and all that type of stuff.
Speaker 86
So like trips, you said. And almost, it's almost like a back-door commission type of setup, right?
I think that's a good assessment.
Speaker 85
And so you're supposed to have the agents and brokers that are talking to your mom or your grandparent saying, "We'd like to enroll you, we think this plan is what's best for you." But what that person doesn't know is that United Healthcare is saying, "We'll give you a vacation if you enroll people in our plan," or, "We'll give you a couple of extra hundred dollars if you enroll someone in a Blue Cross Blue Shield or United plan, or any other number of plans." And in your testimony, you stated that agents and brokers have received 10 billion dollars in this kind of compensation in 2022 alone, right?
Speaker 85
That's 10 billion dollars in taxpayer money. That's being, a lot of it is being funneled through these corporations. And so that is money that is not going to care. It's going to perks and trips to Boca and financial incentives for brokers to enroll people out of traditional Medicare and into for-profit Medicare Advantage plans. That's almost three times, 10 billion is almost three times what they were compensated in 2014.
So not only is this amount a lot, it is exploding. And Dr. Whaley, they actually aren't fiduciaries either, these agents and brokers. So they have no obligation to the people that they are allegedly supposed to help, correct?
Unfortunately, that is correct.
Speaker 85
So I have a sensible piece of legislation that would make a lot, and I know there are a lot of good agents and brokers out there, but from a policymaking perspective, we shouldn't be relying on people to just do the right thing. We do have compensation today that, or rather legislation today that limits and redefines what those caps are so that we can introduce some accountability into this system. And I hope we can have some bipartisan agreement on that. Thank you.
Erin Houchin
Gentlelady yields back. Now recognize the gentlelady from Indiana, Ms. Houchin, for her five minutes.
Thank you, Mr. Chairman. This hearing advances an important part of the subcommittee's ongoing effort to improve healthcare affordability and empower patients to make informed decisions. And the diagnosis hasn't changed. Prices are high, widely variable, and not connected to quality. In most markets, consumers can compare prices before making purchases, but in healthcare, that information remains opaque, difficult to access, and even harder to understand.
Hospital prices have outpaced inflation by more than double over the last decade, two decades. And as big systems have consolidated, independent physicians have been squeezed. Their reimbursements haven't kept pace with the cost of running a practice, so they sell to larger systems, reducing competition in the marketplace and causing prices to go up yet again. Now, transparency is not the whole answer. Every witness here agrees on that, I would think.
But the precondition of transparency is connected to every other issue and every other answer. You cannot have a competitive market when one side of the table can hide the price. That's why legislation like the Patients Deserve Price Tags Act is so important. Transparency only works if it is complete, accurate, and enforceable. By requiring hospitals, insurers, and other healthcare entities to publicly disclose pricing information in a standardized format and by imposing consequences for those who fail to comply, this bill would help hold industry participants accountable while giving patients the information they need to make informed decisions about their care.
This legislation ensures that transparency requirements are not mere suggestions, but enforceable obligations that bring greater accountability to the healthcare marketplace. And I'd like to thank my colleague, Congressman John James, for his work on the bill. We spend a lot of energy asking hospitals to post their prices, and rightly so. But the plan a family chooses is one of the most consequential decisions that they make, and they often make it blindly. And make it blind to how aggressively the plan denies care or uses prior authorization.
The drafts before us would require insurers and Medicare Advantage plans to disclose their denial rates, appeal outcomes, and turnaround times. My first question is for Dr. Ippolito. From a market design standpoint, why does that information matter? And what happens to a plan's incentives when enrollees can finally see it?
Benedict Ippolito
Well, it's a measure of generosity, just like how many hospitals are in the network, which hospitals are in the network, how high is the cost sharing. All of those things matter to patients. We've seen surveys where patients are very clear. They care a lot about prior authorization and denials, but if it's not observable to them, they can't signal their preferences to insurers. They can't direct them to design the plans they want.
So it seems first order to me.
Erin Houchin
Thank you. And you've cautioned that reporting requirements should be kept as simple as possible, something like an above average, average, below average rating so people can easily understand it. Could you walk us through what that useful plain language might look like for disclosure versus a just a kind of data dump that complies but doesn't really tell people anything?
Benedict Ippolito
Yeah, one of the lessons we've had over time is that consumers, they do respond very, very clearly to price signals, but they do it much better when they have relatively straightforward signals. When we have a choice to go in-network versus out-of-network, we all tend to go in-network because it's cheaper.
When we have a choice between a brand drug and a generic drug, the vast majority of us pick the brand or the generic drug because it's much cheaper, right? It's the exact same concept. Keep it simple and people respond to the incentive.
Erin Houchin
And simplification would be important because we wouldn't want to have transparency that that they might just throw all the data at us and then we're still in the dark in terms of our ability to understand what's in what we're looking at.
Benedict Ippolito
Yeah, I still have some confidence that a third party could could deal with that and simplify it for us, but it would be much better for just from the get-go do it the best way possible, as simple as possible.
