`[Senate Hearing 118-442]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-442

                       HEALTH CARE TRANSPARENCY:
                           LOWERING COSTS AND
                          EMPOWERING PATIENTS

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS


                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             JULY 11, 2024

                               __________

                           Serial No. 118-21

         Printed for the use of the Special Committee on Aging
         
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        Available via the World Wide Web: http://www.govinfo.gov
        
                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
57-076 PDF                  WASHINGTON : 2024                   
          
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                       SPECIAL COMMITTEE ON AGING

              ROBERT P. CASEY, JR., Pennsylvania, Chairman

KIRSTEN E. GILLIBRAND, New York      MIKE BRAUN, Indiana
RICHARD BLUMENTHAL, Connecticut      TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts      MARCO RUBIO, Florida
MARK KELLY, Arizona                  RICK SCOTT, Florida
RAPHAEL WARNOCK, Georgia             J.D. VANCE, Ohio
JOHN FETTERMAN, Pennsylvania         PETE RICKETTS, Nebraska
                              ----------                              
               Elizabeth Letter, Majority Staff Director
                Matthew Sommer, Minority Staff Director
                         
                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Robert P. Casey, Jr., Chairman......     1
Opening Statement of Senator Mike Braun, Ranking Member..........     2

                           PANEL OF WITNESSES

Chris Whaley, Ph.D, Associate Director of the Center for 
  Advancing Health Policy Through Research, Associate Professor 
  of Health Services, Policy, and Practice, Brown University 
  School of Public Health, Providence, Rhode Island..............     4
Chris Deacon, JD, Principal Owner, VerSan Consulting, LLC, 
  Moorestown, New Jersey.........................................     6
Cora Opsahl, MBA Health Fund Director, 32BJ Health Fund, New 
  York, New York.................................................     8
Sophia Tripoli, MPH, Senior Director of Health Policy, Families 
  USA, Washington, D.C...........................................    10

                           CLOSING STATEMENT

Closing Statement of Senator Mike Braun, Ranking Member..........    26

                                APPENDIX
                      Prepared Witness Statements

Chris Whaley, Ph.D, Associate Director of the Center for 
  Advancing Health Policy Through Research, Associate Professor 
  of Health Services, Policy, and Practice, Brown University 
  School of Public Health, Providence, Rhode Island..............    31
Chris Deacon, JD, Principal Owner, VerSan Consulting, LLC, 
  Moorestown, New Jersey.........................................    38
Cora Opsahl, MBA Health Fund Director, 32BJ Health Fund, New 
  York, New York.................................................    40
Sophia Tripoli, MPH, Senior Director of Health Policy, Families 
  USA, Washington, D.C...........................................    42

                        Questions for the Record

Chris Whaley, Ph.D, Associate Director of the Center for 
  Advancing Health Policy Through Research, Associate Professor 
  of Health Services, Policy, and Practice, Brown University 
  School of Public Health, Providence, Rhode Island..............    63
Cora Opsahl, MBA Health Fund Director, 32BJ Health Fund, New 
  York, New York.................................................    65
Sophia Tripoli, MPH, Senior Director of Health Policy, Families 
  USA, Washington, D.C...........................................    69

                       Statements for the Record

Statement of 75 Alliances, Unions, and Employers.................    75
Statement of Patient Rights Advocate.Org.........................    77
Statement of Leukemia and Lymphoma Society.......................    78
Statement of American Hospital Association.......................    81
Statement of AHIP................................................    85
Statement of Healthsystem Association of Pennsylvania............    90

 
                       HEALTH CARE TRANSPARENCY:
                           LOWERING COSTS AND
                          EMPOWERING PATIENTS

                              ----------
                              
                                Thursday, July 11, 2024

                                        U.S. Senate
                                 Special Committee on Aging
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:00 a.m., Room 
138, Dirksen Senate Office Building, Hon. Robert P. Casey, Jr., 
Chairman of the Committee, presiding.
    Present: Senators Casey, Blumenthal, Warren, Warnock, 
Braun, Vance, and Ricketts.

                 OPENING STATEMENT OF SENATOR 
                 ROBERT P. CASEY, JR., CHAIRMAN

    Chairman Casey. Good morning. The Senate Special Committee 
on Aging will come to order. Today's hearing will examine 
transparency in health care, and how it affects the ability of 
patients to access affordable health care. This is a very 
important topic as the cost of health care continues to rise, 
and it is clear we must do more, here in the Senate and 
throughout the Congress, to bring down costs for the American 
people.
    I am proud to say we have made some progress, though we 
have more ground to cover, much more to do. Over the last 
several years, Democrats have passed several health packages to 
lower health care costs for Americans. Through the American 
Rescue Plan Act, Democrats reduced health care costs by 
bringing down the cost of premiums and expanding eligibility 
for health care coverage savings. I was proud to support the 
Inflation Reduction Act, so called IRA, which is actively 
bringing down health care costs for Medicare beneficiaries. It 
is also increasing transparency and affordability as the 
federal government, through Medicare, can now negotiate 
prescription drug prices under the Medicare program.
    The IRA capped insulin costs at $35 a month for seniors, 
and then we saw insulin manufacturers extend those savings to 
all patients who pay out-of-pocket for insulin.
    The IRA also includes a provision that caps prescription 
drug costs at $2,000 out-of-pocket each year for Medicare 
beneficiaries. This provision, which goes into effect this 
coming January 1st, will save Medicare beneficiaries an 
estimated $7.4 billion in 2025 alone. This is a lifeline for 
older Americans and shows us the opportunity to help Americans 
without Medicare who are still subject to high out-of-pocket 
drug costs.
    That is why I am introducing the Capping Prescription Drug 
Costs Act with nine of my Senate colleagues. This legislation 
expands on the success of the IRA and extends prescription drug 
cost savings to the commercial health care market by capping 
out-of-pocket costs at $2,000 annually for individuals and 
$4,000 annually for families. Nationwide, 173 million people 
under the age of 65 have private health insurance either from 
an employer plan or in the non-group market. This legislation, 
the Capping Prescription Drug Costs Act will ensure that 
prescription drugs are more affordable for these tens of 
millions of Americans.
    While we have come a long way to make health care more 
affordable and accessible, I look forward to hearing from our 
witnesses today and discussing how transparency can shine a 
light on high health care costs and ways to decrease those 
costs for every American.
    I turn next to Ranking Member Braun.

                 OPENING STATEMENT OF SENATOR 
                   MIKE BRAUN, RANKING MEMBER

    Senator Braun. Thank you, Mr. Chairman.
    Health care costs have risen astronomically from where they 
were just a few decades ago, to now approaching 18 percent of 
our GDP, and it has all occurred very simply, because the 
health care industry has disguised itself as being part of free 
enterprise, which embraces transparency, competition, no 
barriers to entry, and most importantly, an engaged consumer. 
You know that none of that really applies to our current 
industry. You heard the Chairman talk about when you do operate 
like an unregulated utility you are going to have government 
getting involved, so the key is do we go there, when this place 
is going broke systematically over the last decade or two, and 
in a place that is running $2 trillion deficits, or do we 
reform the industry?
    For anyone that is a CEO within the industry, I would 
suggest that you do what all the rest of us have done that run 
businesses--embrace competition. Deal with an engaged consumer 
in full transparency.
    I mean, if we keep going down this trail, we are going to 
end up not only exacerbating the $2 trillion deficits we 
currently have, it is going to get even worse.
    I was able to keep costs low in my own business. It can be 
done. I was so sick and tired of hearing how lucky I was that 
it was only going up five to ten percent every year. I found 
out how much the insurance companies were making on then what 
was a 300-employee plan that hardly had any claims, but they 
were making a fortune on it, and that is because even we did 
not have the full breath of options, and when I found out how 
lucrative it was to be in the insurance business, we self-
insured, and then threw everything and the kitchen sink at 
prevention and wellness, and actually on the user side only, 
controlled costs. My employees got every wellness and 
prevention tool, and they became health care consumers, and in 
that method, we cut costs by over 50 percent, and have not had 
premium increases in 16 years.
    Industry, wake up. It can be done. We need more tools, and 
we need you to get with it.
    President Trump put in place regulations requiring 
hospitals and insurers to disclose prices. President Biden has 
continued to support it. The hospitals have tried to skirt it, 
mostly from the time that happened.
    Today I am releasing a report that highlights the need for 
Congress to enact additional transparency across the health 
care supply chain. This is not going to go away, and it is a 
single place in our Federal Government that if we get it right 
we can reduce our deficits, the government will have a bill to 
pay that his less, if the providers shrink themselves down to 
where it is in most other economies and maybe not do it from a 
command system from government but because entrepreneurism and 
the markets are working.
    The House passed the Lower Costs, More Transparency Act. 
That is a huge step to get us where we are needing to go.
    I am on Health, Education, Labor, and Pensions. Another 
crazy thing about this place, they have got a hearing right 
now. It is at the same time this is, and we have never gotten 
that straight since I have been here. I will try to jump there.
    Bernie Sanders and I introduced the Health Care PRICE 
Transparency Act 2.0, a landmark bill to reveal health care 
prices for Americans that mirrors the House bill in many ways. 
I want to thank Senators Warren and Fetterman, who are members 
of this Committee, for joining as cosponsors.
    I want to cite someone in the audience here, Cynthia 
Fischer, who has been the most passionate individual I know. 
She has run a business over the years about keeping this in the 
limelight. It requires providers to publish actual prices, not 
estimates.
    Another major component of the bill states that group 
health plans have the right to review and audit their claims 
data, and we cannot do that that has got to happen nationally, 
and states need to accommodate that. This will allow self-
insured employers and unions to make changes to their plan and 
save money for their beneficiaries. Our bill puts the power 
back in the hands of Americans, it starts to make it consumer 
driven, and it starts to break up the oligopoly, the monopoly 
nearly, of how health care is provided currently.
    I ask unanimous consent to enter into the record two 
statements, one from Power to the Patient and another from 
Patient Rights Advocate with 75 signatures in support of this 
legislation.
    Chairman Casey. Without objection.
    Senator Braun. I look forward to continuing to work with my 
colleagues on both sides of the aisle to get the Health Care 
Price Transparency Act 2.0 to the President's desk.
    It is time to deliver for our seniors, our families, and 
Americans all across the country.
    I would now like to play a video telling just one of the 
thousands of stories about the impact price transparency can 
have on patients.
    Thank you to Patient Rights Advocate for submitting this 
story and for their leadership in the fight to bring power to 
patients.
    [Video plays.]
    Chairman Casey. Thank you, Ranking Member Braun.
    I will now turn to our four witnesses. I will introduce our 
first witness, and Ranking Member Braun will introduce our 
second and third, and then I will introduce our fourth.
    Our first witness is Dr. Christopher Whaley from 
Providence, Rhode Island. Dr. Whaley is Associate Director of 
the Center for Advancing Health Policy Through Research at 
Brown University. He also serves as Associate Professor in the 
Department of Health Services, Policy, and Practice at Brown 
University School of Public Health. His research is largely 
centered on health care price transparency and evolving market 
structure and the effect of such changes on overall health 
spending and quality of care for patients.
    Doctor, thank you for being with us today and sharing your 
expertise with the Committee.
    Dr. Whaley. Thank you, Chairman Casey and Ranking Member 
Braun.
    Chairman Casey. Doctor, we will just introduce all the 
witnesses and then I will turn to you, if that is okay.
    Senator Braun. It is my pleasure to introduce Chris Deacon. 
She is the founder of VerSan Consulting LLC. She advocates for 
cost-effective strategies that benefit both employers and 
employees. Ms. Deacon has held pivotal roles within the State 
of New Jersey, notably as a director of a state employee health 
benefits program, and school employee health benefit programs.
    Her career in the public sector began with serving as 
Deputy Attorney General and then Special Counsel to Governor 
Chris Christie. She earned her Juris Doctor from Rutgers School 
of Law. Thank you for testifying today.
    It is my pleasure also to introduce Cora Opsahl. She is the 
director of 32BJ Health Fund. She ensures that member and 
families of the union have affordable and high-quality health 
care. Under Ms. Opsahl's leadership, the 32BJ Health Fund has 
saved more than $35 million annually. That is impressive. She 
holds an MBA from St. Louis University. Thank you for being 
here today.
    I yield back.
    Chairman Casey. Thank you, Ranking Member Braun. Our fourth 
and final witness is Sophia Tripoli. She is from Washington, 
DC. Sophia is the Senior Director of Health Policy at Families 
USA, an organization that seeks to achieve accessible and 
affordable health care for all Americans. Her work is largely 
focused on lowering costs of health care and improving health 
care delivery for Americans.
    Thank you very much for being here today and for testifying 
and for sharing your knowledge with the Committee.
    Now we will turn to you, Doctor, for your opening 
statement.

