WHAT’S THE COST?: PROPOSALS TO 

PROVIDE CONSUMERS WITH BETTER 

INFORMATION ABOUT HEALTHCARE 

SERVICE COSTS 

HEARING 

BEFORE THE 

SUBCOMMITTEE ON HEALTH 

OF THE 

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED NINTH CONGRESS 

SECOND SESSION 

MARCH 15, 2006 

Serial No. 109-70 

Printed for the use of the Committee on Energy and Commerce 

Available via the World Wide Web: http://www.access.gpo.gov/congress/house 

U.S. GOVERNMENT PRINTING OFFICE 

WASHINGTON : 2006 

For sale by the Superintendent of Documents, U.S. Government Printing Office 

Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC area (202) 512-1800 

Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001 

27-590PDF 
COMMITTEE ON ENERGY AND COMMERCE 

JOE BARTON, Texas, Chairman 

RALPH M. HALL, Texas 

MICHAEL BILIRAKIS, Florida 

 Vice Chairman 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

PAUL E. GILLMOR, Ohio 

NATHAN DEAL, Georgia 

ED WHITFIELD, Kentucky 

CHARLIE NORWOOD, Georgia 

BARBARA CUBIN, Wyoming 

JOHN SHIMKUS, Illinois 

HEATHER WILSON, New Mexico 

JOHN B. SHADEGG, Arizona 

CHARLES W. “CHIP” PICKERING, Mississippi 

 Vice Chairman

VITO FOSSELLA, New York 

ROY BLUNT, Missouri

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

CHARLES F. BASS, New Hampshire 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE FERGUSON, New Jersey 

MIKE ROGERS, Michigan 

C.L. “BUTCH” OTTER, Idaho 

SUE MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

JOHN D. DINGELL, Michigan 

 Ranking Member 

HENRY A. WAXMAN, California 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

EDOLPHUS TOWNS, New York 

FRANK PALLONE, JR., New Jersey 

SHERROD BROWN, Ohio 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

ALBERT R. WYNN, Maryland 

GENE GREEN, Texas 

TED STRICKLAND, Ohio 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MIKE DOYLE, Pennsylvania 

TOM ALLEN, Maine 

JIM DAVIS, Florida 

JAN SCHAKOWSKY, Illinois 

HILDA L. SOLIS, California 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

BUD ALBRIGHT, Staff Director 

DAVID CAVICKE, General Counsel

REID P. F. STUNTZ, Minority Staff Director and Chief Counsel

SUBCOMMITTEE ON HEALTH 

NATHAN DEAL, Georgia, Chairman 

RALPH M. HALL, Texas 

MICHAEL BILIRAKIS, Florida 

FRED UPTON, Michigan 

PAUL E. GILLMOR, Ohio 

CHARLIE NORWOOD, Georgia 

BARBARA CUBIN, Wyoming 

JOHN SHIMKUS, Illinois 

JOHN B. SHADEGG, Arizona 

CHARLES W. “CHIP” PICKERING, Mississippi 

STEVE BUYER, Indiana 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO, California 

MIKE FERGUSON, New Jersey 

MIKE ROGERS, Michigan 

SUE MYRICK, North Carolina 

MICHAEL C. BURGESS, Texas 

JOE BARTON, Texas 

 (EX OFFICIO)

SHERROD BROWN, Ohio 

 Ranking Member 

HENRY A. WAXMAN, California 

EDOLPHUS TOWNS, New York 

FRANK PALLONE, JR., New Jersey 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

GENE GREEN, Texas 

TED STRICKLAND, Ohio 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

TOM ALLEN, Maine 

JIM DAVIS, Florida 

TAMMY BALDWIN, Wisconsin 

JOHN D. DINGELL, Michigan 

 (EX OFFICIO)

(II)
CONTENTS 

Page 

Testimony of: 

Lipinski, Hon. Daniel, Member, U.S. House of Representatives ..................................... 23 

Gingrich, Hon. Newt, Former Speaker of the House, Founder, Center for Health 

Transformation .............................................................................................................. 30 

Gedwed, William, Chairman, President and CEO, UICI .................................................. 35 

Ginsburg, Paul B.,President, Center for Studying Health System Change ....................... 41 

MacDonald, Dr. David, President, Liberty Health Group ................................................. 48 

Collins, Dr. Sara R., Senior Program Officer, Future of Health Insurance, The 

Commonwealth Fund .................................................................................................... 54 

Goodman, Dr. John, President and CEO, National Center for Policy Analysis ............... 93 

Anderson, Dr. Gerard F., Johns Hopkins Bloomberg School of Public Health, Health 

Policy and Management ................................................................................................ 99 

Additional material submitted for the record: 

Inglis, Bob, prepared statement of ..................................................................................... 129 

(III) 

(1) 

WHAT’S THE COST?: PROPOSALS TO 

PROVIDE CONSUMERS WITH BETTER 

INFORMATION ABOUT HEALTHCARE 

SERVICE COSTS 

WEDNESDAY, MARCH 15, 2006 

HOUSE OF REPRESENTATIVES, 

COMMITTEE ON ENERGY AND COMMERCE, 

SUBCOMMITTEE ON HEALTH, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:03 a.m., in Room 2123 

of the Rayburn House Office Building, Hon. Nathan Deal (chairman) 

presiding. 

 Members present: Representatives Bilirakis, Shimkus, Pitts, Bono, 

Burgess, Barton (ex officio), Brown, Waxman, Pallone, Green, Capps, 

Allen, Baldwin, Dingell (ex officio), and Deal. 

 Staff present: Chuck Clapton, Chief Counsel for Health; Melissa 

Bartlett, Counsel; Ryan Long, Counsel; Nandan Kenkeremath, Counsel; 

Bill O’Brien, Legislative Analyst; David Rosenfeld, Counsel; Brandon 

Clark, Policy Coordinator; Chad Grant, Legislative Clerk; John Ford, 

Minority Counsel; Chris Knauer, Minority Investigator; Purvee Kempf, 

Minority Counsel; Amy Hall, Minority Professional Staff Member; 

Bridgett Taylor, Minority Professional Staff Member; Jessica McNiece, 

Minority Research Assistant; and Jonathan Brater, Minority Staff 

Assistant. 

MR. DEAL. We will welcome our guests to our members of our 

distinguished panel this morning and some are not here and will be 

joining us hopefully before the opening statements are concluded. 

 I recognize myself at this time for an opening statement. 

 Certainly, I think all of us are concerned with the subject that is the 

text for the hearing today and that is how to best increase the level of 

transparency in our health care delivery system. We all know that in 

order for markets to function properly, consumers must have information 

about the goods and services they are purchasing, and the health care 

market is no exception to that rule. Each year, Americans spend over $2 

trillion on their health care, which accounts for 16 percent of our annual 

gross domestic product. Despite the unmountable importance of these 

purchasing decisions, it is virtually impossible for the average American 
2

consumer to find any quality or pricing information about health care 

providers. This situation is unacceptable and I hope will soon change. 

 American consumers have the right to choose their health care 

providers and these consumers deserve to know pricing and quality 

information about these providers so that they can make the right 

decisions. No one purchases a car without first gathering information on 

the prices and quality of the different available models. Why should 

health care be any different? If one hospital charges several thousand 

dollars more for the same procedure, shouldn’t the consumer have access 

to this information? If I am paying for it, out of my own pocket, I would 

like to know that. If one surgeon is significantly more successful at 

performing a certain procedure than another surgeon, shouldn’t the 

consumer have access to this information as well? If it is a member of 

your family or if it is you, I think all of us would agree we would like to 

know that. 

 At a recent visit to one of the largest hospitals in my congressional 

district, the administrator stated that one of their biggest concerns was 

that 90 percent of their self pay patients, which are mainly patients 

without health insurance, never paid for any of the services they 

received. Well, in some ways that is not surprising given the fact that we 

really know that these people are asked to pay some two to four times as 

much as those patients with similar procedures who have health 

insurance. It simply doesn’t make any sense to charge people that cannot 

afford health insurance or choose to pay for some procedures out of 

pocket much more for the same procedure. The uninsured deserve to 

know what prices they are going to pay. I believe that if these patients 

had access to meaningful and understandable pricing and quality 

information, providers would no longer be able to get away with this 

kind of injustice. As we have seen in so many other areas, empowered 

consumers increase the level of quality when driving out inefficiencies 

and waste. It is my hope that we can do the same thing in health care. 

 Again, I want to welcome our witnesses and at this time, I would 

recognize my friend from California, Mr. Waxman, for an opening 

statement. 

 [The prepared statement of Hon. Nathan Deal follows:] 

PREPARED STATEMENT OF THE HON. NATHAN DEAL, CHAIRMAN, SUBCOMMITTEE ON 

HEALTH

3⁄4 The Committee will come to order, and the Chair recognizes himself for an 

opening statement. 

3⁄4 I am proud to say that we have a very distinguished and expert panel of 

witnesses appearing before us today that will help us explore how to best 

increase the level of transparency in our healthcare delivery system. 
3

3⁄4 We all know that in order for markets to function properly, consumers must 

have information about the goods and services that they are purchasing, and the 

healthcare market is no exception to this rule. 

3⁄4 Each year, Americans spend over $2 trillion on their healthcare, which 

accounts for 16% of our annual Gross Domestic Product. 

3⁄4 Despite the undeniable importance of these purchasing decisions, it is virtually 

impossible for the average American consumer to find any quality or pricing 

information about healthcare providers. 

3⁄4 This situation is unacceptable and must change. 

3⁄4 American consumers have the right to choose their healthcare providers, and 

these consumers deserve to know pricing and quality information about these 

providers so that they can make the right decision. 

3⁄4 No one purchases a car without first gathering information on the prices and 

quality of the different available models. 

3⁄4 Why should healthcare be any different? 

3⁄4 If one hospital charges several thousand dollars more for the same procedure, 

shouldn’t the consumer have access to this information? 

o If I’m paying for it out of my own pocket, I know I would like to 

know. 

3⁄4 If one surgeon is significantly more successful at performing a certain 

procedure than another surgeon, shouldn’t the consumer have access to this 

information? 

o If it’s my son or daughter having this procedure done, I know I would 

like to know 

3⁄4 At a recent visit to one of the largest hospitals in my district, an administrator 

stated that one of their biggest concerns was that 90% of their “self-pay” 

patients, which are mainly patients without health insurance, never paid for the 

services they received. 

3⁄4 Of course, this isn’t too surprising given the fact that self-pay patients are often 

forced to pay between 2 and 4 times more for the same procedure than a patient 

with health insurance. 

3⁄4 It simply doesn’t make any sense to charge people that cannot afford health 

insurance or choose to pay for some procedures out-of-pocket so much more 

for the same procedure. 

3⁄4 The uninsured deserve to know what prices they are going to pay, and I believe 

that if these patients had access to meaningful and understandable pricing and 

quality information, providers would no longer be able to get away with this 

injustice. 

3⁄4 As we have seen in so many other areas, empowered consumers increased the 

level of quality while driving out inefficiencies and waste. 

3⁄4 And it is my hope that we can do the same thing for healthcare. 

3⁄4 Again, I welcome our witnesses and thank them for their participation. 

3⁄4 I now recognize my friend from Ohio, Mr. Brown, for five minutes for his 

opening statement. 

 MR. WAXMAN. Mr. Chairman, since Mr. Brown may yet arrive 

would you give me the three minutes rather than five minutes? 

 MR. DEAL. Certainly. 

 MR. WAXMAN. This hearing is a worthwhile one to have. 

Transparency in prices is good. In some cases, particularly in the area of 

drug prices, it can be a benefit to the consumer. But no one should think 
4

that the topic we are addressing today comes to grips with the serious 

issues facing our health care system. Transparency in prices doesn’t 

provide health insurance coverage for the nearly 46 million Americans 

that are uninsured in this country today. Transparency in prices is no 

substitute for real coverage. Transparency in prices doesn’t give the 

individual the ability to negotiate in any effective way. Individuals need 

the negotiating power of a group to secure good prices. Employer 

sponsored group health insurance can negotiate meaningful discounts, 

individuals cannot. 

 And transparency in prices does not make them lower. We only 

need to look at the recent reports of the pricing policy of Genentech for 

its cancer drug Avastan. Why the $100,000 price and dramatic increase 

this year? Because a manufacturer decided it could get away with it. 

That is the reason, pure and simple. So transparency of price is not going 

to help that woman with breast cancer or the man dying of lung cancer. 

This is the kind of cost that won’t be effectively addressed unless 

someone who has strong negotiating power enters the picture. 

 It is ironic that this Republican Congress turned its back on giving 

the Secretary of HHS the authority to use the negotiating power of 40 

million Medicare beneficiaries to get lower drug prices. And it is equally 

ironic that the actual deals and rebates that the private insurance plans are 

negotiating with the drug companies are not made available to the public. 

Instead, we get a list of prices that can be changed by the plans at any 

point. 

 So that just points out several concerns that we have got to keep in 

mind when we hear of the value of transparency in prices. It is no 

substitute for real negotiation. What benefit it can provide is limited. It 

only helps if it is accurate, does not change, and is in useable form. It 

does not help if the information is so voluminous and confusing that the 

average person cannot use it. It does not help if it is not related in a 

meaningful way to quality measures. And it certainly does not help if it 

is really an excuse to justify putting more of the burden of the costs of 

the health care system on the individual. High deductible health plans 

are exactly the wrong answer when people need affordable coverage. 

Putting the individual out there on his own to negotiate better deals from 

the health care system is exactly contrary to what works. 

 So I welcome transparency in prices so long as we all understand 

that is an approach that offers some slight advantage at the margin but it 

should never be confused with an answer to the real problems of the high 

costs of health care and of the millions of Americans who are uninsured 

or underinsured in America today. 

 MR. DEAL. I thank the gentleman. 

 Mr. Bilirakis is recognized for an opening statement. 
5

 MR. BILIRAKIS. Thank you, Mr. Chairman. 

 How much does it cost? That is the question we ask almost daily. 

Why? Because we are smart consumers and want to know that we are 

getting the most bang for our hard earned bucks. This often does not 

apply, however, when talking about health care costs. Too many 

consumers have become oblivious as to how much our health care 

actually costs. We may know that we have to pay a co-pay to visit the 

doctor or go to the hospital but we do not know how much the tests they 

run or surgeons they provide actually cost, or who really pays for them. 

In many cases, it is not because we do not want to know, it is because 

pricing information is difficult to find or not available at all. I hope that 

is beginning to change. 

 We will hear from our former colleague and House Speaker Newt 

Gingrich in a few moments about how health savings accounts in his 

words have unleashed the value driven American consumer on the 

efficient health care market. I agree with Speaker Gingrich when he 

recently wrote that every American has their right to know price and 

quality information before making their health care purchases. I am 

pleased that Florida, led by Governor Jeb Bush, has been a national 

leader when it comes to increasing transparency in health care pricing. 

My State has established a website at Floridacomparecare.com which 

allows Floridians to research prices for various medical procedures at 

State hospitals and compare hospital to hospital patient outcomes in the 

State. Florida’s Attorney General Charlie Crist, and the State’s Agency 

for Health Care Administration, created a website at Myfloridarx.com to 

help consumers shop for the lowest prices in the area for prescription 

drugs. This prescription drug website provides pricing information on 

the 50 most commonly used prescription drugs in Florida. 

 Mr. Chairman, I am eager to hear today’s witness and believe giving 

consumers better information about their health care costs can improve 

health care quality and lower prices. I look forward to working with you, 

Mr. Chairman, and members of the committee as we determine how to 

better educate consumers about their health care choices and the 

increased transparency in health care costs. 

 Thank you, Mr. Chairman. 

 MR. DEAL. I thank the gentleman. 

 Mr. Pallone is recognized. 

 MR. PALLONE. Thank you, Mr. Chairman. 

 According to my Republican colleagues if consumers have a greater 

financial stake in their health care and have access to better pricing 

information, they will be magically transformed into a Nation of health 

care bargain hunters that will help bring runaway health care costs under 

control. And I have to tell you, Mr. Chairman, I just do not buy it. I do 
6

not think it works that way. I made up a little chart over here on the left 

which I am going to use during questions which basically tries to point 

out that, you know, if you think about what the Republicans said, they 

said, okay, I am going to open up the Sunday paper, I am going to look at 

an ad like that, you know, buy two stents get free same day installation 

best buy and somehow, you know, it is as simple as saying two stents for 

the price of one in order to figure out how you are going to save costs. 

And I just do not buy it. Again, I am going to talk about that later during 

questions. 

 But first of all, our Nation is nowhere near providing patients with 

the pricing and quality information they need or in the context that they 

can easily understand. I recently heard someone liken shopping for 

health care to putting together a thousand piece jigsaw puzzle and it is 

just that complicated. And providing public access to a hospital’s charge 

master or price list I do not think changes that. 

 The second thing is who is going to want to buy a bargain basement 

pacemaker or get a mammogram done cheaply? When it comes to their 

health, people do not want, they want the best possible care available, not 

the cheapest care. A man who just had a heart attack is not going to shop 

around before he goes to the emergency room. Similarly, a woman who 

has a lump in her breast is not going to wait so she can search for the 

least costly biopsy. These people want to be treated for their illnesses as 

soon as possible. Even if consumers had access to pricing information 

and they were able to understand it and use it to shop around for low cost 

health care, consumer directed health plans would still do nothing to 

reign in out of control health care costs. That is because they do not 

address what is really driving health care spending; providing care for 

the elderly and people with chronic conditions. What my Republican 

colleagues suggest we force these people to clip coupons and shop 

around for their care. Just ask all the seniors that had to shop for a 

Medicare prescription drug plan how they would feel about doing that 

every time they needed to see a doctor. It would be chaos. 

 Now let us be honest about what is going on here. The truth of the 

matter is that consumer driven health plans are not about empowering 

consumers to take control over the health care nor is it about lowering 

prices. It is about shifting more health care costs onto the backs of those 

who were the most sick and the least able to afford it. And I do not think 

we should be fooled. The Republicans in this hearing today and their 

rhetoric, I think are trying to sell the American people a lemon. And this 

idea of this brave new world of consumer directed health care envisioned 

by my colleagues, I just do not think exists. It is not going to really 

result in any price reductions. 

 Thank you, Mr. Chairman. 
7

 MR. DEAL. I thank the gentleman. 

 We are pleased to have the Chairman of the full committee, Mr. 

Barton and I recognize him at this time for an opening statement. 

 CHAIRMAN BARTON. Thank you, Mr. Chairman. 

 I appreciate our panelists being here this morning. I am looking 

forward to hearing your testimony regarding the transparency in our 

health care market. 

 Unfortunately, the term health care market is an oxymoron in this 

country. Instead of a marketplace, we have a system that prevents 

patients from seeing how much their health care services actually cost. 

The health care system hides prices and it blurs quality and it is most 

perverse. The system treats the poorest like they were the richest and 

charges them the very most. 

 I can tell you personally that the moments during which a patient is 

not interested in learning the price of a health care procedure. I had a 

heart attack on December the 15th. When I was on the gurney in the 

emergency room at George Washington Hospital, I was not real 

interested in what the cost was. I was interested in what the quality was. 

As it turned out, what they billed Blue Cross Blue Shield was over 

$75,000. I think it was worth every penny of it but I do not know 

personally how much they actually paid, but I think it was worth every 

penny of it. It is a true statement though that if I had asked while I was 

in the emergency room what it was going to cost for these lifesaving 

procedures, nobody could have told me that was actually providing the 

treatment. The emergency room staff could not have told me, the doctor 

who provided the surgery procedure could not have told me, and quite 

frankly the hospital administrator could not have told me. And that is 

why health care costs are different from virtually from every other 

economic activity in our life. 

 Most of us would never agree to let a mechanic repair our car or 

have a plumber fix a leaky faucet without first receiving at least an 

estimate of what those expected costs would be. At the same time as I 

have just pointed out, we routinely seek treatment for vital health care 

services with no information about the comparative costs or the quality. 

And the power of the system is such that we never even think to ask. 

 I cannot think of another sector of our economy where consumers 

have less to say about it or have less say. By limiting patient’s access to 

comparative information, we restrict competition and cripple the ability 

of market forces to make health care more affordable. Not surprisingly, 

spending on health care has soared in this country, but does anybody 

here feel like the quality of the care has improved at the same rate as its 

cost? We deserve a better health care system which breaks through the 

conspiracy of silence regarding health care prices and quality. Too often 
8

patients are charged amounts that really do not accurately reflect real 

cost and rarely reflect the rate that providers are paid by private health 

insurers. These list charges should be shown the light of day to highlight 

their impact on unsuspecting consumers. 

 Uninsured individuals are sometimes charged the full amount of 

these charges while insured individual can still be effected by them if 

they go out of network or if your insure base is negotiated rates off of the 

list price. The Oversight and Investigations Subcommittee of this 

committee has done great work on this issue, and I would like to thank 

Congressman Whitfield and Congressman Greenwood, the former 

Subcommittee Chairman, for helping to bring to light some of the 

problems that we are talking about today. 

 We know that transparency in pricing does drive down the cost 

everywhere else in our economy. We have seen how better access to 

prices has allowed customers to receive lower prices for airline tickets, 

cars, and now even homes in some of the markets around our country. 

Price transparency forces sellers to compete and allows purchasers to 

negotiate better deals and save them more money. With increased 

transparency, consumers could examine pricing information. For 

example, to see that an arthroscopic surgery procedure must cost $5,000 

at one facility in Florida, while the same procedure in another facility in 

the same town is listed at $12,000. Rather than trying to regulate or 

restrict variations, consumers could simply be given the ability to see the 

differences and spend their health care dollars as they think they should. 

Maybe the $13,000 procedure is worth it. Maybe it features the world’s 

best surgeon. Who knows, but maybe it does not. If the patient does not 

see the value in spending the extra money, he or she should have the 

choice on spending less. 

 Some providers and insurance are already working towards greater 

transparency. We are going to hear from some of them today about what 

they are doing to show their enrollees the cost that they will pay at each 

provider in their area. These negotiated rates that insurers could make 

transparent which would be most helpful to patients who want to know 

what they will pay out of their own pocket for a specific procedure. 

 I want to applaud Congressman Lipinski who is here to testify today 

and another Congressman who is not here, Congressman Pete Sessions 

of Texas for their work on legislation that would provide consumers with 

better information about the cost and quality of their health care services. 

 Mr. Chairman, thank you again and I look forward to the hearing. 

 [The prepared statement of Hon. Joe Barton follows:] 
9

PREPARED STATEMENT OF THE HON. JOE BARTON, CHAIRMAN, COMMITTEE ON ENERGY 

AND COMMERCE

Good morning. I’d like to welcome the distinguished witnesses we have before the 

Committee today, especially former Speaker of the House Newt Gingrich and my two 

fellow Texans on the panel. I am looking forward to the hearing today regarding 

transparency in the health care market. 

Unfortunately, the term “health care market” is an oxymoron in this country. 

Instead of a marketplace, we have a system that prevents patients from seeing how much 

their healthcare services actually costs. The health care system hides prices and blurs 

quality. At its most perverse, the system treats the poorest like they were the richest and 

charges them the very most. 

Now, I can tell you that there are moments during which a patient is just not very 

interested in learning the price of a health care procedure. When you need it to survive, 

issues of cost do not come to mind. But it is also true that if you asked, nobody could tell 

you. That’s how health care is different from virtually every other economic activity in 

our lives. Most of us would never agree to let a mechanic repair our car or have a 

plumber fix a leaky faucet without first receiving at least an estimate of what the 

expected costs would be. At the same time, we routinely are expected to blindly seek 

treatment for vital health care services, with no information about the comparative cost or 

quality of these services. And the power of the system is such that we never even think 

to ask, even when the circumstance does not involve an emergency. 

I cannot think of another sector of our economy where consumers have less say. By 

limiting patients’ access to comparative information about prices and quality, we restrict 

competition and cripple the ability of market forces to make health care more affordable. 

Not surprisingly, our national spending on health care has soared, but does anybody here 

feel like the quality of their care has improved at the same rate as its cost? 

We deserve a better health care system, which breaks through the conspiracy of 

silence regarding health care prices and quality. Too often, patients are charged amounts 

that do not accurately measure real costs and rarely reflect the rates these providers are 

paid by private health insurers. These list charges should be shown the light of day, to 

highlight their impact on unsuspecting consumers. Uninsured individuals are sometimes 

charged the full amount of these charges, while insured individuals can still be affected 

by them if they go out of network or if their insurer bases their negotiated rates off of the 

list price. 

Our Oversight and Investigations Subcommittee has done great work on this issue. I 

want to applaud Chairman Whitfield and former Congressman Jim Greenwood for 

helping bring to light the great problems caused by a lack of transparency in hospital 

pricing. 

We already know that transparency in pricing drives down the cost everywhere else 

in our economic lives. We have seen how better access to prices has allowed customers 

to receive much lower prices for airline tickets, cars and now even homes in some 

markets. Price transparency forces sellers to compete and allows purchasers to negotiate 

better deals that save them more money. 

With increased transparency, consumers could examine pricing information and, for 

example, see that an arthroscopic surgery procedure would cost $5,204 at one facility in 

Florida, while this same surgery in another facility in the same town is listed at $12,926. 

Rather than trying to regulate or restrict these variations, consumers could simply be 

given the ability to see these differences and spend their health care dollars accordingly. 

Maybe the $13,000 procedure features the world’s best surgeon and mints on your pillow 

every evening, but maybe it doesn’t. If the patient does not see value in spending the 

extra $7,000, he should have the choice of spending less. That’s how competition works, 

and it seems to work everywhere but the hospital. 
10

Some providers and insurers are already working towards greater transparency. I 

know we are going to hear from one health plan today about what they are doing to show 

their enrollees the costs they will pay at each provider in their area. In many cases, it is 

these negotiated rates that insurers could make transparent, which would be most helpful 

to patients who just want to know what they will pay out of their own pocket for a 

specific procedure or office visit. I also want to applaud Congressmen Dan Lipinski and 

my fellow Texan, Pete Sessions for their work on legislation that would provide 

consumers with better information about the cost and quality of their healthcare services. 

I’ve said it many times, but free markets work, and it’s something I think the health 

care sector needs badly. Nobody’s interested in turning the hospital into the health care 

supermarket, but when you’re charged $50 for a mucus recovery system that turns out to 

be a box of Kleenex, something’s wrong. 

Greater transparency is important, both to control the growth of costs and eliminate 

inefficiencies, but also to get patients to take an interest in the cost-effectiveness of their 

care. Thank you Chairman Deal for holding this important hearing today, and I look 

forward to hearing from our witnesses on this subject. 

 MR. DEAL. I thank the gentleman. 

 I know recognize the Ranking Member of the Subcommittee on 

Health, Mr. Brown, for an opening statement. 

 MR. BROWN. Thank you, Mr. Chairman. 

 Thanks to our witnesses for joining us today. I commend our guests 

and colleagues, Mr. Lipinski and Mr. Emanuel and other members of 

both sides of the isle for their efforts to increase the information available 

to patients. Patients should pay a fair price for health care and that 

accurate information on price quality and effectiveness can in fact be 

empowering. I agree that no one least of all the uninsured should pay 

inflated prices for hospital care or any other health care. 

 There is an article in Monday’s Congressional Quarterly about a 

letter our colleague Bill Thomas, sent to Health and Human Services 

Inspector General chastising that office for failing to calculate “an 

excessive level of charges” for hospitals and medical equipment 

suppliers. The goal Mr. Thomas described is to establish a standard price 

for each hospital service and piece of medical equipment. And providers 

who charge more than that price will be excluded from participation in 

Medicare and other programs. He called that scheme a powerful 

economic incentive, I call it price controls. Mr. Thomas went on to say 

that absent such a benchmark pricing system of “a broad transparent 

pricing initiative that concludes hospitals will fail before it starts.” I am 

not questioning his logic or his goal, I am questioning that it is right to 

set prices for hospitals and wrong to negotiate prices for prescription 

drugs. Somehow it is okay to send small medical suppliers into 

bankruptcy unless they reduce their prices, but it is un-American to 

question why U.S. drug prices are two to five times higher than prices in 

other rich countries. 
11

 The pharmacies in our country could safely import medicine from 

these countries which would stimulate price competition. The Federal 

government could negotiate for reasonable drug prices forcing drug 

makers to strike harder bargains with other countries instead of gouging 

U.S. consumers. We can pass Mr. Emanuel’s legislation and shed some 

light on the nebulous link between the price that drug makers charge and 

the true cost of their products. But the Bush Administration and 

Republican leaders in Congress do not take kindly to initiatives that take 

aim at the brand name drug industry, nor do they have any interest in 

going after the insurance companies. According to Health Affairs, 20 

percent of health care costs are associated with insurance, administrative, 

and daily functions. Maybe if we had transparency for insurers we could 

get those costs under control. 

 There is one thing you can say about the current crop of Republican 

leaders whether in Congress or in the White House. You can say that 

they are loyal to their friends, particularly the ones with deep pockets. 

They are all for posting hospital prices and encouraging consumers to 

comparison shop. They are all for keeping hospitals and other providers 

out of Medicare unless they agree to the government price, but they will 

not hold the drug makers accountable for treating U.S. consumers, U.S. 

businesses, and the U.S. Government like a piggy bank. Why the double 

standard? My guess has something to do with political ties and dollar 

signs. 

 The two health care sectors are largely responsible for the dramatic 

increase in health care costs; hospital services, prescription drugs. We 

should not treat one like a sinner and the other like a saint. One more 

thought on transparent, accurate information is good, but all the 

information in the world will not shrink a $5,000 deductible. Price 

competition is good but the best price in the world will not transform 

health savings accounts into a pro-consumer initiative. HSAs are 

tethered to high deductible insurance. High deductible coverage shifts 

major costs onto consumers. If you have to spend $2,000 up front, your 

insurer is probably pocketing your premium and paying out nothing. 