Erin Houchin
Dr. Gr- or Mr. Gremminger, your members are the employers footing the bill. The draft would make insurers publish how much of every premium dollar actually goes to care versus overhead and retained profit. From where you sit, would that change which carriers employers would be willing to buy from?
Shawn Gremminger
Yeah, I think I think it would and I I love the legislation. You know, there's a lot of things that go into a decision that an employers will make about which plan they're going to choose to use, you know, overall coverage, quality of the of the employers, how much we're paying in premiums. But I think it's really critical for us to know effectively just how competitive is this organization and how how much of the money is just going to overhead that we don't know about.
Erin Houchin
Thank you. This seems pretty common sense to me, but I do appreciate your thoughts and your engagement on the issue. I look forward to continuing to working with all of you as we hopefully move this legislation forward. Thank you, I yield back.
Speaker 91
Gentlelady yields back. Now recognize the gentleman from Massachusetts, Mr. Auchincloss, for his five minutes of questioning.
Jake Auchincloss
Thank you, Chairman. This question actually anybody can take it. I didn't see any mention in the testimony about NADAC reporting, National Average Drug Acquisition Cost reporting. But if we're going to get traction on transparency for drug pricing, particularly for reimbursement to pharmacists and for copays for patients, we got to understand what the actual cost of goods sold is. And right now NADAC reporting for pharmacies is voluntary, it's inconsistent, subject to games being played.
And, you know, I've got legislation under the Pharmacists Fight Back Act and and there's been other examples of bipartisan legislation to make NADAC reporting mandatory and also to broaden its scope so that we actually just understand what the actual acquisition cost is of these drugs. Do any of you want to speak on the importance of NADAC reporting, Mr. Gremminger?
Shawn Gremminger
Thank you very much, Congressman. I'm a big fan of of NADAC as a as a benchmark. As you all as you know, most of the other benchmarks that are available out there, WAC, average sales price, etc., are highly gameable. NADAC you can game, but it is actually based on a survey of sort of what a sort of unleveraged pharmacy is able to buy a drug for. Just as we heard earlier, you know, the way in which hospital prices are negotiated is highly variable and so the kind of output is very difficult to understand how we got there.
Same thing very much occurs on the on the drug side. I love the idea of getting to a standard place and I think NADAC is the right place.
Speaker 94
Minnesota recently promulgated some rules on NADAC reporting, which I think are probably the the most expansive of any of the fifty states. This is very wonky, so I don't expect if you don't have any comments that's fine, but does anybody want to talk about whether Minnesota could be a basis for a national law? Ms. Skanes, I think you had comments.
Carol Skeenes
Yeah, thank you for the question. I think in general the stance at Turquoise is if the data is available, let's grab it and analyze it and see what additional transparency can be gleaned from it. There there's a lack of information around prescription drug pricing and and transparency. So any of that, you know, even if it's one state, then we can start there and expand it accordingly.
Speaker 93
Anybody anyone has specific comments on Minnesota? Well, we're talking about transparency and simplicity and is an important element of health care. So I got to talk about 340B, maybe the least transparent, least simple element of our drug pricing system.
And you know, there's been a lot of light and heat on this, partly because of the proposed rebate program from the administration and because of discussions here in Congress, both House and Senate, on what can be done. Mr. Greminger, do you and I'll let others as well want to comment on how we should be thinking about the 340B program?
Shawn Gremminger
As you know, I have a lot to say about this program, but I'll say just as it relates to the rebate program, and it actually highly relates to what's going on in this hearing. Employers have a difficult time accessing their own claims data right now. We have almost no ability to understand the degree to which 340B is impacting us. In part, whenever a drug is sold through 340B, we lose access to the rebates, the discounts that we would otherwise get. The cost of that is significant, and yet it's almost impossible for an employer to track.
The rebate model or similar legislation would enable employers to finally understand what's going on and then try to create plan design to mitigate the impact.
Dr. Whaley.
Christopher Whaley
My own research shows that if you're a cancer patient who gets care at a 340B hospital, the markup on your drugs is almost 700%. And so while I think it's appropriate for hospitals to get revenue, I think it's a very open and challenging question of whether or not cancer patients should be the ones essentially financing the hospital.
Speaker 93
Yeah. We've talked a lot about transparency and simplicity for prices, which agreed. I think it's also an increasingly just as salient to my constituents as about process, and in particular, prior authorization. In addition to not understanding how a bill came, also not understanding why you're being denied care is immensely frustrating for people. And I would just highlight, I don't have a question based on this, but I would highlight that not included in these bills is really strong bipartisan prior auth legislation being that has been proposed by my colleague Susan DelBene from the state of Washington.
I myself am going to be putting forward prior authorization legislation for MCOs and Medicare Part D. But people really deserve electronic, in real-time, evidence-based, human-in-the-loop, accountable prior auth decisions. Because right now, the single biggest use of AI in healthcare that I can see is basically insurance companies playing games with it to deny care. And that would be such a disappointing outcome from what could I think be a helpful technology, but right now it's being used for revenue cycle management. We got to change that arc.