      STATEMENT OF CHRIS WHALEY, PH.D, ASSOCIATE DIRECTOR

       OF THE CENTER FOR ADVANCING HEALTH POLICY THROUGH

       RESEARCH, ASSOCIATE PROFESSOR OF HEALTH SERVICES,

         POLICY, AND PRACTICE, BROWN UNIVERSITY SCHOOL

           OF PUBLIC HEALTH, PROVIDENCE, RHODE ISLAND

    Dr. Whaley. Thank you. Chairman Casey, Ranking Member 
Braun, and other members of the Committee, thank you for the 
opportunity to testify today.
    My name is Christopher Whaley. I am an Associate Professor 
of Health Care Policy at the Brown University School of Public 
Health, where I focus on health care price transparency and the 
evolving structure of U.S. health care markets.
    The United States leads the world in health care spending 
in large part due to high and variable prices. Rising health 
care spending strains government finances and erodes worker 
wages, particularly for middle-and lower-income Americans. 
Prices are opaque, fueling consolidation and leading to patient 
frustration with the U.S. health care system.
    These challenges have important implications for aging 
Americans. First, many elderly individuals receive private 
insurance, most commonly from their current or former 
employers, and thus are impacted by high and variable prices.
    Second, high health care costs and patient financial 
burdens lead to reductions in high-value and necessary care. 
For the under-65 population to age healthily, it is critical 
that they have access to affordable health care.
    Finally, high and differential prices drive health care 
consolidation, which erodes access to care and the quality of 
care for Medicare beneficiaries.
    In response, policymakers have undertaken efforts to 
increase price transparency. However, many of these efforts are 
currently incomplete. Today I will discuss impacts of price 
transparency and ways to improve the use of price transparency 
data in the U.S. health care system.
    First, it is important to recognize that price transparency 
is not a cure-all for the health care system but rather is 
critical to improve the efficiency and regulatory oversight of 
health care markets in the United States. While patients have 
an ethical recent to know prices, many do not actually shop for 
care. However, my research has shown how entrepreneurs and 
innovators can use price transparency to improve health 
insurance benefit designs and to create competition in health 
care markets.
    In addition, price transparency is critical for enabling 
employers and other purchases to fulfill their fiduciary 
obligations to provide health insurance benefits to the 
workforce at fair prices. An appropriate use of price 
transparency is to serve as a hub that enables other benefit 
design innovation and inform policies that reduce spending and 
improve quality.
    As a few examples, and as discussed in more detail in my 
written remarks, we have collected data from many employers in 
the State of Indiana and report what they are paying for 
hospital care. After seeing that they were paying some of the 
highest prices for hospital care in the country, these 
employers have used this type of price transparency data to 
both negotiate for lower prices on behalf of the workforce and 
also push for state policies to make Indiana health care 
markets more competitive.
    In other examples, the State of Oregon public employees and 
schoolteacher have used price transparency data to implement a 
reference-based pricing program that caps prices at 200 percent 
of what Medicare pays. This program saved over $100 million in 
public funds in the program's first two years.
    My co-panelist from 32BJ has used price transparency data 
to design a targeted insurance network that excludes 
inefficient providers. These savings from this type of program 
resulted in a $3,000 bonus for New York City service workers.
    To allow for these types of innovations to occur 
nationwide, recent Federal policies seek to increase price 
transparency through two main requirements. First, hospitals 
are required to post prices for 300 shoppable services, and 
second, insurers are required to post their full set of 
negotiated rates.
    The insurer-posted coverage and transparency data 
represents probably the most complete view into health care 
prices in the United States. While these data have certainly 
had a rollout process, researchers such as myself are now using 
these data to more completely understand health care markets in 
the United States and entrepreneurs are using these data to 
drive health care market competition.
    While a terrific resource, these data can certainly be 
improved by reducing duplicate entries and posting of prices 
among providers who do not actually perform services. Requiring 
insurers to limit posted prices to providers who actually 
perform service or potentially include the number of services 
billed would greatly improve data quality and accessibility. 
These data could also be centrally hosted by CMS using modern 
data base technologies.
    Additionally, despite the 2021 Consolidated Appropriations 
Act provisions, many employers and purchasers do not have 
access to their own plan claims data. Proposed bipartisan 
legislation codifies access to self-funded plans' claim data, 
and these data are necessary for employers to be responsible 
fiduciaries and purchasers of health care services on behalf of 
their workforce.
    In conclusion, the large variation in health care prices 
and opaque nature of prices in the United States drives 
frustration with the U.S. health care system. Federal policies 
to improve transparency are important first steps, and I 
believe that building on these efforts will improve the U.S. 
health care system and lower spending, particularly for aging 
Americans.
    Thank you, and I look forward to your questions.
    Chairman Casey. Dr. Whaley, thanks so much for your 
testimony.
    We will now continue testimony with Ms. Deacon.

        STATEMENT OF CHRIS DEACON, JD, PRINCIPAL OWNER, 
         VERSAN CONSULTING, LLC, MOORESTOWN, NEW JERSEY

    Ms. Deacon. Chairman, Ranking Member, and distinguished 
members of the Committee, thank you for the opportunity to 
testify today on the critical issue of transparency in health 
care.
    Imagine, if you will, that you are the CFO of a company 
where you give the company credit card to your suppliers and 
vendors. Instead of receiving an itemized statement at the end 
of the month you receive one paper with one number--no 
receipts, no details, just the total amount owed. No business 
would ever allow such a practice.
    Yet this is exactly what happens in our health care system 
today. Employers are forced to hand over the company credit 
card to Blue Cross Blue Shield, Cigna, Aetna, United, allowing 
them to pledge company dollars and member dollars to a health 
care system that can charge whatever they want, however they 
want, with little to no accountability or oversight. That is 
why we are here today. Transparency, or rather lack of 
transparency, facing employers and unions that are responsible 
for purchasing health care for almost 160 million Americans.
    You likely know the statistics and the alarming rate at 
which health care costs are growing, but I know the people 
behind these statistics. As the former administrator for the 
State of New Jersey's public sector health plans, I know 
firsthand how the lack of transparency impacts our teachers, 
firemen, police officers, and public sector workers.
    Sadly, this year in New Jersey, over 200 school positions 
will be eliminated due to budget constraints, constraints 
largely driven by health benefit costs, and public safety 
workers are facing a 16 percent premium hike, eroding years of 
wage growth and further stretching scarce public safety 
resources.
    ERISA, which governs most employer sponsored health plans 
in the country, is intended to protect plan participants and 
beneficiaries by mandating that plan sponsors act as 
fiduciaries. When employers lack access to meaningful claims 
data and transparent information on the cost and quality of 
care, the promise of ERISA remains unfulfilled.
    Let me share three examples that illustrate the magnitude 
of this issue.
    At the Mayo Clinic in Jacksonville, Florida, if you were to 
use your Federal Employee Health Benefits Blue Cross Blue 
Shield card for an arthrocentesis procedure it would cost you 
and the Federal Government approximately $2,500, but if you 
were to not use your card and pay cash, you would pay just 
$392. That is six times more.
    At the University of Pennsylvania Hospital in Philadelphia, 
the cash price for an ACL repair is approximately $9,500, but 
if you are a servicemember and you use your TRICARE coverage 
your price, and the Federal Government's price, is $37,489. 
That is almost a 300 percent markup.
    Or consider when a third-party administrator, or TPA, 
overpays for a claim or pays a claim in error with a self-
funded employer or union's money. If--and I emphasize "if"--the 
TPA seeks to correct their error and recover the employer's 
funds, it will cost them. TPA's regularly charge employers 25 
to 50 percent of the recovered payment. This is the ultimate 
fox guarding the henhouse.
    Finally, there are the misaligned financial incentives that 
play out when a TPA is able to pay providers one price and then 
charge the employer or the union many times more for the exact 
same claim. In several recently unsealed court documents out of 
a case in the Central District of California, it was revealed 
that a group health plan paid over $4 million for one claim, 
but the provider only received approximately $876,000 of that 
$4 million. What accounted for the difference? Cigna kept over 
$2.5 million in fees, and their subcontractor, Multiplan, kept 
another $678,000. The fees were over three times higher than 
what the provider was actually paid.
    These examples are just the tip of the iceberg in terms of 
the waste, abuse, and inefficiencies in the current market, 
driven, in large part, by the lack of transparency and 
meaningful access to data for employers.
    If we expect employers and unions to exert any type of 
market forces to rein in health care costs we must empower them 
with actionable data and transparent pricing. The company 
credit card has been abused for too long by the PBMs and TPAs. 
It should not be unreasonable to demand receipts for payment, 
itemized statements, and the ability to protect our businesses 
and plan members, and that is what S. 3548 uniquely 
accomplishes, in a superior manner, in my opinion, to the Lower 
Cost More Transparency Act with respect to access to claims 
data. Federal lawmakers must rebalance the information 
asymmetry to empower employer purchasers and unions to push 
back against egregious pricing, gross overreach, and 
profiteering. This will help protect the American workers' 
paychecks and ensure a fair, more accountable health care 
system for all.
    Thank you.
    Chairman Casey. Ms. Deacon, thanks very much for your 
testimony.
    Ms. Opsahl.

          STATEMENT OF CORA OPSAHL, MBA, HEALTH FUND 
         DIRECTOR, 32BJ HEALTH FUND, NEW YORK, NEW YORK

    Ms. Opsahl. Good morning. Thank you Chairman Casey,
    Ranking Member Braun, and the rest of the Committee on 
Aging for inviting me to speak today.
    My name is Cora Opsahl, and I am the Director of the 32BJ 
Health Fund. The 32BJ Health Fund is a self-insured, Taft-
Hartley benefit fund that provides health benefits to over 
200,000 union members and their families. Our members are 
essential workers who work in the real estate industry, 
security officers, school workers, and airport workers. We are 
based primarily in the New York/New Jersey area, but we have 
families up and down the East Coast including Pennsylvania and 
Massachusetts.
    The fund is jointly governed by a board of trustees 
appointed by the Union and the Employers, and we provide high-
quality benefits with no premium sharing, $0 in-network 
deductibles, and low in-network copays. We believe the fund has 
an important role in tackling the problem of health care 
affordability, and we have spent years doing just that by 
leveraging our data, challenging the status quo, and finding 
innovative ways to manage our benefit.
    Having access to our claims data is foundational to our 
work, and we have been fortunate to have access to our medical, 
pharmacy, and ancillary claims data. We use this data to 
understand our health care spend, make benefit decisions, and 
ensure we are a good steward of the fund's resources, because 
of our data, we know the following:
    In 2023, we spent $1.4 billion in health care. Of the $1.4 
billion, 55 percent is spent on inpatient and outpatient care. 
In 2021, we paid 271 percent over Medicare prices for the same 
care, which is up from 219 percent of Medicare in 2016, and in 
the past 10 years, health care has risen from 17 percent of 
total compensation to 37 percent of total compensation. Wages 
have gone up 54 percent but health care costs have gone up a 
whopping 230 percent, and to put that into a dollar amount, our 
members could have had $5,000 more in annual wages had health 
care spend risen at just the same rate of inflation.
    While having your data and being able to see how your 
benefit is being spent is important, as a plan we know this is 
only the first step. The next step is taking action on the 
data.
    In 2018, after spending 10 years looking at our claims 
data, it became abundantly clear to us that we needed to 
address the prices we were paying. The data showed we were 
paying wildly different prices for the same procedures, 
depending on what hospitals our members went to. For example, 
we were paying approximately $10,000 for a colonoscopy at New 
York Presbyterian system versus approximately $4,000 at Mount 
Sinai Hospital system. The same pattern was true at other high-
priced systems. Based on our data, we tiered our network on 
price beginning in 2019. Members could still access the higher-
priced hospitals, but they would have to pay higher copays to 
do so.
    While we had won the right to tier our plan in 2019, in 
2021, New York Presbyterian told Anthem, Blue Cross Blue 
Shield, that they would have to be preferred in all networks, 
leveraging a clause in their contract. In 2022, the fund won 
permission to remove them from our network. This change has 
saved the plan approximately $35 million every year by members 
receiving care from lower-priced facilities and providers.
    In the most recent contract negotiations, the union and 
employers leveraged the savings in our benefits to give union 
members a one-time bonus, the largest wage increase in contract 
history, and a pension increase, and they were able to limit 
employer premium contribution increases to no more than three 
percent every year through 2027.
    While these benefit changes showcased our ability to 
leverage our data, both changes also illuminated the contract 
terms between providers and carriers that obstruct, hinder, and 
limit the ability for us and other employers to take action on 
their data.
    Recently, the Health Fund led a procurement for a medical 
and hospital benefit third party administrator, or carrier. We 
were adversely affected by anti-competitive contract provisions 
between providers and carriers, such as requirements to be in 
network, anti-steering and anti-tiering provisions, limitations 
in how claims are allowed to be paid, and even limitation in 
access to claims data. Due to these contract provisions, every 
TPA bidder, except one, was unable to meet our network 
requirements, including that New York Presbyterian remain out 
of network.
    Other provisions routinely demanded by hospitals include 
restrictions on retroactive claim reviews, exclusion of 
"lesser-of" provisions, and limits on payment recoupment. None 
of those contract provisions are beneficial to the employer-
sponsored plans or their membership. The experience showcased 
how difficult it is for employers and self-funded plans, even 
of our size, to have a highly competitive bid process.
    We would not be where we are today without access to our 
data, allowing the union and employers to give raises and limit 
premium increases, ensuing our members can continue to have 
access to high-quality and affordable care. Employers having 
access to their claims data and the terms in which their 
benefits are being managed are essential for them to be able to 
do the same thing. That is why we need the Braun-Sanders bill, 
and Section seven in particular.
    Thank you for having me.
    Chairman Casey. Ms. Opsahl, thank you for your testimony. 
We will turn to our final witness, Ms. Tripoli.