Evidence shows that for many people, having a high deductible policy is 

the same as having no insurance at all. People on these policies have 

similar problems accessing and delaying care as those without insurance. 

 I was visiting a plant near my district yesterday where people who 

work there 25 years are making $14 an hour and they have a $2,000 

deductible health insurance plan. They all agree, we just never go to the 

doctor or hospital unless we are just deathly ill, of course. There is a link 

to these poorly conceived policies and increased consumer medical debt. 

Whether your deductible is in your pocket or in your HSA, it is still your 
12

money, it is still replacing dollars that used to be paid by insurance. 

Transparency is good, so is real insurance. 

 Thank you, Mr. Chairman. 

 MR. DEAL. I thank the gentleman. 

 I recognize Mr. Shimkus at this time for an opening statement. 

 MR. SHIMKUS. Thank you, Mr. Chairman. 

 And just for the benefit of our panelists, I will not go into the big 

debate and rebut, but I would just say that transparency is important; 

competition, individual choices, whether it is a full line of insurance of 

associated health plans or health savings accounts. I mean the more 

choices the better in getting the consumer involved. 

 By the way, I am taking this time to welcome my Illinois colleagues. 

First as was mentioned earlier, Mr. Lipinski has a bill along with a 

similar bill by Pete Sessions, that would require the disclosure of hospital 

and ambulatory surgery care center pricing. And obviously, I am 

interested in hearing how he proposes that helps in this price disclosure 

debate and I am glad that he is here. I am assuming he will be joined by 

my other Illinois colleague, Mr. Emanuel, and I am sure he is going to 

thank us for the Deficit Reduction Act and the fact that we have included 

the price disclosure on A&P prices which he has requested and which is 

part of his bill, so I think he will come thanking the Republican Congress 

and the Deficit Reduction Act, and I look forward to hearing his 

testimony. 

 With that, Mr. Chairman, I yield back my time. 

 MR. DEAL. I thank the gentleman. 

 Ms. Capps is recognized for an opening statement. 

 MS. CAPPS. I thank you, Mr. Chairman and thank you for holding 

this hearing today, for each of our witnesses for being here especially our 

colleagues in Congress. 

 I can tell even before we get to your testimony that there is a 

difference in this room between those who believe that health care is 

simply a commodity that can be bought and sold, and those of us who 

believe it is an essential service with the goals of quality and access. 

 I wish we were here to discuss other ways to expand health coverage 

to the growing number of uninsured in our country. But when it comes 

to health care, transparency of cost, as big as it is, will not necessarily 

result in patients receiving the best quality of care. And ensuring that 

patients receive the best quality of care has to be our primary objective. 

Making costs more transparent so that Medicare, Medicaid, the VA, and 

insurance companies can negotiate more appropriate rates of 

reimbursement makes sense, however, encouraging individuals to 

participate in health savings accounts and determining their obtainment 

of health care based primarily on prices could be a disaster for patients’ 
13

health. We can recall the study conducted by Employee Benefit and 

Research Institute which found that individuals participating in HSAs 

who earned under $50,000 per year are more likely to avoid or delay 

necessary medical procedures. If low-income people are forced to bear 

greater cost sharing and they cannot afford it, we can expect to see 

people foregoing inexpensive primary care, ending up in the hospital 

with expensive care once the condition has worsened. This will 

perpetuate a vicious cycle whereby patients will be left picking up the tab 

for expensive emergency and acute care because they were encouraged 

to spend less in the first place. 

 Individuals are less likely to consider costs in emergency situations 

that require high priced care. When emergencies arise, a patient’s only 

concern should be accessing care as quickly as possible. Every 

American deserves to know that he or she can get the health care services 

they may require. Promoting plans that may discourage preventive and 

primary care are leaving low-income and sicker patients to pay higher 

costs. It will not result in the best possible quality care for our country. 

It is unrealistic to conduct health care that way. It is also unrealistic to 

compare choosing your health care provider like you choose a car or 

television set. When lives are at stake, there is no time for price 

shopping. And if someone is incapacitated, they certainly do not have a 

choice in the matter. But instead of worrying about worst case scenarios, 

let us try to prevent them by reducing the number of uninsured with the 

goal being that everyone have access to primary and preventative care. 

 I yield back the balance of my time. 

 MR. DEAL. I thank the gentlelady. 

 I recognize Dr. Burgess for an opening statement. 

 MR. BURGESS. Thank you, Mr. Chairman. And I too want to thank 

you for convening this panel today. We are very fortunate today in that 

we have two Texans on the panel, Dr. Goodman who is the Patron Saint 

of Patient Power, the book that he wrote many years ago, and Mr. 

Gedwed from my backyard down in North Richland Hills, Texas, who I 

will speak a little bit more of later on. 

 I came to Congress having owned a medical savings account for five 

years before I arrived here. I am a believer in medical savings accounts. 

When patients would ask me, gee, doctor, you always complain about 

HMOs and insurance companies, what would you recommend, and I 

never hesitated, I said, I would get a medical savings account. I made it 

available for every physician and non-physician staff member in my 

office. At that time, we numbered about 45. Only about five of us took 

it, but those of us who took it over the years saw the dollars in that 

account grow and it made me a believer in the private ownership of 

Social Security accounts when we had that discussion up here last year. 
14

 The number one things that drives me on every piece of legislation 

that I look at and every piece of legislation that I have hoped for that 

deals with health care or whether or not I cosponsor a bill has to do with 

affordability. We were told back in medical school that there are three 

things people look for in health care; affordability, access, and quality. 

And you can only have two at a time. Taking that to heart, I am only 

going to focus on affordability during my congressional tenure however 

long that is because I believe that the American medical system does 

provide quality care and I trust it to continue to do so and I believe we 

will increase access by increasing affordability. 

 The uninsured are not uninsured by choice, they are uninsured 

because they cannot afford the $9,500 insurance premium that we require 

them to pay because of the all the mandates that we put on health 

insurance. We need to take a minute and think about the phenomena 

known as specialty hospitals. Specialty hospitals have a mechanism at 

their disposal for reducing the cost of care by increasing competition, 

increasing the quality of care through communities, but we do have to be 

careful about not running out the community hospital while the specialty 

hospitals increase. 

 We also have to recognize that there is a dark side to transparency in 

the health care market. Opacity exists not because people like opacity, 

but because it brings value to the system. And as long as we require the 

cross subsidization of our Medicare and Medicaid programs, how is the 

private sector going to make up that difference? There is going to be a 

need for opacity in the system so we need to look at that. 

 Our Chairman brought up the issue about the mechanic and you do 

not go to the mechanic and leave your car without knowing what it is 

going to cost. But I would also submit to you the Government would 

never go to the mechanic shop and say since it is up on the rack anyway, 

we will pay for the brake job but the muffler and changing the 

transmission fluid are bundled in and those are just included in the cost 

of the brake job. We see this every day in the Medicare system in this 

country. 

 We do want to be careful not to disrupt what is already there and 

working and again, Mr. Gedwed, from my neck of the woods has a very 

valuable product that is proprietary, but he has assembled that product 

from public data that is readily available. I understand he has data on my 

practice performance. I hope it is satisfactory. I look forward to learning 

that today. I look forward to hearing the rest of our panel members. 

 Thank you, Mr. Chairman, I will yield back. 

 MR. DEAL. I thank the gentleman. 
15

 We are pleased to have the Ranking Member of the full committee 

with us and I will recognize Mr. Dingell at this time for an opening 

statement. 

 MR. DINGELL. Mr. Chairman, I thank you for your courtesy and I 

thank you for holding this hearing on price transparency. 

 I want to welcome my two colleagues, Mr. Lipinski and Mr. 

Emanuel, thank you for being here. 

 I want to comment about this matter of disclosing prices. It is a good 

thing, particularly if it is extended to prices on pharmaceuticals and for 

health insurance companies. I have less hope of that happening than I do 

for other things. The hope is that the consumers will know how much 

their health care costs then they will then be able to shop around for the 

best deal and therefore reduce the overall cost of health care; a wonderful 

hope. 

 That is the market. How medical care is currently administered and 

delivered, there is no guarantee that it will bring down health care costs. 

It has never been so as it is now administered, and if that process 

continues as it is, it probably never will, unless extraordinary changes are 

made. This is a gross misconception. Health care does not work like a 

trip to the grocery store or to buy a sink. You do not always know what 

items you need or even what items are available. And more often than 

not, someone else such as your physician is by necessity selecting the 

items that go into your shopping cart and also addressing the question of 

prices. 

 Transparency is not enough. In addition to prices, consumers must 

know about quality. Today’s health care systems are a long way from 

having the infrastructure to support reasonable assessments and 

reasonable comparisons of quality. We need to encourage collaboration 

to promote the development of quality measures and studies of the 

comparative effectiveness of different medicines and treatments. Then 

we need to figure out how best to communicate this often complex 

information to those who are frightened and off times uninformed people 

who are in a state of a little desperation. 

 Of course the question we should ask is why now are we seeking to 

turn people out on their own in the health care market? Is an individual 

really going to be able to negotiating anywhere near as good a discount 

as an entity negotiated on behalf of tens of thousands of individuals? If 

an individual can, why are my Republican colleagues so intent on 

harnessing the power of the group to get better discounts through 

association health plans? 

 Finally, a central tenet of this consumer driven philosophy is shifting 

more financial responsibility onto families, passing the buck for the 

hospital bed down the line through high deductible health care plans. 
16

American families are already burdened by out of pocket medical 

expenses. Sometimes they are terrifying in size and scope. More than 

one in five people with chronic conditions live in families with problems 

paying their medical bills. And research shows that the medical bill 

problems are more common amongst those in insurance with higher 

deductibles. Asking people to pay more does not necessarily produce 

better outcomes. It can, and frequently does, produce vastly worse. In 

fact, it has been shown to have a negative effect on care, most 

significantly for those who are of low-income or chronically ill. The end 

result is people skipping or delaying care. And the one remarkable thing 

about this is it results in much more costly treatment later and much 

larger costs to all concerned. 

 To conclude, more price transparency in the American health care 

system is a good thing but we should not delude ourselves into thinking 

it is a panacea for our Nation’s health care costs or for the problems of 

the uninsured. I would note, speaking on the subject of transparency, 

that I have been having many meetings with my constituents lately on 

these kinds of subjects. I have been asked not once about price 

transparency. Many have asked me about the continuing and serious 

problems of the selection and other matters of Medicare Part D drug 

benefits. People are confused. People are outraged. People feel that 

they cannot come to a sensible or workable conclusion and that there is 

no place that they can get that kind of information. So I hope my friends 

in the Majority will find time in the coming weeks to allow the 

Democrats to have the additional round of hearings on Part D that we are 

entitled to under the rules of the House which we have requested. 

 I thank you, Mr. Chairman. 

 MR. DEAL. I thank the gentleman. 

 Ms. Bono is recognized for an opening statement. 

 MS. BONO. Thank you, Mr. Chairman. 

 I just would like to thank our panelists and waive my opening 

statement. 

 [The prepared statement of Hon. Mary Bono follows:] 

PREPARED STATEMENT OF THE HON. MARY BONO, A REPRESENTATIVE IN CONGRESS FROM 

THE STATE OF CALIFORNIA

Chairman Deal and Ranking Member Brown, I would like to take this opportunity to 

thank you for allowing a hearing on this important issue. It is critical that we evaluate 

how to increase transparency in our healthcare market. Improved transparency will 

improve the costs and quality of healthcare services. 

A recent Wall Street Journal article pointed out that it is difficult to enlist consumers 

in the effort to reduce healthcare costs if they don’t know what those costs are. Simply 

put, informed consumers make the best decisions and informed consumers need 

information. The public has a right to know price and quality information when making 
17

decisions and what decision could be more important than choosing life sustaining and 

life saving medical services? 

The healthcare industry should be centered on the consumer. Consumers rely on 

pricing and quality information to make intelligent and cost-effective decisions. 

There are an estimated 45 million uninsured Americans, seven million of which 

reside in my home state of California. The uninsured are frequently victims of 

outrageous price gouging and, even worse, are generally unaware of the extreme prices 

that they will be forced to pay in the coming weeks. This is not right and it is simply not 

fair. I believe that increased transparency has an important role to play in creating a more 

level playing field for those who seek medical services. I also believe that it is an 

important step in establishing and maintaining a healthcare system that is cost-effective, 

efficient and accessible. 

I look forward to hearing from our witnesses today as to what their policy 

recommendations are and how we can continue to move towards such a system. 

Thank you Mr. Chairman and I yield back the remainder of my time. 

 MR. DEAL. I thank the gentlelady. 

 Mr. Allen is recognized for an opening statement. 

 MR. ALLEN. Thank you, Mr. Chairman. 

 I appreciate the importance of this hearing of providing consumers 

with better information about their health care costs. I think based on the 

conversation we have had already it is pretty clear that the information 

about quality is probably more important to a great many people. 

 I do question the underlying assumption of this hearing which is that 

if patients can easily obtain the price of different health care services 

they will then shop around for the least expensive care. Chairman 

Barton made it quite clear that when he had his heart attack that was not 

foremost in his mind and it is not likely to be foremost in the minds of 

others who have a serious health condition. 

 It is important that we deal with this system in all of its complexity. 

We mentioned a couple of things. We know that the health care costs are 

driven largely by people who have two or more chronic conditions and 

the treatment of that, those conditions, can be very expensive. We know 

that the increase in health care costs is driven largely by developing 

technologies and we know that compared to other countries, our system 

is much more expensive because of the administrative costs that come 

with a complicated private insurance system that is much more 

complicated and much more expensive than other countries have. But 

within the system itself there are also complexities. 

 Uma Rinehart has laid out I believe a compelling argument that if 

you combine HSAs with high deductible health plans, that shifts costs 

within the system or it shifts the burden within the system, within the 

health care system. Particularly it shifts costs from wealthier people to 

poorer people and it shifts costs from healthier people to sicker people. 

And that is something that is, that is a direction that consumer driven 

health care will take us--HSAs we saw just recently articles saying that 2 
18

million people so far have taken out HSAs in this country but only 1 

million have put any money into them. And the bottom line is if you are 

relatively wealthy in this society, you can set up an HSA, you can put 

money into that kind of account, and as Dr. Burgess said and others I will 

admit it works for people. But it does not work for people who cannot 

afford health insurance today. And it does not reduce the overall cost of 

the system. 

 One closing comment, when I first ran for Congress, I went to the 

head of the main medical center and he said well think of the health care 

system as being 14 percent of our GDP, a giant pool of money and every 

player in the system is getting a certain amount of money out of that pool 

and now he said just you try to change it. And that is the complexity. 

That is the difficulty. We ought to be looking at those things that will 

reduce system costs, not simply shift the cost of health care within the 

system to those who can least afford it and to those who are the sickest. 

 I yield back the balance of my time. 

 MR. DEAL. I thank the gentleman. 

 Ms. Baldwin is recognized at this time for an opening statement. 

 MS. BALDWIN. Thank you, Mr. Chairman and I thank the witnesses. 

 Like my colleagues, I support increased price transparency. And I 

think that price transparency efforts we are discussing today should go 

hand in hand with increased reporting of quality measures. We certainly 

do not want to encourage people to simply seek out the cheapest health 

care if that means sacrificing quality to do so. 

 In my home State of Wisconsin there has been a number of exciting 

efforts on both the price and quality reporting front. The Wisconsin 

Hospital Association has been a leader in this effort. They have 

developed two systems; one that reports on quality and the other that 

reports on charges and this information is now available on line. The 

Wisconsin Collaborative for Healthcare Quality has initiated a similar 

system that goes one step further. It combines both quality and pricing 

data in the same reporting system so consumers can look on one chart to 

see where a given hospital would fall on both the quality and price 

spectrum. 

 In order to truly educate consumers, we need to ensure that they are 

able to access the full picture. Consumers need to know about where 

they can get the best health care at the most affordable price. And in 

many aspects, the health care prices must be a part of this, including 

prescription drug prices. So our efforts regarding increased transparency 

must focus on both of these pieces. But I do think it is important to keep 

in mind that increased health care transparency has limitations as many 

of my colleagues have pointed out. Knowing that a certain procedure 

costs $500 in one setting and $625 in another does little to help a family 
19

that has no health insurance and no spare resources to pay the price. 

Comparison shopping only works if you have the financial comfort to 

afford the purchase and the time and ability to investigate the options. 

 Similarly, I am concerned that proposal is such as health savings 

accounts which rely heavily on increased price transparency would 

predominately benefit the healthy and the wealthy in our society. Having 

a health savings account is not going to help a family who cannot afford 

to put money into their account. Instead, HSAs will only serve to 

accelerate the erosion of our already crumbling health care system by 

causing more employers to switch from comprehensive health care 

coverage to high deductible HSAs, weakening the risk pooling system 

that we have and making comprehensive health care coverage even 

harder to obtain in our country. 

 Thank you, Mr. Chairman. 

 MR. DEAL. I thank the gentlelady. 

 Mr. Green is recognized for an opening statement. 

 MR. GREEN. Thank you, Mr. Chairman. 

 I would like to welcome my colleagues on both sides of the aisle. 

And I support like all we have heard the efforts to provide additional 

transparency in the health care system to allow consumers and medical 

professionals and policymakers the insight into the cost of health care. 

But it is clearly the Administration’s push for pricing transparency as 

part of the larger effort to promote health savings accounts and I would 

hope we can support price transparency without supporting health 

savings accounts. Now that health savings accounts are not part of the 

problem, the solution to deal with the lack of health care coverage, but I 

do not think it covers anywhere near the number of people that they think 

it would be. Because similarly not only with the increased health care 

costs but also the burden for negotiating their health care with the 

provider. 

 And I know, like our Chairman and all of us, when we go to a 

physician or a hospital specifically on an emergency basis instead of 

being able to say by the way I am going to save $50 by going to this one 

instead of that other one. And I believe pricing information should be 

available, but this information alone will not help consumers make better 

decisions. Consumers also need information about the quality of the 

care, the delivered products. And I know there has been an effort and I 

see that at least on the hospital side. So maybe we need to see both 

consumer information on pricing and also the quality as it is rated, 

otherwise consumers are likely to use the cheapest health care which 

may or may not always be the best. It is also practical to expect 

consumers to shop around. As I said for example, a pregnant woman has 

months maybe to make a decision about who is going to provide her 
20

maternity care and can take into account the many factors but a parent 

with a child that needs an emergency surgery may not be able to. 

Getting the child the health care quickly is the most important factor in 

the parent’s decision process. 

 The pricing transparency as part of the consumer directed health care 

is supposed to lower health care costs. We must also ask ourselves 

lowered at what price? If a 50-year-old with an HSA and a high 

deductible health plan knows the cost of a colostomy yet forgoes the 

procedure because of those cost implications, is that consumer really 

getting better health care? No, in fact, I think that is what we have seen 

from HSAs. People will postpone some of the easier things until they 

actually have to go and have the catastrophic and get to that $5,000 

amount. 

 So that, Mr. Chairman, again, I think we can support price 

transparency and better consumer information without necessarily 

signing on to HSAs panacea for our health care crisis. 

 Thank you. 

 MR. DEAL. I thank the gentleman. 

 Mr. Pitts is recognized for an opening statement. I thank the 

gentleman. 

 Well we will proceed. I believe we have covered everyone’s 

opening statements here. We will proceed with our very distinguished 

members of our panel. We are pleased to have two of our colleagues 

who are here to testify and I will recognize these two gentlemen first, and 

then we will proceed after that to recognize the other remaining members 

of the panel. First of all, we are pleased to have Mr. Daniel Lipinski who 

is here, a Member of our current congressional delegation from Illinois 

and his colleague also, Mr. Rahm Emanuel from Illinois is here as well. 

We will begin with you two gentlemen and Mr. Lipinski I will recognize 

you first for five minutes. 

STATEMENTS OF HON. DANIEL LIPINSKI, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF 

ILLINOIS; AND HON. RAHM EMANUEL, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF 

ILLINOIS 

MR. LIPINSKI. Mr. Chairman, I would like to thank you and Ranking 

Member Brown who looks a lot like Mr. Pallone right now, and all the 

members of the Health Subcommittee for giving me the opportunity to 

speak about H.R. 3139, the Hospital Price Reporting and Disclosure Act, 

which I introduced last year with Representative Bob Inglis of South 

Carolina. 
21

 As health care costs continue to rise, families are struggling more 

and more to figure out how to pay for the medical bills. This problem is 

made worse by the fact that there is no way to know how much you are 

going to be charged when you check into the hospital for care. Lack of 

information prevents families from making well-informed cost-effective 

choices. That is why I introduced this bipartisan bill to require every 

hospital to give Americans clear, concise information about what they 

charge for common procedures and medications. 

 Many of us would never consider getting our car repaired without 

first getting an estimate. Well this is exactly what we do when we go 

into a hospital for health care. Two years ago, I was involved in a 

serious bike accident, a bicycle not a motorbike that has been sometimes 

reported. But in the sense that I broke my hip which was certainly the 

biggest shock but as anyone who has gone into a hospital has had happen 

to them, I got a second shock when I got the bill. Just to give you one 

small example, I was charged $5 for this tiny packet of ointment. When 

you go to any pharmacy and get the same thing 32 times the size for $7. 

Now this and the other costs charged to me on the itemized bill lead me 

to the question why can’t we know what hospitals charge before we get 

admitted to the hospital. At that point, I do what most people do. I do a 

Google search to see if anyone else was working on this problem. I 

found that California had just recently required hospitals to disclose all 

the prices that they charge. That is the hospital’s charge master. Now 

this disclosure revealed a big disparity between hospitals and what they 

charge for the same procedures. And actually one hospital cost $120 for 

the same chest X-ray another hospital costs $1,500. At one hospital they 

would give you a Tylenol capsule for free another hospital would charge 

you $7 for the same capsule. 

 So last year, I introduced the Hospital Price Recording and 

Disclosure Act, to make information available for all hospitals across the 

country and give all Americans the ability to make informed choices 

about where they seek medical care. This bill would require hospitals to 

report twice a year to the Secretary of Health and Human Services the 

average and median price that they charged over the last six months for 

the 25 most commonly performed in-patient procedures, 25 most 

common out-patient procedures, and the 50 most used medications. 

These prices would then be posted on a user friendly website where 

Americans could easily access them. This type of information would be 

simpler for the average person to understand than if the entire dense 

charge master list was provided. 

 Numerous States besides California have also taken recent action on 

this issue. My home State of Illinois has passed legislation to require 

disclosure of prices for both in-patient and out-patient procedures. 
22

Florida, Georgia, Ohio, and South Dakota have all passed similar 

legislation. Wisconsin, as Representative Baldwin’s talked about, has 

this type of information available on a public easy access website and I 

highly recommend that website. At least two more States right now are 

currently talking about this as they have legislation pending on hospital 

price disclosure. On a national level, it was initially reported that the 

Administration has discussed the proposal to have HHS implement and 

oversee a voluntary program that publicizes the prices health care 

providers charge for their services. All of these are a good start. I 

believe Congress should act to make price disclosure mandatory on a 

national level. 

 Obviously price is not the only factor that a family should take into 

account when making health care choices. Quality information is also 

critical and I am happy that the Centers for Medicare and Medicaid 

Services are making some of this quality information available now, but 

much more is needed. We must always remember though that when 

seeking medical care the advice of professionals will always be essential 

in making health care choices. But these are not reasons to oppose 

making hospital price information available. Price information is 

especially critical to 46 million uninsured Americans. A recent report on 

60 Minutes demonstrated the high impact that undisclosed hospital prices 

have on uninsured Americans. While you work to get coverage for the 

uninsured which is something that is very critical, we should give them 

the information that will help them to make more cost-effective health 

care choices. 

 This issue is not Democratic or Republican. We not only have 

bipartisan support for this bill in the House, but a companion bill was 

introduced in the Senate by Democrat Dick Durbin and Republicans Jim 

DeMint and John Cornyn. President Bush has also stated his support for 

price transparency. When I am home in Illinois and I talk about this bill, 

they call it one thing, common sense. We expect to have price 

information for every other purchase that we make, why do we not have 

this information available when we go into the hospital? Because when 

it comes to health care, information is good for you. 

 I would like to thank the Chairman for this opportunity to testify and 

I look forward to working on this issue in the future with the committee. 

Thank you. 

 [The prepared statement of Hon. Daniel Lipinski follows:] 
23

PREPARED STATEMENT OF THE HON. DANIEL LIPINSKI, A REPRESENTATIVE IN CONGRESS 

FROM THE STATE OF ILLINOIS

Mr. Chairman: 

I would like to thank you, Ranking Member Brown, and all the members of the 

Health Subcommittee, for allowing me the opportunity to speak about healthcare price 

transparency, specifically, H.R. 3139, the Hospital Price Reporting and Disclosure Act, 

which I introduced with Representative Bob Inglis of South Carolina. 

As healthcare costs continue to rise, families are struggling more and more to figure 

out how to pay their medical bills. This problem is made worse by the fact that there is 

no way to know how much you will be charged when you go to a particular hospital for 

care. Lack of information prevents families from making well-informed, cost-effective 

choices. This is why I have introduced the Hospital Price Reporting and Disclosure Act, 

a bipartisan effort to require every hospital to give consumers clear, concise information 

about what they charge for common procedures and medications. 

Most of us would never consider getting our car repaired without first receiving an 

estimate of the charges, but this is exactly what we do when we need to go to a hospital 

for treatment. Two summers ago I was involved in a serious bicycle accident. Breaking 

my hip was certainly the most serious shock, but like anyone else who has experienced 

time in a hospital, I was hit with a second shock when I received the bill. Just to give you 

one example, a tiny single-use packet of ointment was billed to me at almost five dollars. 

If you walk down the street to any pharmacy you can get a tube 32 times the size for 

about seven dollars. This led me to ask the question, “Why can’t we know what hospitals 

charge before we are admitted?” At that point I did what most people would do, conduct 

a Google search to see if anyone else was asking this question. I found that the state of 

California had just recently required hospitals to disclose their entire price list – their 

“charge master.” This disclosure revealed that there was a great disparity between 

California hospitals in what they charge for common procedures and medications. One 

hospital charged $120 for a chest x-ray while another charged more than $1500. And 

while a Tylenol capsule was free at one hospital another charged over 7 dollars for the 

same medicine. 

So last year I introduced The Hospital Price Reporting and Disclosure Act to make 

price information available for all hospitals across the country, and give all Americans 

the ability to make informed choices about where they seek medical care. This bill would 

require hospitals to report twice a year to the Secretary of Health and Human Services 

(HHS) the price they charge for the twenty-five most commonly performed inpatient 

procedures, the twenty-five most common outpatient procedures, and the fifty most 

frequently administered medications. These prices would then be posted on a userfriendly web site so that Americans could easily access this information. Our bill does 

not require the disclosure of the entire charge master because the experience of 

Californians has suggested that the size and complexity of these lists make it difficult for 

the average person to find helpful information. 

Numerous states besides California have also taken recent action on this issue. My 

home state of Illinois has passed legislation that provides for disclosure of prices charged 

by hospitals for both in-patient and out-patient procedures, and states like Wisconsin and 

Oregon already have this kind of information available to the public on easy to access 

websites. I highly recommend the Wisconsin website (http://wipricepoint.org) to see 

how well this can be done. 

Obviously price is not the only factor that families should take into account when 

making health care choices. Quality information is also critical, and I am happy that the 

Centers for Medicare and Medicaid Services (CMS) is beginning to make some quality 

measures available; more is certainly needed. And the advice of health care professionals 
24

will always be essential when making care decisions. But these are not reasons to oppose 

making price information available. 

Price information is especially critical to the 46 million uninsured Americans. The 

recent report on 60 Minutes demonstrated the high impact that undisclosed hospital prices 

have on uninsured Americans. While we work to get coverage for the uninsured, we 

should give them information that will help in their health care choices. We expect to 

have price information for every other purchase that we make, why shouldn’t we have the 

same when it comes to health care? 

This is not a Democratic or a Republican bill. We not only have bipartisan support 

in the House, but Senators Dick Durbin, Jim Demint, and John Cornyn introduced a 

companion bill in the Senate. President Bush has also stated his support for price 

transparency and it’s been reported that the Administration has discussed a proposal to 

have the Department of Health and Human Services implement and oversee a voluntary 

program that would publicize the prices healthcare providers charge for their services. 

But when I’m home in Illinois talking to my constituents, they call this bill one thing – 

common sense. Because when it comes to health care, information is good for you. 

I would like to thank the Chairman for the opportunity to speak on my legislation, 

and I look forward to hearing the testimony of the other witnesses. 

 MR. DEAL. I thank the gentleman. 

 Mr. Emanuel, you are recognized for five minutes for your 

presentation. 

MR. EMANUEL. Thank you, Mr. Chairman. Thank you for this 

hearing. 

 In the concept of transparency, I not only advocate for legislation as I 

have done on the prescription drug pricing and Medicaid Fraud 

Prevention Act--I also practice it. If you go to my website, you can see a 

Costco in Chicago pricing for ten of the most common drugs used by 

seniors and Costco in Toronto. Now the Costco in Toronto, and we 

update it every month, on average is $1,200 cheaper for those same ten 

drugs, same dosage, than they are at the Costco in Chicago. And I want 

everybody in the Chicago area to know and that is why I instituted it. 

And remember it is Costco which is a price competitive shopping area. 