I yield back.
Speaker 95
Gentleman yields back. Now recognizes gentlelady of Texas, Ms. Fletcher, for her five minutes of questioning.
Lizzie Fletcher
Well, thank you, Mr. Chairman, and thank you to our witnesses. This has been a very useful hearing, and I think we've covered a lot of ground here. And it's a hugely important topic, something that I hear about from my constituents all the time. And you've heard I think a lot of bipartisan agreement today, as there has been on this topic for a long time. So I do hope that we can move forward on some of the thoughtful recommendations and ideas that we've heard not only today, but over the last several years.
And as this hearing comes to a close, I just I do want to take a minute to bring it back to where where we started, which is we are in a healthcare affordability crisis. And transparency is a part of the answer, but it isn't all of the answer. And I so appreciated the comments from Mr. Auchincloss just now about prior authorizations. That's something I hear from my constituents, both the physicians and the patients. I represent a lot of physicians.
I represent Houston and have the district right outside the Texas Medical Center. So I have a lot of physicians I represent who are so frustrated that they can't give the patients the care they need, and they spend so much of their time trying to get authorization for the care they know their patients need through the insurance companies. And I think it's this overall transparency. We had a conversation just the other day about the challenges in kind of the shorthand of Medicare for All, which of course is just the payer side of the equation.
And there's so much else that we don't understand. And I think it's a shorthand for healthcare for all. Everyone should have access to affordable healthcare and they should be able to get the care they need and understand the costs, the rationale, the coverage options that they have. So the conversation about Medicare Advantage also hugely important. But as we know, healthcare costs continue to go up even with all of these good legislative ideas.
And we cannot ignore the fact that a huge part of the reason these healthcare costs are going up is because this is an ecosystem and the decisions that this Congress has made in the last year, year and a half to drastically cut funding for Medicaid, which the estimates are that 10 million Americans are going to lose healthcare coverage because of those cuts. But also the elimination of the tax credits relating to the Affordable Care Act's enhanced premium tax credit program. In my district, that was 125,000 people who were relying on those tax credits. And so they're facing increased costs. They're getting worse plans for more money and less coverage because they can't afford their healthcare.
And it's estimated that that's more than 4 million Americans that are going to be in that situation. And they don't even cover, those numbers don't cover the people who are forced to change their plans because they're all becoming more unaffordable. I know too, hearing from the folks who work in our hospitals in Texas where we already have the highest uninsured rate in the country, as I'm sure you all know, that those rates are going up even more and that our hospitals are seeing an increased number of uninsured patients and that's increasing their uncompensated care costs. All of this is an ecosystem and what decisions we make in one area affect decisions in another. And so as we work to address costs and transparency, we also have to address what is driving up costs.
And it's just one piece of it. And so I do think it's critically important. I feel like we've heard a lot of really interesting and important testimony today. And so Ms. Tripoli, I just want to end the hearing and my time with you with a question. If you could just answer whether there's anything you feel like we didn't touch on in the hearing today about how healthcare consumers that you work with and your organization works with have been impacted by these healthcare cuts.
If there's anything that we haven't covered in this hearing today that you think is important for us to know or any most salient points you just want to make sure that we have clarity on as we end this hearing.
Sophia Tripoli
Thank you. I mean, I would say first and foremost, consistent with what we have talked today is that there is a suite of legislation discussion draft, a discussion today, much of it which should move forward and is an important step in addressing the affordability crisis, not sufficient, but a majorly important step. Second, in terms of the cuts, we know that the cuts, obviously the trillions of dollars of healthcare cuts in Medicaid are having an incredible harm on people. Up to 10 million people are likely to lose coverage. We just saw an interim final rule come out from the administration just a couple weeks ago going even further than HR 1, putting paperwork upon paperwork for beneficiaries to maintain their Medicaid coverage.
And we are now going to see, they're already seeing the effects of what happened with the expiration of the enhanced premium tax credits. Over a million people less enrolled this year than last year because those tax credits did expire. And as new, the final data comes out over the next, over the summer, we expect to see that much, much higher. So this is in fact, there are significant harm that's ongoing and that we will continue to see this year from the HR 1 bill that was enacted last year as well as the failure to extend the premium tax credits.
Lizzie Fletcher
Thank you, Ms. Tripoli. And with that, I've gone over my time. So I thank you, Mr. Chairman, for allowing me to ask that final question as we close the hearing.
Thank you and I yield back.
H. Griffith
Gentlelady yields back and that concludes our time of questions. I would ask unanimous consent to insert into the record the documents included on the staff hearing document list. Without objection, so ordered. I would like to thank all of our witnesses once again for being here today. Members may have additional written questions for you.
I'll remind members they have 10 business days to submit questions for the record. I ask the witnesses to respond to those questions promptly. Members should submit their questions by the close of business on Friday, June 26th. Without objection, subcommittee is adjourned.
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