       STATEMENT OF SOPHIA TRIPOLI, MPH, SENIOR DIRECTOR 
        OF HEALTH POLICY, FAMILIES USA, WASHINGTON, D.C.

    Ms. Tripoli. Chairman Casey, Ranking Member Braun, and 
members of the Committee, thank you for the opportunity to 
testify today. It is an honor to be with you. On behalf of 
Families USA, a leading national nonpartisan voice for health 
care consumers, I want to thank you for this critical 
discussion.
    No one in America could have to choose between going to see 
their doctor and buying groceries to feed their family. Yet 
almost half of all Americans do not get needed medical care 
because of the cost, and 48 million older Americans fear they 
will not be able to afford lifesaving care.
    Every American knows that we pay too much for the health 
care we get, but many Americans do not know why--because health 
care consolidation, particularly among hospitals, has 
eliminated competition and allowed monopolistic pricing to push 
our Nation's families to the brink of financial ruin.
    Particularly concerning is that health care is one of the 
only sectors in the U.S. economy where consumers are blinded to 
health care prices until after they have received a service and 
a subsequent bill. This lack of transparency is a major barrier 
to the health care sector competing based on fair prices and 
high-quality care, and there is no question that our Nation's 
families are suffering the consequences.
    Take the story of Kyunghee Lee from Mentor, Ohio. Once a 
year she goes to a rheumatologist for a steroid injection in 
her hand to relieve pain associated with her arthritis. Each 
round of injections costs her $30, but in 2021, when she 
arrived at her usual office for her usual treatment she found 
they had moved up one floor in the building. She thought 
nothing of it until weeks later she received a bill for nearly 
$1,400. Ms. Lee's infusion clinic was moved from an office-
based practice to a hospital-based setting, resulting in a 
price increase of almost 4500 percent for the exact same 
service, from the exact same provider, or take the story of Ben 
Los and his then 5-year-old son from Monument, Colorado. In 
2022, Ben and his wife rushed their son to the doctor after he 
began experiencing seizures. They were referred to a specialist 
and received confirmation that their son's EEG scan would be 
covered. Weeks later the Los family received a bill for $2,500. 
When they called the hospital about the bill they were told it 
was a facility fee, that the physician service was covered, but 
now they had to pay the hospital.
    Frustrated with a bill he could not pay and grappling with 
his son's health, Ben wanted answers about why this happened, 
but found it nearly impossible to determine who actually owned 
the hospital. It was a giant black box. Ultimately, Ben 
discovered that this hospital system raked in billions of 
dollars in profits just in the first nine months of 2022, all 
while he was struggling to pay his medical bill.
    These stories are far too common in the U.S. health care 
system, particularly since the role of hospitals in our economy 
has shifted drastically over the last 60 years. What were once 
local charitable institutions built to serve the community have 
now become large corporate entities, focused on maximizing 
revenue rather than improving health. Fundamentally, the 
business interests of the sector are no longer aligned with the 
health and financial security of the patients they serve.
    Study after study shows that privately insured consumers 
and employers are paying two to three times what Medicare pays 
for the same hospital services. Commercial insurance prices for 
hospitals and physician services in more monopolistic markets 
like Florida, South Carolina, and Tennessee, cost at least 
twice as much as the same services in competitive markets.
    Take the average price of a knee replacement, which costs 
three times more in Sacramento, California, than in Tucson, 
Arizona, or the price of an MRI at Mass General Hospital in 
Boston, that costs five times more just depending on the 
insurance carrier. These higher prices result in higher 
premiums, lower take-home pay, and higher cost-sharing for the 
more than 176 million Americans who get health insurance 
through their employer or directly from a health plan.
    Medical monopolies are forming in nearly every state, 
whether it is a private equity-backed firm buying up hospitals 
and then cutting service lines and laying off workers, as we 
see is the case of Steward Health System in Massachusetts, or 
price gouging and suppressing wages in the case of UPMC in 
Pennsylvania, or the giant medical monopoly that is HCA 
Healthcare, which has facilities in 20 states, including 
Indiana, Georgia, Florida, and South Carolina. Notably, HCA 
Healthcare ended 2023 with more than $5 billion in profits, on 
$65 billion in revenues, allowing their CEO to take home a 
salary of more than $21 million. These billions of dollars of 
profits are made on the backs of people like Ben Kyunghee Lee, 
and the one-third of Americans who cannot afford to buy 
groceries or pay their rent because of rising health care 
costs.
    Congress has used its power to rein in the corporate abuses 
of Big Oil, Big Tobacco, Big Banks, and Big Tech. Last year, 
the Senate examined how to protect people from price gouging 
for concert tickets. It is past time to scrutinize big health 
care corporations and protect families in America from the 
greed of medical monopolies.
    We urge this Committee to support well-vetted, bipartisan 
solutions, including strengthening and codifying price 
transparency rules, implementing site-neutral payment, and 
addressing dishonest billing, increasing transparency of 
ownership data, limiting harmful contracting terms, and 
strengthening FTC and DOJ enforcement of anti-competitive 
practices.
    This Committee has a responsibility to put the needs of our 
Nation's families ahead of the greed of big health care 
corporations. Our health is not a game, and no one should be 
allowed to play Monopoly with it.
    I thank the Committee for your time and look forward to 
answering any questions.
    Chairman Casey. Ms. Tripoli, thank you for your testimony. 
I will start our round of questions.
    Dr. Whaley, I will start with you, and I am grateful for 
your testimony today. We all know health care costs in the 
country are continuing to rise. Hospital costs have risen 
faster than health care costs overall. These increasing costs 
directly impact Americans' access to health care, and before we 
get to solutions, which we are, of course, trying to arrive at 
today, we need to understand the underlying causes of these 
high prices.
    What are the major--and if you can just, and I know this is 
part of your testimony, if you can itemize again for us the 
major drivers of rising hospital costs, in particular.
    Dr. Whaley. We know that in particular hospital costs are 
driven by provider consolidation, and are actually not driven 
by differences in quality of care, and I think this is 
particularly relevant because over the last two decades we have 
seen over 2,000 hospital mergers in the United States, which 
have resulted in a hospital market that is incredibly 
concentrated.
    Chairman Casey. 2,000 mergers, in what time period?
    Dr. Whaley. Over the last two decades.
    Chairman Casey. That is an alarming number.
    I wanted to turn next to Ms. Tripoli. As we know, the cost 
of health care has implications at all levels of our economy. 
Health care spending affects both government and employers. It 
affects, obviously, patients and families. As costs rise and 
patients continue to struggle to afford care, which often 
results in delayed care or care that is actually foregone, in 
2022, more than a quarter of adults reported delaying or 
foregoing health care due to the costs, so it is a disincentive 
to seek out the care they need. Others may still receive needed 
care but go into medical debt when they do so.
    Here are kind of two questions in one. How do high hospital 
costs impact the lives of patients. That is one, and the second 
question is what might an unexpected surgery or other medical 
expense mean for a family's budget?
    Ms. Tripoli. Thank you very much for the question. I think 
high hospital costs, what it means is an increasing impact on 
our premiums, for example, increasing cost sharing, and what 
many folks do not actually realize is that for people in the 
commercial market for employees that more of their take-home 
pay is going to rising health care costs instead of being able 
to come home with them to afford things like buying groceries.
    At the same time, premiums are increasing much faster than 
workers' wages, so we are creating a real crisis, from workers 
who are showing up every single day, doing exactly what they 
should be doing, and yet they are continuing to struggle to 
afford the skyrocketing costs of health care.
    Chairman Casey. Any examples you have, or walk me through, 
if you can, the scenario of an unexpected surgery or other 
medical expense in terms of a family budget.
    Ms. Tripoli. Absolutely. I think data suggests that more 
than half of Americans have no emergency savings on hand, and 
of the ones that do, they have less than $1,000 on hand at any 
given moment, so you are talking about an emergency surgery or 
any type of unexpected health care need, that would literally 
bankrupt the American family that more than half of Americans 
would not be able to afford the care. That is why we are seeing 
100 million Americans, and growing, with medical debt.
    Chairman Casey. Thank you. I wanted to move to another 
question before my time runs out. We have discussed hospital 
costs, obviously. I also wanted to focus, as well, on 
prescription drugs. We know those costs account for a high 
percentage of health care spending. I mentioned my legislation, 
Capping Prescription Drug Costs Act. Senator Warnock and I have 
introduced that together. That would expand on the success of 
the IRA provision on extending prescription drug costs to 
patients.
    What can high prescription drug costs mean for a family 
that is already struggling to make ends meet?
    Ms. Tripoli. Absolutely. I mean, we know that 30 percent of 
adults do not actually take their prescription drug medication, 
either rationing the drug, skipping it, or foregoing it 
altogether because they cannot afford it, and that actually 
results in 125,000 deaths a year. For most people, not being 
able to afford their drugs, not being able to afford their 
medical care, is literally a decision between life or death.
    Chairman Casey. Give me that number again. You said 
125,000----
    Ms. Tripoli [continuing]. deaths per year.
    Chairman Casey. Caused by----
    Ms. Tripoli. Adults not being able to afford their 
prescription drugs, either from delaying care, rationing their 
medication, or foregoing taking the drug altogether.
    Chairman Casey. Mr. Tripoli, thanks for your testimony and 
answers to those questions.
    I will turn to the Ranking Member.
    Senator Braun. Thank you, Mr. Chairman. I am going to start 
with Ms. Deacon and Ms. Opsahl. This whole idea of claims data, 
for the benefit of the Committee and other listening, on self-
insured plans why has that not been the default that you will 
get it? What has the industry done to keep the one thing, when 
you do have, like when I formed my own plan we finally got rid 
of the profit margin that the insurance company was making. 
Give us a little background on why they have been so begrudging 
in terms of giving that basic information.
    Ms. Deacon, I will start with you, and then Ms. Opsahl will 
go next. Go ahead.
    Ms. Deacon. I think the example I gave in my opening 
remarks is probably the best example of why a carrier or a TPA 
would not want a self-funded employer to have access to their 
data. What you will see in the data is that you are often 
paying above billed charges. You might also see that the rate 
you are paying under their negotiated discounts can be six 
times, ten times higher than the cash rate, and what they have 
done to sort of block access to this data over the years, 
anything from draconian NDA provisions, proprietary data 
formats, claiming that the data is proprietary and 
confidential, limited data sharing provisions, implementing 
prohibitive cybersecurity policies in order to access your own 
data, and even so far as limiting what data warehouses are able 
to share with employers and third-party----
    Senator Braun. That is the ultimately behavior of a 
monopoly, and remember, they are the supplier, and this is 
going against their own customers, and that, to me, is 
indicative of why we are in the pickle we are in.
    Has this been the general dynamic across all states? Have 
some places been able to fix that? Has it just happened 
recently, where plans have been able to sue to get the 
information? Give me a little kind of background on how long we 
have been dealing with this and what has kind of cracked the 
ice at this point.
    Ms. Deacon. It has been a long time that self-funded 
employers are dealing with a lack of access to data, but with 
the Consolidated Appropriations Act of 21, we had hoped that 
some of the provisions in that act would lead to more access to 
claims data. Employers were restricted from entering into 
contracts that would limit their access to claims data. 
However, in practice, that has not necessarily played out how 
we had hoped it would, and employers are still facing these 
roadblocks and barriers in getting access to their claims data, 
but the sort of crack that you mentioned is we now have this 
law so that employers are litigating. They are filing suit to 
say this is my----
    Senator Braun. Are they winning mostly, or are they losing?
    Ms. Deacon. We have not really had a case that has come all 
the way to decision. We are at the outset of some of those 
cases, and some of them have settled outside of the public 
domain, so we do not necessarily know what----
    Senator Braun. All insurance companies basically do this.
    Ms. Deacon. All of the big ones, yes.
    Senator Braun. All of the big ones, so maybe it needs to be 
where employers start looking at other than the big guys that 
seem to not want to bargain fairly, with information that 
should not be theirs in the first place.
    Ms. Opsahl, can you kind of explain how you finally cracked 
through, how long it took, and are you still wrestling with it?
    Ms. Opsahl. Thank you so much for the question. I will 
start with, yes, we are still wrestling with it. We just 
recently went through a procurement, and still had to reassert 
our agreement and right to this claims data.
    I look at claims data as receipt for payment. You do not 
pay your credit card bill without an itemized list. You should 
not be paying claims. As a self-funded employer, it is our 
responsibility to pay these claims.
    We won the right to get our claims data a little over 15 
years ago, but had to do that through leaving a big carrier and 
coming back. It should not take employers having to go through 
a comprehensive procurement process to have to win enough power 
to get access to their claims data, but again, we still fight 
that today. If we want to add a new field--we were just talking 
about this this morning--add a new field, well, that is in 
System A, and we are actually pulling this from System B, and 
so it is going to take nine months to add this flag that says 
whether or not, you know, which hospital systems and things of 
that nature.
    It is not simple. It is not easy, and I have eight people 
on my staff who look at the data every day to even see how good 
it looks.
    Senator Braun. Thank you. I am out of time but I do have 
another round of questions, but I would like to point out to 
the public, I do not know of one other industry where we have 