It is the same ten drugs so we are comparing the same drugs that seniors 

most commonly use--blood thinners, arthritis, blood pressure, all types of 

medication. And so I believe in the notion of transparency is making 

people better shoppers and getting price competition. 

 That is also why I wrote a letter to the Secretary of Health and 

Human Services asking them originally when they put up on their 

website the pricing Medicare.gov that they include the prices in Europe 

which they--I know it is going to come as a shock to you, they did not do 

but for everybody to know then about the competition and what pricing 

was. That is why I believe in re-importation as a concept of allowing 

people access and allowing competition and choice to exist in the market 

and you can have price competition. And I practice that at our office so 
25

people in Chicago, the old Costco in Chicago and Costco in Toronto. 

Toronto is an hour away and $1,200 cheaper for Chicago. 

 Now I introduced this legislation, which my colleague from Illinois, 

Congressman Shimkus said some of the stuff was implemented in the 

budget reconciliation but not all of it. Today, Medicaid covers about a 

third of the budget, a third of the cost of the budgets for our State 

governments. And we all know they are going on a fast track to about 

half the State budgets. And one of the biggest price points in there, if not 

the biggest, one of the driving factors is the cost of prescription drugs. 

And that is what we are paying now. I think about a third of the States 

right now pay more for Medicaid than they do for access to higher 

education. And in short order that is what we need for every State. That 

is going to happen. And prescription drugs and the price of prescription 

drugs is one of the driving factors there. 

 So we introduced this to give both competition and also as a way to 

fight fraud. Now what we did last year was halfway but not the full 

effort. And what we have to do is get all of the information, all of the 

transparency there, not just the average manufacturing price or the 

second, how you compute the average manufacturing price. Without that 

information, all that information we will never know. And in fact, in 

2004, Schering-Plough settled with the Government for $345 million on 

the issue of pricing and Medicaid. There were also in 2003 Bayer, I 

think the exact price was $257 million and GlaxoSmithKline for $86 

million. So in fact, fraud to taxpayers exists as it relates to pricing 

prescription drugs through Medicaid and the payments. 

 Lastly, we have to get the best prices out there. So although we have 

done certain things, we have to finish the job as it relates to transparency, 

otherwise taxpayers are going to continue to be paying for bills they 

should not be paying and paying money they should not be paying and 

we cannot have a position where Medicaid is going to go from a third of 

our State budgets up to half of our State budgets. And all this 

information would make our State governments and therefore our 

taxpayers better buyers of prescription drugs. We now know there is a 

problem up there. That is why we settled these cases in the last two 

years and made millions of dollars. But how you compute the average 

manufacturing price and the best prices is essential because right now we 

are playing hide the ball with the prescription drug companies and that is 

wrong. Now we know there is a problem here and we cannot do 

halfhearted efforts to get all the pricing and all the information. We 

would not have addressed it in the budget reconciliation unless we 

thought it was a problem and yet fraud is being committed on taxpayers, 

and on Medicaid, and on the consumers and yet we are not doing what 

we should be doing. And all we are asking for is the type of information 
26

to be available. And as Secretary Michael Leavitt said just yesterday, 

people deserve to know, they have a right to know the quality of care 

they are receiving and its cost. And unless you know how you compute 

the average manufacturing price and unless you know what the best 

prices are available, we are never going to get the best costs for our 

taxpayers and for the people who use Medicaid, the most vulnerable in 

our society. And these costs are rising. 

 And I know I am out of time so I want to thank you very much for 

holding this hearing and hope that rather than doing half of it as we did 

last year, we finish the job this year when it comes to full transparency. 

 MR. DEAL. I want to thank both gentlemen for being with us and 

would invite you to join us on the dais if you would choose to do so. 

 MR. EMANUEL. I am on my way to a Medicare event on the issue of 

pricing. 

 MR. DEAL. Thank you for being here. 

 And Mr. Lipinski you have the same invitation to join us if you 

would like or I understand you have other schedules like most of us do. 

But thank you both for being here. 

 MR. LIPINSKI. Thank you. 

 MR. DEAL. It is my pleasure now to introduce the remaining 

members of the panel and they are certainly distinguished individuals. 

First of all my former colleague from Georgia and our Former Speaker of 

the House of Representatives, the Honorable Newt Gingrich, we are 

pleased to have you with us today. Mr. William Gedwed who is the 

Chairman and President and CEO of UICI from New Richland Hills, 

Texas that I believe Mr. Burgess referred to earlier in his statement; Mr. 

Paul Ginsburg who is President of the Center for Studying Health 

System Change, pleased to have you as well. Dr. David MacDonald, 

President of Liberty Health Group from Charlottesville, Virginia; Dr. 

Sara Collins, Senior Program Officer, Future of Health Insurance of the 

Commonwealth Fund from New York; Dr. John Goodman, President and 

CEO of the National Center for Policy Analysis from Dallas, Texas; and 

Dr. Gerard Anderson, Johns Hopkins Bloomberg School of Public 

Health and Health Policy and Management from Baltimore. Certainly a 

distinguished group and Speaker Gingrich we will start with you. 

STATEMENTS OF THE HON. NEWT GINGRICH, FORMER 

SPEAKER OF THE HOUSE, FOUNDER, CENTER FOR 

HEALTH TRANSFORMATION; WILLIAM GEDWED, 

CHAIRMAN, PRESIDENT & CEO, UICI; PAUL B. 

GINSBURG, PRESIDENT, CENTER FOR STUDYING 

HEALTH SYSTEM CHANGE; DR. DAVID MACDONALD, 

PRESIDENT, LIBERTY HEALTH GROUP; DR. SARA R. 
27

COLLINS, SENIOR PROGRAM OFFICER, FUTURE 

HEALTH INSURANCE, THE COMMONWEALTH FUND; DR. 

JOHN GOODMAN, PRESIDENT & CEO, NATIONAL 

CENTER FOR POLICY ANALYSIS; AND DR. GERARD F. 

ANDERSON, JOHNS HOPKINS BLOOMBERG SCHOOL OF 

PUBLIC HEALTH, HEALTH POLICY AND MANAGEMENT 

 MR. GINGRICH. Thank you, Mr. Chairman. 

 I very much appreciate this hearing and the focus on the public’s 

right to know, to use Secretary Leavitt’s language, I might point out to 

the committee that 93 percent of the country at least in one recent poll, 

said people should have the right to know price and quality information 

before they make decisions on health care. 

 I would also point out that in terms of fraud, there is dramatically 

less fraud in a place like McDonald’s or UPS or FedEx than there is in 

Medicaid because you have a direct relationship between the buyer and 

the seller. If UPS or FedEx does not pick up your package, you do not 

pay them. And if they do not deliver the package, you call because you 

know what is going on. The New York Times reported that in Medicaid 

in New York State there is an estimated $4.4 billion a year in fraud, just 

in New York alone. And I think that is because the current system is 

inherently impossible. You cannot have a third party payment model in 

which for example in New York they had one dentist who applied for 

982 procedures per day and got paid. The system is just simply hopeless. 

 And so I want to start with, and Congressman Allen made a point 

about, the complexity of the system and that is exactly why the Austrian 

School of Economics emphasizes markets. Because the Austrian School 

looked at the fact that if you hold all the decisions, and actually the 

original story was they looked at the pricing of fish in a pre-refrigerated 

world in Vienna and the fact that the price dropped every 15 minutes all 

day and that different people would come to buy fish at different times of 

the day as a function of how wealthy they were or what they were going 

to use the fish for. And their conclusion was that just in trying to price 

fish, the bureaucracy was hopeless because it could never keep up with 

the changing pattern of values and opportunities. Now you apply this to 

15 or 18 percent of the economy and it is hopeless. 

 I mean, I said this years ago and got in trouble but I am going to 

repeat it. The Centers for Medicaid and Medicare Services is inherently 

a Soviet style command bureaucracy. It has 44,000 thousand pages of 

regulations. It is impossible. And if the Congress had simply found the 

fraud in New York State, you would solve all of your five year budget 

number without affecting anybody who was delivering honest health 

care. But you cannot find it inside the current model. George Rowe 
28

wrote the perfect article in describing Gorbachev’s crisis. And this says 

something that Von Misis and Hayek wrote about 70 and 100 years ago. 

He said Gorbachev was a true communist and he wanted to have 

Perestroika and Glasnost to have an open, innovative communist. And 

he said you are either for markets or you are for bureaucracy. But to try 

to be for half and half is like asking the citizens of your country for half 

of them to drive on the right side of the road and half of them to drive on 

the left side. It is not possible. 

 And that is the muddle we are in right now. We pretend we want a 

market oriented system. We have a Medicare system, a Medicaid 

system, a veteran system, a tri-care system that are in fact command 

bureaucracies. We have private corporations that go out and buy huge 

quantities of health insurance by a human resources department that is a 

bureaucracy. And then we wonder why you get all these problems. Let 

me give you a few examples. The current system is a hopeless mess. I 

would argue if you go to a market oriented system with real information, 

you will both get better care and lower costs, in fact, enough lower cost 

that I believe you could get to 100 percent insurance coverage with a 

savings. That is how big I think the waste and fraud is in the current 

system. And it is not the government one is better. The Florida 

Medicaid system, only 16 percent of the children get dental screenings, 

only 4 percent of the women get mammograms. Government delivered 

health care has not proven in this country to be a better system. Look at 

the Indian Health Service as an example. 

 I think that Congresswoman Baldwin was right; you ought to be 

looking at both quality and price. I think that is exactly right. We will 

not have a 300 million payer system with the savings out of the--by 

getting a better system. But let me give you a couple quick examples. 

Those who oppose the right to choose by citizens refer to emergencies 

and a $50 savings. Both are erroneous. Less than 1 percent of all the 

decisions in health care are a function of emergencies. More than 99 

percent are decisions about which you can make rational decisions. 

 Second, the savings are radically greater than $50. The Henry Ford 

Health System in Detroit went through a model of putting the 

information about drugs on a PDA so that doctors knew price as well as 

drug choice. The first year on a million dollar investment they saved 

$3.5 million because doctors moved to less expensive drugs. You cannot 

put the congressional budget off. It is a score there which is another 

issue. You should have an accurate scoring caucus because nobody at 

this CBO can score marketplace behavior. In fact, they do not believe in 

it, they are a bureaucracy. And so the Henry Ford System invested $1 

million and the first year saved $3.5 million and saved three hours per 

nurse per week of time not spent talking to pharmacists. 
29

 The second example, I would urge this committee to go to 

myfloridarx.gov which Governor Jeb Bush developed with great 

leadership from Alan Levine, the Commissioner of Health. They put in 

real pricing for the State of Florida. You put in your zip code, you put in 

the drug you want to buy, in one instance which was in my testimony 

which I have submitted for the record, in one instance for the same drug 

in a 2 mile area you can pay as much as $202 and as little as $131. So in 

that one transaction, we pass the $50 number that was mentioned earlier 

by one of your colleagues. 

 We believe that a Travelocity model which Med Impact has 

developed for us, that if you would force Medicare to move to a 

Travelocity model of real time pricing for real time choice, we think you 

would take 40 percent out of the cost of drugs, and it would be cheaper 

than Canada because theoretically the bigger markets should be less 

expensive. It is an anomaly of the current structure that the American 

market is expensive. 

 Finally, I recommend you go to floridacomparecare.gov which is 

another thing that Governor Bush has put up where you can look at the 

number of times a hospital performs a procedure, the price of the 

procedure, and the quality. And it turns out, by the way, consistently the 

best hospitals are cheaper. This is not like buying a car or jewelry. In 

health care, better systems have fewer mistakes, fewer infections, greater 

accuracy, move patients back home faster, and as a result your choice is 

a hospital that does 300 procedures a year or two. Always pick the 300 

procedures because they actually know what they are doing, whereas the 

guy doing two is thrilled that he has another chance to experiment. So 

these are real cases. 

 Lastly, I want to encourage this committee to look at something we 

have run across at the Center for Health Transformation that I am 

absolutely amazed at. There are some medical device companies that 

now require hospitals to sign contracts that they will not, they cannot tell 

the patient or the doctor what the device costs. Now this is turning the 

price of the medical device into a trade secret in a way which is insane. I 

use that word deliberately. How can you talk about a free market? How 

can you talk about any kind of transactions and say that the price is 

secret? And I would urge this committee first of all to hold hearings on 

this which we have been checking on and find to be absolutely correct 

and we can submit contract language to you that has $65 billion a year in 

sales. And I would suggest to you that you ultimately want to move 

towards legislation that says any medical device that is going to be sold 

to any aspect of the Federal government which normally includes Federal 

employee health benefit plans, Tri-care, Veterans’ Administration, Indian 

Health Service, Medicaid, and Medicare, the price ought to be public. 
30

These are commodities. They may be scientifically based commodities, 

they may be sophisticated commodities, but they are commodities. If 

you walked into a store and said I would like to buy a TV set and they 

said well, we can show you four options but by the way we are not 

allowed to tell you the price. You would think they were crazy. And for 

medical device companies to be so arrogant as to think that they can keep 

their price a secret by contract, I think is a violation of everything that we 

are trying to accomplish in transparency, and I would urge you to look 

into that particular area as a particularly egregious example of an 

unjustifiable secrecy in the health system. 

 And I appreciate the chance to testify. 

 [The prepared statement of Hon. Newt Gingrich follows:] 

PREPARED STATEMENT OF THE HON. NEWT GINGRICH, FORMER SPEAKER OF THE HOUSE,

FOUNDER, CENTER FOR HEALTH TRANSFORMATION

Chairman Deal, Ranking Member Brown, and members of the subcommittee: 

I appreciate the opportunity to testify today about how giving health consumers 

access to price and quality information for medical services will help us build a 21st

Century Intelligent Health System that saves lives and saves money for all Americans. 

If healthcare in America is to transcend the challenges of the future, America must 

build this 21st Century Intelligent Health System. Building such a system will require 

fundamental changes of the health system we know today, but they are changes that are 

absolutely necessary. 

To get there, ensuring that every American has the right-to-know price and quality 

information about health and healthcare products and services is absolutely critical. 

Let me describe a 21st Century Intelligent Health System. In a 21st Century 

Intelligent Health System, every American will be covered by insurance, have access to 

the care that they need when they need it, own their health records, and will be 

empowered to make responsible decisions about their own health and healthcare because 

they will have the right-to-know the price and quality of health products and services 

before making purchasing decisions. 

In a 21st Century Intelligent Health System, the focus will be on prevention and 

wellness. Innovation will be rapid, and the dissemination of health knowledge will be in 

real time and available to all Americans. Reimbursement for health care will be a 

function of quality outcomes, not a function of volume. 

We are right at the edge of moving forward toward a 21st Century Intelligent Health 

System centered on the individual. This system I am describing is a wholesale departure 

from the bureaucratic, third party payer model that has dominated our healthcare 

financing for the last forty years. The new model promises better health outcomes at 

lower cost. 

In order to be successful in this transition, healthcare consumers must have complete 

and total access to information about their healthcare providers and the products and 

services they provide. Yet lack of price and quality information about various healthcare 

services may cripple this much-needed transformation before it can ever get off the 

ground. 

Americans are accustomed to leading their lives empowered with the responsibility 

and knowledge to determine what is best for them. Outside of healthcare, we live in the 

world of Expedia, Travelocity, CraigsList and Consumer Reports. Within minutes, any 

citizen can find price, cost, and performance data on an infinite number of products and 
31

services. This transparent system puts the consumer squarely at the center of the 

market—and as a result, consumers have more choices of greater quality at lower cost. 

Healthcare is the only area of America’s economy where the consumer and the 

provider have no idea what the goods and services they trade cost. Think about that for a 

minute. Patients and doctors truly do not know the cost of even a standard office visit, not 

to mention myriad of complicated procedures delivered in an emergency room. 

Sometimes there is a very determined effort to keep the prices of medical products 

and services hidden and/or deliberately vague. 

Not surprisingly, this has the intended effect of keeping prices artificially high for 

consumers because there are no natural market forces to create downward cost 

pressures.1 If healthcare were a real market we would see more choices of higher quality 

coupled with falling prices. 

There is no other sector of our economy with as little information about price and 

quality as in the $2 trillion healthcare industry. American consumers can find all types of 

cost and quality information about cars, computers, homes and vacation destinations. It 

is even common these days for potential buyers and owners to have lengthy online 

discussions about the pros and cons of, and alternatives to, every make and model. 

But this type of rich consumer information is sorely lacking when it comes to 

something as important as choosing a physician or a hospital. More important than the 

lack of available information about prices is the stunning absence of quality data in the 

hands of patients. Few Americans could tell you which of the five hospitals nearest to 

them has the best outcomes for cancer care, or obstetrics, or orthopedic surgery. 

Significantly, they would have trouble even getting this information if their health or their 

life depended on it. This is wrong and it must change. 

 Individuals are at the mercy of an antiquated system that has not kept pace with the 

technological advancement, transparency, and modernization that nearly every other 

industry has embraced. The information age has left healthcare behind, and the 

consequences are tragic: medical errors continue to kill thousands; costs continue to rise 

faster than inflation; the number of uninsured continues to climb; and consumers still 

remain at the edges of the system. We can change this. But in order to do so, informed 

and proactive consumers must be at the center of the healthcare system. 

The American people clearly want this to change. In one survey, 93 percent of 

Americans believe they have the right-to-know price and quality information about their 

healthcare providers. 

It’s hard to find any issue that garners the support of more Americans. By 

comparison, “only” 91 percent of Americans support keeping the words “under God” in 

the Pledge of Allegiance. 

January 1, 2004, will be looked back upon as the “big bang” in healthcare policy. It 

was on this date that health savings accounts (HSAs) became available to all Americans 

who buy private health insurance. This was the most significant improvement in 

healthcare financing in two generations because it began to unleash the value-driven 

American consumer on the inefficient healthcare market. 

 

1

 Take for example the elaborate efforts undertaken to maintain secrecy about the costs of certain 

implantable medical devices. Implantable medical devices (the devices used in cardiac, orthopedic and 

spinal surgeries) are one of the single biggest drivers of increased hospital supply costs today. What’s 

driving and maintaining these hight costs? One factor is that it appears that device vendors often seek 

to hide the true costs of their devices behind confidentiality provisions that they insert into their 

contracts with hospitals. In a case that I’ve recently been made aware of, one device vendor claims 

that its pricing is somehow a “trade secret”, and that hospitals that buy its devices may not disclose 

their prices to the doctors who use them, the private payers who reimburse the hospitals for them, or 

the patients who receive them. The inevitable result is that no price shopping can take place and price 

competition, a fundamental market force, can’t take root. 
32

The most comprehensive, real world survey of HSAs was released last week by the 

trade group America’s Health Insurance Plans. It showed that nearly 3.2 million 

Americans own HSAs as of January, 2006. The U.S. Treasury Department estimates that 

there will be 14 million Americans with HSAs by 2010, less than four years from now. 

We should extend the opportunity to own HSAs to those on Medicaid and Medicare, 

and allow them to enjoy the advantages of having more control over their healthcare 

dollars and the opportunity to build wealth by staying healthy. 

Owners of HSA-health insurance plans are starting to ask their doctors a longoverdue question: “How much does it cost?” That question, so commonplace everywhere 

else in the economy, has been almost unheard of, until now, in the doctor’s office. As the 

number of these plans grows, it will create greater and greater pressure for accurate 

information about prices and more and better information about quality of health 

services. In a world of Google, Ebay, Edmunds.com, Travelocity, and Craigslist, where 

detailed information is available on nearly everyone and everything, it is indefensible that 

healthcare lags behind. 

U.S. News and World Report, for example, is looked to as the best rater of colleges 

and universities. Today, some private sector companies are also beginning to provide 

much more health information to rate healthcare services. Websites like Subimo and 

HealthGrades offer subscription services where paying customers can gain access to 

information about quality. Insurers like Aetna and Humana are in the early stages of 

providing their enrollees with details about hospital outcome data. Not all hospital 

administrators are enthralled with these rating systems, but up until now they have failed 

to develop a nationally agreed upon set of standards whereby hospitals would rank 

themselves. They may never agree, but because this information is so valuable to 

consumers, we must ensure that it is not kept from them. 

Government at the federal, state, and even county level can play a critical role in 

addressing the dearth of price and quality information available to consumers of 

healthcare. 

Secretary Leavitt and CMS Administrator Mark McClellan deserve considerable 

credit for pursuing more transparency with hospitalcompare.hhs.gov, which allows 

patients, family members, and physicians to get quality measures on how often hospitals 

provide the recommended care to get the best results for most patients. Available on the 

site is the standard recommended care that an adult should get if being treated for a heart 

attack, pneumonia, and other complications. 

The Administration is also moving ahead with additional transparency measures. 

Over the course of the next several weeks the Medicare website will begin to display the 

prices it pays hospital and physicians. Additionally, the Office of Personnel Management 

is exploring the possibility of requiring plans participating in the Federal Employee 

Health Benefit Program to make public the reimbursement rates they pay to providers. 

The State of Florida now has two websites FloridaCompareCare.com and 

MyFloridarx.com that display hospital price and outcome data, and prescription drug 

prices respectively. These websites cost less than $200,000 per year to operate. They are 

cheap and highly effective. Every state in America should follow Florida’s lead and make 

this critical information available to all citizens. 

An article from this past Sunday’s South Florida Sun-Sentinel reports about the real 

life impact of the new web site MyFloridaRx.gov. I recommend this story by health 

writer Bob LaMendola to anyone wanting to learn about the tremendous price 

discrepancies in price for the same medicine in the same neighborhood. At Morrison’s 

RX pharmacy in the city of Plantation, for example, 30 Nexium pills sell for $202. Two 

miles away at the Costco in Davie, the exact same pills cost $131. Visitors to 

MyFloridaRx can get the “usual and customary” prices for the 50 most common 

prescribed drugs in the state. 
33

In an additional example, a month’s supply of albuterol for asthma inhalers can cost 

as little at $6.16 at Sam’s Club in South Florida. The average cost around the region is 

$21. Green’s pharmacy in Palm Beach sells the identical product for $43 and it retails for 

$88 in Broward County at ProScript in Davie. This is the kind of information that is 

critical to asthmatics, particularly if they are uninsured, own a HSA, or don’t have a copay and therefore have to pay for prescription drugs out of their own pockets. Now, they 

have an objective online tool to help them compare prices and save money. 

At the Center for Health Transformation2 we have developed a model of drug 

purchasing called Pilot Rx modeled on Travelocity. We believe that this model could take 

between 20 – 40 percent out of the cost of prescription drugs by offering real-time online 

prices to patients. Each individual’s plan would reimburse for 100 percent of the cost of 

the lowest cost generic drug in a therapeutic class. From that point on up, the patient 

would be responsible for paying the difference. This visibility of prices, we believe, 

would crash costs significantly. 

FloridaCompareCare.gov is the other Florida website that is proving itself of 

significant value to patients and potential patients. This very user-friendly site allows 

visitors to search for a wide range of price and outcome data for all hospitals and 

ambulatory surgery centers in the state. Visitors can retrieve the risk-adjusted number of 

hospitalizations, average length of stays, charges, and readmission, infection, 

complication, and mortality rates for every facility in the state. Certainly this is data you 

would want and deserve if you or a loved one needed an operation. 

Florida officials are also shining the light on the underperformance of the traditional 

Medicaid fee-for-service system. It turns out that only half of the children in standard feefor-service are getting well child check ups. Only 16 percent of children are getting 

preventive dental screenings. Only 4 percent of women are getting mammograms. The 

highest death rates from breast cancer are among African-American women. 

50 percent of Florida Medicaid beneficiaries are either black or Hispanic. These 

populations are two to three times more likely to suffer from asthma, diabetes, heart 

disease, and infant mortality. These figures are troubling to be sure. But they need to be 

out in the open before we can begin discussing how to close these unacceptable gaps in 

health outcomes. 

Florida’s innovative new Medicaid waiver includes important innovations in 

information transparency. It will include participation from a range of health plans that 

will receive risk-adjusted premiums per enrollee. HMOs, Minority Physician Network, or 

a hospital-based Provider Service Network will have their performance monitored by the 

state. The state will be measuring plans in a range of areas including: percentage of kids 

getting well child check ups, percentage of kids getting dental screenings, and the 

percentage of kids getting the proper vaccinations. Consumer satisfaction will also be 

measured. Most importantly, these measurements will be made available for all to see. 

It is the nature of a science and technology based entrepreneurial free market to 

provide more choices of higher quality at lower cost. 

Americans deserve exactly this but are not getting it from our current health system. 

A major reason for this is the lack of reliable, useful information about price and quality 

of health and healthcare products and services. We can and must do better in order to 

create a 21st Century Intelligent Health System that will save lives and save money. 

 MR. DEAL. I thank you. 

 Mr. Gedwed, we will recognize you next. 

 

2

 The Center for Health Transformation is a collaboration of transformational leaders dedicated to 

the creation of a 21st Century Intelligent Health System in which knowledge saves lives and saves 

money for all Americans. For more information on the Center and our Right to Know Project, 

please contact project director Jim Frogue at 202.375.2001.
34

 I will say to all of you, we have made your testimony that you have 

submitted in advance a part of the record so you can feel free just to take 

excerpts from it if you would choose to do so. 

 Mr. Gedwed? 

MR. GEDWED. Thank you, Mr. Chairman and members. 

 On behalf of the 2,700 employees of UICI, it is a pleasure to offer-- 

 MR. DEAL. Would you turn on the microphone so we can hear you? 

 MR. GEDWED. Thank you. 

 It is a pleasure to offer comments today on price transparency in the 

health care industry. UICI, a New York Stock Exchange company based 

in North Richland Hills, Texas, is a leader in providing affordable health 

care coverage to individuals, small businesses, and the self-employed. 

For more than 20 years, UICI has focused on delivering innovative 

products and services to help our customers in 44 States better manage 

their health care needs. 

 As you know, most insured Americans receive their health care 

coverage through an employer sponsored plan. That coverage is costly, 

averaging just under $11,000 per year. Out of that, the employee 

typically is responsible for paying about 25 percent. In short, most 

Americans receive coverage that is highly subsidized by the employer. It 

should be noted, however, that the number of Americans receiving 

coverage from these employer subsidized health programs is declining as 

costs continue to rise. And even to make it clearer that at UICI, our 

customers live in very different circumstances. We serve the guy who 

owns the independent muffler shop on the corner, the entrepreneur with a 

start-up firm, and the single mom waiting tables. But most of our 1.2 

million customers, if UICI was not there with affordable health insurance 

coverage, chances are they would have no insurance at all. 

 But a concept of consumerism has recently entered into the health 

care debate. Our members have always had to be smart consumers. 

When you have to pay 100 percent of the cost of health care coverage, 

you have to be a smart consumer. Health care decisions are some of the 

most important and potentially costly choices Americans face. Often 

these health care decisions are made without the benefit of knowing 

ahead of time the true cost and/or quality of that service. In fact, based 

on recent research, customers are likely to spend more time researching 

the purchase of a car or a computer than evaluating a doctor or hospital. 

Our company has changed that for our customers. 

 Through our HealthMarket division, we have pioneered benefit and 

price transparency. HealthMarkets award-winning web-based tools 

which took more than four years and over $100 million to build and 

perfect. We provide our members with unparallelled power to manage 

their health care spending. We believe consumers should have at least as 
35

much information about health care cost and quality as they do about 

cars or computers. When the cost of health care coverage represents 

nearly 10 percent of our customer’s annual income, it is our 

responsibility to ensure they have all the information necessary to make 

informed decisions. 

 While many of our competitors are today just beginning to introduce 

limited forms of price transparency, we already have invented true 

transparency into every facet of our business. Our members have access 

to detailed information on approximately two-thirds of the Nation’s 

medical providers located in all 50 States. That means more than 

430,000 medical professionals, 4,000 hospitals and medical centers, and 

26,000 other resources such as labs, MRI centers, medical equipment 

providers, and home health care providers. Our members benefit from 

price transparency on more than 20,000 procedures or services from the 

cost of a routine office visit to a consultation by a specialist. Most 

important to our customers, all this information is available in advance of 

an office visit or procedure. 

 Now how do we provide this information to our customers? Our 

company aggregates information from provider networks in a wide 

variety of services and then we share it with our members in an easy to 

use format. We use a green, yellow, red pricing structure to inform 

consumers on the cost of a provider relative to their benefits. In short, 

we match the level of their plan benefits that we offer them with 

expected costs so our customers can seek medical care and not incur any 

out-of-pocket expense if they so choose. We provide the wealth of 

information over a range of channels, like the Internet, mail, and 

telephone access. In addition, when customers need help, trained nurses 

are available to guide them through the health care decisions. 

 And I am pleased to tell you our tools can be applied to help State 

and Federal agencies better manage their Medicare and Medicaid costs. 

In fact, today UICI is engaged in conversations with several State 

agencies about using our tools. 

 Be at rest that I look forward to a day when all Americans will have 

access to health care HealthMarkets customers have today. 

 Thank you very much. 

 [The prepared statement of William Gedwed follows:] 

PREPARED STATEMENT OF WILLIAM GEDWED, CHAIRMAN, PRESIDENT AND CEO, UICI 

On behalf of the more than 2,700 employees of UICI, I am honored to submit these 

remarks regarding price transparency in the health care industry. In particular, I’m here to 

emphasize our strong support for further actions the 109th Congress may consider taking 

to empower consumers to make better informed choices about health care. 
36

UICI is a leader in providing affordable health care coverage to individuals, small 

businesses and the self-employed. For most of our 1.2 million customers, if UICI was not 

there to deliver, chances are they would not have insurance at all. 

The word consumerism has recently appeared on the Health Care horizon. but for 

our company, it has long been a way of life – reflecting the special needs of our 

customers. Unlike most Americans who receive health care from their employer and pay 

only a fraction of the true costs of that coverage, our customers pay 100 percent of theirs. 