had to bring, at the federal government level, a transparency 
bill. Every other industry out there engages with an informed 
consumer, and you have got that information on the Web, you 
have got it so many places. In my own business I remember it 
was so competitive, your customers would put you on speed dial 
to see who was going to give the best price, and you could have 
accomplished that all within about four or five minutes. We are 
so far from that. The industry better take note that it is not 
normal to operate the way they do.
    I will yield back for now.
    Chairman Casey. Ranking Member Braun, thank you for your 
questions, and as you all know, on a Thursday we have got 
Senators that are in and out, competing demands, especially 
competing hearings, as Senator Braun mentioned. He and I are 
both members of the HELP Committee, so we cannot transport 
ourselves quite yet, but we are going to be in and out. People 
will be in and out today, but I wanted to thank Senator 
Ricketts for being here. He might have close to 100 percent 
attendance record. There is some prize for him somewhere, but I 
will turn next to Senator Ricketts.
    Senator Ricketts. Thank you, Mr. Chairman. Thank you, 
Ranking Member, and thank you to all of our witnesses for being 
here today to provide testimony.
    As the population of the United States ages it is vital 
that we take a closer look at the institutions and programs 
that we trust to take care of them. It is our job to protect 
America's most vulnerable citizens and ensure that they are 
equipped with the tools to make the best decisions for their 
own care. In addition, we must ensure that programs like 
Medicare and Medicare Advantage have accurate and easily 
understandable information that is accessible for those who 
rely on it.
    This past February I held an Aging Committee hearing in my 
home State of Nebraska, and we focused on educating older 
Americans on health plans through Medicare. While there are 
resources through Medicare and state health insurance 
assistance programs, SHIPS, many older Americans fail to become 
properly educated on the wide variety of health plans.
    For 2024, it is estimated that there are a total of 8,676 
different Medicare Advantage plans. According to a recent 
report, one of the biggest challenges with Medicare Advantage 
plans is poor patient education. If a person enrolls in 
Medicare Advantage when they first become eligible for Medicare 
they can switch to original Medicare and Medigap within the 
first 12 months of their plan. However, if an enrollee fails to 
switch their plan within that first 12 months, there are 
additional requirements to switch back to Medicare and a 
Medigap plan that can be very challenging.
    Ms. Tripoli, it is often the case that older Americans sign 
up for plans that do not cover many of their needs and cover 
their out-of-pocket costs. Do you have recommendations for 
addressing this issue, and maybe education gaps? What can we do 
to be able to help folks who are getting ready to make this 
decision to be able to make the right plan choice for them?
    Ms. Tripoli. I mean, absolutely. I think in general we need 
a lot more transparency of information across the health care 
system. Medicare Advantage is no different. One of the things 
that we often see in Medicare Advantage is a very aggressive 
marketing of supplemental benefits, for example, and plans are 
using it as a hook to get seniors to sign up for the plan and 
then they are enrolled and they actually find out, oh, that is 
not exactly the benefit that was marketed to me.
    I think one of the solutions both around supplemental 
benefit and just in general is we need much more transparency. 
We need more data that is accessible for researchers, for the 
public, and for policymakers to understand what is actually 
happening underneath the hood of the health care system, so we 
can have more targeted decisions to make sure that consumers, 
the end user of the health care system, are actually getting 
the care they need, that is affordable, and it is meeting their 
health needs.
    Senator Ricketts. As we were talking about this 
transparency, is this something where we would be able to 
require, like these plans, to be able to provide--I don't know, 
we were talking about some of the cost differences in different 
procedures. Certainly, there are common things that our seniors 
need or get requirements. Is that something that maybe the 
plans should have to be able to talk to seniors about and say, 
hey, for a typical thing that our seniors are going to need 
this is what it may cost you?
    Ms. Tripoli. Absolutely. Seniors and older Americans and 
just the general public needs much more data about the cost of 
care and the quality of care that is associated with that cost, 
so they can understand what is the value of what I am getting, 
and then they can make more informed choices about plan 
selection, whether they need a service, whether they want to 
shop for one MRI at this hospital versus another hospital, but 
yes, absolutely.
    Senator Ricketts. Actually, you bring up a great point 
there, because we have talked a lot about costs and 
transparency on costs. How do we go about tackling the quality 
aspect of it? Some of the folks have mentioned the quality as 
an aside, but how do we educate consumers on that quality 
aspect of it too, because there is always a cost-quality 
tradeoff. How do we measure the providers on that quality?
    Ms. Tripoli. I think you are asking probably the million-
dollar question right now. Obviously, we have a lot of quality 
reporting requirements, but there are a lot of requirements, 
and there is not necessarily a harmonized set of quality 
measures that we can pull down and assign to a specific 
service, so we actually need quite a bit of work on the quality 
side, and CMS, as well as multiple stakeholders from a lot of 
different sectors have been working to address this issue, but 
it takes time, and much more work is needed.
    Senator Ricketts. Great. Thank you.
    Ms. Deacon, in 2020, Congress passed legislation to stop 
third-party administrators of self-insured employer and union 
health care plans from writing contracts that denied plans 
access to their data on prices and health services, but it 
sounds like, from earlier legislation, this legislation has it 
stopped the gag clauses from being implemented?
    Ms. Deacon. Thank you for the question. In my experience, 
no, it has not. I have worked with multiple employers and 
unions that continue to face these roadblocks, and again, some 
of the examples that I gave earlier, draconian NDA clauses that 
even if they are getting access to the data they cannot do 
anything with it. They cannot audit their own claims. They 
cannot look for retrospective payment reviews, so it is very 
limited even when they are getting access to the data, but that 
is when, and I would say that, by and large, we have not had 
the sea change that we were hoping for after that law.
    Senator Ricketts. Thank you. Mr. Chairman, if I could just 
have another minute or so.
    Chairman Casey. Sure.
    Senator Ricketts. I would like you, Ms. Deacon, to comment 
on the quality question, as well.
    Ms. Deacon. The quality question?
    Senator Ricketts. Yes, because again, there is cost-
quality. How do we tackle that part of it?
    Ms. Deacon. Yes. To sort of echo Ms. Tripoli's point, there 
is a lot of work that needs to be done on the quality side, as 
well. CMS obviously has some star ratings on hospitals. We have 
different associations and stakeholders that are also issuing 
quality ratings, but what I will say is that the consumer 
today, unfortunately, is left with sort of improperly 
correlating brand name and high cost with quality, but as Dr. 
Whaley would probably attest, there is no direct correlation 
between increased price and higher quality. In fact, oftentimes 
it is the inverse.
    Again, we need to provide consumers and purchasers with 
more information on quality so they are not left to make that 
decision, an improper correlation on their own.
    Senator Ricketts. Yes, and just to be clear, when you are 
talking about the star ratings on hospitals, that is the 
hospital, in general. It is not about a particular procedure 
that hospital may be doing, right?
    Ms. Deacon. That is right.
    Senator Ricketts. Even that data does not really mean that 
much to an individual who is getting a procedure in one 
hospital versus another because the hospital may have a high 
star rating but it may do this procedure particularly poorly 
versus another provider.
    Ms. Deacon. Right.
    Senator Ricketts. Fair?
    Ms. Deacon. Yes, absolutely, and they might be great at 
transplants, but, you know, not necessarily cardiac, so we 
definitely need more information on the quality side.
    Senator Ricketts. Great. Thank you, Ms. Deacon. Thank you, 
Mr. Chairman.
    Chairman Casey. Thank you, Senator Ricketts. Senator 
Warren.
    Senator Warren. Thank you, Mr. Chairman, and thank you and 
Ranking Member Braun for holding this hearing on price 
transparency. For almost every other type of service you can 
look up the price before deciding whether or not to purchase, 
but when it comes to health care it is virtually impossible, 
even though Americans are paying more for health care than any 
other country in the world, so when patients need health care 
they should be able to easily find out the price of those 
services.
    Here is something else they should be able to find out 
easily--who owns the hospital or the physician practice that 
you or a loved one may visit to receive that care? Today nearly 
80 percent of doctors are employed by corporate entities, 
including private equity firms, and once in control, these 
firms raise their prices and cut corners to line their own 
pockets while the quality of care suffers.
    Let me start with you, Dr. Whaley. You are an expert on 
private equity in health care. If a patient wanted to find out 
whether a neighborhood hospital or a primary care practice was 
owned by private equity, how hard would that be to do?
    Dr. Whaley. Senator Warren, I think it is virtually 
impossible for a patient to know whether or not their doctor's 
office is owned by a private equity company.
    Senator Warren. Yes, so virtually impossible, because 
private equity firms do not have to report ownership, it is 
nearly impossible to find out if the doctor's office you visit 
is owned by one of these corporate vultures.
    Well, let's ask about the workers. How hard is it for the 
workers to find out? Ms. Opsahl, you lead the health fund at 
labor union 32BJ. If one of your members wanted to find out if 
a potential employer of any kind was owned by a private equity 
company, how simple would that be to do?
    Ms. Opsahl. Similar to what Dr. Whaley said, next to 
impossible, and I would even say as the employer or as the 
sponsor of the plan, I do not know who I am writing my self-
funded checks to, as well.
    Senator Warren. Okay, so next to impossible, virtually 
impossible. I am sensing a trend here. Patients cannot find 
this information. Workers cannot find this information. Even 
antitrust regulators have a hard time finding this information. 
These are the agencies that are responsible for cracking down 
on anti-competitive behavior, and they cannot get their hands 
on these data, and it matters because private equity ownership 
has real consequences for the families and the workers who need 
help here.
    Dr. Whaley, once private equity firms take over health care 
companies what happens to health care costs and quality?
    Dr. Whaley. Several studies have shown that when a private 
equity company acquires a health care practice, whether it be a 
physician or a hospital or other type of health care provider, 
prices increase quite substantially. We have also seen 
evidence, particularly in nursing homes, that quality goes 
down, again quite substantially.
    Senator Warren. I just want to relate this to the earlier 
line of questions, where you said people are using higher price 
as a signal that they are going to get better care, and yet the 
data show us that when private equity takes over, price goes up 
and quality of care actually goes down. Is that right, Dr. 
Whaley?
    Dr. Whaley. That is what the host of studies that have 
examined the question have said.
    Senator Warren. So not just one study. You see it across 
the board in all of the studies that have looked at this.
    You know, I saw this firsthand in Massachusetts after 
private equity drove Steward Healthcare into bankruptcy, and 
that is why I introduced the Corporate Crimes Against 
Healthcare Act, which, among other things, would require 
private equity-owned health care companies to publicly report 
mergers, acquisitions, changes in ownership and control, and 
financial data, so at least the information would be out there.
    Let me ask, Dr. Whaley, would these data help state and 
federal regulators prevent crises like the Steward failure in 
the future?
    Dr. Whaley. I think having accurate and transparent data on 
ownership is incredibly important and can help both state and 
federal regulators monitor health care markets and get ahead of 
what is happening in many cases.
    Senator Warren. Yes. It is shameful that these firms can 
hide in the shadows while patients and workers suffer. My 
Corporate Crimes Against Healthcare Act would shine a light on 
private equity's most parasitic practices. I would also claw 
back compensation from private equity executives that drive 
portfolio companies into bankruptcy. It would impose criminal 
penalties on executives when their failure result in patient 
deaths, and it would empower regulators to prevent crises like 
Steward from ever happening again.
    There is a lot of work we need to do here, Mr. Chairman. 
Thank you.
    Chairman Casey. Senator Warren, thanks for your questions. 
I will turn to Senator Vance.
    Senator Vance. Thank you, Mr. Chairman, and thanks to you 
and the Ranking Member for your work on this, and thanks to the 
four of you for being here with us.
    I have to sort of give special credit to both the Ranking 
Member and also to President Trump's administration for, I 
think, working a lot and getting a lot done on the question of 
price transparency, and obviously there is a lot more to do. I 
know Senator Braun has a bill that has done a lot on this 
space, and hopefully we can get some work on it.
    I wanted to direct my questions to you, Ms. Deacon, and ask 
a little bit about just the connection between price 
transparency and actual price, because it is something that, 
you know, as somebody who has never worked in the health care 
space, at least not directly, I do not fully understand this 
entirely.
    The basic argument, as I get it, is that if you provide 
more price transparency it gives people more information to 
negotiate better prices for certain services and so forth, but 
then obviously if you are an individual, self-insured, maybe 
small group insurance, it is going not be a little harder for 
you to negotiate a price than if you are part of a large group 
plan where effectively the insurance company is negotiating the 
price for you, so I am just very curious. Walk me through the 
interaction here between, especially for smaller consumers, 
between price transparency and hopefully lowering health care 
prices.
    Ms. Deacon. Great. I think for a small business that 
provides health insurance for their members, whether self-
funded or fully insured, they have an incentive and a financial 
reason to ensure that their members are going to the most cost-
effective hospitals or providers in their area, and so that 
does not just mean the cheapest or lowest price but that is 
price and quality.
    If a small employer, that might not be able to have the 
weight of negotiation power with a big hospital or with a 