For this reason, UICI for more than 20 years has focused on developing innovative 

products and services to help our customers better manage their health care. 

Health care decisions are some of the most important, costly choices people face. 

And yet, Americans often make them without any real way to evaluate the cost 

and/or quality of medical service providers. 

Often these health care decisions are made without the benefit of knowing – ahead 

of time – this valuable information. 

In fact, consumers are far more likely to use the Internet to research a car or 

computer than a doctor or hospital, according to recent research, including a survey our 

company commissioned last year. It is our position that one reason consumers don’t use 

the Internet to research health care is it’s simply not available to most Americans. 

We believe that’s wrong. Consumers should have at least as much information about 

health care cost and quality as they do about cars or computers. When the cost of health 

care represents nearly 10 percent of our customers’ annual income, it’s our responsibility 

to ensure they have all the information necessary to make informed decisions. 

It is for this reason our company acquired HealthMarket in 2004. We saw great 

potential in HealthMarket’s technology and innovative products, which pioneered the 

category of consumer-guided insurance. 

The crown jewel of HealthMarket is its award-winning web-based tools, which 

provide cost and benefit transparency. These innovative tools took more than four years 

and over $100 million to build and perfect. Armed with these resources, our members 

enjoy unparalleled power to manage their health care spending. 

While many of our competitors are today just beginning to introduce limited forms 

of price transparency, we already have embedded true transparency into every facet of 

our business. As a result of our commitment to our customers: 

 Our members have access to detailed information on approximately two-thirds 

of the nation’s medical providers located in all 50 states -- that means more 

than 430,000 medical professionals, 4,000 hospitals and medical centers, and 

26,000 other resources such as labs, MRI centers, medical equipment providers 

and home health care centers. 

 Our members benefit from price transparency not for just 25 or 30 procedures 

like some of our competitors provide, but for virtually every procedure and 

supply code imaginable – more than 20,000 procedures or services in all, from 

the cost of a routine office visit to a specialist consultation to knee surgery. 

 Our members have access to health plans that utilize price transparency in more 

than a dozen states, with another five states currently pending. 

 Our members have access to data that is updated monthly, putting at their 

fingertips the most comprehensive, up-to-date price information available in the 

marketplace. 

Our members use our site to look up participating physicians and hospitals anywhere 

in the country and compare cost information. 

Many of our customers are surprised to learn that excellent, board-certified doctors 

may charge vastly different prices for the same medical procedure. 

Here’s how our website works. 

The first screen provides a quick overview of providers’ charges. A unique 

“thermometer scale” allows members to visually scan the list of providers and quickly 
37

determine who charges a lot or a little compared with the rest of the market. A doctor “In 

the Green” is less expensive than a doctor colored red. A doctor who is “In the Green” 

will not likely require any out of pocket payments from the consumer, after the 

deductible and co-insurance. 

The low-cost physicians are listed first, with the high-cost physicians last. A 

physician can move up in the ranking by bringing charges into line with the rest of the 

market. that means providers compete, and they have an incentive to keep costs in check. 

If members wants more detail, they can click to the next screen. This provides costs 

for each specific service a doctor or hospital provides. As I mentioned, we have cost data 

on more than 20,000 services or procedures, organized by their CPT code. For those 

without computer access, this information is also available over the telephone. 

Most importantly, cost information is available to enrollees in advance of an office 

visit or procedure so that they may take this information into account when making 

healthcare decisions. 

But not knowing the cost of services is just one major problem wih managed-care 

health plans. Two others are: 

1. Enrollees lack any sense of ownership over the money they spend. 

2. Information on quality, outcomes, and training of physicians and hospital staff is 

often hard to find. 

Now, a word of caution. Some insurance companies seem to use the Consumer 

Directed term as little more than a marketing buzzword meaning “low benefits / low 

cost.” 

A plan that truly puts the consumer in the driver’s seat must do several things: 

 The plan must offer price transparency, as discussed. 

 Members need a reason to care about price – a sense of ownership over the 

money they spend. 

 Members need access to quality and outcomes information. 

When insurance companies set up the co-pay as the only responsibility an enrollee 

has, it’s no wonder the enrollee doesn’t care what the overall charges are. 

At HealthMarket, our consumer plans give enrollees a sense of ownership through 

several innovative structural designs: 

-- The MAC, or Maximum Allowable Charge, is the foundation of all HealthMarket 

Consumer Guided plans. 

The MAC is the maximum fee the plan pays for a given service. It is set for each 

covered service, with a large portion of contracted providers within a given area at or 

below the MAC. It is set locally, based on provider contracts. If the member goes to a 

provider who charges more than the MAC, the member is responsible for paying the 

difference out of his or her own pocket. 

Providers who charge below the MAC and are depicted as “In the Green” on the 

member’s website. 

Market forces point the way to those physicians who charge reasonable rates in 

relation to their experience, location, and qualifications. 

-- The StartWell Account is available in many plan designs and presents an excellent 

example of how to create a sense of ownership over spending. 

On day one of coverage, enrollees take ownership of a spending account for many 

routine, preventive, and diagnostic care services (options range from $500 to $1,250). If 

the member ends the year with a positive balance, he or she is entitled to roll over all or a 

portion of that balance on renewal of the policy, which is added to the next year’s 

replenished beginning balance. If the fund is depleted, routine services remain covered, 

but are subject to deductibles and coinsurance. 

The StartWell Account is applied to services such as check-ups, mammograms, 

allergy testing, and lab tests - all with no deductible, coinsurance, or co-payment. This 
38

plan design is actually richer than most co-pay plans, but with the critical difference that 

the enrollee now has his or her first experience in caring about the cost of care. 

Our members receive a rich benefit for preventative, diagnostic care – but also have 

a strong incentive to spend money only when needed - and to take cost into account when 

choosing a provider. 

Many CDHP companies today use Health Savings Accounts (HSAs) to create a 

sense of ownership over healthcare spending. These accounts set up a personal financial 

asset that enrollees can spend as they see fit. 

This is an excellent way to encourage consumerism since enrollees now have a 

personal stake in their spending. What is important - and often lacking - is that the 

insurance company must give enrollees the tools and information they need to be able to 

spend their own money wisely. This means knowing the costs before buying services. 

The best HSA plan, without cost information, is only half the puzzle. It’s a superficial 

solution that leaves enrollees frustrated and unable to spend their own money wisely. 

In addition to cost transparency, a consumer guided plan must provide access to 

provider quality and outcomes information. 

We believe that to focus only on the money and not on quality would be to miss the 

whole point of health care. 

We provide our members with access to best-in-class quality data from Subimo. 

Our partnership with Subimo gives our members information on doctor backgrounds 

– such as board certification, medical school, and years in practice. 

It offers information on hospitals such as adherence to patient safety standards, 

volume of procedures, and clinical outcomes. 

Our website even allows enrollees to offer feedback on physicians, so that once 

results are made available, one enrollee will be able to benefit from the feedback of 

another, just as eBay or Amazon.com users can read what other users have said about 

various sellers. 

All this information is made available to enrollees before they make what may be 

life-altering healthcare decisions. The goal is to provide the most information for the best 

decision possible. 

Our members also receive access to detailed sources of health information such as 

in-depth health libraries. These enable enrollees to research symptoms, conditions, and 

treatments; determine a physician’s hospital-admitting privileges; and even compare 

hospital survival rates for various procedures. 

As much as a Consumer-guided plan tries to make life easier for members, health 

care consumerism can be complicated. Therefore, it is imperative to provide members 

with outstanding education and support. Without this component, plans may frustrate 

customers who understand the importance of making wise spending decisions and who 

know that the information is out there somewhere – but just don’t know how to navigate 

the system to get it. 

The otherwise glowing McKinsey & Company June 2005 report found an “Achilles’ 

heel” in many consumer plans: 80 percent did not provide sufficient information on the 

prices doctors charge. Less than half of the consumers studied reported that they were at 

least as satisfied with their consumer-driven plan as they had been with their previous 

plan. “The long-term success of CDHPs will be highly dependent not only on whether 

consumers receive appropriately transparent information to help them make decisions, 

but also on whether the information can be easily obtained,” the report concluded. 

We offer an unparalleled array of support services that help to make them savvy 

users of the consumer tools described above. Following are just a few examples. 

Our Consumer-Guided members are asked to participate in A “Verification Call” 

upon joining the plan. This call allows a customer service representative to describe in 

detail how the plan works and how the member can use the online and telephonic support 

tools to their advantage. 
39

 Another source of education about the plan are our personal assistants. In addition 

to handling traditional health insurance questions, these representatives are trained to 

discuss the critical issues faced by healthcare consumers: how to compare costs among 

various providers; how to use online self-service tools; and how to manage financial 

accounts, such as the StartWell Account. 

 The Personal Assistant program allows enrollees access to a toll-free number staffed 

by professionals who act as a concierge service. Some of the actions they take on behalf 

of enrollees and their family members include 

• Getting medical records transferred 

• Arranging for transportation 

• Discussing bills or unexpected charges with the provider 

• Finding home-care or adult daycare programs for an enrollee’s elderly parent 

• Setting up appointments to see specialists 

• Putting the enrollee in touch with our 24/7 Nurse Line. 

In Conclusion... 

Consumer guided plans should be evaluated based on whether they provide: 

-- price and quality transparency 

-- a sense of ownership over health dollars spent 

-- and adequate customer support. 

The nation did not arrive at its current consumer-unfriendly system overnight, so 

unleashing the power of consumerism in America will take time. We at HealthMarket 

look forward to a day when most Americans become strong health care consumers. We 

look forward to a future that offers top-notch health care without skyrocketing costs that 

have come under the current system of managed care. 

At HealthMarket, we believe in a future where all health plans sold in America will 

be of the consumer-guided variety - serving consumers who are able to manage their 

healthcare decisions as well as they do their vacation-planning or refrigerator inventory. 

We are building this future now, because consumerism in health care is an idea 

whose time has come. 

 MR. DEAL. Thank you. 

 Dr. Ginsburg. 

MR. GINSBURG. Thank you, Mr. Chairman, members of the 

subcommittee. 

 I am President of the Center for Studying Health System Change 

which is an independent, non-partisan, health policy research 

organization funded principally by the Robert Wood Johnson Foundation 

and affiliated with Mathematica Policy Research. Its mission is to 

provide policymakers with objective and timely research on 

developments in health care financing and delivery and their impacts on 

people. 

 With funding from the California HealthCare Foundation, HSC has 

conducted research on shopping for price in medical services. The 

research has covered the overall potential of the approach to improve 

value, and the experience in self-paying markets such as LASIK, and 

working papers on these two studies are available on request. 

 My statement makes three key points. First, fostering price shopping 

does have the potential to contain costs. Some people will use higher 
40

value providers and many providers will feel market pressure to increase 

the value of their services. But some are overselling the potential of 

price shopping to solve our health care problems. For one thing, many 

services are too complex or too urgent for effective shopping and those 

patients responsible for the bulk of dollars spent in health care are 

beyond the reach of patient financial incentives in typical benefit 

structures. 

 The second point is that health plans play a key role in consumer 

price shopping but some advocates have been ignoring this role. Health 

plans have long been consumers most powerful asset through their 

substantial discounts negotiated with providers. As benefit structures 

change to put more emphasis on price shopping, a lot of innovation and 

tools to increase plan value are starting to go on like my colleague 

mentioned from his company. Some of these innovations are high 

performance networks providing incentives for patients to use providers 

with higher value data on the right of costs of different providers. 

Insurers basically have the potential to employ their formidable data and 

analysis resources to translate the complexity of health care pricing into 

something usable by consumers. Forcing disclosure of contracts between 

health plans and providers especially hospitals will have unintended 

effects of raising prices. It is well known in anti-trust circles that in 

concentrated markets, posting of price information leads to higher prices. 

It can do this either by facilitating collusion among sellers or buyers and 

also by leading to smaller market share gains for those who are willing to 

offer discounts. My testimony describes a well intention attempt at 

disclose that misfired. 

 Third, consumers experience in self-pay markets, such as LASIK, 

have been romanticized. We studied LASIK, dental crowns, in utero 

fertilization, and cosmetic surgery. We found serious price shopping 

only in the market for LASIK. There has been a decline in price for 

LASIK over time but consumer protection has been a problem and the 

FCC and State Attorney’s General have been involved for a number of 

years. Some of the issues are misleading advertising. For example, the 

commercials for $299 per eye are very misleading because very few 

people are eligible for that price. In fact, only 3 percent of LASIK 

procedures cost less than $1,000. Second, misrepresentation of what 

services are included in the price is also a consumer protection issue. 

And one implication of the LASIK experience is the degree to which the 

presence of insurers actually prevents some of the consumer protection 

issues that we found. 

 In conclusion, increased price transparency is generally a good thing 

but it will not solve all the problems of the health care system, not even 

the problem of decreasing affordability of health care. And we must 
41

proceed with caution and selectivity providing information truly useful to 

consumers and not inadvertently increasing the power of entities in 

concentrated markets. 

 Thank you very much. 

 [The prepared statement of Paul B. Ginsburg follows:] 

PREPARED STATEMENT OF PAUL B. GINSBURG, PRESIDENT, CENTER FOR STUDYING HEALTH 

SYSTEM CHANGE

Mr. Chairman, Representative Brown and members of the Subcommittee, thank you 

for the invitation to testify about providing consumers with better information about the 

cost of health care services. My name is Paul B. Ginsburg, and I am an economist and 

president of the Center for Studying Health System Change (HSC). HSC is an 

independent, nonpartisan health policy research organization funded principally by The 

Robert Wood Johnson Foundation and affiliated with Mathematica Policy Research. 

HSC’s main research tool is the Community Tracking Study, which consists of 

national surveys of households and physicians in 60 nationally representatives 

communities across the country and intensive site visits to 12 of these communities. We 

also monitor secondary data and general health system trends. Our goal is to provide 

members of Congress and other policy makers with objective and timely research on 

developments in health care markets and their impacts on people. Our various research 

and communication activities may be found on our Web site at www.hschange.org. 

With funding from the California HealthCare Foundation, HSC has conducted 

research on consumer price shopping for health services, focusing both on self-pay 

services, such as LASIK, and analyzing the issue of price transparency for medical 

services that tend to be insured.1

 My testimony today will make three points: 

• Fostering consumer price shopping for health services does have potential for 

containing costs without sacrificing quality—but some are overselling the 

magnitude of this potential. 

• For most consumers who are insured, their health plan has long been their most 

powerful asset in shopping for lower prices, and insurers have the potential to 

become even more effective agents as they develop more sophisticated benefit 

structures and information tools to support consumers in choosing effective 

treatments from higher-quality, lower-cost providers. 

• Consumers’ experiences with markets for self-pay services, such as LASIK, 

have been romanticized and do not offer much encouragement as a model of 

effective shopping for health care services without either a large role for 

insurers or regulation. 

BACKGROUND 

I perceive the current policy interest in price transparency as essentially a second 

stage of the evolution of consumer-driven health care. The first stage was financial 

incentives for consumers in the form of greater cost sharing—high deductibles and 

greater coinsurance. Now, we are focusing on the tools needed by consumers to make 

effective decisions on reducing the costs of their care. As insurers compete vigorously to 

sell consumer-driven products, they seek to differentiate their products on the basis of the 

 

1

 Two working papers from this project, “Shopping for Price in Medical Care, ” by Paul B. 

Ginsburg, and “How Consumers Shop for Health Care When They Pay Out of Pocket: Evidence 

From Selected Self-Pay Markets,” by Ha Tu and Jessica H.May, are available by request by 

contacting HSC. 
42

tools offered to consumers to compare price and quality across providers. Policy makers 

are interested in government’s role in fostering greater cost-consciousness and a more 

favorable environment for consumers to make informed choices about health care 

services. 

Traditionally, health insurance has either removed or sharply diluted consumer 

incentives to consider price in choosing a provider or treatment strategy. It is difficult for 

consumers to get price and quality information from providers, who have to date shown 

little interest in competing for patients on this basis. Likewise, there is little information 

available to help patients examine the effectiveness of treatment alternatives. The lack of 

quality information understandably makes consumers reluctant to choose a provider on 

the basis of a lower price. It is one thing to wind up with a low-quality provider when 

price is not an issue but another to get there as a result of opting for a lower price. 

Similarly, lack of information on effectiveness of treatment alternatives makes consumers 

more reluctant to consider price in the choice of treatment. 

Unfortunately, much of the recent policy discussion about price transparency 

downplays the complexity of decisions about medical care and the dependence of 

consumers on physicians for guidance about what services are appropriate. It also 

ignores the role of managed care plans as agents for consumers and purchasers in 

shopping for lower prices. Well-intentioned but ill-conceived policies to force extensive 

disclosure of contracts between managed care plans and providers may backfire by 

leading to higher prices. 

POTENTIAL FOR MORE EFFECTIVE PRICE SHOPPING 

If you define effective shopping as obtaining better value for money spent, then 

consumers do have the potential to be more effective shoppers for health care services. 

There are direct and indirect benefits of choosing providers that offer better value. The 

direct benefits are simply the cost savings, for example, of choosing the lower-cost of two 

providers of comparable quality. 

But the indirect benefits are potentially more important. If enough consumers 

become active in comparing price and quality, this will lead to market pressure on 

providers to improve their performance on both cost and quality dimensions. Providers 

that measure up poorly on the value dimension will lose market share and will be 

motivated to revamp their operations to remain viable. Our market economy offers many 

examples of competitors responding to loss of market share by making difficult changes 

and regaining their edge, and examples are starting to appear in health care as well. The 

gains from providers improving their operations will accrue broadly to the health care 

system. 

But we need to be realistic about the magnitudes of potential gains from more 

effective shopping by consumers. For one thing, a large portion of medical care may be 

beyond the reach of patient financial incentives. Most patients who are hospitalized will 

not be subject to the financial incentives of either a consumer-driven health plan or a 

more traditional plan with extensive patient cost sharing. They will have exceeded their 

annual deductible and often the maximum on out-of-pocket spending. Recall that in any 

year, 10 percent of people account for 70 percent of health spending, and most of them 

will not be subject to financial incentives to economize. 

When services are covered by health insurance, the value of price information to 

consumers depends a great deal on the type of benefit structure. For example, if the 

consumer has to pay $15 for a physician visit or $100 per day in the hospital, then 

information on the price for these services is not relevant. If the consumer pays 20 

percent of the bill, price information is more relevant, but still the consumer gets only 20 

percent of any savings from using lower-priced providers. And the savings to the 

consumer end once limits on out-of-pocket spending are reached. 
43

In addition to those with the largest expenses not being subject to financial 

incentives, much care does not lend itself to effective shopping. Many patients’ health 

care needs are too urgent to price shop. Some illnesses are so complex that significant 

diagnostic resources are needed before determining treatment alternatives. By this time, 

the patient is unlikely to consider shopping for a different provider. 

Some of these constraints could be addressed by consumers’ committing 

themselves, either formally or informally, to providers. Many consumers have chosen a 

primary care physician as their initial point of contact for medical problems that may 

arise. Patients served by a multi-specialty group practice informally commit themselves 

to this group of specialists—and the hospitals that they practice in—as well. So shopping 

has been done in advance and can be applied to new medical problems that require urgent 

care. This is a key concept behind the high-performance networks that are being 

developed by some large insurers. 

Even when services are good candidates for shopping by consumers, comparison of 

prices is not easy. Much treatment is customized. For example, an elective rhinoplasty, 

more commonly known as a nose reconstruction, is not a commodity, and a plastic 

surgeon cannot provide an estimate without examining the patient. Often a medical 

treatment involves an uncertain number of services by a number of separate providers, 

but few bundled prices are available in the marketplace today. As mentioned above, 

limitations in useful comparative quality data make patients reluctant to choose a 

provider based on lower price. 

Shifting from choosing a provider to choosing treatment strategies, the absence of 

neutral financial incentives for providers is a serious problem. The most typical situation 

today is one where the provider gets paid on a fee-for-service basis, so the incentive is to 

recommend more services, especially those that have higher unit profitability.2 

Increasingly, physicians have an ownership interest in services, such as imaging, beyond 

their usual professional services, creating an additional conflict between physicians’ 

interests and those of their patients. 

SELF-PAY MARKETS 

Many have pointed to markets for medical services that are not covered by insurance 

to show the potential of consumer price shopping. Since these services are not medically 

necessary—the basis for not being covered by insurance—they should be prime 

candidates for more effective consumer price shopping. HSC has studied markets for 

LASIK, in-vitro fertilization (IVF), dental crowns and cosmetic surgery by interviewing 

providers, consultants and regulators in these fields. Our findings are not as encouraging 

as one hears from advocates of consumerism. 

LASIK has the greatest potential for effective price shopping because it is elective, 

non-urgent, and consumers can get somewhat useful price information over the 

telephone. Prices have indeed fallen over time. But consumer protection problems have 

tarnished this market, with both the Federal Trade Commission and some state attorneys 

general intervening to curb deceptive advertising and poorly communicated bundling 

practices. Many of us have seen LASIK advertisements for prices of $299 per eye, but in 

fact only a tiny proportion of consumers seeking the LASIK procedure meet the clinical 

qualifications for those prices. Indeed, only 3 percent of LASIK procedures cost less 

than $1,000 per eye, and the average price is about $2,000. I can only wonder about the 

extent to which policy advocates have themselves been deceived by these advertisements 

and inadvertently perceived a sharper decline in prices than has been the case. 

For the other procedures that we studied, we found little evidence of consumer price 

shopping. For dental crowns and IVF services, many consumers are unwilling to shop 

 

2

 See Paul B. Ginsburg and Joy M. Grossman, “When the Price Isn’t Right: How Inadvertent 

Incentives Drive Medical Care,” Health Affairs, August 9, 2005. 
44

because they perceive an urgent need for the procedure, and other consumers are 

discouraged from shopping by the time and expense of visiting multiple providers to get 

estimates. In cosmetic surgery, a limited amount of shopping does occur, facilitated by 

free screening exams offered by some surgeons. However, quality rather than price is the 

key concern to most consumers in this market; in the absence of reliable quality 

information, most consumers rely on word-of-mouth recommendation as a proxy for 

quality, instead of shopping on price. 

ROLE OF INSURERS IN PRICE SHOPPING 

Much of the policy discussion about price transparency has neglected the important 

role that insurers play as agents for consumers and purchasers of health insurance in 

obtaining favorable prices from providers. Even though managed care plans have lost 

some clout in negotiating with providers in recent years, they still obtain sharply 

discounted prices from contracted providers. Indeed, in my experience as a consumer, I 

often find that the discounts obtained for the PPO network for routine physician, 

laboratory and imaging services are worth more to me than the payments by the insurer. 

Insurers are in a strong position to further support their enrollees who have 

significant financial incentives, especially those in consumer-driven products. Insurers 

have the ability to analyze complex data and present it to consumers as simple choices. 

For example, they can analyze data on costs and quality of care in a specialty and then 

offer their enrollees an incentive to choose providers in the high-performance network. 

Insurers also have the potential to innovate in benefit design to further support effective 

shopping by consumers, such as increasing cost sharing for services that are more 

discretionary and reducing cost sharing for services that research shows are highly 

effective. 

Insurers certainly are motivated to support effective price shopping by their 

enrollees. Employers who are moving cautiously to offer consumer-driven plans want to 

choose products that offer useful tools to inform enrollees about provider price and 

quality. When enrollees become more sensitive to price differences among providers, 

this increases health plan bargaining power with providers. Negotiating lower rates 

further improves a health plan’s competitive position. One thing that insurers could do 

that they are not doing today is to assist enrollees in making choices between network 

providers and those outside of the network by providing data on likely out-of-pocket 

costs for using non-network providers. 

The Administration has recently been pushing hospitals and physicians to provide 

more information on prices to the public. If this is limited to prices paid by those who are 

not insured or those who are insured but are opting to use a non-network provider, 

additional price information for the public is likely to be a positive. But if hospitals and 

insurers are precluded from continuing their current practice of keeping their contracts 

confidential, this could damage the interests of those who pay for services, especially 

hospital care.3

Antitrust authorities throughout the world have recognized that posting of contracted 

prices tends to lead to higher prices. In highly concentrated markets, posting of prices 

facilitates collusion. Even in the absence of collusion, posting would mean that a hospital 

offering an extra discount to an insurer would gain less market share because their 

competitors would seek to match it. Of course, this works on both the buying and selling 

side of the market, but if hospitals tend to be more concentrated than insurers, disclosure 

will raise rather than lower prices. 

 

3

 I do not have such concerns about physician prices because the physician services tend to be far 

less concentrated than hospital services in most markets. But information on contracts with 

physicians would not be particularly useful because prices paid by insurers vary much less. 
45

The experience in Denmark, where the government, in a misguided attempt to foster 

more competition in a concentrated market, posted contracted prices in the ready-mix 

concrete industry is instructive. Within six months of this policy change, prices increased 

by 15-20 percent, despite falling input prices.4

 Drawing on this and other experience, the 

Federal Trade Commission in 2004 testified in the California Legislature against 

Assembly Bill 1960, which would have required the disclosure of certain price 

information from contracts between pharmacy benefits managers (PBMs) and 

pharmaceutical manufacturers.5

Some health plans are now experimenting with ways to communicate to their 

enrollees the fact that certain hospitals have particularly high or low negotiated fees, 

without violating their agreements to hospitals and their desire to maintain the 

confidentiality of their price negotiations. For example, Blue Cross of California, which 

tends to rely heavily on coinsurance in its benefit structures, has been posting ratings of 

the costliness of hospitals for PPO enrollees. It follows the approach of Zagat guides to 

restaurants, where “$” is assigned to the lowest cost hospitals and “$$$$” is assigned to 

the highest cost hospitals. This approach not only maintains the confidentiality of 

contracts with hospitals, but it also engages the formidable actuarial resources of the plan 

to simplify complex and voluminous hospital data for consumers. Humana Inc. has 

presented hospital price information to some of its Milwaukee enrollees that maintains 

confidentiality by using ranges and combining hospital costs with physician costs. I 

expect that insurers will come up with more innovative ways to present price information 

to enrollees. 

CONCLUSION 

The need for consumers to compare prices of providers and treatment alternatives is 

increasing and has the potential to improve the value equation in health care. But we 

need to be realistic about the magnitude of the potential for improvement from making 

consumers more effective shoppers for health care. Whatever the gains from increased 

shopping activity, rising health care costs will, nevertheless, price more consumers out of 

the market for health insurance and burden governments struggling to pay for health care 

from a revenue base that is not growing as fast as their financing commitment. For those 

who have health insurance, their health plan will be a key agent in facilitating their 

obtaining better value. Government needs to take care not to interfere with this 

relationship and should focus instead on the needs of those without insurance. 

 MR. DEAL. Thank you. 

 Dr. MacDonald? 

DR. MACDONALD. Thank you very much, Mr. Chairman and 

Ranking Member Brown. 

 I am Dan MacDonald. I am a family physician. And I would like to 

share some thoughts from the front line. I have listened with interest to 

some opinions. They have been very interesting opinions of people that 

are not even involved in the situation. 

 

4

 Albaek, Svend, Peter Mollgaard, and Per B Overgaard, "Government-Assisted Oligopoly 

Coordination? A Concrete Case," Journal of Industrial Economics, Vol. 45 (1997): 429-43. 

5

 Federal Trade Commission, Competitive Effects of California Assembly Bill No. 1960, V040027, 

(September 7, 2004). 
46

 One is the situation of health care delivery, how does it impact the 

uninsured? I would like to share a few thoughts with you. As a family 

doctor, I started posting my prices in 1997 and I did that because I could 

not stay alive with the reimbursement from insurance carriers. I had 

people come in and see me that did not have insurance. For example, 

one guy came in and he needed to have his hernia repaired. He is a 

construction guy, had no insurance, and he came in. So what did I do? I 

called the local hospital. I found out that the bill was going to be 

$10,000 plus. Actually I did a price comparison on my own back in ‘97 

which was very hard. I found out it was actually $15,000. So this guy 

did not have that. What can we do? I called a surgeon that I know, a 

very good surgeon, anesthesia, told him the situation. We got everything 

done for $1,800. The guy could easily pay $1,800. He could not even 

fathom paying $15,000. As a result, an old man on the work site came to 

see me. He said, I have a hernia, too. I put off getting care because I do 

not have insurance but I can afford $1,800. Can you set up the same 

deal? So we did it. 

 I am here to talk about practical application, not theory. I am not in 

politics. I appreciate the tennis games that happen in politics, but let me 

tell you from the streets it hurts. How does transparency hurt the 

uninsured or the lack of transparency? I included in my briefing a recent 

example in California. Somebody asked me to help them with their 

hospital bill. He was uninsured, hospitalized, did not plan on it, certainly 

did not plan on the bill that he got. And if you look at the briefing that I 

did, I summarized Tri-Care pricing. It is the only reference point I could 

get, the hospital would not give me any prices, they would not deal with 

me, it was very tough. I took the bill that they gave him and if you look 

at the comparison that this uninsured person was expected to pay just in 

two areas they expected to pay ten times what they are accepting from 

insurance carriers. This is the reality of what the lack of transparency is 

doing. 

 Am I a fan of HSAs? I love the application. The concept is a great, 

but the application is not so great for this reason. There is no real 

transparency when you are passing dollars in those health care HSAs. 

For those that are in favor of HSAs, I applaud you, it is a good deal. If 

you are not including transparency on what the thing costs, you are in lala land if you think it is going to control costs over time. It just is not. 

We have to have transparency on the insurance end. We have to have 

transparency on the pharmacy end. 

 In my little world, and I remind you, I am going to remind you I am 

only a family doc, okay? But in my world a pharmacy, here is what 

happens. The drug is not that expensive when it hits the streets. What 

do I mean by the streets? When it comes out of the pharmacy, the 
47

production line, it is approved, and then it goes through the pipeline. 

There are so many little people that are taking off money and rebates. 

There are so many funny things happening, we have to address that issue. 

One small company we helped in Spokane was able to save $55,000 just 

on the pharmacy rebates. How about lab cost? Well in my world costs, 

if you go through the insurance world, a typical panel of chemistry lipid, 

thyroid, and CBC will cost about $400 to $500. How do I know? I just 

had it done. Six months ago I had it done, and I thought that is crazy. 

There has got to be a better way. While through a lot of other venues 

were able to get that same group of tests for $89. So we are able to bring 

down costs for the surgery, we are able to bring down costs of pharmacy 

when you get all the middle people out. We are able to bring down costs 

of out-patient costs when there is real transparency. 

 I am here today to ask this committee for help. The hospital is a big 

deal. They are some very powerful folks and without your help 

transparency at the hospital level is almost impossible. I appreciate one 

side of this room saying that they are in favor of hospital pricing but let 

us not just focus on hospitals. I applaud you. Let us have transparency 

on everything. The uninsured are uninsured for a reason. I believe we 

might have 250 million over-insured and 42 million underinsured. I 

believe the market will drive costs where they need to be. I believe you 

can take out the waste, the administrative waste, and in Washington State 

it is reported to be 68 percent of every dollar that goes through the health 

care pipeline. Let us get the waste out. There is enough money in there. 

 Here’s the kicker, let us not be naive to think providing insurance for 

everybody answers the problem. Why do I say that? There are two 

references in my briefing. One is from USA Today, Kaiser Family 

Foundation, and Harvard. They did a survey and they found that of those 

wrestling to pay health care costs, 61 percent had insurance. If you do 

not believe that, look at the Harvard study where 47 percent of 

bankruptcies were related to health care costs. And if you read the study, 

75 percent of those had insurance. So let us not be naive to think that 

providing insurance is the panacea that is going to fix it. 

 I am a free market guy. I love free market because it works. I also 

want to take care of the uninsured. I get frustrated with health care when 

it becomes a ployable tennis match. 

 Thank you very much. I guess that means I am out of time, thank 

you. 

 [The prepared statement of Dr. David MacDonald follows:] 
48

PREPARED STATEMENT OF DR. DAVID MACDONALD, PRESIDENT, LIBERTY HEALTH GROUP

Chairman Deal, Ranking Member Brown, and members of the Subcommittee... 

I appreciate the opportunity to testify today about the need for transparency in health 

care prices. As a family physician, former residency director and LTC, U.S. Army, cofounder of SimpleCare, and President of Liberty Health Group, I have a wide variety of 

experience. Today the focus is transparency. 

Most will never experience what the uninsured/underinsured face when trying to 

access health. You may be surprised that it could take more than a dozen phone calls 

before you get an answer to a simple question, “What does ‘this’ cost?” One can even 

outline scenarios of care (complicated/ uncomplicated visit; EKG; Echo; etc) and it is still 

a challenge to get a price. If the educated have a hard time getting a price, imagine how 

challenging it is for those who know nothing about the system! 

I recently visited a prestigious university medical center for a cardiology visit. I 

received bills that were four times the amount quoted! Also, I observed courtroom 

proceedings by this hospital for “judgments” of unpaid hospital bills. Those in court were 

the ones who should benefit from the non-profit status afforded hospitals. We cannot 

expect hospitals to give away care, but neither should they continue with billing practices 

that border on extortion. 

“I know what I know; I know what I don’t know; but I don’t know what I don’t 

know.” Robert Ricciardelli 

Nobody would tolerate a “managed grocery” card that enabled you to go the grocery 

store, purchase various items and then get a bill 30 days later. Either the purchaser of the 

card would financially collapse because consumers abused the card; or the consumer 

would become irate when they had to pay their bill. Basically, this is what is happening in 

health care. 

For those who think that providing insurance for everyone is the answer, there are 

two reports that suggest that this will not be the answer many hope for... 

USA Today/Kaiser Family Foundation/Harvard Survey regarding health care – of 

those who reported experiencing challenges paying medical bills, 61% had insurance. 

Health Affairs, 2 February 2005 – 47% of bankruptcies are related to medical bills; 

yet 75% had insurance at the beginning of the medical challenge. 

Without addressing transparency issues, providing insurance is not the answer. 

Individuals must still pay their maximum out of pocket charge and other bills not covered 

by their insurance (Ambulance services). Many believe increasing costs of insurance is 

because the cost of health care is rising so fast. When health care costs are insulated from 

free market forces, costs escalate at a rate much greater than medical inflation. 

According the HealthINFLATION News (3/31/04; Vol. 13, No. 3), inflation for 

various aspects of health care is as follows: 

Annual Inflation March February Net Increase 

Health Care Indexes 2003 2004 in inflation 

Dental Care 3.6 5.2 1.6 

Eye Care -0.1 1.4 1.5 

Medical Equipment -0.2 1.2 1.4 

Non-prescription drugs 1.2 1.6 0.4 

Physician Care 3.0 3.4 0.4 

Health Care 4.3 4.2 -0.1 

Prescription Drugs 3.7 2.8 -0.9 

Inpatient Hospital Care 7.2 5.9 -1.3 

Nursing Home Care 5.5 4.4 -1.1 

Misc. Professional Care 3.2 1.8 -1.4 

Outpatient Hospital Care 11.9 6.0 -5.9 
49

If benefits were based upon actual costs of health care, we would not have a health 

care “crisis.” Health care consumers are insulated by co-pays, deductibles, nondisclosure 

of prices by hospitals, and fear of posting prices by physicians. 

Costs are not the only issue to be concerned about. Innovation, quality and access to 

care are also important. In a free market world, costs should be controlled while 

increasing access to better quality products. The United States has “invested” in health 

care more than other countries. Our investments have paid off by the innovative 

medications and interventions that have been discovered. The United States has more 

Nobel Prizes than any other nation. In fact, we have more Nobel awards for Physiology 

and Medicine than all other countries combined! Many are benefiting from the United 

States’ investment in new technology and medications. 

The computer is the best example of the power of free market forces controlling 

technology costs. Computers are consistently less expensive while the features and 

options continue to improve. Innovative technology is responsive to free market forces. 

Health care technology may be more expensive initially but should become progressively 

less expensive when exposed to market forces. 

Liberty Health Group has experienced success in controlling costs in most aspects of 

health care delivery. Lab tests, surgical procedures, and diagnostic studies are less 

expensive with transparency and an engaged consumer. When the consumer has 

knowledge of costs and quality, they make decisions tailored to their preferences. Some 

may prefer a more expensive option because of better quality or service. Others may 

prefer less expensive options and save money for future medical needs. Transparency in 

prices should not be confused with socialism (all prices are the same). In fact, the 

freedom to charge different prices rewards innovative services. 

The ones who suffer the most from hidden costs are the uninsured and underinsured. 

Hospitals routinely charge 400% more for the uninsured/underinsured. It is impossible to 

determine what a hospital receives from insurance carriers for comparable visits or 

procedures. Supposedly, insurance carriers represent large purchasing groups that justify 

deeper discounts. 42 million uninsured are a significant purchasing group and should be 

afforded the same discounts as insurance carriers! False scales can never be justified! 

 Here is an example of the prices an uninsured individual faced when hospitalized in 

California. I compared CMAC/ Tricare pricing to the hospital prices. The hospital 

would not tell what they accepted from other insurance carriers for similar care and 

services. Our goal - pay an amount accepted from an insurance carrier. The billing 

department was not cooperative and resisted giving any information. 

Lab Tests (code) CMAC/Tricare Pricing Hospital Prices

 80053 $16.09 $229 

 84484 $14.98 $218 

 82805 $43.19 $480 

 83520 $19.70 $234 

 

 Summary of some tests $229.62 $2832

 Procedure Codes CMAC/Tricare Pricing Hospital Prices

 CT Scan (71260) Global $348.05 $2,614 

 HHN (94640) $12.90 X 31 = $399 $125 X 31 = $3875 

 ER (99285) $149.20 $419 

 EKG tracing (93005) $17.93 $329 

 Pulse Oximeter (94760) $4.75 $328 

 

The discrepancies are glaring and beg an explanation! Our goal was to resolve this 

matter without legal intervention. Even if the CMAC/Tricare numbers are low, there 
50

cannot be such a wide disparity between the hospital bills and the CMAC/Tricare 

maximum allowable charge. The hand held nebulizer (HHN) therapy bill and pulse 

oximeter bills are almost unbelievable! Sadly, this is not an uncommon example. 

The notion that hospitals must charge more to make up for the “abuse by the 

uninsured” is not supported by sound ethical or business discussions. A study by Alwyn 

Cassil, Center for Studying Health System Change, focused on the frequency of ER visits 

1996/97 – 2000/01. They found a 16% increase (108 million/year) in ER visits. Those 

with insurance or Medicare accounted for 66%. The self-pay or those not charged 

accounted for 10%. Medicaid/Cash patients reported waiting longer and rated the service 

they received lower than insured patients. The uninsured were not a major factor for 

increased crowding in the ER. 

It is imperative that hospitals reveal the amount they accept from insurance carriers 

for a procedure, lab, or service. Mandating they post a price will not resolve the 

disparity. The result be like the Average Wholesale Price (AWP) used for pharmacy 

prices, or the shadow that “discounts” create – neither one is practically useful. AWP is a 

meaningless business term. A 30% “discount” of an inflated price is often worse than 

100% payment of a legitimate price. 

It is unconscionable to allow this two-tiered billing practice to continue. I have 

spoken to Hospital Administrators who fear the wrath of the “Medicare Fraud Squad.” 

They are concerned that they cannot accept less than their billed rate from the 

uninsured/underinsured. A transparent price would eliminate this fear. Furthermore, it 

does not seem logical to give insurance carriers a price break when they pay their 

executives multiple million dollar salaries. Sliding scales do not produce transparency. 

Liberty Health Group has success with outpatient costs. We have seen progressively 

less expensive lab tests, diagnostic tests, medication costs controlled, and renewal rates 

that are consistent with medical inflation (2-4%). New technology and medications will 

always be more expensive. The individual should be allowed to decide if the more 

expensive medication is worth the money. 

Small businesses are also affected by non-transparent pricing. They are challenged 

to keep up with premium inflation that is triple medical inflation. Many business owners 

cannot afford to continue to offer benefits. Mandating coverage does not resolve the 

problem posed by non-transparent prices. 

The Department of Treasury and IRS issued guidance that gave small businesses 

more leverage in their health benefits options by expanding the use of Health 

Reimbursement Arrangements (HRA), Section 105 of the Internal Revenue Code (June 

2002). The employer credits pre-tax money to their employees that may only be used for 

qualified medical expenses. Unspent money can accumulate for future medical needs. 

Cafeteria plans (Section 125 of the Internal Revenue Code) are similar. The 

employer and employee can contribute pre-tax money into these accounts for qualified 

medical expenses. These plans work best for predictable medical expenses. However, 

unspent money in the Cafeteria plans does not accumulate. As a result, there are end of 

year spending sprees with the remaining money. 

Health Savings Accounts (HSA) are another exciting option. The employer and 

employee may contribute to these plans that include a pre-tax medical account and a 

qualified high-deductible policy. In my experience these plans are rich in concept but 

disappointing in application. The main reasons they are disappointing are: a lack of 

transparency regarding pricing (HSA holders pay “retail” prices at the doctor and 

hospital); and renewal rates are disproportionately high after 2-3 years into the plan. 

When employees have control of a portion of their health care dollars, they will shop 

for health care. Preventive services are more likely to be used, less expensive medication 

options will be pursued, and routine care/immunizations are not neglected. 
51

Legislative efforts that would help control costs, increase access to care, and 

encourage saving unspent money for unpredictable medical events might focus on the 

following: 

1. Hospitals: 

a. Remove the fear Hospital Administrators have expressed regarding the 

“Medicare Fraud Squad” evaluating and assessing fines. 

b. Assess non-profit status of hospitals who continue to expect payment from 

the uninsured that is 400% higher that what is accepted from insurance 

carriers. 

c. The word “profit” must be defined. There are “for profit” hospitals that 

are efficient, less expensive than comparable hospitals, and treat all in the 

ER. Society would be much better served by a “for profit” hospital that 

posted prices than a non-profit hospital that charges those who need help 

the most 400% above an acceptable insurance payment. 

d. Something to ponder...Why can hospitals own physicians but physicians 

cannot own hospitals? Is there ethical superiority of one relationship to 

the other? 

“You must deodorize profit and make people understand that profit is not something 

offensive, but as important to a company as breathing” 

Sir Peter Parker 

Chairman, British Rail 

“End of year spending sprees by the Federal Government is an egregious waste of tax 

payer’s dollars.” ...unknown 

2. Pharmacy prices: 

a. Disclose rebates and all financial benefits related to pharmacy issues. 

b. Average Wholesale Price (AWP) is a meaningless number for most 

discussions. The question is rather simple, “What does the drug cost?” 

3. Insurance costs: Eliminate restrictions for purchasing health insurance across state 

borders. 

4. Physician fees: Encourage physicians to “post their prices” without fear of fines. I 

posted my prices since 1997 without any legal problems. Those concerned about a 

“two-tiered system” must agree that our health care delivery system currently has a 

“two-tiered system” that favors the insurance carriers and discriminates against the 

uninsured. This must end! 

5.

Transparency issues in health care are vital for the success of any health care 

delivery system. Costs are controlled, access improved, and innovation appropriately 

rewarded when prices are transparent and free market forces are allowed to work. I know 

from the front lines of health care that we could rapidly and dramatically improve health 

care for the uninsured and underinsured with non-discriminatory, transparent pricing. 

“We do not have to see eye to eye to walk hand in hand.” 

 Phillip Gambel 

 MR. DEAL. No, but you are. 

 DR. MACDONALD. Well, thanks. 
52

 MR. DEAL. What that means is we have got some business on the 

Floor we may have to attend to in just a minute but thank you, very 

interesting testimony. 

 Dr. Collins? 

DR. COLLINS. Thank you, Mr. Chairman for this invitation to testify 

on the importance of making health care cost information publicly 

available. 

 MR. DEAL. Would you pull that a little closer, Doctor? There you 

go. 

 DR. COLLINS. Transparency and better public information on cost 

and quality are essential for three reasons: to help providers improve by 

benchmarking their performance against other providers, to encourage 

private insurers and public insurance programs to reward quality and 

efficiency, and to help patients make informed choices about their care. 

Transparency is also important to level the playing field. The 

widespread practice of charging patients different prices for the same 

care is not equitable, especially when the uninsured are charged more 

than other patients. But it is unreasonable to expect that information on 

prices, total bills, and quality will cause health care markets to perform 

like markets for other goods and services. Health care is not 

homogeneous and patients will never have as much information about 

the care they need as the physicians who care for them. Health care 

decisions are made under emergency conditions, emotional stress, and in 

many occasions both the insurance industry and the health care delivery 

sector are highly concentrated, leaving patients with few real choices. 

 As important as price transparency is, price information is of little 

value by itself. Knowing the prices of health care services is not very 

helpful when you do not have information on the total cost of caring for a 

given condition and the quality of the outcomes of that care. 

 The current state of health care information is inadequate. Patients 

report that they rarely have cost and quality information available to 

them. Physicians rarely have comparative information on the quality of 

their own care or on the quality of the care to physicians to whom they 

refer patients. Patient use of information, however, is not likely to 

transform the health care market. Patients are in the weakest position to 

demand greater quality and efficiency. Payers, Federal and State 

governments, accrediting organizations, and professional societies are 

much better positioned to insist on high performance. 

 Posting a greater financial burden on the sickest and poorest patients 

through cost sharing and high deductibles is not the right prescription for 

what currently ails the health care system. Americans already pay far 

more out of pocket for their health care than citizens in other 

industrialized countries and people in high deductible health plans either 
53

coupled with health savings accounts or not allocate substantial amounts 

of their income to their health care. They also are much less satisfied 

with their care than adults in more comprehensive plans. Most troubling 

is that people in high deductible plans are far more likely to delay, avoid, 

or skip health care because of cost. The problem is particularly 

pronounced among people with low-incomes and health problems. 

When people in high deductible plans do access care, there is evidence 

that they are more likely to have problems paying bills and to accumulate 

medical debt. 

 So what needs to be done to achieve transparency in our health care 

system? Medicare should assume a leadership role in making cost and 

quality information by provider and by patient condition publicly 

available. It should forge public and private partnerships to create a 

multi-payer database, uniform quality measures, and transparent 

methodologies for adjusting quality and cost. As the IOM has 

recommended, a national quality coordination board within HHS could 

be created. The board could set priorities, oversee the development of 

quality and efficiency measures, and ensure the collection of information 

on those measures. Health information technology should be invested in 

and fundamental changes in current payment methods should be made. 

Medicare’s physician group demonstration project is a step in the right 

direction. 

 HSA health savings account legislation should be modified to reduce 

its potentially harmful effects on vulnerable populations. Legislative 

modifications might include permitting lower HSA eligible deductibles 

for lower wage workers, exempting primary care, as well as preventative 

services from the deductible, exempting prescription drugs essential for 

the management of chronic conditions, and guaranteeing choice of a 

comprehensive plan to workers who are covered under employer plans, 

permitting greater flexibility and benefit design, and setting an income 

ceiling on eligibility for HSAs to reduce the tax subsidy for higher 

income individuals. 

 Price transparency is the beginning, but it is unlikely to have a major 

impact in the absence of better information on quality and the total bills 

for the treatment of various acute and chronic conditions. Creating a 

database with this information is certainly feasible but it requires Federal 

leadership. This hearing is an important step towards achieving that 

outcome. 

 Thank you. 

 [The prepared statement of Dr. Sara R. Collins follows:] 
54

PREPARED STATEMENT OF DR. SARA R. COLLINS, SENIOR PROGRAM OFFICER, FUTURE OF 

HEALTH INSURANCE, THE COMMONWEALTH FUND
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 MR. DEAL. Thank you, Dr. Collins. 

 I am going to try to get both of you in before we have to break for a 

series of three votes and as you know that would take us a little while to 

get back. So Dr. Goodman, we will proceed with you now. 

MR. GOODMAN. Thank you, Mr. Chairman and members of the 

committee. 

 Will we some day be able to buy health care the way we buy 

groceries? Some people think that day is coming but before our 

consumers can be savvy shoppers in the medical marketplace, they must 

have information about prices and quality and must be able to compare 

prices and compare value. 

 A recent Harris Poll found that Americans could guess the price of a 

new Honda within $300 of the actual price, but when asked to guess the 

price of the cost of four days in the hospital, they were off on average by 

$8,000. 

 Now some have suggested in this hearing that we need new 

legislation, but I would say before we legislate, we should stop and ask 

why are we having this problem in the first place? It is not normal for 

sellers to hide their prices. In normal marketplaces the sellers advertise 

prices, they attract buyers by offering discounts. So what is it that is so 

different about the medical marketplace? I would suggest to you that the 

big overriding difference is that decade after decade, going back almost 

100 years, we have various institutions actively suppressing normal 

market forces. And so today we are living with the effects of 100 years 

of, in my opinion, unwise legislation. 

 Doctors today primarily do not compete with each other on the basis 

of price. And prices in the doctor market price are primarily not 

allocated research. That is not the way we allocate doctor time. And the 

same is true of hospitals. The hospitals are not competing with each 

other on the basis of price, and prices in the hospital marketplace are not 

allocating resources. The examples of hospital prices that Representative 

Lipinski gave us are examples of prices that are pure artifacts. They 

were chosen by hospitals in order to maximize reimbursement formulas. 

They are not equating supply and demand. 

 Now, although we like to think that our health care system is very 

different from the system in Canada, the fact of the matter is that we pay 

doctors here about the same way that doctors are paid in Canada. On 

average, every time patients spend $1 in this system, only .10 is paid out 

of pocket at a doctor’s office. In Canada the physicians and services are 

free. In America they are almost free. In both countries we are not 

allocating the doctor’s time on the basis of price. We are not rationing 

on the basis of money. We are rationing by the patient’s time. We are 

rationing by waiting. 
92

 Now, does the health care marketplace have to work this way? The 

answer is no. And Dr. Ginsburg pointed to the example of cosmetic 

surgery and LASIK surgery. These are important markets. Third party 

payers have not been in these markets for years. For cosmetic surgeries 

probably two decades since third party payers paid. What we found in 

these markets is price is readily available. It is not just a price, it is a 

package price that covers doctor, nurse, and anesthetists, and facility. 

People know what they are going to pay. Now Dr. Ginsburg said we 

have some problems in this market. Well, we may have problems but 

they pale in comparison. They are miniscule in comparison to the 

problems that Dan Rather talked about on Sunday night on 60 Minutes 

that we are having with other kinds of surgery. 

 Now, we can find other examples in the medical marketplace where 

third party payers are not involved. Wherever the third party is not 

involved, we find prices performing the normal function that we expect 

prices to be found. Minute clinics in the Target stores in the upper 

Midwest have prices for all their procedures. People know what they are 

going to pay, there is very little waiting, and they work very well. WalMart wants to take this system nationwide. Steve Kassis’ organization 

also wants to take them nationwide. No third parties are involved. The 

TelaDoc service, you can actually talk to doctors on the telephone with 

this service. You know what you are going to pay, you are charged for 

the number of minutes you talk. Prices are very visible, they are very 

transparent, and it works very well. Luminous now allows patients to 

email their doctors and have email consultations. People know exactly 

what they are going to pay. They pay from their health savings accounts. 

 Going forward, we have remarkable new technologies that I think do 

not require any legislation. We simply need to let these technologies 

spread. For drugs, RX Examiner allows patients to see where the 

authentic and generic substitutes and over the counter substitutes for 

expensive brand name drugs. And DestinationRx.com allows patients to 

compare prices nationwide. And I would guess that the average patient 

can cut his drug prices in half simply by shopping nationwide for drugs. 

Some patients can cut their cost by 90 percent, enormous opportunity for 

reduction in cost. 

 In HealthMarket we have already heard has a brand new technology 

that is really exciting. Prices for 400,000 doctors and 20,000 procedures 

readily available with a computer program. Simbro is a company that 

has developed a product that allows a lot of quality comparisons among 

hospitals. eMedicalfiles allows another kind of transparency. It allows 

the doctors to see what other doctors have done and what is happening in 

other facilities for the patient, and does it all while protecting the privacy 

in accordance with the HIPAA regulations. 
93

 I would say that the most important factor that we can identify in all 

of this is empowering patients. That is why I think we need expanded 

medical savings accounts, and flexible medical savings accounts. Forget 

the high deductible, forget the co-payment, we just need the patients 

being in charge of the money. The supply side will respond. 

 Thank you, Mr. Chairman. 

 [The prepared statement of Dr. John Goodman follows:] 

PREPARED STATEMENT OF DR. JOHN GOODMAN, PRESIDENT AND CEO, NATIONAL CENTER 

FOR POLICY ANALYSIS

Will consumers some day be able to shop for health care the way they shop for 

groceries? As farfetched as that idea may seem, some believe it will become a reality. 

But in order for patients to become savvy shoppers in the medical marketplace, they must 

be able to discover what things cost and to compare prices as well as value. Today, that 

is not easy to do. 

A recent Harris Poll found that consumers can guess the price of a new Honda 

Accord within $300. But when asked to estimate the cost of a four-day stay in the 

hospital, those same consumers were off by $8,100! Further, 63 percent of those who 

had received medical care the last two years did not know the cost of the treatment until 

the bill arrived. Ten percent said they never learned the cost.1

This is not an academic issue. If you are like most other Americans, your employer 

has raised your health insurance deductible and copayment within the last few years. 

And, you may have a special account from which to pay bills directly. Increasingly, 

employees are being asked to make their own choices and manage their own health care 

dollars. 

The medical marketplace is not prepared for these changes. Not only do patients 

typically not know the cost of the medical services they receive, the institutions of health 

care delivery often make price and quality information difficult, if not impossible, to 

obtain. 

Why is information consumers have ready access to in other markets not generally 

available in health care? What institutional and technological changes are needed in 

order to make such information routinely available prior to health purchases? What is the 

appropriate role for public policy? 

Source of the Problem 

The principal reason why prices are not publicly quoted and commonly known in 

health care is that prices do not serve the function in health care that they do in other 

markets. Specifically, doctors and hospitals do not compete on the basis of price and 

prices do not ration scarce resources the way they do in other markets. 

Although ours is a very different system from the health care system of Canada,2 the 

way in which we pay providers in both countries is surprisingly similar. In general, fees 

are set by third-party institutions and those institutions pay all, or almost all, of those 

fees. 

 

1

 Kathy Gurchiek,“Consumers savvier about cost of a new care than a hospital stay,” Human 

Resource News, August 2, 2005. 2

 John C. Goodman, Gerald L. Musgrave, & Devon M. Herrick. Lives at Risk: Single-Payer National 

Health Insurance Around the World. ( Lanham, Maryland: Rowman and Littlefield Publishers, 

2004.) 
94

On the average, every time Americans spend a dollar on physicians’ services, only 

11 cents is paid out-of-pocket; the remainder is paid by a third party (an employer, 

insurance company or government).3 From a purely economic perspective, then, our 

incentive is to consume these services until their value to us is only 11 cents on the dollar. 

Moreover, millions of Americans do not even pay the 11 cents. Medicaid enrollees, 

Medicare enrollees who have medigap insurance, and people who get free care from 

community health centers and hospital emergency rooms pay nothing at the point of 

service. Most members of HMOs and PPOs make only a modest copayment for primary 

care services. Clearly we are not rationing health care on the basis of price. 

But if not price rationing, how do we ration physicians’ services? We ration the 

same way other developed countries ration care. We force people to pay for care with 

their time. The services of physicians are a scarce resource and a valuable resource. So 

at a price of zero (or at a very low out-of-pocket price) the demand for these services far 

exceeds supply. Unable to bring supply and demand into balance with money prices, our 

system does that next best thing. We ration by waiting. 

Some may object that the real demand for physicians’ services is not determined by 

time or money but by the amount of sickness in society. Yet this view is surely wrong.4

 

Consider that 12 billion times a year Americans purchase over-the-counter (OTC) drugs 

and suppose that on their way to these acts of self-medication all of the purchasers 

stopped to get professional advice. To meet that demand, we would need 25 times the 

number of primary care physicians we currently have!5

 

Now suppose that instead of physically going to a doctor’s office, purchasers of 

OTC drugs could get professional advice by means of telephone or email. The same 

problem would arise. The demand for advice would far exceed the ability of physicians 

to supply it. 

In general, patients cannot have the best of both worlds. If they communicate with 

doctors the way they communicate with lawyers, they will have to be charged money 

prices for the use of the doctor’s time (the way they pay legal fees). Health care cannot 

be both easily accessible and free. It must be one or the other. Waiting is not an 

accidental by product of modern health care delivery. It is an essential ingredient. 

What difference does this make? A great deal of difference. In general, if doctors 

do not compete with each other on the basis of price, they do not compete at all. 

One consequence of rationing by waiting is that the time of the primary care 

physician is usually fully booked, unless she is starting a new practice or working in a 

rural area. This means that almost all the physician’s hours are spent on billable 

activities. Further, there is very little incentive to compete for patients the way other 

professionals compete for clients. The reason: neither the loss of existing patients nor a 

gain of new patients would affect the doctor’s income very much. Loss of existing 

patients for example, would tend to reduce the average waiting time for the remaining 

patients. But with shorter waiting times, those patients would be encouraged to make 

more visits. Conversely, a gain of new patients would tend to lengthen waiting times, 

causing some patients to reduce their number of visits. Because time, not money, is the 

currency we use to pay for care, the physician doesn’t benefit (very much) from patient 

 

3

 K. Levit, C. Smith, C. Cowan, H. Lazenby, A. Sensenig, & A. Catlin. 2003, “Trends in U.S. 

Health Care Spending, 2001” Health Affairs, 22(1), pp. 154-164. 

5

 Simon Rottenberg. “Unintended Consequences: The Probable Effects of Mandated Medical 

Insurance,” Regulation, 1990, 13(2), 27-28. 
95

pleasing improvements and is not harmed (very much) by an increase in patient 

irritations. 

What about the hospital sector? As is the case for physician services, fees for 

hospital services are set and paid by third-party payers. And, as is the case for physician 

services, the scarce resource again is the doctor’s time. Here, however, it is not patients 

who are waiting on doctors; it is hospital beds (and other facilities) that wait on doctors. 

In many ways, the two sectors are mirror images of each other. In neither sector do 

prices clear markets. And in neither sector is competition among providers based on 

price. 

Can Health Markets be Different? 

There is nothing normal or natural about rationing by waiting. The exterior offices 

of lawyers, accountants, architects and other professionals are called “reception areas,” 

not “waiting rooms,” and very little waiting actually goes on. The reason: waiting is a 

wasteful way to allocate resources. In markets for other goods and services, the 

consumer’s cost is typically the producer/seller’s income. But when people pay for 

goods with their time, their waiting cost is not someone else’s income. It is a net social 

loss. 

Rationing by waiting is not only socially wasteful, it is a poor way of delivering 

health care. Under such a system, there is no way to insure that those who need care the 

most get it first, or even get care at all.6 Human resource experts estimate that onequarter of physicians visits are for conditions that patients could easily treat themselves.7

 

Balanced against these “unnecessary” visits are all of the potential visitors who choose 

not to seek care. Undoubtedly, many of those are “necessary” but unrealized visits; and, 

hence, the patients go without professional treatment. 