carrier, has this information they might be able to direct 
their members to the high-value provider that is in their 
community. Perhaps they have to drive an additional five miles 
or maybe even 10, but if they are able to send their members to 
high-value providers that they have access to they can 
dramatically lower their costs, without having to have the 
might of hundreds of thousands of lives behind them.
    Senator Vance. Got it, and so part of this, effectively, is 
employers, especially small employers, effectively using their 
claims data effectively, right. What are some of the barriers 
to using that claims data? Why don't we already just have the 
system? Why can't they do it already?
    Ms. Deacon. I mean, I believe that most of the carriers 
today do not have an incentive. In fact, they have a 
disincentive to provide access to that information to 
employers, because they know what employers will see and they 
know what employers can do with that.
    Senator Vance. When you say carriers, do you mean insurers?
    Ms. Deacon. Yes, third-party administrators in the case of 
a self-insured employer, or a carrier in a fully insured 
product, but absolutely, you know, especially for small 
employers, one of the reasons that the Braun-Sanders bill is so 
important is because it makes this data available in a 
standardized format that we know every carrier and/or TPA has 
access to, and it has the capability of providing that 
information in specifically standardized formats that they are 
using today, so small employers will really benefit from access 
to tools and technology that can leverage that standardized 
formatting in the claims data to really do a good job managing 
their health care costs for their businesses and their 
employees.
    Senator Vance. Got it. Well, thank you, Ms. Deacon. It 
sounds like a good endorsement of the Braun-Sanders bill, and 
apologies to the other three for not getting to you. Thank you 
all for being here. Thanks.
    Chairman Casey. Thank you, Senator Vance. I will turn next 
to the Ranking Member.
    Senator Braun. Thank you, Mr. Chairman. Ms. Tripoli, I 
would like you to talk about another aberration in the hospital 
system--site neutrality, in this whole business of when 
hospitals buy clinics. Explain to the American public, to the 
Committee what that is about.
    Ms. Tripoli. Absolutely. Site-of-service payment 
differentials really originate in Medicare payment, where 
Medicare pays more for services performed in an outpatient 
department than it does for the same service and the same 
quality if it is performed in a physician's office, and what 
this does is it does two things. First, it creates this 
incentive to push patients to higher costs of care settings, 
which, of course, increases the cost for everybody, and second, 
it creates a financial incentive, an economic incentive, for 
hospital systems to actually buy up physician practices, 
rebrand them as outpatient department, and all that is really 
happening is they change the sign on the door to name it a 
hospital outpatient clinic.
    Senator Braun. That average jack in price is about 40 
percent?
    Ms. Tripoli. Yes.
    Senator Braun. That is why hospitals now comprise about 45 
percent of the health care dollar because they have bought up 
so many clinics, and as soon as they buy the clinics the prices 
go up. That is another ripoff that happens nowhere else. Thank 
you for explaining it.
    I want to expose this part of what was really essentially 
when I fixed it in my own business. The consumer is really 
disengaged, and then complains about the bill, holds his or her 
breath, three to four months later when you get it, and hope 
that the plan was right, and I have never seen a business 
either, for the folks that can afford it, and when the 
insurance companies told me that it is minor health care, and 
the overutilization of it, and the fact that there is no skin 
in the game among consumers, that that has driven costs high.
    I mentioned earlier, insurance should be for indemnifying 
against critical illness or accident. I would like your 
opinion, Dr. Whaley and Ms. Deacon, on how do we get what 
drives most markets would be unfettered competition, no 
barriers to entry, price transparency, but an engaged consumer? 
How important is that part of the equation on the people that 
can afford it to be shopping around for their primary health 
care and to where we take insurance out of it completely?
    That is what I did. That was a key element that actually 
brought it into line, because my employees became health care 
consumers and they exercised their power in doing it. Dr. 
Whaley?
    Dr. Whaley. I think that aspect is critical. I think one 
really good example actually comes from the California Public 
Employees Retirement System, or CalPERS, which recognized the 
huge variation in price that was not tied to quality and the 
exact same site-of-care differentials that we just discussed, 
and so what they did is they decided to give consumers skin in 
the game and said to patients, "We know that there are low-
priced providers and we are going to fully cover those 
providers. If you want to go to a higher-priced, inefficient 
provider then you are going to have to pay that difference."
    What we have seen in several studies with CalPERS is that 
over 90 percent of patients chose the lower-priced provider, 
and there is a huge reduction in prices, an improvement in 
quality, and substantial savings.
    Senator Braun. Ms. Deacon?
    Ms. Deacon. Yes. I definitely believe that there is a 
greater role that the consumer can play if and when they get 
access to good information and actual price. Again, this is one 
of the reasons that real prices, as opposed to estimates, are 
so important. When you get access to real prices, as opposed to 
estimates, you are much more likely to rely on those for your 
financial well-being and making decisions, so there is a set of 
what we will call shoppable services that you are able to do, 
that engage in that consumerism, but then there is the other 
sort of set of services, and more have to do with inpatient 
stays and sort of unplanned services, and that is really when 
the employer or plan sponsor has to step in and take a role in 
terms of making better decisions and choices in who are they 
letting into their network, what they are paying for that 
network rate, and the value that they are getting for their 
members and for their business.
    Senator Braun. By the way, before my time runs out, back in 
2008, the insurance companies told me that if you can create a 
market and an engaged consumer you will save so much money. By 
then dealing with the slim amount of information--that was 16 
years ago--it happened every time. When you had to pick up the 
phone, get on the Web, you were experiencing 30 to 70 percent 
savings.
    They also told me you would save so much money you can 
protect your employee with not having to engage in the 
coinsurance, which is when you have a significant illness or 
accident you blow outside the deductible and that is what takes 
you to bankruptcy court. We got rid of that, and also got rid 
of copayments, and that has held everything flat since then, so 
they became health care consumers. People love it, because 
sooner or later you have a critical illness or a bad accident, 
and when you never have to pay outside your deductible and you 
help save money by shopping within a broken system, imagine if 
providers would make that easy what we could do to lower health 
care costs.
    Thank you.
    Chairman Casey. Thank you, Ranking Member Braun. I knew 
that Senator Warnock was on his way, and he appeared exactly at 
the right time. Senator Warnock.
    Senator Warnock. Thank you very much, Chair Casey and 
Ranking Member Braun. Great to work with both of you on so many 
important things. Chair Casey, I am especially grateful to be 
working with you on the Capping Prescription Costs Act, so we 
can finish the job of the Inflation Reduction Act when it comes 
to lowering drug costs. That means so much for the populations 
that we are discussing in this hearing.
    Nearly 15 years after the passage of the Affordable Care 
Act, 10 states have not extended access to affordable Medicaid 
coverage for nearly three million Americans, in my own State of 
Georgia more than 600,000 Georgians. Ms. Tripoli, there is a 
lot of mischaracterizations about who is left in the coverage 
gap. Can you paint a picture for us about those who are left 
behind? Who are these people?
    Ms. Tripoli. Absolutely. These are people who are very 
poor, who do not currently meet the eligibility or category 
requirements to qualify for Medicaid in states that have not 
expanded, in the 10 states, but they also fall underneath the 
Federal poverty level, so they do not qualify for subsidies in 
the marketplace either, and these are disproportionately people 
of color, disproportionately people with disabilities, and 
without access to health care it is very difficult road. They 
essentially have to forego or delay care, and we know that that 
often exacerbates their health conditions and can be often a 
life-or-death situation.
    Senator Warnock. Disproportionately people of color.
    Ms. Tripoli. That is right.
    Senator Warnock. Disproportionately the working poor.
    Ms. Tripoli. That is right.
    Senator Warnock. Working people, and I underscore that 
because we hear a lot of moralizing in this space, in so many 
of our government spaces, about people needing to work, but 
often our policy literally gets in the way of people who are 
quite literally dying to get to work, and I say that, and I am 
thinking about Heather Payne, a traveling nurse in Dalton, 
Georgia. I have gotten to know Heather. She was my guest at the 
State of the Union address. I talked to her this morning. She 
is a relatively young woman who has had a series of strokes 
that literally changed her life. She was a traveling nurse, and 
sometimes she had health care and sometimes she did not, so she 
has found herself in a terrible situation, and the tragic irony 
that here she is a traveling nurse who has dedicated her whole 
career to caring for people, and she has had to put off 
essential medical procedures because she simply cannot afford 
to pay out-of-pocket costs and cannot afford plans on the 
Marketplace because she does not qualify for subsidies.
    I literally talked to her about this this morning. I could 
both hear and feel her stress around these issues, even as she 
is trying to get her life together. She wants to go on and get 
another nursing degree and hopefully get her health back I 
order, but she cannot see the specialist she needs, so that is 
why today I am introducing the Bridge to Medicaid Act, with 
Chair Casey's support, which would temporarily extend subsidies 
to people in the coverage gap to buy private insurance.
    Ms. Tripoli, how does access to affordable health care 
benefit people like Heather who are in the coverage gap?
    Ms. Tripoli. I mean, simply it is a lifeline. It allows 
them to have access to the preventive services--cancer 
screening, prescription drug medication, diabetes management--
--
    Senator Warnock. They want to get back to work.
    Ms. Tripoli. Exactly
    Senator Warnock. I am encouraged by recent developments, 
and I believe we are closer than ever to closing the coverage 
gap in all 50 states, for those who want to make this a red/
blue issue. Most of the states have expanded, blue states and 
red states, but as those conversations continue, people like 
Heather are caught in the crosshairs, so my legislation would 
give vulnerable Americans access to affordable health care 
while state politicians, I hope, move closer to making the 
right decision for their constituents.
    I am a pastor, but those who are not moved by the moral 
argument, you know, that would be sad.
    Let me underscore the economic argument. A report from the 
Georgia Health Initiative, in March 2024, found that closing 
the coverage gap would create 51,264 jobs statewide, and boost 
economic output by $9.3 billion during the first three years of 
full expansion. That is just in the State of Georgia. Not to 
mention that we saw $3 billion of uncompensated care that our 
hospitals had to carry in Georgia in 2021 alone, while 
politicians play this game.
    Can you talk about how states have benefited economically 
from Medicaid expansion?
    Ms. Tripoli. Absolutely. I think that is exactly right, and 
I think the other economic benefit for states who have 
expanded, particularly states with a lot of rural hospitals, is 
that we have seen, in states that have expanded Medicaid, we 
have seen a reduction in the amount of rural hospitals that 
have had to close their doors, so Medicaid expansion is very 
important, obviously important for people to get access to 
care, and important for the economy, as well.
    Senator Warnock. Thank you so very much, Ms. Tripoli, and 
thanks to all of our witnesses. Georgians and Americans in nine 
other states cannot afford to wait around for state leaders to 
make the right choice, and that is why today I am proud to 
introduce, along with Chair Casey, the Bridge to Medicaid, 
which temporarily extends subsidies to the millions of 
Americans in the coverage gap. This legislation is not a 
replacement for full Medicaid expansion, but we are doing it 
because people like Heather Payne cannot wait.
    Georgia still, by the way, has the option to fully expand, 
and $1.2 billion in additional Federal funding will be waiting 
for Georgia when it finally does the right thing.
    Thank you so very much.
    Chairman Casey. Thank you, Senator Warnock, and thank you 
for your work on these issues, especially Medicaid, all these 
years.
    Senator Braun, the Ranking Member, just went to the HELP 
hearing, so I want to make sure that we have time to close so I 
can get to the same hearing. We are juggling today.
    I want to note for the record, as well, that Senator 
Blumenthal joined us earlier, and as I said today, it is a busy 
Thursday, but we are grateful for those who attended the 
hearing. We are certainly grateful for the expertise and 
experience brought to this Committee by the witnesses.
    As we heard today, rising health care costs are a terribly 
significant problem for so many Americans, and this issue has 
to be addressed. As hospital prices rise, individuals are 
increasingly faced with the unacceptable decision, the awful 
decision to delay or forego necessary care or go into medical 
debt to receive lifesaving health services. Improving 
transparency is one of the many policy proposals that has the 
potential to help lower costs for patients.
    As we heard today, especially from Ms. Tripoli, a broader 
rethinking of economic incentives in the health care sector is 
necessary to better meet the goal that we all share to improve 
health for both patients and families. Along with transparency 
measures we must continue efforts to address all factors 
impacting health care costs.
    We have heard from our witnesses today about the various 
factors driving up hospital costs, and we know that patients 
also struggle with costs associated with prescription drugs, 
costs associated with doctor visits, and health insurance 
premiums.
    I look forward to working with my colleagues to address 
rising health care costs and ensure that all Americans can 
afford quality care.
    I will have Ranking Member Braun submit his closing remarks 
for the record, and I want to thank again all of our witnesses 
for being here, for taking the time to be with us, and to 
provide your expertise to the Committee.
    If any Senator has additional questions for the witnesses 
or statements to be added to the hearing record, the record 
will be open for seven days, until next Tuesday, July 18th. 
Thank you all for participating today. We are adjourned.
    [Whereupon, at 11:20 a.m., the hearing was adjourned.]

                 CLOSING STATEMENT OF SENATOR 
                   MIKE BRAUN, RANKING MEMBER

    Thank you, Chairman Casey. Thank you to our witnesses for 
sharing your testimonies and personal experiences.
    Today, we heard about the importance of health care price 
transparency and how access to this information will lower 
costs for Americans. We need policies that empower patients and 
provide employers with the information necessary to create the 
best health care benefit for their employees. With transparency 
throughout the health care supply chain, Americans will be able 
to see the cost of health care services before they receive 
them. This will increase competition and lower prices as 
patients have the ability to shop around for the best price and 
highest quality.
    I hope today we recognized that there are bipartisan 
solutions that thoughtfully address this issue.
    I am encouraged by the work being done by all of our 
witnesses here today, and I appreciate our Committee's focus on 
this issue.
    I yield back.

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                                APPENDIX

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                      Prepared Witness Statements

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                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                       Prepared Witness Testimony

                            Dr. Chris Whaley

    Chairman Casey, Ranking Member Braun, and members of the 
Committee, thank you for the opportunity to testify today. My 
name is Christopher Whaley. I am an associate professor of 
Health Policy at the Brown University School of Public Health 
and Associate Director of the Center for Advancing Health 
Policy through Research (CAHPR). My research focuses on health 
care price transparency, the impacts of evolving health care 
markets, and studying employer and purchaser innovations that 
are enabled by price transparency information.
    In the United States, employers and purchasers of health 
care play a significant role in shaping the U.S. healthcare 
system. Employers provide health insurance for over 160 million 
Americans the largest source of health insurance in the United 
States.\1\ In most cases, employers select employee plan 
offerings and thus determine the types of health plans 
available to their employees and their families. Employers also 
play a critical role in financing the U.S. healthcare system. 
Collectively, employer-sponsored insurance accounts for 
approximately $1.4 trillion in health care spending.\2\The 
average premium for an employer-sponsored family health 
insurance plan is now nearly $24,000. As health care spending 
has increased over the last two decades, employers have reduced 
wages for workers.\3\ \4\ \5\ \6\
---------------------------------------------------------------------------
    \1\ Employer Health Benefits Survey. KFF. Published October 18, 
2023. Accessed July 8, 2024. https://www.kff.org/health-costs/report/
2023-employer-health-benefits-survey
    \2\ Centers for Medicare & Medicaid Services. Historical/CMS. 
https://www.cms.gov. Published December 13, 2023. https://www.cms.gov/
data-research/statistics-trends-and-reports/national-health-
expenditure-data/historical
    \3\ Arnold D, Whaley CM. Who Pays for Health Care Costs? The 
Effects of Health Care Prices on Wages. RAND Corporation; 2020. https:/
/www.rand.org/pubs/working--papers/WRA621-2.html
    \4\ Baicker K, Chandra A. The Labor Market Effects of Rising Health 
Insurance Premiums. Journal of Labor Economics. 2006;24(3):609-634. 
doi:10.1086/505049
    \5\ Brot-Goldberg Z, Cooper Z, Craig SV, Klarnet LR, Lurie I, 
Miller CL. Who Pays for Rising Health Care Prices? Evidence from 
Hospital Mergers. Published online June 2024. doi:10.3386/w32613
    \6\ Anand, Priyanka. 2017. Health insurance costs and employee 
compensation: Evidencefrom the national compensation survey. Health 
Economics, 26(12): 1601 1616.
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    Particularly for lower-income households, rising health 
care costs for employer-sponsored insurance create financial 
burdens when receiving care, which can limit access to care, 
because health benefits are financed from wages, employers have 
both a legal and moral obligation to be responsible fiduciaries 
when they purchase health benefits on behalf of their 
employees.
    Unfortunately, many employers face challenges purchasing 
affordable health care coverage that provides real value for 
their workers, as more often than not they are having to make 
decisions while blind to prices for services in the 
marketplace. Many employers cannot access plan claims data, 
limiting their ability to monitor prices negotiated on their 
behalf and prudently design plan offerings. Furthermore, even 
when employers can access comparative cost information, they 
far too often face consolidated provider markets with limited 
access to lower-price, high-quality providers. The combination 
of a lack of price transparency and health care consolidation 
has made fulfilling their fiduciary obligations challenging for 
even the most engaged employers and purchasers.
    My testimony today will focus on why making price 
information transparent is critical for addressing health care 
affordability and ensuring efficient health care markets. I 
will make three main points:
        1. Health care prices in the United States are high and 
variable and are driven by provider consolidation and market 
power, and those high prices are not linked to increases in 
quality.
        2. Rather than placing the responsibility of navigating 
the US healthcare system on patients, effective price 
transparency can be a hub that enables impactful programs and 
policies developed by employers and policymakers that improve 
access to lower-priced, high-quality providers and ensure 
health market competition.
        3. There are potential steps Congress and the federal 
government could consider to increase both transparency on 
prices and ownership structure in health care markets and 
enable price transparency to reach its cost-containment 
potential.

    U.S. Health Care Prices are High and Variable

    The United States leads the world in health care spending, 
largely due to high prices.\7\ Prices also vary considerably, 
both within and across markets. Several studies document 
substantial variation in U.S. health care prices. My recent 
research shows employer and private insurance prices for 
hospital care average 254 percent of Medicare. However, prices 
are below 200 percent of Medicare in states like Arkansas, 
Iowa, and Michigan, but over 300 percent of Medicare in states 
of West Virginia, Florida, and Georgia.\8\ In addition, both 
Medicare and commercial insurers pay roughly twice as much for 
common services, such as laboratory tests, diagnostic imaging 
services, and outpatient surgeries, performed in hospital-based 
settings than non-hospital sites of care.\9\
---------------------------------------------------------------------------
    \7\ Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It s The 
Prices, Stupid: Why The United States Is So Different From Other 
Countries. Health Affairs. 2003;22(3):89-105. doi: doi. https://
www.org/10.1377/hlthaff.22.3.89
    \8\ Whaley CM, Kerber R, Wang D, Kofner A, Briscombe B. Prices Paid 
to Hospitals by Private Health Plans: Findings from Round 5 of an 
Employer-Led Transparency Initiative. RAND Corporation; 2024. Accessed 
July 8, 2024. https://www.rand.org/pubs/research--reports/RRA1144-
2.html
    \9\ Robinson J, Whaley C, Dhruva S. Prices and Complications in 
Hospital-Based and Freestanding Surgery Centers. The American Journal 
of Managed Care. 2024;30:179-184. Accessed July 8, 2024. https://
www.ajmc.com/view/prices-and-complications-in-hospital-based-and-
freestanding-surgery-centers
---------------------------------------------------------------------------
    High and variable health care prices are often not linked 
to quality and are driven by provider consolidation and market 
power. Over the last two decades, U.S. health care provider 
markets have experienced three main types of consolidation. The 
first involves horizontal consolidation, primarily driven by 
hospital and health system acquisition of other hospitals. U.S. 
health care markets have seen over 2,000 hospital mergers. 
Hospital mergers lead to meaningful increases in prices, 
without improvements in quality.\10\ \11\ The second form of 
consolidation involves vertical consolidation, where large 
entities, primarily hospitals and health systems, acquire 
intermediaries, primarily physician practices. Over the last 
decade, the share of U.S. physicians employed by a hospital or 
health system has approximately doubled. Currently, over half 
of U.S. physicians are employed by a hospital or health system. 
Driven by site-of-care payment differentials in both Medicare 
and commercial payment rates, this form of consolidation 
changes referral patterns for many downstream services, thereby 
increasing both Medicare and commercial spending.\12\ \13\ A 
more recent form of vertical integration involves insurers 
directly acquiring both physician practices and other types of 
providers.\14\ Particularly for Medicare Advantage populations, 
this form of consolidation raises concerns about access to care 
and payment gaming.\15\ Finally, the latest wave of health care 
consolidation is driven by private equity, which owns a growing 
share of U.S. physician practices. Studies show private equity 
acquisition leads to price increases without commensurate gains 
in access or quality. Importantly, these models of 
consolidation disadvantage the healthcare workforce, with 
physicians and nurses receiving lower pay following 
consolidation.\16\ \17\
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    \10\ Cooper Z, Craig SV, Gaynor M, Van Reenen J. The Price Ain t 
Right? Hospital Prices and Health Spending on the Privately Insured. Q 
J Econ. Published online 2018. doi:10.1093/qje/qjy020
    \11\ Liu JL, Levinson ZM, Zhou A, Zhao X, Nguyen P, Qureshi N. 
Environmental Scan on Consolidation Trends and Impacts in Health Care 
Markets. RAND Corporation; 2022. Accessed January 19, 2024. https://
www.rand.org/pubs/research--reports/RRA1820-1.html
    \12\ Whaley C, Paul DRL, Perkins J. Addressing Site-of-Care Payment 
Differentials in the United States Health Care System. Brown University 
School of Public Health 2024.Accessed July 8, 2024. https://
www.cahpr.sph.brown.edu/sites/default/files/documents/
Site%20Neutral%20Payment%20Policy%20Brief-2.pdf
    \13\ Richards MR, Seward JA, Whaley CM. Treatment consolidation 
after vertical integration: Evidence from outpatient procedure markets. 
Journal of Health Economics. 2022;81:102569. doi:https://www.doi.org/
10.1016/j.jhealeco.2021.102569
    \14\ Zhao X, Richards MR, Damberg CL, Whaley CM. Market Landscape 
and Insurer-Provider Integration: The Case of Ambulatory Surgery 
Centers. Health affairs scholar. 2024;2(6). doi:https://www.doi.org/
10.1093/haschl/qxae081
    \15\ Rooke-Ley H, Shah S, Fuse EC. Medicare Advantage and 
Consolidation s New FrontierThe Danger of UnitedHealthcare for All. New 
England Journal of Medicine. Published online July 6, 2024. doi:https:/
/www.doi.org/10.1056/nejmp2405438
    \16\ Prager E, Schmitt M. Employer Consolidation and Wages: 
Evidence from Hospitals. American Economic Review. 2021;111(2):397-427. 
doi:https://www.doi.org/10.1257/aer.20190690
    \17\ Whaley CM, Arnold DR, Gross N, Jena AB. Physician Compensation 
In Physician-Owned And Hospital-Owned Practices. Health Affairs. 
2021;40(12):1865-1874. doi:https://www.doi.org/10.1377/
hlthaff.2021.01007
---------------------------------------------------------------------------
    While high and variable prices directly impact those with 
commercial insurance, they also have important implications for 
aging Americans. First, many over-65 individuals receive 
private insurance, most commonly from current or former 
employers, and are thus impacted by high and variable prices. 
Second, numerous studies show the health impacts of high 
healthcare costs for patients in the form of reductions in 
high-value and necessary care. For the under-65 population to 
age healthily, it is critical that they have access to 
affordable health care. Finally, high and differential prices 
drive health care consolidation, which erodes access to and 
quality of care for Medicare beneficiaries.\18\ \19\ \20\
---------------------------------------------------------------------------
    \18\ Beaulieu ND, Dafny LS, Landon BE, Dalton JB, Kuye I, 
McWilliams JM. Changes in Quality of Care after Hospital Mergers and 
Acquisitions. New England Journal of Medicine. 2020;382(1):51-59. 
doi:https://www.doi.org/10.1056/nejmsa1901383
    \19\ Levin JS, Komanduri S, Whaley C. Association Between Hospital, 
Physician Vertical Integration and Medication Adherence Rates. Health 
Services Research. Published online October 22, 2022. doi:https://
www.doi.org/10.1111/1475-6773.14090
    \20\ Whaley CM, Zhao X, Richards M, Damberg CL. Higher Medicare 
Spending On Imaging And Lab Services After Primary Care Physician Group 
Vertical Integration. Health Affairs. 2021;40(5):702-709. doi:https://
www.doi.org/10.1377/hlthaff.2020.01006

    What is the role of price transparency in addressing rising 
---------------------------------------------------------------------------
health care costs?