To find radically different physician behavior, one must look at markets where thirdparty payers are not involved at all, such as the markets for cosmetic and lasik surgery. 

Unlike other forms of surgery, the typical cosmetic surgery patient can (a) find a package 

price in advance covering all services and facilities, (b) compare prices prior to the 

surgery and (c) pay a price that is lower in real terms than the price charged a decade ago 

for comparable procedures — despite the considerable technological innovations in the 

interim.8 

Ironically, many physicians who perform cosmetic surgery also perform other types 

of surgery. The difference in behavior is apparently related to how they are paid. A 

cosmetic surgery transaction has all the characteristics of a normal market transaction in 

which the seller has a financial interest in how all aspects of the transition affect the 

buyer. In more typical doctor-patient interactions, doctors are not paid to be concerned 

about all aspects of care and therefore typically ignore the effects on the patient of the 

cost of time, the cost of drugs, and other ancillary costs. Note, this holds for HMO 

doctors as well as fee-for-service doctors and what is true for U.S. doctors in general is 

also true of doctors who practice in the government-run health systems of other 

developed countries. 

Whenever there is waste and inefficiency in a market, there is an opportunity for 

entrepreneurs to make profits by eliminating that waste and inefficiency. The health care 

market is no exception. What makes entrepreneurship difficult in health care is that in 

 

6

 Goodman, et al. Lives at Risk. 

7

 D.R. Powell, “Implementing a Medical Self-Care Program,” Employee Benefits Journal, 

International Foundation of Employee Benefit Programs. September 2003. 

8

 Devon Herrick. “Why Are Health Costs Rising?” National Center for Policy Analysis, Brief 

Analysis No. 437, 2003. 
96

order to eliminate waste and inefficiency, the entrepreneurs must step outside of the 

normal payment mechanisms. This means that patients who take advantage of these 

services often must pay out-of-pocket for what theoretically should be covered by their 

insurer. 

The entrepreneurial activities we have identified tend to have two characteristics: (a) 

they allow patients to economize on time and (b) they step outside the normal 

reimbursement channels, usually asking for payment at the time of service. Here are 

some examples: 

• Minute clinics. These are walk-in clinics located in selected Target and 

Club Food stores and some CVS Pharmacies, and Wal-Mart has signaled 

its interest in providing a similar service through its stores nationwide. 

They are staffed by nurse practitioners. No appointments necessary and 

most office visits take only 15 minutes. Treatments range from $25 to 

$105. In contrast to standard physician practice, medical records are 

stored electronically and prescriptions are also ordered that way. 

• TelaDoc. This service offers medical consultations by telephone. A 

doctor usually returns patient’s calls within 30 to 40 minutes. If the call is 

returned later than 3 hours the consultation is free. Access is available 

around the clock. Registration for the service costs $18. Phone 

consultations are $35 each, with a monthly membership fee ranging from 

$4.25 to $7. 

• Doctokr. This is the Virginia medical practice of Dr. Alan Dappen. 

Although he offers in-office appointments, he encourages most patients to 

have either an e-mail consultation or a phone consultation. Dappen 

charges based on the amount of time required. A simple consultation 

generally costs less than $20. 

• CashDoctor.com. This is a loosely-structured network for doctors across 

the country that are “cash friendly.” Practices styles and fee schedules are 

available online. 

Is Needed Technology Available? 

It is possible to have a health care system in which third-party payers neither set the 

fees nor pay the fees of providers. For example if health insurance worked like casualty 

insurance (the type of insurance people purchase for their homes and automobiles), 

insurance reimbursements would cover the expected cost of care for most providers; but 

patients would be free to negotiate with individual providers and pay more (for better 

service) if they found extra value warranted the extra charge. 

Even in this imaginary market, however, there has to be a way for patients to gain 

access to price and quality information. So how exactly would that work? Some assume 

that we need a new government program to kick-start needed technological changes. Yet 

while pundits talk and politicians threaten to legislate, the private sector already has 

developed many of the tools to solve these problems. 

• In the market for drugs, the web site Rxaminer.com allows patients to 

discover therapeutic and generic substitutes for brand name drugs as well 

as over-the-counter alternatives; the site DestinationRx.com allows 

patients to compare prices nationwide. 

• A model developed by Health Market allows its insureds to compare the 

price they will pay for 20,000 procedures performed by virtually every 

doctor in the country. 

• A product developed by Subimo allows patients to compare quality and 

price data for most hospitals in the country. 
97

• A product developed by eMedicalfiles creates needed transparency for 

doctors – it allows medical records to travel electronically as patients go 

from doctor to doctor and hospital to hospital. 

What Public Policy Changes are Needed? 

If we do not need government to fund or regulate new technologies, what changes 

are needed? New government policies can help in two ways. First, in markets where 

government is the primary third-party payer (e.g., Medicare or Medicaid), policymakers 

can use existing technology to let its own insureds have access to price and quality 

information. (Some modest steps in the right direction are already underway.) 

Second, we need to change the tax law to make it easier for people to self-insure for 

medical expenses instead of over-relying on third-party insurance. In order to have a 

workable, well-functioning medical marketplace, we need to fundamentally change the 

way we pay for health care, including the way we pay doctors. A step in the right 

direction is the creation of Health Savings Accounts (HSAs). Instead of an employer or 

insurer paying all the medical bills, about 3.2 million people are managing some of their 

own health care dollars through these accounts and another 3 million have Health 

Reimbursement Arrangements.9

Despite their many advantages, HSAs can be made even better. Under the current 

system, HSA plans with deductibles and copayments graph onto the current payment 

system and reinforce it rather than challenge it. Under the current HSA rules, if a patient 

pays for care with dollars, those dollars count toward a deductible and move the patient 

closer to the point when a third-party will pay all remaining financial costs. But if a 

patient pays for care with time, this does not count toward the deductible. Further under 

most HSA plans, time-saving innovations are typically not covered expenses. In these 

ways, most HSA plans are tacked on to the existing payment system, rather than an 

alternative to it. 

The current HSA law’s primary problem is that decisions the market should make 

have been made by the tax-writing committees of the U.S. Congress instead. What is the 

appropriate deductible for which service? How much should be deposited in the HSAs of 

different employees? How can we use these accounts to meet the needs of the 

chronically ill? In finding answers, markets are smarter than any one of us because they 

benefit from the best thinking of everyone. Further, as medical science and technology 

advance, the best answer today may not be the best answer tomorrow. 

 MR. DEAL. Thank you. 

 Dr. Anderson? 

DR. ANDERSON. I do not know if I am going to make it. 

 MR. DEAL. Switch chairs? 

 DR. ANDERSON. No, I think I will be fine, I am a loud person. 

 Thank you, Mr. Chairman for the opportunity to testify this morning. 

 My overall message is that simply publishing prices will not allow 

consumer to comparison shop and will not bring prices down. 

Additional information will be necessary for comparison shopping to 

occur. Let us assume you went to the hospital and the hospital presented 

you with their price list. The price list is called a charge master file and 

 

9

 Source: HealthMarket Survey, U.S. Census Bureau and Americas Health Insurance Plans (AHIP), 

2006. 
98

it lists the prices for approximately 25,000 different items. First, you 

probably would not understand most of the items on the charge master 

file. As a result of the testimony I gave two years ago at an Energy and 

Commerce Committee hearing, I have been involved in numerous court 

suits involving the rates that hospitals charge the uninsured. I also was 

on 60 Minutes last week talking about this issue. 

 Because of many of these court suits, I have been reading far too 

many charge master files. One of the items on the charge master file for 

example is the head bugger upper body cover. The charge for one 

hospital is $77.50 for that. Another item on the charge master file was 

the lactated wingers and the charge at that hospital is $189. Charge 

master files have 25,000 different items like this. The normal person and 

probably most doctors cannot understand what is on the charge master 

file. In order for price lists to be useful, the price lists need to be 

understandable. 

 Second, a patient needs to know which of these 25,000 items on the 

charge master file he or she will need. Most patients entering the 

hospital have no idea what services they would need. Should they 

compare prices for the head bugger upper body cover? Should they 

compare it for the lactated ringers? The typical patient, in-patient, will 

probably need only 50 different items. The problem is you do not know 

which of these 25,000 items you are going to need, and it is unlikely the 

hospital or the doctor can tell you in advance which of these 50 items 

you are likely to need. Transparency, price transparency works only if 

you know what you are going to buy. 

 Third, the patient is unlikely to be making the final decisions. The 

team of doctors caring for you is the one who makes the final decisions. 

When you go to the emergency room because you broke your wrist, you 

do not make the final decisions. Same story when you go to the hospital 

for cancer treatments or to treat your diabetes. The decisions are 

generally left to the doctor because most of us do not know what a head 

bugger upper body cover or a lactated ringer even does. 

 Fourth, the prices that you will be quoted on the charge master file 

are not the prices that most people pay. In my testimony, I include a tape 

of the charge to cost ratios for hospitals in each State. In 2003, New 

Jersey had the highest charge to cost ratio at 3.75. What this means is 

that New Jersey hospitals charge $3.75 for an item that costs them $1. 

Does this mean that hospitals in New Jersey are earning enormous 

profits? No. Available data suggested New Jersey hospitals are earning 

only small profits. The reason is clear. Although they charge $3.75 for 

an item that costs them a dollar, they do not receive $3.75 from these 

patients. Health insurers, health plans, Medicare, and Medicaid do not 

pay full charges. They negotiate rates, we negotiate rates which are 
99

much closer to cost than to full charges. The only patients asked to pay 

these full charges are the uninsured, some people with high deductible 

health savings accounts, and the international visitors. It does not make 

sense to post prices that only a few patients actually pay. For the prices 

to be useful, they need to reflect what most insurers are actually paying 

and not the hospitals price wish list. 

 Fifth, the prices can change daily. A person could do comparison 

shopping and find the best price. Then when they actually enter the 

hospital, they would find that all the prices have changed. In fact, the 

prices could change while the person was in the hospital. It would be 

necessary to force the hospital to maintain its price to allow comparison 

shopping. 

 Sixth, if you require hospitals to disclose prices for just a limited set 

of procedures, it would lower the prices for just those limited set of 

procedures. Would you go into a Wal-Mart if they would tell you the 

prices for only 50 items but wanted you to buy everything? 

 My testimony so far has only focused on hospitals. Inadequacy of 

simply posting prices also applies to physicians and drug plans. For 

example, the Medicare prescription drug plans can change the prices of 

prescription drugs any time they choose. They can also change the coinsure amounts any time they choose. As a result, a Medicare 

beneficiary who initially found the least expensive plan may quickly find 

that these prices have all changed. 

 So what can be done to improve price transparency? My proposal is 

to require all providers to quote their prices in terms of Medicare rates. 

The hospital or physician could say I charge X percent of the Medicare 

rate. One hospital might charge 120 percent of the Medicare rate and 

other hospital would charge 125 percent of the Medicare rate. For 

certain items, the hospital or physician could deviate from the Medicare 

rate. The advantage to this is it would allow each patient to compare one 

number, one price. The Medicare rates are publicly available 

information and nearly all doctors and hospitals are familiar with 

Medicare prices. Currently there are 25,000 items on the hospital charge 

master file and over 10,000 items CPT codes that physicians use. There 

is no way for a patient to compare this many prices especially when he or 

she does not even know what services she is going to use. 

 I appreciate the opportunity to testify this morning. 

 [The prepared statement of Dr. Gerard F. Anderson follows:] 

PREPARED STATEMENT OF DR. GERALD F. ANDERSON, JOHNS HOPKINS BLOOMBERG 

SCHOOL OF PUBLIC HEALTH, HEALTH POLICY AND MANAGEMENT

Mr. Chairman, members of the Committee, thank you for this opportunity to testify 

this morning. My name is Gerard Anderson and I am a professor in the Bloomberg 
100

School of Public Health and a professor in the School of Medicine at Johns Hopkins 

University. I am also the Director of the Johns Hopkins Center for Hospital Finance and 

Management. 

I believe health care prices should be more transparent. Currently, it is very difficult 

for consumers to be aware of the prices that they will pay for hospital, physician, and 

other medical services as well as the prices they will pay for products such as drugs. 

However, simply publishing the price will not allow patients to compare prices and will 

not bring prices down. Two additional steps are necessary. First, patients need to know 

what services they will use. Most patients do not understand what goods and services 

they may need and so they cannot do comparative shopping. Second, prices must reflect 

market forces. List prices are established by the hospitals and physicians without any 

market constraints. Too often list prices have no relationship to the prices that are 

actually being paid by insurers. The prices should reflect the market place and should not 

be dictated by only the hospitals and physicians. One way to allow prices to be more 

transparent is to base all rates on a single price standard. The Medicare payment rate is 

one logical suggestion and one that is commonly used in negotiations between insurers 

and providers. Providers could simply say that they charge X% of the Medicare rate. 

Why Does The United States Spend So Much on Medical Care? – Its Prices Stupid

Making patients aware of the prices they are paying for medical services is 

especially important when you compare the prices that Americans pay for medical 

services to the prices people pay in other countries for similar services. Every year I write 

an article in the journal Health Affairs which compares the level of spending on health 

care services in the United States to the level of spending in other countries. I have 

attached a copy of the most recent article in this series. 

What the article shows every year is that the United States spends nearly twice as 

much for medical care as many other industrialized countries. In 2003 (the most recent 

year comparative data is available) the United States spent $ 5635 per person compared 

to $ 3003 in Canada, $2996 in Germany, $2231 in the United Kingdom and $ 2139 in 

Japan. 

These higher levels of expenditures can make it difficult for American industry to 

compete in the international market place. For example, the financial problem the 

American auto industry is having is partially related to the high costs of medical care. 

The price of a car sold by General Motors includes over $1500 in health care costs. In 

other countries, cars incorporate much lower health care costs. 

Each year we use the article in Health Affairs to investigate why health care in the 

United States is so much more expensive compared to the other countries. We have 

investigated a number of hypotheses including: malpractice costs, defensive medicine, 

aging of the population, the lack of waiting lists in the United States, the obesity levels in 

the United States, and the high level of technology that is available in the United States. 

We have investigated each of these factors in one or more of the articles. 

What we have found is that each factor is partially responsible for the higher costs in 

the United States. However, none of them really explains why the United States spends 

nearly twice as much as other industrialized countries. 

As we continue to examine the data we have reached the following conclusion - “Its 

Prices Stupid.” This was the title of our article in Health Affairs in 2003 and it remains 

our primary conclusion of why health care in the United States is so expensive today. 

Comparing Drug , Hospital and Physician Prices in the United States to the Prices 

Other Countries

In 2004, we published an article in Health Affairs entitled Doughnut Holes and Price 

Controls which compared the drug prices for the 25 most commonly prescribed drugs ( 

both brand name and generic) in the United States to the drug prices for the same 25 
101

drugs in Canada, France and, the United Kingdom. What the article shows is that the 

United States patient is paying approximately double the prices for drugs as patients in 

Canada, France and the United Kingdom are paying. This explains the desire for 

reimportation among United States consumers. 

We have also compared the expenditures for hospital and physician services. The 

United States spends twice as much per capita for hospital and physician services as other 

industrialized countries. When we examined the reason we first discovered that quantity 

was not the reason – Americans are receiving fewer hospital days per capita and fewer 

physician visits per capita than people in most other industrialized countries. In fact, 

managed care and other initiatives have eliminated many unnecessary hospitalizations 

and shortened the average length of a hospital stay. 

A second explanation we examined was technology and we found that access to 

expensive technology was not a major reason for the higher per capita hospital spending. 

The United States, for example, has approximately the same number of CT scanners and 

MRI machines as the average industrialized country. The Japanese have access to the 

most technology. For example, Japan has 4 times more MRIs per capita and 7 times more 

CT scanners per capita than the United States. In spite of using all this technology, health 

expenditures per capita in Japan are only 38 percent of the United States. 

Per capita spending for American hospital services is more much more expensive 

than other industrialized countries because of the price of a hospital day. The price of a 

day in an American hospital is nearly two and a half times the price of a hospital 

stay in other industrialized countries. 

A similar argument can be made for physician services. Americans do not receive 

more physician services than people in other industrialized countries. Yet the price of a 

physician visit in the United States is over twice the price in other countries. 

Because of the work we have done comparing the prices in the United States to the 

prices in other countries I am in total support of the efforts to control prices in the United 

States. The reason why the United States health care system is much more expensive 

can be summarized in three words – “Its Prices Stupid.” 

Policy Initiatives To Control Prices in the United States

Public payors such as Medicare and Medicaid have undertaken a number of 

initiatives to control prices. The first major initiative was the Prospective Payment 

System to control hospital rates in the Medicare program. It was soon followed by the 

Resource Based Relative Value System that is used to pay physicians in Medicare. Other 

prospective payment systems have followed for other types of providers. Medicaid 

programs have followed a similar approach to Medicare. 

Over the past 20 years little public policy attention has focused on controlling 

prices in the private sector. The last public policy attempt to control prices in the private 

sector was President Carter’s Hospital Cost Containment initiative. This was an attempt 

to control the rate of increase in hospital rates for all insurers and for self pay patients. 

It is always surprising to me that prices are substantially higher in the private 

sector than they are in the public sector. MedPAC numbers continually show that the 

private sector pays 10 – 20 percent (and in some years more) than the public sector. I 

have often wondered why the private sector cannot get better rates. Some have argued 

that the public sector shifts costs to the private sector. The real policy question is why the 

private sector allows the “cost shift” to occur. Why can not the private sector use 

competitive forces to get lower rates than the public sector? 

Because the private sector is paying higher rates than the public sector, the public 

sector has difficulty keeping prices low. If the public sector was paying substantially 

lower rates then the hospitals and physicians could restrict access to public beneficiaries. 

The differential between the public and private rates cannot become too great. The public 
102

and private sectors need to be able to work together to keep prices low. In the United 

States this means the private sector becoming a strong force in controlling prices. 

Does the United States Get Value For the Higher Prices?

It is difficult to compare outcomes across countries. Without an ability to compare 

outcomes it is impossible to calculate value. There have been a number of initiatives to 

compare outcomes. 

For years we have known that the life expectancy is lower in the United States than 

in many other industrialized countries and that the infant mortality rates are generally 

higher. This would suggest that we are not getting value for the much higher spending in 

the United States. Critics of these comparisons have correctly pointed out that life 

expectancy and infant mortality rates are determined by many factors and that health care 

may play only a minor role. 

To examine if the health care in the United States is better than the health care in 

other countries we conducted a study comparing the clinical outcomes in the United 

States to the clinical outcomes in England, Australia, New Zealand, and Canada. We 

selected 21 indicators to compare. For example, two of the indicators were 5 year 

survival rates following a diagnosis of breast cancer and mortality from asthma in people 

are 5 -39. The 21 indicators covered a number of illness categories but were not designed 

to be a comprehensive list. 

What we found was that the United States was the best on a few indicators, the 

worst on a few indicators, and in the middle on most indicators. Not a good showing for a 

country that spends more than twice as much per capita as these other countries. 

Internationally it is clear that higher prices in the United States do not necessarily 

result in better outcomes. 

We have also looked at how these other countries have been able to control prices 

for hospitals, physicians, drugs and other goods and services. The answer in some other 

countries is that the prices are set by the government. In other countries all the insurers 

get together and negotiate as a group with the providers. Imagine all the insurers on one 

side of the table and all the providers on the other side of the table and the end result of 

the negotiation is a set of prices that all insurers will pay. 

An examination of the experiences of these other countries suggests that either 

regulation or collective negotiation could work if the objective was to control health 

care prices. There are, however, a number of obstacles to overcome. United States policy 

makers have not believed that regulation is an effective way to control prices and having 

all insurers negotiate together would violate antitrust policy. 

 

Pricing Transparency – What Else Is Needed

For the reasons discussed above, I am in favor of a renewed policy emphasis on 

lowering health care prices. The United States is now considering a different approach – 

to make prices more transparent. This approach has some merit although simply posting 

prices will not achieve the objective of allowing consumers to engage in comparison 

shopping and will not bring down prices without additional steps being taken. The 

remainder of my testimony suggests what else needs to be done and finally makes 

suggestions regarding what actions the Congress should take in addition to requiring 

prices to be posted 

First, it is critical for patients to know the services they are going to use. 

Comparison shopping is not possible if the patient does not know what goods and 

services he/she is are going to buy. Second, the prices need to be reasonable. By 

reasonable I mean the prices must reflect what is being paid in the market place. The 

list prices that are established by hospitals and doctors generally do not reflect what 

insurers are actually paying. 
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Comparison Shopping

Imagine going into a grocery store or a department store and not understanding: (1) 

what most of the products you are purchasing actually do, (2) what is actually on the bill, 

and (3) having no idea what you are going to buy when you enter the store. In this case 

you would not be a good comparative shopper even if you knew the prices. You need to 

understand what you are buying before you make the purchase. 

In health care there is often an additional factor. Imagine that you are not even the 

person picking out the goods in the grocery store or the department store. Imagine that 

someone else is making the decisions about what to buy for you. Health professionals, 

most commonly doctors, make most of the decisions when you go to the doctor’s office 

or the hospital. For many clinical conditions this will always be the case. 

The following sections explain why simply requiring hospitals, physicians, and drug 

plans to post prices is insufficient. Without these additional steps, the market place will 

not work and comparison shopping will not be possible. 

Hospitals

The hospital charge master file lists the prices for each service the hospital provides. 

The hospital charge master file contains 10,000 items in a small hospital and 50,000 

items in a large hospital. Simply posting the prices on the charge master file will provide 

the patient little information if the patient wants to do comparison shopping for 

hospital services. 

1. The typical hospital bill contains 10 to 500 items. These could be $1000 for an 

hour of operating room time or $5 for a Tylenol. The patient will never use 

most of the items on the charge master file. Without knowing what services 

he/she will use it is impossible for the patient to do comparison shopping. 

2. Unfortunately, in most cases hospitals and/or the doctor cannot tell the patient 

in advance which services they will need. The hospital or the physician may 

estimate that the procedure may require an hour of operating room time but the 

operation may require only 30 minutes or may require two hours. The hospital 

or the physician cannot know if the patient will want or need a Tylenol. 

Without knowing precisely what services are going to be used it is impossible 

to really do comparison shopping. Should the patient compare prices for 30 

minutes, 60 minutes or 120 minutes of operating room time? Should the patient 

compare prices for Tylenol or ibuprofen? 

3. Comparing the 10,000 to 50,000 items on the charge master file is foolish when 

the patient will probably use less than 100. The problem is that the patient does 

not know exactly which 100. 

4. Many of the items on the charge master file and ultimately on the hospital bill 

are written in code so that only the hospital administrators and a few other 

experts in the field can understand. The charge master file will need to be 

translated if the consumer is going to understand what he/she is buying. 

5. I examined a hospital bill for a person who was charged over $30000 for an 

outpatient procedure. A $30000 charge for a procedure that did not even 

require an overnight stay. 

6. The bill contained numerous charges. Many of the services on the bill were 

written in a strange language. I wonder how many people in this hearing room 

know what a “Bairhugger upper body cov’” is or why the charge is $77.55. The 

same hospital bill contained the following items and associated charges: 

a. Furosemide/20MG/2ML/V – $4.54 

b. Toradol 30MG/ML 1ML S - $ 22.02 

c. Versed 1 MG/ML 2CC VIA - $11.37 

d. Lactated Ringers 2B2324 - $189.00 

e. Valve IV - $7.15 
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f. Pack Custom Cysto - $58.00 

g. Set Tur - $35.35 

h. **Zofran 1 Mg dose – 155.18 

If the consumer is going to effectively comparison shop, then these items will 

need to be described in English. 

7. Hospitals are currently allowed to change their prices at any time. A patient 

could comparative shop for hospital services on Monday and enter the hospital 

on Tuesday and find that the prices have all been changed. In fact, the patient 

could enter the hospital on Tuesday and remain in the hospital until Friday and 

see the prices changed every day they were in the hospital. This same issue 

applies to the Medicare Prescription Drug benefit. The drug plans are able to 

change their prices at any time. If patients are going to engage in comparative 

shopping the prices have to be fixed so that the patients can compare prices. 

Physicians 

1. In most cases it is the physician who is making the decision about what type of 

care the patient will receive. The physician is unable to provide any guarantees 

in most cases concerning what services he/she will ultimately provide. As a 

result, comparative shopping will be impossible since you do not know the 

prices of what services to compare. 

2. Comparison shopping for certain physician services is possible. Probably the 

best example is LASIK surgery. It is a relatively standard procedure and 

therefore it is possible for the physician and the patient to compare services and 

compare prices. In this case a price list is probably sufficient. LASIK, however, 

is more the exception than the rule. 

3. The more common encounter between a physician and a patient is when the 

patient does not exactly know what is wrong and the physician has to order a 

series of tests to discover what is wrong and then to decide on the appropriate 

treatment. This cannot be predicted at the beginning. Then once the treatment 

starts it is often unclear what will be needed and how long it will take. 

4. For example, each woman with breast cancer will probably respond differently 

to treatment. As a result, the oncologist cannot specify in advance what services 

will be provided or what will be charged. If a woman was trying to comparative 

shop for an oncologist she would need to know what services will be provided 

and not just the prices that will be charged for services that she may or may not 

need. The same principle applies to people with chronic conditions such as 

diabetes, congestive heart failure, or asthma. No physician can tell the patient 

in advance what services he/she will require in the next year and therefore true 

comparison shopping will be impossible. 

5. In the Medicare program two thirds of Medicare spending is by the 23% of 

beneficiaries with 5 or more chronic conditions. These beneficiaries see an 

average of 13 different physicians during the year. Their condition is always 

changing. It will be impossible for these beneficiaries to predict what services 

they will need in the coming year and therefore comparison shopping for 

physician services is impossible.

Pharmaceuticals

1. The Medicare Modernization Act allows Medicare beneficiaries to compare 

drug prices in different health plans. Many consumers have found this 

comparison shopping very difficult. 

2. The drug plans participating in Medicare Part D do not have to disclose the 

price that they are paying for the drugs. All that is provided to the Medicare 
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beneficiary is the retail price. Drug plans are likely to obtain discounts from the 

pharmaceutical companies. 

3. Medicare beneficiaries are locked in to a specific drug plan which they choose 

based on the prices of the drugs and the cost sharing arrangements. However, 

the drug plans are free to change prices and change cost sharing arrangements 

during the year. A drug plan that was the least expensive for a beneficiary 

with one set of prices could become a very expensive plan if the drug plan 

changed the prices during the year or changed the cost sharing 

arrangements.

4. Next year another problem is likely to arise – Medicare beneficiaries 

developing new diseases which require new drugs that they did not anticipate. 

5. A major problem for Medicare beneficiaries doing comparative shopping is that 

they are locked in to a particular plan for a year. Many have found the least 

expensive plan assuming their use of drugs does not change during the year. 

However, for millions of Medicare beneficiaries the drug regimen is likely to 

change and at that time they may not have the least expensive plan. 

6. Unfortunately, Medicare beneficiaries get sicker as they age. Some years they 

develop a new chronic condition and that chronic condition may require them 

to take a new drug or multiple new drugs. The typical Medicare beneficiary 

acquires an additional chronic condition every two or three years. As noted 

earlier in this testimony, 23% of Medicare beneficiaries have 5 or more chronic 

conditions. These beneficiaries fill an average of 50 prescriptions during the 

calendar year. Many of them change prescriptions during the year. 

7. Without knowing what drugs you are going to use in the year it is difficult to do 

comparative shopping. 

In summary, price comparisons have little value unless the person knows 

exactly what goods and services they are buying. In health care it is difficult to 

predict in advance what goods and services will be needed and doing comparison 

shopping while a procedure is being done is not generally feasible. 

Reasonable Prices

It is not sufficient simply to post prices. The prices must be reasonable. By 

reasonable I mean that the prices must reflect the market place. The list prices that are 

in the hospital charge master file do not reflect market forces for reasons that will be 

described below. The same applies to most physician charges. 

Let’s assume that a hospital had prices of $1,000,000 per day. Would that be a 

reasonable price? I suspect most reasonable people would say no. What if a doctor had 

prices of $1,000,000 for an office visit – would that be a reasonable price? Again I 

believe most reasonable people would argue that $1,000,000 for an office visit is an 

unreasonable price. 

Under the current system hospitals and physicians have the ability to post any 

price they choose. There is not a requirement that anyone ever pays that posted price 

and in fact the posted price is seldom paid. 

The question then becomes how does Congress determine what is a reasonable 

price? It makes no sense to require hospitals and physicians and others to post 

unreasonable prices. Two possible standards to determine if the prices are reasonable are 

(1) costs and (2) the market place. 

Costs are relatively easy to calculate for hospitals. Groups such as MedPAC 

routinely use costs to compare to what Medicare is paying. The Medicare Cost Report 

calculates Medicare allowable costs for nearly every hospital in the United States. Costs 

are more difficult to calculate for physicians, health plans, etc. 

One reason for not using costs is that they do not encourage efficiency. The prices 

could be high because the hospital is very inefficient. A second reason for not using costs 
106

to determine if the price is reasonable is that costs may not reflect market forces. A 

hospital with very high costs may be unable to lower its prices sufficiently to enter into 

an agreement with a health plan or an insurer. 

An alternative is to use the prices that are actually being paid in the market place. 

The prices reflect the discounts that hospitals, physicians and other groups negotiate with 

insurers. 