    Due to the high and variable nature of U.S. health care 
prices, improving price transparency has been a potential 
policy option for several years. Early price transparency 
models relied on patient-driven use through apps and online 
tools.\21\ Despite initial promise, these models had little 
success.\22\ \23\ Relying on patients to navigate the 
complexities of the U.S. healthcare system with even the best 
price transparency tools is a challenging task.\24\ However, 
the lack of usable price transparency limits the ability of 
researchers to understand health care markets, entrepreneurs 
from adding competition to healthcare markets, and regulators 
from monitoring market conduct and competition. Rather than 
placing the responsibility of navigating the US healthcare 
system on patients, effective price transparency can be a hub 
that enables impactful programs and policies. Several employers 
and purchasers have used price transparency to redesign 
benefits.
---------------------------------------------------------------------------
    \21\ Whaley C, Chafen Schneider J, Pinkard S, et al. Association 
Between Availability of Health Service Prices and Payments for These 
Services. Journal of the American Medical Association. Published online 
October 22, 2014.
    \22\ Desai S, Hatfield LA, Hicks AL, Chernew ME, Mehrotra A. 
Association Between Availability of a Price Transparency Tool and 
Outpatient Spending. JAMA. 2016;315(17):1874-1881. doi:10.1001/
jama.2016.4288
    \23\ Desai S, Hatfield LA, Hicks AL, et al. Offering A Price 
Transparency Tool Did Not Reduce Overall Spending Among California 
Public Employees And Retirees. Health Affairs. 2017;36(8):1401-1407. 
doi:10.1377/hlthaff.2016.1636
    \24\ Chernew M, Cooper Z, Hallock EL, Scott Morton F. Physician 
agency, consumerism, and the consumption of lower-limb MRI scans. J 
Health Econ. 2021;76:102427. doi:10.1016/j.jhealeco.2021.102427

    Example 1: California Public Employees Retirement Systems 
---------------------------------------------------------------------------
(CalPERS)

    The California Public Employees Retirement System 
(CalPERS), which provides health benefits to approximately 1.4 
million individuals, recognized the wide variation in prices 
within their network that was not tied to clinical outcomes. 
Rather than implementing a punitive high-deductible plan, they 
worked in conjunction with their labor representatives to 
design a steerage program that uses financial incentives to 
encourage the use of lower-priced providers and non-hospital 
providers. Across several services, this program reduced 
spending by approximately 20 percent and improved care 
quality.\25\ \26\ \27\
---------------------------------------------------------------------------
    \25\ Robinson JC, Brown TT. Increases In Consumer Cost Sharing 
Redirect Patient Volumes And Reduce Hospital Prices For Orthopedic 
Surgery. Health Affairs. 2013;32(8):1392-1397. doi:https://www.doi.org/
10.1377/hlthaff.2013.0188
    \26\ Robinson JC, Brown TT, Whaley C, Finlayson E. Association of 
Reference Payment for Colonoscopy With Consumer Choices, Insurer 
Spending, and Procedural Complications. JAMA Internal Medicine. 
2015;175(11):1783. doi:https://www.doi.org/10.1001/
jamainternmed.2015.4588
    \27\ Robinson JC, Brown TT, Whaley C. Reference Pricing Changes The 
Choice Architecture Of Health Care For Consumers. Health Affairs. 
2017;36(3):524-530. doi:https://www.doi.org/10.1377/hlthaff.2016.1256

    Example 2: State of Oregon Hospital Reimbursement Caps and 
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All-Payer Claims Database

    A similar example comes from the State of Oregon. 
Recognizing the wide variation in hospital prices, Oregon 
passed legislation that caps the prices of hospital care at 200 
percent of the Medicare rates for Oregon's public employees and 
educators. My colleagues have demonstrated that this program 
led to over $100 million in savings in the first two years of 
the program, without impacts on the quality of care or the 
provider workforce.\28\ If adopted among other states, we 
estimate that this model could reduce public employee spending 
by approximately $7 billion, which could be used to increase 
public employee pay or returned to taxpayers, and nearly $90 
billion if expanded to the broader commercial market. Oregon 
also invested in an all-payer claims database, which allows 
state authorities to monitor price and spending trends.
---------------------------------------------------------------------------
    \28\ Murray RC, Brown ZY, Miller S, Norton EC, Ryan AM. Hospital 
Facility PricesDeclined As A Result Of Oregon s Hospital Payment Cap. 
Health Affairs. 2024;43(3):424-432. doi:https://www.doi.org/10.1377/
hlthaff.2023.01021

    Example 3: 32BJ Health Fund - Private-Sector Adoption of 
---------------------------------------------------------------------------
Innovations

    These innovations are also being adopted by private-sector 
organizations. In one notable example, the 32BJ Health Fund, 
which provides health benefits to approximately 200,000 service 
workers, reviewed its claims data and realized some providers 
had exceptionally high prices. After several attempts at 
negotiation, 32BJ excluded a single hospital from its network. 
This decision saved the Health Fund approximately $100 million 
per year, which it returned to its workers in the form of the 
largest worker pay increase in its history and a $3,000 bonus 
for each member.\29\
---------------------------------------------------------------------------
    \29\ SEIU 32BJ Healthcare Savings Case Study. 
PatientRightsAdvocate.org. Accessed July 8, 2024. https://
www.patientrightsadvocate.org/seiu-32bj-healthcare-savings-case-study

    Example 4: Indiana employers using data to push for policy 
---------------------------------------------------------------------------
changes

    Another example comes from employers in the state of 
Indiana. Through the Employer s Forum of Indiana, we worked 
with Indiana employers to analyze their claims data and found 
they were paying some of the highest prices in the country.\30\ 
In addition to using price transparency data to monitor prices 
negotiated on their behalf and to inform both benefit design 
and purchasing decisions, Indiana employers pushed for 
legislation that limits facility fees and adds additional 
transparency to Indiana health care markets.\31\ These efforts 
use price transparency data to add oversight into an opaque 
market and inform policies that improve market competition.
---------------------------------------------------------------------------
    \30\ Abelson R. Many Hospitals Charge Double or Even Triple What 
Medicare Would Pay. The New York Times. https://www.nytimes.com/2019/
05/09/health/hospitals-prices-medicare.html. Published May 9, 2019.
    \31\ Mathews AW. These Employers Took On Healthcare Costs, and the 
Fight Got Nasty. WSJ. Published September 28, 2023. https://
www.wsj.com/health/healthcare/these-employers-took-on-healthcare-costs-
and-the-fight-got-nasty-54674114
---------------------------------------------------------------------------
    These are notable examples and there are many more 
entrepreneurs and innovators that are using price transparency 
data to develop similar programs that steer patients to lower-
priced providers,\32\ modernize payment methods in ways that 
align incentives between patients, providers, and payers,\33\ 
and add competition to health care markets.
---------------------------------------------------------------------------
    \32\ Whaley CM, Vu L, Sood N, Chernew ME, Metcalfe L, Mehrotra A. 
Paying Patients To Switch: Impact Of A Rewards Program On Choice Of 
Providers, Prices, And Utilization. Health Affairs. 2019;38(3):440-447. 
doi:https://www.doi.org/10.1377/hlthaff.2018.05068
    \33\ Whaley CM, Dankert C, Richards M, Bravata D. An Employer-
Provider Direct Payment Program Is Associated With Lower Episode Costs. 
Health Affairs. 2021;40(3):445-452. doi:https://www.doi.org/10.1377/
hlthaff.2020.01488
---------------------------------------------------------------------------
    While these policies and programs are designed to fit the 
needs of each group's market and population, a common theme is 
that each group relied on price and network data, most commonly 
from medical claims data, to innovate. These organizations also 
take seriously their responsibilities as health care purchasing 
fiduciaries. These types of models are critical to ensure 
affordable access to high-quality providers across the aging 
lifecycle.

    What more can be done to enable price transparency to reach 
its cost containment potential?

    In recognition of the importance of price transparency, 
recent federal policies have sought to expand access to price 
transparency information. On January 1, 2021, requirements for 
hospitals to negotiate their prices for all items and services 
went into effect.\34\ Following that, on July 1, 2022, a 
federal rule went into effect that requires health plans to 
disclose the negotiated prices they pay physicians and 
facilities for each item they provide, known as Transparency-
in-Coverage (TiC) data.\35\ Both of these policies greatly 
expand health care price transparency.
---------------------------------------------------------------------------
    \34\ Department of Health and Human Services. 45 CFR Part 180. 
Published November 27, 2019. https://www.ecfr.gov/current/title-45/
subtitle-A/subchapter-E/part-180#180.40
    \35\ FAQS about Affordable Care Act and Consolidated Appropriations 
Act, 2021 Implementation Part 49.; 2021. https://www.cms.gov/CCIIO/
Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-Part-49.pdf
---------------------------------------------------------------------------
    While there have been some concerns with the implementation 
of the rules, there have been significant positives to each. 
The insurer-posted (TiC) data provides the most comprehensive 
view of U.S. health care prices currently available. There were 
initial concerns about the TiC data usability, but researchers, 
including myself, have been able to use data to measure price 
variation. Entrepreneurs are also using these data to improve 
benefit design innovations.
    While these data are important, they, like most things, can 
also be improved. There are several steps Congress and the 
federal government could consider to increase price 
transparency in health care markets and enable price 
transparency to reach its full cost-containment potential.

    Increase compliance enforcement and standardization of 
hospital-posted price transparency data

    The hospital-posted price transparency data represent an 
initial step into expanding access to price transparency. 
However, compliance with requirements to post negotiated rates 
for 300 shoppable services could have been better, largely due 
to more enforcement. While recent enforcement has increased, 
compliance still needs to improve, with estimates suggesting 
that only 16 to 35 percent of hospitals are fully 
compliant.\36\ \37\ Other studies find strategic non-compliance 
is related to a hospital s market environment.\38\ Even among 
complying hospitals, data formats, reported services, and price 
measurements vary widely. To ensure that these data are useful 
for informing policy decisions, it is important for CMS to 
enforce compliance and standardize data submission.
---------------------------------------------------------------------------
    \36\ MRF Tracker. Turquoise Health.Accessed July 8, 2024. https://
www.turquoise.health/mrf--tracker
    \37\ Patient Rights Advocate. Sixth Semi-Annual Hospital Price 
Transparency Report February 2024. Patient Rights Advocate; 2024. 
https://www.patientrightsadvocate.org/semi-annual-report-feb2024
    \38\ Mittler JN, Abraham JM, Robbins J, Song PH. To be or not to be 
compliant? Hospitals initial strategic responses to the federal price 
transparency rule. Health Services Research. Published online November 
6, 2023. doi:https://www.doi.org/10.1111/1475-6773.14252

    Reduce the duplicative prices and prices for providers that 
do not perform listed services from the TiC data and centralize 
---------------------------------------------------------------------------
data posting

    The TiC data include many duplicative prices and prices for 
providers that do not perform listed services. These features 
greatly inflate the size of the TiC data, reducing its 
applicability and accuracy. Second, the TiC data are completely 
updated on a monthly basis, which further adds barriers to data 
use. To further improve this innovative resource, CMS could 
require insurers to only post prices for providers with 
submitted claims for a given procedure. CMS could also limit 
monthly updates to new or changed prices, rather than a 
complete data refresh.
    Additionally, the TiC data are currently hosted 
individually by plans and insurers. CMS could centralize TiC 
data by acting as a central hub for hosting these data. The 
data are also currently posted in non-standard data formats, 
which contributes to inflated data size. CMS could use common 
modern database technologies to allow a broad set of users to 
access the data and substantially reduce data size and 
complexity without losing any valuable data.

    Require a centralized national database to enhance 
transparency of provider ownership and control

    While existing transparency efforts primarily focus on 
prices, provider ownership and affiliation arrangements are 
often complex and opaque. Existing data resources do not 
adequately track ownership structure, limiting appropriate 
measurement of consolidation activities and policies to guard 
against adverse impacts of consolidation.\39\ Researchers, and 
importantly, policymakers, lack comprehensive data on who owns 
or controls health care entities and physician practices. Many 
provider organizations are organized through complex corporate 
structures that obscure the identity of the owner or control 
entity and prevent accountability.\40\ Patients often have 
little information on their physician s actual employer. As a 
result, estimates of both the extent and impacts of 
consolidation are limited and incomplete. Ownership 
transparency could be improved by requiring provider 
organizations to report not just direct ownership but also 
management, joint venture, and related arrangements. Developing 
a centralized national database to enhance the transparency of 
provider ownership and control will allow for a more complete 
understanding of the true extent and effects of consolidation 
in US health care markets, including changes in prices, 
utilization, and quality of care.
---------------------------------------------------------------------------
    \39\ The Perils Of PECOS: Using Medicare Administrative Data To 
Answer Important Policy Questions About Health Care Markets. Forefront 
Group. Published online January 7, 2021. doi:https://www.doi.org/
10.1377/forefront.20201222.615286
    \40\ Hearing on Strengthening U.S. Economic Leadership: The Role of 
Competition in Enhancing Economic Resiliency. Published online 2024. 
https://www.judiciary.senate.gov/committee-activity/hearings/
strengthening-us-economic-leadership-the-role-of-competition-in-
enhancing-economic-resiliency

    Ensure that self-funded purchasers have access to data on 
---------------------------------------------------------------------------
price, utilization, and quality

    While these efforts have been primarily focused on 
expanding access to publicly-available price transparency data, 
many employers and self-funded purchasers rely on medical 
claims data to measure prices, track quality, and ensure access 
to efficient providers. Yet, many employers and purchasers face 
barriers in accessing their medical and pharmacy claims data. 
The 2021 Consolidated Appropriations Act (CAA) removes many 
restrictive and anti-competitive clauses from plan contracts, 
but does not ensure that self-funded purchasers have access to 
their claims data.\41\ As a result, many employers have had to 
sue to get access to their own data.\42\ It is important that 
purchasers have access to data on price, utilization, and 
quality that these data provide. Proposed bipartisan 
legislation codifies access to these data, which are necessary 
for self-funded plans to be responsible fiduciaries and monitor 
prices negotiated on their behalf.\43\
---------------------------------------------------------------------------
    \41\ Consolidated Appropriations Act, 2021 (CAA)/CMS. https://
www.cms.gov. https://www.cms.gov/marketplace/about/oversight/other-
insurance-protections/consolidated-appropriations-act-2021-caa
    \42\ Kraft Heinz Co. Employee Benefits Administration Board, et 
al., v. Aetna Life Insurance Company, 2:23-cv-00317, District Court, 
E.D. Texas, June 30, 2023, https://www.versanconsulting.com/post/kraft-
heinz-co-employee-benefits-administration-board-et-al-v-aetna-life-
insurance-company; Massachusetts Laborers Health & Welfare Fund v. Blue 
Cross Blue Shield of Massachusetts, 66 F.4th 307 (1st Cir. 2023), April 
25,2023, https://www.casetext.com/case/mass-laborers-health-welfare-
fund-v-blue-cross-blue-shield-of-mass-1; Owens & Minor, Inc. and Owens 
& Minor Flexible Benefits Plan v. Anthem Health Plans of Virginia, 
Inc., 3:23-cv-00115, February 13, 2023, https://
www.millerchevalier.com/sites/default/files/resources/General--Alerts/
2023-02-13--Owens-v-Anthem--Complaint.pdf; Bricklayers, Craftworkers, 
Sheet Metal Workers Unions v. Elevance, 3:22-cv01541-VLB, December 5, 
2022, https://www.documentcloud.org/documents/23378734-bricklayers-
craftworkers-sheet-metal-workers-unions-v-elevance.
    \43\ 118th Congress S.3548 - Health Care Prices Revealed and 
Information to Consumers Explained Transparency Act. https://
www.congress.gov/bill/118th-congress/senate-bill/3548/all-info