The charge master file submitted by the hospital does not reflect market prices. In 

most cases neither do the charges established by physicians. Few patients actually pay 

these charges. Insurers obtain large discounts off these list prices – often as high as 75 

percent. I have actually seen contracts where the discount from list price was over 900 

percent and in this case the hospital was still earning a profit from the insurer because the 

negotiated rate was above the hospital’s actual costs. For a price list to be reasonable it 

needs to reflect what is actually being charged in the market place. 

Because the issue is easier to understand in the hospital context, I will focus on the 

unreasonableness of hospital charges as shown in the charge master file.

How Charges Are Set By Hospitals

Hospital charges are determined by a charge master file and the hospital or hospital 

system determines the charges in the charge master file. The hospital or hospital system 

has complete discretion to set each and every charge on the charge master file. 

 The hospitals often do not know how they set each charge on the charge master file. 

There is not a formula that hospitals use to set charges. 

According a December 2005 MedPAC report entitled “A Study of Hospital Charge 

Setting Practices” “The hospital charge description master (CDM), or “charge master” is 

extensive, usually containing between 12,000 and 45,000 individual charge items and 

procedures across hospital department providing patient services. Every chargeable item 

in the hospital must be part of the charge master in order to bill the patient, payer, or 

health care provider.” 

 The MedPAC report was based on interviews with 57 participating hospitals and/or 

systems involving 238 hospitals. Some of the quotes in the Report from the interviews 

the team conducted with hospital executives involved in setting hospital charges 

demonstrate that the charges are not set by market forces or using a systematic 

methodology.

“With over 45,000 items in the charge master, the vast majority have no relation to 

anything, and certainly not to cost.” 

“There is no rationality to the charge master and costs still do not have much 

relevance.” 

“Charges have less and less meaning each year...” 

There have been numerous academic articles written describing how hospitals 

determine their charges. However, perhaps the most illuminating presentation was a 

newspaper article that was published in the Wall Street Journal on December 27, 2004 

and written by Lucette Lagnado. The article takes advantage of the data on hospital 

charges that California hospitals are required to report. The article also contained a quote 

from William McGowan, chief financial officer at the University of California, Davis 

Health System and a 30 year veteran of hospital pricing policy implementation. In the 

article Mr. McGowen explained the rationale of hospitals charges “There is no method 

to the madness. As we went through the years, we had these cockamamie formulas.” His 

conclusion is not much different than what the hospital executives said to MedPAC in the 

December 2005 report. 

The same Wall Street Journal article includes a chart that shows the variation in 

charges in seven California hospitals for services such as chest x-rays, complete blood 

count, CT Scan, Tylenol, etc. The chart below shows the variation in charges at the seven 

California hospitals for just Tylenol and a chest x-ray. The range for one tablet of 
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Tylenol was free to 7.06. The range for a routine chest x-ray was from $120 to $1519.00. 

These are substantial charge variations. 

Charge for Tylenol Charge For x-ray 

Scripps Memorial La Jolla $7.06 $129.90 

Sutter General – Sacramento No Charge 790.00 

UC Davis – Sacramento 1.00 451.50 

San Francisco General 5.50 120.00 

Doctors – Modesto No Charge 1519.00 

Cedars Sinai – LA 0.12 412.90 

West Hills – West Hills 3.20 396.77 

 As noted earlier it would therefore be unreasonable to expect a person to do 

comparison shopping on all items in the charge master file, the vast majority of which 

he/she would never use. If you only had the information on this chart which hospital 

would you choose? The two hospitals that do not charge for Tylenol have the highest 

charges for an X-ray. Unless the patient knew if he/she would need an X-ray or would 

need Tylenol the price information is useless. 

There are a few items on the charge master file where a consumer would know the 

products and could compare prices. These are items the person might purchase outside of 

the hospital. I reviewed the charge master file at one hospital and this is what I found. 

In 2002, the charge for one tablet of ibuprofen was over $5.00. The charge for one 

chewable tablet of a multivitamin was also over $5.00. A 12 packet of Rolaids was over 

$10.00. If the person needed a 15 minute massage the charge was over $50.00 or over 

$200 per hour. In 2002, the person was being charged over $600 per day for a 

semiprivate room. Many of these charges increased in 2003, 2004, and 2005. 

 Why Hospital Charges Are Set So High

 When a person goes to the drug store to purchase ibuprofen, multivitamins, or 

Rolaids the prices are clearly labeled. The prices in other drug stores are clearly labeled. 

A drug store that charges high prices will likely lose business. The market place operates. 

In contrast, the amount that any hospital proposes to charge for ibuprofen, 

multivitamins or Rolaids or any of the other 25000+ items on the charge master file is not 

set by market forces. As a result, they are much higher than they would be if market 

forces prevailed. The following section explains why it is inappropriate for consumers to 

pay what is on the charge master file. 

Before 1929, patients did not have health insurance and patients paid hospitals 

directly for each service. Patients paid charges. To some extent, market forces 

influenced the amount a hospital could charge. One hospital might charge $4.00 for a 

day in the hospital while another hospital charged $5.00. It was relatively simple for 

patients to compare hospital charges when all that the patient was comparing was one 

number – the price for a day in the hospital. 

As the depression worsened in the 1930s, the ability of people to pay their hospital 

bills worsened. Blue Cross and other insurance programs developed in response to the 

inability of people to pay their hospital bills. 

During this period, hospitals’ charges were based on the cost of providing care, plus 

a markup typically of less than 10%. Because health insurers paid the charges, there was 

little or no gap between the amount billed and the amount collected by hospitals. Market 

forces were operating to some extent to hold-down charges. 

By 1960 most hospitals had moved away from a per day charge and were using a 

charge master file to bill patients. In 1960, however, the charges set by hospitals were 
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still based on the cost of providing care plus a small allowance for profit. Most insurers 

continued to pay charges. The charge master listed all the services the hospital provided 

for the patient: ibuprofen, multivitamins, Rolaids, etc. 

In 1960, the typical charge master file established by hospitals had 5000 separate 

items. This was a major expansion from 1930 when there was typically only a room and 

board charge. It was becoming difficult for market forces to operate by 1960 because an 

individual patient did not know which of the 5000 different items he/she would need. 

Comparison shopping was becoming more difficult. 

The hospital bill was calculated by multiplying the amount on this charge master file 

by the number of units received. For example, if the hospital charged $1000 per day in 

the hospital for room and board and the person remained in the hospital for 4 days, the 

room and board charge would be $4000. Two hours in the operating room might cost 

$500. Other services the patient received would be added to this bill to calculate a total 

charge. 

Competition for patients kept hospital charges close to the level of hospital costs. 

Nearly all hospital bills were paid on a charge basis. Market forces continued to operate 

to some extent through the early 1960s. 

Fewer and Fewer Insurers Pay Full Charges After 1960

Between 1960 and 2003 fewer and fewer insurers paid hospitals on the basis of 

charges. First the public sector and then the private sector stopped paying full charges. 

When public and private insurers stopped paying hospitals on the basis of charges, 

market forces no longer served to hold down hospital charges. By 2003, market forces 

and regulations were operating to hold down hospital prices for many public and private 

insurers such as Medicare, Medicaid, United Healthcare, Anthem, and Premier. 

At the same time, hospital charges were being increased to very high rates. This 

became know as “cost shifting.” Cost shifting meant that patients being asked to pay full 

charges were paying higher and higher charges while the rate increases for insurers like 

Medicare, Medicaid, United Healthcare, Anthem, and Premier were much lower. 

When the Medicare program was established in 1965, Congress decided that the 

Medicare program would pay hospital costs and not hospital charges. Congress 

recognized that charges were greater than costs and that the Medicare program would be 

able to exert little control over hospital charges. This was the first real break from paying 

hospital charges. 

 A very detailed hospital accounting form called the Medicare Cost Report was 

created to determine Medicare’s allowable costs. In order to allocate costs between the 

Medicare program and other insurers, the Medicare program required hospitals to collect 

uniform charge information. For example, if 40% of the charges were attributed to the 

Medicare program, then the cost accounting system would allocate 40% of the costs to 

the Medicare program. 

In order to prevent fraud and abuse, the Medicare program required hospitals to 

establish a uniform set of charges that would apply to all insurers. Otherwise, the 

hospital could allocate charges in such a way that would result in more costs to the 

Medicare program. 

Hospitals continued to have complete discretion on how they established their 

charges. The Medicare program did not interfere with how hospitals set charges for 

specific services. The Medicare cost report simply required the hospitals to report their 

charges. 

Two major changes occurred in the 1980s that severed any impact that market forces 

would have on hospital charges. One occurred in the public sector and the other occurred 

in the private sector. 

First, Medicare created the Prospective Payment System for inpatient hospital 

services in 1983. In 1990, the Medicare program moved away from paying costs for 
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outpatient services and instituted the Ambulatory Payment Classification System that sets 

rates for outpatient services. Most Medicaid programs adopted their own Prospective 

Payment Systems. 

Second, most private insurers began negotiating discounts or using some other 

mechanism other than paying charges to pay hospitals. Managed care plans began to 

negotiate with hospitals in the early 1980s. They wanted discounts in return for placing 

the hospital in their network. They successfully negotiated sizeable discounts with 

hospitals. As indemnity insurers began to compete with managed care plans in the mid 

1980s, they also began to move away from paying full charges and started negotiating 

their own deals. Nearly all indemnity insurers and managed care plans stopped using full 

charges as the basis of payment by 1990. 

Insurers such as Aetna, Cigna, Medical Mutual, and United Healthcare get 

substantial discounts. In many hospitals these insurers are paying only one third of the 

billed charges. 

 

Comparing Hospital Charges

Because of these regulations and negotiations few if any insurers actually pay full 

charges. Because virtually no public or private insurer actually pays full charges, charges 

are an unrealistic standard for comparison. A more realistic standard is what insurers 

actually pay and what the hospitals have been willing to accept. That should be a standard 

of comparison to see if the amount paid is reasonable. 

The amount charged is determined solely by one party in the transaction - the 

hospital. It is not a market transaction. The amount paid that is determined by both parties 

in the transaction is a reasonable amount. These are the rates determined in a negotiation 

between insurers and hospitals. 

Self Pay Patients

In 2006, only three groups routinely paid full charges. The three groups were: (1) 

the uninsured, (2) international visitors and (3) some health savings accounts that carry a 

high deductible. Together these are commonly known as “self pay” patients 

Because the federal government, state governments, private insurers, or managed 

care plans do pay full charges, the regulatory and market constraints on hospital charges 

were virtually eliminated. Each insurer has developed a different way to pay hospitals; 

this lead to a phenomenon known as “cost shifting”. The self pay patients continued to 

pay higher and higher charges as hospitals “shifted” costs to self pay patients. 

Between 1960 and 2006 hospitals began increasing their charges much faster than 

their costs. The reason is that market forces were not holding down charges. The greatest 

acceleration occurred after 1995. This can be seen by examining the ratio of charges to 

costs and by examining the rate of increase in hospital charges compared to the rate of 

increase in hospital costs. 

Self pay patients have virtually no bargaining power. A patient with an emergency 

does not have the ability to compare prices and comparison shop. They are likely to go to 

the nearest facility or where the ambulance takes them. During an emergency situation 

the person or their family cannot bargain or negotiate. The provider has all the power. 

Most visits are not emergencies and so it would be possible for self pay patients to 

comparison shop. However, the ability of a person to negotiate with a hospital or 

physician is very limited. For the reasons stated earlier the self pay person does not know 

what services he/she will need with any certainty and therefore would not know what 

prices to compare. Going to a doctor or going to a hospital is not like going to the WalMart and filling your shopping cart. In the medical setting you do not select the services 

and you do not know what services that you will need until you receive them. A person 

contemplating open heart surgery, a person with diabetes, a person with a pain in their 
110

hip will not know what services they will need and cannot therefore realistically compare 

prices. 

The relative bargaining power is totally skewed in favor of the provider for a self 

pay patient. I have read numerous depositions where a self pay patient needed hospital 

care and tried to negotiate a discount off of list price. In virtually every case the person 

was turned down. Some hospitals have a discount policy for self insured patients but it is 

often very complicated for the person to access. The rates that self patients pay are often 

three times the rates that health plans are paying. Health plans pay a rate that is 

generally 10-20 percent above cost, not 100 – 300 percent above cost. 

Ratio of Charges to Costs

The most common way to examine the relationship between charges and cost is by 

the ratio of charges to cost. It is a routinely used statistic in the hospital management 

and hospital finance literature. As the ratio between charges and cost increases, the 

divergence between charges and costs increases. A ratio of 3.0 means that charges are 

three times costs. This suggests a 200% profit margin if the patient pays the full charges. 

Table 1 shows the ratio of charges to cost by state for 2000-2003. In 2003 New 

Jersey was the state with the highest ratio of charges to costs. According to table 1, the 

ratio of charges to cost for all hospitals in New Jersey was 4.51 in 2003. In other words, 

the average hospital in New Jersey was charging $4.51 for each $1.00 it cost. This is a 

351% profit margin. 

Maryland has the lowest charge to cost ratio. Since the mid 1970s Maryland has 

been regulating hospital prices and not allowing the ratio of charges to cost to exceed 

certain values. In Maryland the prices for self pay patients are the same as for people with 

health insurance, only Medicaid gets a slight discount. 

Table 1 also shows that charges were increasing much faster than costs in most 

states 

during the 2000 -2003 period. The relationship between charges and costs was continuing 

to erode over this time. In New Jersey, for example, the ratio of charges to costs 

increased from 3.16 in 2000 to4.51 in 2003. In other words, the markup over costs 

increased from 216 percent to 351 percent over a three year period in New Jersey. Other 

states had similar increases in their ratios of charges to cost. 

What Can Be Done To Improve Price Transparency?

Patients cannot ever understand the 10-50,000 items on the charge master file. Also 

it does not make sense for them to examine all the items on the charge master file when 

they will only need 10-500 items. The same holds true for the 10,000+ CPT codes that 

physicians use. There needs to be a way for hospitals and physicians to signal their 

relative prices. 

When each hospital and each physician has complete discretion to establish its own 

price list, it will be impossible for the patient to do comparison shopping. Because they 

do not know what services they are going to need, they cannot be good comparison 

shoppers. 

Also because each hospital and each physician has discretion to set the rates for each 

individual service, it is difficult to determine if the prices are reasonable. If there were 

one basic price list, then it would be possible to easily compare prices. Not all insurers 

would have to pay the same rate but they would use the same set of relative prices. 

One possibility is for the hospitals, physicians and other providers to say that their 

prices are X% of the Medicare rate. One hospital could say that they accept 125% of the 

Medicare DRG rate. They would accept the same percentage above or below the DRG 

rate for all DRGs unless they explicitly made an exception for certain DRGs. Another 

hospital could accept 120% of the Medicare Prospective Payment rate. 
111

For physician services a physician could say that he/she charges 125% of the 

RBRVS rate. The physician could say that for certain procedures he/she charges more or 

less than 125% of the Medicare rate. The same principles would hold for other providers. 

The providers would announce their prices with reference to Medicare rates. 

This could solve both problems that I have mentioned. The patient would know 

the price of one provider relative to another provider. The patient would not have to 

know the price for any specific service; instead the patient would know how the prices 

generally at one hospital compare to the prices at another hospital. Second, it would be 

obvious when a provider set a price that was not in the market range. It would be 

obvious that hospitals and physicians are charging patients much more than what insures 

such as Medicare are paying. 

Thank you for the opportunity to testify this morning. I would be happy to answer 

any questions. 

 MR. DEAL. Thank you. 

 I apologize, we are going to have to take a brief recess while we go 

vote and we will be back and reconvene at that time. 

 [Recess] 

 MR. DEAL. I call the hearing back to order. We have several 

witnesses who need to leave, Speaker Gingrich being one of them, I 

understand very soon so Members will come as you have noticed, they 

sometimes come, sometimes they go. Hopefully some will come back. 

 I will begin the questioning and let me just tell all of you that I think 

this has been one of the more interesting panels that I have heard because 

certainly, first of all, the issue is a current and important issue. Your 

points of view I think have all been well taken and I appreciate that, and I 

am sure the members of this committee do, too. So let me try to get a 

handle on some of it though. 

 First of all, I am a supporter of health savings accounts but as Dr. 

MacDonald said, if we do not know what we are paying for and we are 

taking the money out of our own health savings accounts that is one 

thing we need to know what we are actually going to be charged. The 

one that bothers me, I suppose even more than that, is we have all heard 

the arguments that the Government is negotiating the prices on behalf of 

the government programs, primarily Medicare and Medicaid. The health 

insurance industry is negotiating their prices on behalf of their insured’s. 

Therefore, the only ones that do not have anybody negotiating for them 

are the ones where they get hit the hardest. The argument being that we 

have been squeezed so much by the Government and we have been 

squeezed so much by the private insurance industry that that is the only 

place that we can stay alive. Now is there any validity to that argument 

first of all? Mr. Speaker, what is your take on that? 

 MR. GINGRICH. Well I want to say again thank you for letting us 

come and talk today. And I thought the panel was actually very, very 

interesting and this is a topic that could go on endlessly. 
112

 I just want to start with a very important ascertation that this system 

is a mess. Any time you go to somebody that is trying to pay the bills at 

a hospital, at a doctor’s office, at a pharmacy, a pharmaceutical 

company, or you name it. They are always going to have reasons inside 

this system that are perfectly reasonable because they get up every 

morning saying how do I maximize my revenue in a system that is a 

mess? So everybody has good stories. I mean if you have malpractice 

litigation reform, prices can come down. You see that in Texas and 

Missouri right now. If you have other kinds of reforms, prices can come 

down. So the last suspects who are unable to defend themselves are 

small businesses and the uninsured. Small businesses and the uninsured 

both get gouged and that is just a fact. 

 But in a true market where price transparency was available and 

quality information was available, people would in fact rapidly migrate 

to less expensive better solutions. In airlines, the price has dropped from 

.23 a mile in 1979 or ‘78 in constant dollars to .12 a mile in 2003. Now 

that is a breathtaking change and the average American today can fly 

more places at lower costs than any time in history, and as a result more 

people fly. So I would argue that until you decide you are really going to 

be in a market, and, it is going to be. Look, I used to represent Delta 

Airlines, Eastern Airlines, Southern Republic, PanAm, go down the list. 

It is very painful to make a transition from a regulated secret operation to 

an open market operation. I will tell you, it is going to be painful in the 

health field too, but in the end you are going to get better results for more 

people and I would take the money saved on waste and fraud and I would 

turn that money into tax credits so that every American of every income 

level was inside 100 percent. I am for a 300 million payer system where 

every American has insurance coverage. You can afford that if you take 

the waste and fraud out of the system. You cannot afford that inside the 

current system. 

 MR. DEAL. Yes, Dr. Goodman. Push the button down. 

 MR. GOODMAN. If an uninsured person goes to the hospital and gets 

emergency care, there never was a contract and there never was a 

meeting of the minds. You might consider legislatively determining 

what a fair price is. It might be what the cost is paying. Or if the 

hospital is getting a significant disproportionate share of money, you 

might say that a fair price is the Medicare price or the Medicaid price 

whichever is lower. If an uninsured person goes in for elective surgery 

again, if there is a meeting of the minds and agreement on price, that is 

fine, but if there is not, again you might go back and rely on some 

legislative benchmark of what is a fair price. 

 MR. DEAL. Dr. MacDonald, I am very intrigued by what you have 

done and I apologize that I am running out of time. Maybe we will have 
113

some time for more questions but, you know, it seemed to me in the 

whole context of this that if you are paying cash or paying out of your 

pocket or reaching into your health savings account and that is the source 

of the money, it is not going through all the bureaucracy of having to file 

the insurance claims and having to argue with the insurance company as 

to whether this is appropriate or that is appropriate. You know it would 

seem to me that ought to be the cheapest customer because they have 

cost you less in overhead. Am I wrong? 

 DR. MACDONALD. No, you are correct. And actually that is part of 

the problem with the HSAs, I mean you go in and use your HSA dollar, 

you are paying retail price not wholesale price. So it should not be a 

surprise that people with a high deductible are not pursuing care. A lot 

of people are missing the point. They are using high deductibles as the 

deterrent to care. Well the deterrent to care is paying ten times what is 

accepted from an insurance carrier. What I do not consider is places like 

California. Take the frequent flyers in the emergency room, the people 

that are coming in and they do not understand, attach them with mentor. 

Get dollars currently being spent in Medicaid or Medicare, whatever pot 

you want and let us look at those dollars. Track them, qualified medical 

expenses, only so it is not beer and pretzels that they use the money for. 

It is real things, and let us see if we can make an impact on the frequent 

flyers in the emergency room. A lot of people think they are the reason 

for the high cost and that is not true. Cassil in my briefing, I referenced 

the article you can look at it and see. They looked at the emergency 

room visits for about four years, 16 percent increase, 66 percent were 

Medicare and those with insurance, ten percent for those without 

insurance. The burden to care is not a high deductible policy. The 

burden to care is the reality if it is confusing. And I am glad the 

gentleman had spoke, they do not understand 25,000 lists, master lists. 

Well they do not really care, and you do not care either. You only care 

about the one thing that is on your list. See no one in this room cares 

about 25,000 doodads. They really do not. You only care when you get 

sick and you see that bill. That is what you care about. I mean, you pay 

with a dollar that swipes and it is gone, you should not pay the 

administrative burden. 

 MR. DEAL. Mr. Pallone? 

 MR. PALLONE. Thank you, Mr. Chairman. 

 I wanted to ask either Dr. Anderson or Dr. Collins or both of them a 

question that relates to my poster. They have seen my poster before 

about buying two stents and you get free same day installation. I 

developed this basically to highlight to absurdity of trying to transform 

the health care market into other types of commodity markets. And 

reality is you cannot treat health care like a simple commodity in my 
114

opinion. But that is what I wanted to ask you. I mean, do you think, can 

you treat health care like a simple commodity? I mean part of the 

problem is the tremendous amount of uncertainty that exists within 

health care. It is not like going to buy a car and saying you want to pay 

X amount of dollars to get power steering and power brakes. That is my 

opinion but that is what I want to ask you. In other words, you know, do 

you think we can look at this like a simple commodity? Do you think we 

can look at it in the way that we buy a car or, you know, get power 

brakes? And are there other unknown variables that may factor into the 

price? 

 DR. ANDERSON. When you go and buy a car, you can kick the tires, 

you can look at the power steering, you can make all those decisions. 

When you go to the doctor, when you go to the hospital, you cannot do 

all that because you do not know what services you are going to need 

until you actually receive those services. So to take your stent example, 

you do not know which of the many stents you are going to use so you 

could not do comparison shopping to say I want this stent or that stent. 

You do not know clinically which stent is the best you have got to rely 

on your doctor. He or she is going to make those decisions for you. I 

had the privilege of being on 60 Minutes last Sunday and the stent 

example was used actually in a particular hospital and they were 

charging, they essentially bought it for less than $10,000 and were 

charging the patient $50,000 so they had a markup of basically 5 to 1 on 

this particular stent. But as a consumer, I would not know whether 

$50,000 was the appropriate price or $10,000 was the appropriate price. 

I would not even know whether or not I was going to need a stent until I 

showed up at the hospital and my doctor said that is the way that we are 

going to treat your heart attack or that is the way we are going to take 

care of your veins. So it is much more complicated than buying a car. 

 MR. PALLONE. Dr. Collins? 

 DR. COLLINS. Patients are really in the weakest position really to 

demand lower prices and higher quality from their providers. 

Accrediting organizations, the Federal government, State governments 

are in a much stronger position to negotiate prices. It is really 

unreasonable to think that this market is ever going to function like 

markets for other goods and services. It is far too concentrated both on 

the insurer side and also on the provider side. So we really need to look 

at different ways to solve both the quality and the cost problem. 

 MR. PALLONE. And she brings me into the next question which 

relates to individual consumers not having, you know, the ability to 

negotiate, you know, discounts on provider payment rates. In other 

words, the individual versus, you know, large volume consumers. And I 

wanted to ask Dr. Ginsburg, you know, basically that. There seems to be 
115

some idea that consumers, particularly the uninsured if they know the 

actual price for a medical procedure will be able to negotiate a better rate 

with a provider of their choice. But Dr. Ginsburg, that seems to fly in the 

face of what we know about how markets work today. Discounts are 

granted based on volume for the most part. And one side to an 

individual in need of an appendectomy for example does not have a lot 

of leverage to try to negotiate a better rate for that procedure. So I 

wanted you to comment on this. How well are consumers going to be 

able to negotiate discounts on their own? Isn’t that what insurance is 

supposed to do? 

 MR. GINSBURG. I agree with you that consumers are in a very weak 

position in medical care and other markets to actually negotiate. What 

consumers can do is if they are aware of the prices and different 

providers, they can decide to go to a provider with a lower price. They 

are more likely to do that if they not only find, but have good price 

information but if they have information on quality which usually is not 

the case. 

 The key thing in this area is that uninsured people have very 

different needs than insured people. For the most part insured people 

have their insurer negotiating for them and for all the other enrollees so 

that if you are considering whether Government should do something to 

increase price transparency, the focus should be on uninsured people and 

so just to make it easier for them to compare, not to negotiate but to 

make comparisons across providers. 

 MR. PALLONE. And just to, I do not know if we have time for this, 

Mr. Chairman, but one of the health care proposals that we wind up 

discussing this year is association health plans. And the premise behind 

those is by allowing small businesses to band together, they can negotiate 

better prices largely exempt from consumer protection laws. Now isn’t 

the premise there exactly the opposite of what many who would also 

support AHP’s are arguing today, that it is the individual would could 

potentially negotiate the discount. The whole premise is the opposite, it 

seems to me. 

 MR. GINSBURG. Yes, that is right. I think the motivation, you know, 

that is stated is the combining and being able to, I mean, larger groups do 

get better rates for health insurance. That is well understood. And the 

notion is that by smaller groups coming together into a larger group they 

can get a better rate. And there are a lot of other things involved with the 

association health plan issues such as risk selection and whether you are 

going to form a pool of healthier than average people, get a better rate on 

that basis and wind up in a sense imposing costs on people not in your 

pool. 

 MR. PALLONE. Thank you. 
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 Thank you, Mr. Chairman. 

 MR. DEAL. Chairman Barton? 

 CHAIRMAN BARTON. Thank you, Mr. Chairman. 

 Mr. Speaker, in your remarks you talked about health care being a 

commodity like any other commodity. When I took economics way back 

in the ‘70s, my recollection is that my economics professor indicated that 

health care was a little bit different kind of a product. That it wasn’t a 

pure commodity because it actually affected people’s health and was just 

a little bit different. So do you want to elaborate on that? 

 MR. GINGRICH. Yes, thank you for the question. Let me say first of 

all the term commodity does not simply apply. There are very complex 

commodities. But the question is does the interaction tend to respond to 

market behaviors? And so I am going to just say a couple of comments 

have been made in the last couple minutes. You have very large markets 

for airline tickets in which individuals get dramatically better choices 

because collectively they apply amazing downward pricing pressure on 

the airlines. They do not negotiate directly with the airline, they 

negotiate with the market. And they say to the market, I am not going to 

pay this price and the result is prices come down. The evidence is 

overwhelming, but you can in fact describe most hospital costs and the 

people can make rational decisions. And again I am not talking about in 

an emergency room when you are in a crisis whether it is a heart problem 

or it is an automobile accident, but I would suggest to you that most 

decisions in health care are not in fact situations of absolute helplessness. 

In every other aspect of American life where people make complex 

decisions, what kind of home do you want to live in? What kind of job 

do you want? How far from your job do you want to live? What kind of 

car do you want to build? Which kind of vacation do you want to go on? 

We have amazing complexity even for senior citizens. Senior citizens 

are allowed to go to Wal-Mart with 258,000 items and nobody has 

suggested that they are too stupid to go around Wal-Mart, but you get to 

health and we say gee, people cannot understand this. They cannot 

understand it because the current system is professionals, bureaucrats, 

and regulators talking to themselves. So people never make it simple 

enough, all right? That happened even with the Medicare Part B where 

the CMS bureaucracy, despite its best efforts, could not talk in a 

language that would be perfectly normal for most people. 

 So I am going to start and just say that if you look at general 

patterns, and there was discussion mentioned earlier, look at dentistry, 

which is not a simple process. When you go to the dentist’s office, the 

dental assistant is giving you an X-ray and it is being read in real time 

while you are sitting there and you are discussing with the dentist what 

ought to happen to your mouth. And people have this conversation every 
117

day. Look at laser surgery. I do think the problem of fraud is real, but 

that is a commercial market problem with any product. You can have 

fraud with automobiles, you can fraud with stock, and there is always 

something that gets fraud because some people are nasty and mean 

spirited. 

 CHAIRMAN BARTON. Even if we agree that health care is a different 

kind of commodity or is not the same as airline tickets exactly or some of 

the other automobile parts, there is no reason to state that transparency 

and pricing information would not help. Does anybody disagree with 

that, regardless of what you think health care is that more transparency is 

a good thing not a bad thing and price information is a good thing not a 

bad thing? Does anybody disagree with that? 

 I hope I did not make the Speaker mad. We do not normally have 

witnesses just get up and walk out of the room. Yes, sir? 

 DR. ANDERSON. Well I think that transparency is a good idea at the 

same time it is very different in health care than it is in other services. 

So I do not think transparency will buy you very much. In my testimony, 

I talked about this but let me take Speaker Gingrich’s example of WalMart versus health care. In Wal-Mart, you go out with your shopping 

cart and you make all the choices yourself, you know all of the prices. 

When you go into the doctor’s office or go into the hospital, you are not 

the person making the choices as to what to put in your shopping cart. 

When you got E care at Georgetown University Hospital you were not 

making the choices of which service to get, which stent to get, which 

kinds of activities and you were not in a position most of the time nor 

was your family member at that time in the position to make it. So as 

somebody who still teaches health economics at Johns Hopkins 

University, I can tell you that at least I am not teaching it as a 

commodity. 

 CHAIRMAN BARTON. My time has expired but this I think is worth 

telling. They asked me as I was going into the surgical room for my 

operation or incision for my heart attack if I wanted to be sedated and I 

said not unless you have to. I want to be awake if it is allowed. So they 

gave me some sort of mild drug to make me feel good, but I was 

conscious. So I am watching the doctors get ready to put these stents in 

my heart and they are talking about it and so I did ask the doctor, I said 

do you mind if I ask you what that stent costs? He said well this stent, it 

costs, I am not sure but it costs between $2,000 and $3,000. He said we 

are going to put three of them in your heart, and I said that is a good 

thing, right? And he said, yeah, that is a good thing. He said I do not 

want to talk politics with you because he had learned that I was a 

congressman and I was Chairman of the committee that had jurisdiction 

over health care, but he said if you were a Medicare patient, Medicare 
118

would only pay for one of these stents. He said now we practice the best 

practices of medicine. You need three and we are going to put three in 

your heart, but if you were a Medicare patient, Medicare would only pay 

for one. I said we will change that, and we are trying to change it. I may 

have changed it, and do not know it because since I had my heart attack I 

did not finish the final negotiations on the Medicare/Medicaid budget 

reform package but I instructed that we change it in that package. So 

even on the operating table I was asking the cost question but I did not 

say do not put it in because it costs to much, I said put all of them in you 

need. 

 I yield back, Mr. Chairman. 

 MR. DEAL. Where did you send the bill? 

 CHAIRMAN BARTON. Blue Cross Blue Shield. 

 MR. DEAL. Ms. Capps is recognized for questions. 

 MS. CAPPS. Thank you, Mr. Chairman. 

 And thank you each of you. I am sitting here very frustrated and I 

will come out with my bias as having a background in public health in 

just a minute. But I want to associate myself with the Chairman’s 

remarks. Mr. Barton, when you were willing to sort of own up to your 

experience, both in your opening remarks and now, it seemed to fly in 

the face of a lot of the discussion about free market commodity and all of 

this; but I agree with you. If we are talking about health care as a 

commodity, it certainly is a very complex and service laden quality based 

situation we are talking about. And Dr. MacDonald knew I was 

frustrated too and he, as provider of care--and I have a lot of respect for 

family physicians--and there is something about being on the front lines 

and seeing whatever comes in the door and understanding what you 

acknowledged to me personally. And the Speaker also said this is a 

broken system and we have too many people on the panel, and we are 

taking on too many topics. Transparency is a good thing. Health savings 

accounts are an important discussion point but they are not going to save 

health care. They are not the solution. I am not a big fan because it 

skims off a lot of people. When Mr. Gingrich got up and left I was going 

to say, you know, a lot of people luckily can talk about choosing their 

home, choosing the credit card they are going to buy, choosing their job. 

But what about the people who never have those kind of choices who 

also need health care who are barely lucky to be able to rent, who get the 

job that nobody else wants, and cannot afford--here is where my bias 

comes out. I remember when managed care came to California. I have 

been a nurse there all my adult life before I came here and it was nonprofit, it was Kaiser. And it was effective to me in that it allowed people 

in the plans, it incentivized people to do preventative health care, to lose 

weight, to change. The most important thing we should do as a Nation is 
119

to give people incentives to practice the behaviors that will lower their 

health care costs and keep them out of the hospitals where it is very 

expensive to get health care. But I have watched managed care do a 

number on my State in my area and there are not any programs left 

because it became profit making and they could not afford to do all those 

things. 

 But I am concerned about one aspect of medical savings accounts 

because it seems like if people choose a savings account, they are going 

to choose a high deductible plan. Most of us think we are not going to 

get sick. Dr. Collins, I will pick on you but anybody else can jump in if 

there is time. When the people choose high deductible plans, what does 

that say about the public health system at large and about doing the kinds 

of things that will be the most cost effective as a Nation providing care or 

receiving care? 

 DR. COLLINS. The Commonwealth Fund sponsored a survey with 

the Employee Benefit Research Institute where we did a nationwide 

survey of people who had both comprehensive plans and also people in 

consumer driven plans, plans with high deductibles and no savings 

accounts and plans with high deductibles and savings accounts. What we 

find is that people in the plans have much higher out of pocket costs in 

the plans being the consumer driven plans or high deductible plans have 

much higher out of pocket costs than those in the more comprehensive 

plans. Most worrisome is that we do find that people when asked if they 

skipped care, avoided care, delayed care because of the cost when they 

were sick. People in the high deductible plans, in the consumer driven 

plans, the plans with savings accounts and without were much more 

likely to say yes to that question. So there is some evidence that people 

are avoiding the kinds of care that they need to keep them healthy over 

the long term. We also asked about prescription drugs. We asked if 

other people had skipped those just to make their medication last longer. 

 MS. CAPPS. Right. 

 DR. COLLINS. If they had not filled a prescription because of the 

cost and we find the same thing. With a particular, the problems 

particularly pronounced among people who have health problems and 

low-incomes. 

 MS. CAPPS. I hate to be so rude to see if anyone knows are there 

studies that demonstrate that this actually adds to the cost of health care 

for this Nation by people doing this, by seniors? I mean that is what I 

would like to find out. If we are talking about fixing a broken system, a 

system that is way too expensive, is there anybody who knows of studies 

that when people do not get the care they need because they cannot 

afford the high deductible, where is that cost going? 
120

 DR. COLLINS. There was a study done by Tamblyn that looked at 

whether people who had high out-of-pocket costs reduced their 

prescription drug use and they found that they did and that there were 

adverse health consequences as a result of that. 

 MS. CAPPS. Which could be more--could Dr. MacDonald just--he 

wants to answer that. 

 DR. MACDONALD. Well the Rand data is contrary to what you said 

in that when people had control of their money, mothers would pursue 

preventative care, immunizations, and routine care so there is data to 

support contrary to what your study showed. In my experience with 

Medicaid patients, many came in to see if I could help them pay for the 

medication. We actually worked on ways to get rid of the medication. 

So my practical experience of seeing people without money, they would 

ask how can we get rid of the need for the medicine. 

 MS. CAPPS. I just submit to you that a lot of them came to me as a 

Member of Congress and said they cannot take their medicine and, they 

did not have a doctor who would work with them like you did. So I 

think we need more information. 

 Okay, well I went over my time. 

 MR. GOODMAN. Well the Commonwealth study was a really bad 

study because it confused the difference between a high deductible plan 

which was in the market for decades, and plans in which people actually 

managed their own health care dollars. All reporting for the industry is 

when the health savings accounts are funded, when people have the 

money there, they get more preventative care than under traditional plans 

and they do quite well and there is no evidence that they skimp on 

needed care. There is evidence that they skimp on or cut back on 

unneeded services, have fewer unnecessary trips to the doctor, and fewer 

prescription drugs. 

 MS. CAPPS. Okay. 

 MR. GOODMAN. Especially from brand name to generic. 

 MS. CAPPS. Right, so those who are in the savings accounts but 

again I come back to the point that a lot of people have never, so many 

people do not have a savings account at all and this is a moot point for a 

lot of the people that I represent in my congressional district. 

 MR. DEAL. Mr. Shimkus is recognized for questions. 

 MR. SHIMKUS. Thank you, Mr. Chairman. 

 This is really a telling hearing because it does highlight a huge 

difference between protecting bureaucracies or the Government versus 

empowering individuals and giving them choices. One of the benefits of 

health savings accounts is where you have 44 to 46 million uninsured 

Americans. I think most Americans are concerned about catastrophic 

issues. With health savings accounts you would make catastrophic 
121

coverage more affordable for everybody. And that is a fact. And then so 

the question is that I would like to in talking about this Dr. MacDonald, 

how much of the health care costs are in these emergency room aspects, 

the emergency visits of all the health care costs what is the percentage of 

that? 

 DR. MACDONALD. I do not know the number, I just know in the 

emergency room. 

 MR. SHIMKUS. Yes. 

 DR. MACDONALD. I thought this discussion was what was the cost. 

I am confused because I think we are distracted into an HSA discussion. 

I thought we wanted to talk about what is the cost. What is the cost in 

the ER, it is inflated about ten times what is accepted from insurance 

carriers. The uninsured cannot bear that bill so what is the percentage, I 

am not sophisticated enough to know that number. 

 MR. SHIMKUS. Well ask around, let us follow up on your comment 

then. 

 DR. MACDONALD. In the emergency room, the average bill right 

now for the insured is about $400 to $500 starting plus whatever goes on 

top of that. When the insurance carrier coded the right visit 99C85, $149 

is what they pay. 

 MR. SHIMKUS. See I am from the Midwest, from Southern Illinois, a 

rural area where people still want to pay their bills and people will do all 

they can to make sure they pay bills do. If they have no coverage and if 

they have an inflated emergency room cost, do you think that is a system 

which would encourage them to try to pay their costs, or if it is inflated 

by ten fold, what would the person with moderate to no income, what 

would they probably do? 

 DR. MACDONALD. I have talked to a lot of administrators, hospital 

administrators, who write it off. I have looked at the 5500’s of a lot of 

hospitals and if you analyze and scrutinize the 5500 which is the tax 

reporting and see where all the money is going, it has been a very 

interesting event for me. I have learned things that I did not want to 

learn and that is when people say they are not making money. Look at 

the 5500’s and you will see what non-profits are doing. I think the nonprofit status needs to be reevaluated because someone goes to the ER and 

gets a bill they are not going to pay it. They are just not going to pay it. 

They are going to write it off or go to collections or get a judgment. I 

have been in the courtroom with people that are having judgments put 

against them by a non-profit hospital for a bill that is ten times what is 

accepted for an insurance carrier. It has just got to end. 

 MR. SHIMKUS. One of the reasons why I kind of try to stay off this 

committee for a couple cycles was the funding aspects of health care is 

just too confusing and it is. What I have come to the conclusion is such 
122

cost shifting that does, it is the uncompensated care, all these millions of 

uninsured, people claiming that they are writing off and they are writing 

off inflated costs, that is why the transparency debate. What is the best 

model to clean up waste, fraud, and abuse? And I would like--go ahead, 

sir. 

 MR. GOODMAN. This is not confusing in those areas of health 

marketplace where third party payers are not paying most of the bills. If 

you went to a Target Store in the upper Midwest in a shopping mall you 

would see a list of prices. You know exactly what you are going to pay. 

I would bet that those prices that are being charged to people in Target 

Stores are less than what Blue Cross pays and I would bet they are even 

less than what Medicare or Medicaid pays. So markets really can work, 

people can shop, and people can compare prices for a lot of health care 

services and there is no reason to deny them this opportunity. 

 MR. SHIMKUS. And we see some of this already. I would like to 

claim the name of a former colleague, Dr. Greg Gansky who served with 

us here. He is very knowledgeable, and was great on the Health 

Subcommittee. Who can answer the question of as far as LASIK surgery 

or elective plastic surgery one that is not in essence regulated, how has a 

competitive model worked in those two areas? 

 MR. GOODMAN. It is very good. Over the decade of the 1990’s, the 

price of all cosmetic surgery, the real price went down. 

 MR. SHIMKUS. Even Dr. Gansky would--I have heard him say that a 

number of times as a Member of Congress because that is the type of 

medicine that he practiced. 

 MR. GOODMAN. For every other surgery we are getting 10 percent a 

year increases where prices are going up and down in real terms in this 

market and even though we have all kinds of technological innovations, 

huge surgeon demand, huge surgeon procedures, this is a market that 

works like real market, people get prices. The thing that I think that 

needs to be emphasized here is you are not getting transparency because 

anybody negotiated for it or because anybody regulated it. You are 

getting transparency because markets are always transparent when they 

have to deal with consumers spending their own money. 

 MR. SHIMKUS. And my time has expired, Mr. Chairman, I yield 

back. 

 MR. DEAL. Mr. Green you are recognized. 

 MR. GREEN. Thank you, Mr. Chairman. 

 And following my colleague from Illinois, I can understand the 

concern about, I like to empower an individual. The problem I have is 

most insurance spreads the risk. So I can buy a high deductible for my 

auto insurance and save a lot of money. How many people have $5,000 

for their auto insurance for, you know, if they have an accident? You 
123

know they may have $250, $500, maybe $1,000. But we are talking 

about a $5,000 deductible for health care and you are spreading that risk. 

If I am healthy, then I am probably going to want an HSA and have the 

income to be able to put that money aside. But if I am not, if I am a blue 

collar worker that has to pay those every month or the employer requires 

him to pay monthly, HSAs are really not going to be helpful to them very 

much and I think that is what a lot of the studies that I have seen. But I 

like the idea of, and that is the focus of this hearing is, transparency. I 

have no problem with transparency. 

 And I will follow up on our Chairman who really did not have a 

choice on his stents because it was emergency. But I was diagnosed up 

here two years ago that I needed to have a CAT Scan, and because I 

might need stents, I said well wait a minute, it is going to take me five 

days if that is going to happen? My family is in Houston, I have two 

great heart facilities there with both Dr. Cooley and Dr. DeBakey. I said 

I am going to go home. So I went home. Admittedly, I did not call Dr. 

Cooley and ask him by the way, how much will you charge for my CAT 

Scan or call Dr. DeBakey at Baylor and compare to UT. I did not do 

that. I called my daughter who said the best one she thought would be 

Dr. Cooley because she is also a UT doctor. But be that as it may, I do 

not thing consumers can make that even when they have that choice. 

Now, and that is what bothers me, but I like the transparency because in 

all honesty it works for the things that are elected. LASIK surgery, I 

wear glasses most of the time. I have not wanted to do LASIK surgery 

because I do not know of the comfort level of me not wearing glasses 

would be worth whatever risk, the concern I have about the process. But 

it also does not always work when you have children because again 

having two children that grew up, you know, we wanted them to go to 

their pediatrician. I do not know if my wife would have been willing to 

shop around for pediatricians that charged $25 instead of $30. She went 

with a pediatrician that was recommended by her OB-GYN. And so 

again, I like the transparency and I like to do that but I also do not think 

that it works, it is the panacea that everybody is looking for. And again, 

my problem with the hearing is that if we are trying to do transparency 

and is the next step to show HSAs are really good, I think you have a 

long way to go. 

 Let me ask Dr. Ginsburg, one of the other witnesses, Mr. Goodman 

talks about HSAs as devices to motivate shopping. In fact is it the high 

deductible plans that motivate shopping while the HSAs delete the 

incentives especially for high income people because people have what 

essentially amounts to free cash to spend on their HAS? 

 MR. GINSBURG. Yes, I agree with that. It is the high deductible plan 

that qualifies you for an HSA that proves the incentives for you to be 
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careful in your health care shopping. If you just had a high deductible 

plan, you would have the sharpest incentives. If you are fortunate 

enough to have an HSA as well, in a sense the HSA dilutes your 

incentives because here is money in an account that I can only use for 

health care. 

 MR. GREEN. Yes. 

 MR. GINSBURG. And I also know that if I can afford to and if it is 

used, I can put more in it and get a very substantial tax subsidy. If I am 

high income, it is probably worth a 45 percent tax subsidy. So in a sense 

it is not the HSA which is the cost saving thing, it is the high deductible 

plan and the HAS, if anything, makes that plan more acceptable to 

consumers if they are going to have a balance to buffer them. 

 MR. GREEN. Sure. If you are getting a tax incentive to do it. 

 MR. GINSBURG. That is right. 

 MR. GREEN. But we could also encourage and I would hope 

business, you know, because we are seeing a lessening of businesses 

providing not only better care for their employees but also attended care, 

higher cost to the employee based on their care, and also their 

dependence. But maybe it is Congress and this is not the committee to 

talk about tax incentives but maybe if Ways and Means look at tax 

incentives for--that would include these other than HSAs. Sure, let us 

put HSAs in there but let us also look at other health plans that we could 

buy instead of making just a regular deduction. We could actually 

incentivize people to say hey, I want a full service plan because 

particularly I have two small children and they have to go get shots, it is 

going to have to do all this. 

 MR. GINSBURG. Because there is really a lot that can be done as far 

as thinking through the entire structure of tax subsidies for health care 

and making them more rational. For example, making greater use of tax 

credits instead of the exclusion of the employer contributions from 

taxable income would have some very different distributional effects. 

And even the HSA, I think a lot of people have complained about the 

rigidity of the requirements and it has to be $1,000 deductible for 

individual, $2,000 for a family. I am sure that if the idea is to encourage 

people to have a plan that leaves them with some incentives to 

economize in the cost of care, there must be better ways of doing this. In 

particular if you just specified what I would call the technical term the 

actuarial value of the term of the plan which basically is the percentage 

of the bill that the insurance pays. If you just say that we do not want 

actuarial values above a certain percentage that then would give the 

insurance industry all the flexibility to come up with benefit structures 

that are suitable and people like rather than having legislated a very 

specific benefit structure that some people do not like. 
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 MR. GREEN. Thank you, Mr. Chairman. 

 MR. SHIMKUS. [Presiding] Thank you. 

 I would now like to recognize the doctor from the State of Texas, Dr. 

Burgess. 

 MR. BURGESS. Thank you, Mr. Chairman. 

 I appreciate the panel’s forbearance for staying with us so long 

today. I guess I need to make a personal observation too since everyone 

else is doing it and the Chairman’s no longer here. The Chairman of the 

full committee is no longer here but he needs to understand that the 

doctor was offering him a sedative before the cath for the doctor’s 

benefit so that he would not ask questions during the cath. At least that 

is what I always used to do in my practice. I did not do cardiology but it 

worked in my-- 

 MR. SHIMKUS. Who paid for that sedative? Should the doctor or the 

patient? 

 MR. BURGESS. You did on April 15. 

 Doctor, your story, is a very compelling story and I have actually 

been in the same place on more than one occasion myself. A patient 

needed a tubal ligation and we tried to take her to the hospital. It was 

$12,000. She could go to a surgery center down the street where it is 

$1,000. It was a pretty easy choice to make. And the question then 

would come up why am I not going down to the street to the surgery 

center for all tubal ligations. You ask a very good question in your 

testimony and forgive me if you covered it and I just missed it but under 

your points in the end is something to ponder, why can hospitals own 

physicians but physicians not own hospitals? That is an opinion that we 

struggle with on this committee a great deal and I thank you for bringing 

that observation to the committee because while it may not be germane 

to the discussion today, it is very germane to a number of things that we 

do take up on this committee. You make another point about eliminating 

the restrictions for purchasing health insurance across State borders that 

would be what was described as a blood feud here one night about ten 

months ago when we marked up a bill to that extent. But again, you just 

have to ask the question who are we serving here? Are we serving one 

side or the other or are we serving patients? And I think we cannot 

understand why we cannot get together and decide on a basic package of 

benefits that might be offered across State lines and agree on that, tie it 

up in a nice package and make it available to people. 

 I had a situation a little over ten years ago where I had a family 

member, a child, an adult child who was unemployed by choice as it 

turns out, but nevertheless, it was almost impossible in 1994 to buy 

insurance for a young single adult. I was a physician, I was willing to 

write a big check, it did not need to be a little check, I would have paid 
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for the cost because I did not want the cost of the hospitalization over a 

car wreck or an accident of some type, a couple of days in the ICU can 

be absolutely prohibitive to try to pay for that. But there was no product 

available. Contrast that with now you can go on the Internet, type in 

health savings account in Google and you have a whole panoply of 

products that are available to you; some of which cost as little as $55 a 

month for a person in the 20-year-old age bracket. So there are new 

tools, and I guess I would just ask the question and Dr. MacDonald, 

please feel free to start off, but what percentage of people who have 

health savings accounts would you reckon were previously uninsured 

that are taking advantage of this? 

 DR. MACDONALD. Well I would like to preface that with again this 

discussion is about transparency and cost, and I am not in favor of health 

savings accounts as much as some are because it is a distorted price. So I 

want to just clarify that many people are still on the delusion and 

misconception that group policies are cheaper than individual policies. 

And having done this for a long time, and check it out yourself and prove 

me wrong, you can get an individual policy in most States cheaper than 

the group policy that you are under at your job. Prove me wrong, check 

it out, send me an email, I would love to hear the response and I have 

done this because we have a lot of companies. People get insurance, and 

we help them get insurance. A health savings account is not always the 

best buy. 

 MR. BURGESS. Correct. And I thank you for doing it. I am going to 

interrupt you because the time is running out and I want to ask Mr. 

Gedwed about our premise here today of course was to talk about some 

of the legislative products that are out there that could be enacted into 

law. Do you see in your business and I just got to tell you, I think it is a 

fantastic thing that you are doing. And really the whole hearing should 

be about you, sir, but is anything that we are likely to do bothersome to 

you? Is it going to hurt your business or help your business? 

 MR. GEDWED. No, I think, Congressman, it is going to help our 

business. I can tell you today as we talk we are getting really confused a 

lot. We work with people every day who are single moms who wait 

tables and cannot afford coverage. The first question they ask us is what 

can I get in health coverage for this amount of money, and that is all I 

have available. All we do is give them as much information on quality 

and price. They now can walk into the provider when yesterday they 

would charge them $100 per particular visit and they can say well why 

does the doctor down the street only charge $80? And at that point, the 

provider gives them a lower point. 

 MR. BURGESS. Let me just interrupt you there because quickly I 

want to go to Dr. Goodman. 
127

 Do you see any downsize to legislation that we might be doing? 

 MR. GOODMAN. I think if you require hospitals to post prices that 

will not accomplish very much at all because if you watched 60 Minutes 

Sunday night, the hospital association said we have the same price for 

everybody, the difference is is that some people get huge discounts and 

other people do not. What I wish you would do is to go back to who 

owns the hospital. I wish you would appeal the stock amendment or 

greatly roll it back so that hospitals and doctors can get together on the 

same team and make profitable improvements in their product and offer 

package prices. I would like to see us take all the restrictions at the same 

time off the specialty hospitals. If doctors want to go from their own 

hospital they can. I would like to see an override of all State laws that 

say that the hospital cannot charge a lower price to the uninsured than 

they charge to Blue Cross. So there are some things that you could do 

that I think would be very, very positive. 

 MR. BURGESS. Thank you. 

 Thanks, Mr. Chairman. 

 MR. SHIMKUS. Thank you. 

 The Chair recognizes the Ranking Member of the full committee, 

John Dingell. You are recognized, sir. 

 MR. DINGELL. Mr. Chairman, thank you for your courtesy. This has 

been a very useful hearing and I commend you for it. 

 These questions are for Dr. MacDonald. Doctor, good morning. The 

question, the first question at least we need only a yes or no answer. 

Now let me ask you about your view on these matters. You favor and 

support price disclosure for hospitals, for physicians, and pharmaceutical 

manufacturers. Is that correct? 

 MR. GOODMAN. I do not think that kind of legislation will help. 

 MR. DINGELL. I am sorry? 

 MR. GOODMAN. I do not think that kind of legislation will be 

helpful. 

 MR. DINGELL. I did not ask about helpful, I just said do you favor 

that kind of situation? 

 MR. GOODMAN. I do not favor legislation to force imposed prices, 

no. 

 MR. DINGELL. My question is a very simple one. I am addressing 

this question to Dr. MacDonald. Is that your name? 

 MR. GOODMAN. I am sorry. 

 MR. DINGELL. Since you have become Dr. MacDonald and I have 

addressed Dr. MacDonald, I hope you will respond that you were a little 

bit early. Dr. MacDonald, do I have your attention? 

 DR. MACDONALD. Yes. 

 MR. DINGELL. Is there only one Dr. MacDonald at the table? 
128

 DR. MACDONALD. To my knowledge. 

 MR. DINGELL. I am comforted to hear it. Doctor, is it true that you 

support price disclosure for hospitals, for physicians, and for 

pharmaceutical manufacturers? 

 DR. MACDONALD. The cost of reimbursement yes, posting prices is 

meaningless. The cost of what they receive from insurance carriers is 

more meaningful. 

 MR. DINGELL. And is it true that you also support our transparency 

for insurance companies? 

 DR. MACDONALD. Absolutely. 

 MR. DINGELL. Absolutely. Now Doctor, according to a December 

Health Affairs study, 20 percent of the health care costs are associated 

with billing and administrative functions of insurers. Isn’t it true that 

transparency in this area would be enormously helpful to enable 

consumers to pick and choose a better health plan? To pick one that 

devoted more of the premium to actual health care? 

 DR. MACDONALD. Yes. 

 MR. DINGELL. Thank you. Now is it also true that while price 

disclosure can be good, making it only for hospitals, doctors, and 

pharmaceutical houses is just another way to help insurance companies 

to negotiate better prices without assuring that these better prices will do 

anything other than to increase their profits? 

 DR. MACDONALD. In my experience that is not true because we 

stabilize the long term re-insurance cost, renewal rates for the businesses 

we are trying to help. And if the insurance company does not continue to 

come through, we get a different insurance carrier. 

 MR. DINGELL. I sense that you are a man of the most exquisitely 

trusting character and I am comforted to know that there is a man of that 

character about especially where it concerns dealing with insurance 

companies. Now according to one source, United Health Care made a 

profit of $66,265 per employee in 2005. Aetna suffered along with only 

$61,217 per employee. Large hospital chain HCA had only a profit for 

employee of $10,253 in 2005. Now Dr. MacDonald, isn’t it true that 

given this information, insurance companies are doing splendidly and if 

we are really concerned about where our health care dollars are going 

maybe we should be looking at insurance company disclosures as well? 

 DR. MACDONALD. Yes, sir. If you stop watering the plant, it dies. 

 MR. DINGELL. So you do think we ought to require a measure of 

helpful disclosure by insurance companies? 

 DR. MACDONALD. Absolutely. We actually are getting that, we are 

getting disclosure and competition. 

 MR. DINGELL. Good. 
129

 DR. MACDONALD. We are not in agreement with the multiple 

million dollar executive salaries and then going to the hospital and they 

are getting a better price than the uninsured. It does not make sense and I 

hope this committee does something about that. 

 MR. DINGELL. Thank you, Doctor. 

 And Dr. Goodman, I will thank you for your assistance. I will try 

and be more clear next time. 

 Thank you, Mr. Chairman. 

 MR. SHIMKUS. Thank you. 

 The Chair would like to thank our panel today for your patience 

obviously through debates but also your great testimony has given us a 

lot of food for thought and we appreciate it. This hearing is adjourned. 

 [Whereupon, at 1:07 p.m., the subcommittee was adjourned.] 

SUBMISSION FOR THE RECORD BY BOB INGLIS

Statement for the Record 

The Honorable Nathan Deal 

Chairman, Subcommittee on Health 

The Committee on Energy and Commerce 

Dear Mr. Chairman, 

I want to thank you for holding a hearing on the important issue of hospital price 

transparency. The difficulty in obtaining affordable health care is one of the greatest 

challenges facing American families. An estimated 46 million Americans are uninsured, 

and the cost of health care continues to grow far faster than inflation. Our current health 

care system encourages over utilization of services, restricts choice, and gives consumers 

little incentive to look for low-cost alternatives (like generic drugs). In other words, it’s 

broken. 

Consumer-driven health care models must be part of the fix. By bringing increased 

market forces to bear on the insulated world of health care, consumer-driven health care 

models can apply the brakes to runaway growth in health care costs. Health Savings 

Accounts, for instance, hold the potential to transform our complex managed care system 

of PPOs and HMOs into a cost-effective system in which consumers turn to the insurance 

company only for the big things. For the same (or less) money than we’re currently 

spending for managed care coverage, we can (1) buy high deductible (less expensive) 

policies; and (2) put the remainder in health savings accounts to cover the deductibles, 

rolling the extra from year to year. Millions of Americans have already adopted HSAs, 

and millions more are expected to adopt them in coming years. 

However, the long-term prospects of consumer-driven health economy depend on 

our ability to help consumers gain access to accurate and understandable information 

about the cost of health care services. An increasing number of policy experts are 

recognizing the importance of increased price transparency in the health care sector. The 

President has been actively publicizing the need for hospital price transparency in recent 

weeks; media outlets regularly publish the stories of uninsured consumers stuck with 

inflated bills after hospital visits; and several states have already passed laws requiring 

hospitals to make their charges public. Hospital price disclosure is an idea whose time 

has come. 
130

Ideally, hospitals and physicians would make price lists available voluntarily. In 

fact, some insurance companies—including Aetna and Humana—are already 

experimenting with making pricing information available online. These forward-looking 

companies should be encouraged. However, other providers will need some prodding. 

As the largest payer in our health care system, the federal government must take the lead. 

The hospital pricing system is a labryinthe that traps too many consumers, leaving 

them wandering and confused. Prices for simple procedures and drugs vary wildly from 

hospital to hospital, and list prices often bear little relationship to cost. Theseus 

successfully navigated the original labyrinthe only because he had the help of a magic 

ball of yarn that led him safely through the maze. Congress needs to act now and provide 

health care consumers with their own “ball of yarn,” a system of easy-to-access 

information that will help them make cost-effective decisions. 

That is why I am pleased to serve as the primary cosponsor of H.R. 3139, the 

Hospital Price Reporting and Disclosure Act of 2005. This bipartisan legislation—

introduced by Rep. Dan Lipinski—would require hospitals and ambulatory surgical 

centers to report the prices they charge for the most frequently performed procedures and 

most frequently administered inpatient drugs. The Secretary of Health and Human 

Services would then post that information on a publicly available, user-friendly website. 

This bill will not solve all of our health care woes; but increased transparency can only 

help consumers navigate the twists and turns of America’s health care system. 

 Best regards, 

 Bob Inglis 

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