---------------------------------------------------------------------------
    Conclusion

    Health care prices in the United States are high, variable, 
and opaque. High prices are both a cause and a consequence of 
health care consolidation, which has left many communities with 
a single provider system and worsened access to high-quality 
care. Arguably, the most significant bipartisan federal 
agreement in recent years has centered on enhancing 
transparency in healthcare pricing. In combination with 
expanded insight into provider ownership and management, 
broadened transparency can help employers and health care 
purchasers fulfill their fiduciary obligations to provide 
access to high-quality and affordable care. It also aids 
regulators and policymakers in overseeing healthcare market 
competitiveness and ensuring patient access to high-quality, 
cost-effective care. While not a cure-all for the U.S. 
healthcare system, given the widespread impact on all 
individuals navigating the healthcare system, these initiatives 
enjoy substantial public backing. To accomplish these goals, 
Congress can improve the existing Transparency-in-Coverage 
policies that provide substantial insight into US health care 
prices, ensure transparent reporting of provider ownership and 
management, and codify self-funded employer and purchaser 
access to their claims data.

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                       Prepared Witness Testimony

                              Chris Deacon

    Chairman, Ranking Member, and distinguished members of the 
Committee,
    Thank you for the opportunity to testify today on the 
critical issue of transparency in healthcare. Imagine, if you 
will, you are the CFO of a company where you give the company 
credit card to your vendors and suppliers. Instead of receiving 
an itemized statement at the end of the month, you are handed a 
sheet of paper with one number-no receipts, no details, just 
the total amount owed. No employer would ever allow such a 
practice. Yet, this is exactly what happens in our healthcare 
system today. Employers hand over the company credit card to 
Blue Cross Blue Shield, Aetna, United, Cigna, Optum and CVS, 
allowing them to pledge company dollars to a healthcare system 
that can charge whatever they want, however they want, simply 
because they can.
    Where are the checks and balances in healthcare? Balance 
necessarily requires equal access to information, and that is 
why we are here today.
    Transparency. Or rather, the lack of transparency facing 
employers and unions that are responsible for purchasing 
healthcare for over 160 million Americans.
    You likely know the statistics and the alarming rate at 
which healthcare costs are growing, but I know the people 
behind these statistics. As former administrator for the State 
of New Jersey employee health plan I know first-hand how the 
lack of transparency impacts our teachers, firemen, police 
officers, and public sector workers. Sadly, this year in New 
Jersey over 200 school positions will be eliminated due to 
budget constraints, driven in large part by the cost of health 
benefits.\1\
---------------------------------------------------------------------------
    \1\  https://www.nj.com/education/2024/07/nj-schools-are-cutting-
hundreds-of-jobs-this-summer-heres-why.html
---------------------------------------------------------------------------
    ERISA, which governs most employer sponsored health plans 
in the country, is intended to protect plan participants and 
beneficiaries by mandating that plan sponsors act as 
fiduciaries. When employers lack access to their own data and 
transparent information about the cost and quality of care, 
they are unable to fulfill ERISA's promise.
    Let me share three examples to illustrate the magnitude of 
this issue:

          	At Mayo Clinic in Jacksonville, if you were to use 
your Federal Employee Health Benefit BCBS card for an 
arthrocentesis procedure it would cost you and the federal 
government $2,516.\2\ If you were to pay cash for the same 
procedure, you would pay just $392.60. That is six times more 
than the cash rate. At University of Pennsylvania Hospital, the 
cash price for an ACL repair is $9,523.36,\3\ but if you are a 
service member covered by TRICARE, your price is $37,489.74, 
that is 294% more than the cash rate.
---------------------------------------------------------------------------
    \2\ https://https://www.turquoise.health/health--systems/mayo-
clinic/services/?q=Arthrocentesis+%28drainage%29+of+joint&service--
name=arthrocentesis-drainage-of-joint
    \3\ https://https://www.turquoise.health/health--systems/
university-of-pennsylvania-health-system/service--category/
musculoskeletal/
---------------------------------------------------------------------------
          	Or consider when a third-party administrator, or 
TPA, pays twice for a claim in error, or pays for an improperly 
upcoded claim, because TPAs act as middlemen, similar to a PBM, 
and uses the employer's funds to pay claims, they bear none of 
the risk. And when a TPA pays the inflated or improper bill 
with the employer or unions' funds, there is no obligation for 
the TPA to recover those payments. If, and I emphasize IF, the 
employer is lucky enough to benefit from an attempted recovery, 
it will be less the TPA's savings fee, ranging anywhere from 
25-50%. This is the ultimate fox guarding the hen house.
          	But TPA's are not always "overpaying;" in fact, 
quite often they are paying providers one sum, and then 
charging the employer many times more for the same claim. In 
several recently unsealed court documents it was revealed that 
an employer sponsored health plan paid $4,078,652.42 on a 
claim, but the provider only received $875,809.76.\4\ What 
accounted for the difference? Cigna took $2,524,898.98 in fees, 
and their subcontractor Multiplan took $677,943.68. The fees 
were 2.9 times the provider's payment.
---------------------------------------------------------------------------
    \4\  htttps://https://www.dockets.justia.com/docket/california/
cacdce/8:2020cv00269/772742 See attached TML Recovery Services, Ltd. 
unsealed exhibit
---------------------------------------------------------------------------
    These examples are the tip of the iceberg in terms of the 
waste, abuse and inefficiencies in the current market, driven 
in large part by lack of transparency and meaningful access to 
data. Though we may increasingly be able to pull up the 
hospital prices, and carrier negotiated rates, unless and until 
employers are able to have access to run their own numbers, 
identifying this type of conduct will remain elusive to 
employers and unions.
    If we expect employers and unions to exert any type of 
market forces to reign in healthcare costs, we must empower 
them with actional data and transparent pricing. The company 
credit card has been abused for too long by the PBMs, TPAs and 
other industry players. It should not be unreasonable to demand 
for receipts of payment, itemized statements, and the ability 
to protect their members. This is what S3548 uniquely 
accomplishes, in a superior manner, in my opinion to the Lower 
Cost More Transparency Act. Federal lawmakers must rebalance 
the information asymmetry to empower employer purchasers and 
unions to push back against egregious pricing, unfair billing 
practices, gross overreach, and profiteering. This will help 
protect the American workers' paychecks and ensure a fairer, 
more accountable healthcare system.
    Thank you.

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                       Prepared Witness Testimony

                              Cora Opsahl

    Good morning. Thank you Chairman Casey, Ranking Member 
Braun, and the rest of the Committee on Aging for inviting me 
to speak this morning.
    My name is Cora Opsahl, and I am the Director of the 32BJ 
Health Fund. The 32BJ Health Fund is a self-insured, Taft-
Hartley benefit fund that provides health benefits to over 
200,000 union members and their families. Our members are 
essential workers who work in the real estate industry, 
security officers, school workers, and airport workers. We are 
based primarily in the New York/New Jersey area, but we have 
families up and down the East Coast including Pennsylvania and 
Massachusetts. The Fund is jointly governed by a board of 
trustees appointed by the Union and the Employers, and we 
provide high-quality health benefits with no premium sharing, 
$0 in-network deductibles, and low in-network copays. We 
believe the fund has an important role in tackling the problem 
of healthcare affordability, and we have spent over a decade 
doing just that by leveraging our data, challenging the status 
quo, and finding innovative ways to manage our benefit.
    Having access to our claims data is foundational to our 
work. For almost 20 years, we have been fortunate to have 
access to our medical, pharmacy, and ancillary claims data. We 
use this data to understand our healthcare spend, make benefit 
decisions, and ensure we are a good steward of the Fund's 
resources, because of our data, we know the following:

      	In 2023, we spent $1.4 billion in healthcare.
      	Of the $1.4B we spend in healthcare, 55% is spent on 
inpatient and outpatient care
      	In 2021, we paid 271% over Medicare prices for the same 
care, which is up from 219% of Medicare in 2016
      	In the past 10 years, healthcare has risen from 17% of 
total compensation to 37% of total compensation; wages have 
gone up 54% but healthcare costs have increased 230%; and to 
put that into a dollar amount, our members could have had 
$5,000 more in annual wages had healthcare spend risen at the 
same rate of inflation

    While having your data and being able to see how your 
benefit is being spent is important, as a plan we know this is 
only the first step. The next step is taking action on this 
data.
    In 2018, after spending over 10 years looking at our claims 
data, it became abundantly clear to us that we needed to 
address the prices we were paying. The data showed we were 
paying wildly different prices for the same procedures, 
depending on what hospitals our members went to. For example, 
we were paying approximately $10,000 for a colonoscopy at NY 
Presbyterian system versus approximately $4,000 at Mount Sinai 
Hospital system. The same pattern was true at other high-priced 
hospitals. Based on our data, we tiered our network on price 
beginning in 2019. Members could still access the higher priced 
hospitals, but they would have to pay higher copays to do so.
    While we had won the right to tier our plan in 2019, in 
2021, NY Presbyterian and our carrier, Anthem, were up for 
their network renewal. During that renewal, NY Presbyterian 
told Anthem they would have to be preferred in all networks, 
leveraging a clause in their contract. Eventually, NY 
Presbyterian granted the Fund permission to remove them from 
our network only in 2022. This change has saved the plan 
approximately $30M every year by members receiving care from 
lower priced facilities and providers. Additionally, in the 
most recent contract negotiations, the union and employers 
leveraged the savings in our benefits to give union members a 
one-time bonus, the largest wage increase in contract history, 
a pension increase, and limit employer premium contribution 
increases to no more than 3% every year through 2027.
    While these benefit changes showcased our ability to 
leverage our data, both changes also illuminated the contract 
terms between providers and carriers that obstruct, hinder, and 
limit the ability for us or any employers to take action on 
their data.
    Recently, the Health Fund led a procurement for a medical 
and hospital benefit third party administer, or carrier. We 
were adversely affected by anti-competitive contract provisions 
between providers and carriers. The provider contracts included 
items such as requirements to be in network, anti-steering and 
anti-tiering provisions, limitations in how claims are allowed 
to be paid, and even limitation in access to claims data. For 
us, the network inclusion and other contracting demands of 
hospitals limited participation of TPA bidders in our 
procurement process. Every TPA bidder, except one, was unable 
to meet our network requirements, including that NY 
Presbyterian remain out of network. Other network provider 
contract provisions routinely demanded by hospitals include 
restrictions on retroactive claim reviews, exclusion of lesser-
of provisions, and limitations on overpayment recoupment. None 
of those contract provisions are beneficial for employer 
sponsored plans or their membership. This is just one example 
of how difficult it is for employers and self-funded plans, 
even of our size, to have a highly competitive bid process.
    While our bidding process faced limitations by the anti-
competitive contracting provisions in provider and carrier 
contracts, we would not be where we are without access to our 
data, allowing the Union and Employers to give raises and limit 
premium increases ensuing our members can continue to have 
access to high quality and affordable care. Employers having 
access to their claims data and the terms in which their 
benefits are being managed are essential for them to be able to 
do the same thing. That s why we need the Braun Sanders bill, 
and section seven in particular.
    Thank you for having me.

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                       Prepared Witness Testimony

                             Sophia Tripoli

    Chairman Casey, Ranking Member Braun, members of the 
Committee, thank you for the opportunity to testify at this 
critical hearing focused on health care affordability and the 
harmful impact of medical monopolies that flourish under our 
health care system's lack of transparency and healthy 
competition. It is an honor to be with you today.
    My name is Sophia Tripoli, and I am the Senior Director of 
Health Policy at Families USA. For more than 40 years, Families 
USA has been a leading national, non-partisan voice for health 
care consumers working to achieve our vision of a nation where 
the best health and health care are equally accessible and 
affordable to all. In October 2022, we launched the Center for 
Affordable Whole Person Care to affirm and enhance our 
commitment to revolutionize America's health care system to 
hold the health care industry accountable for delivering 
affordable, equitable, high-quality and person-centered health 
care.
    We greatly appreciate the work of this Committee to examine 
and advance bipartisan solutions to lower costs and improve 
health system transparency for aging Americans and families 
across the country. This work is urgently needed: Our health 
care system is in crisis, evidenced by a severe lack of 
affordability and poor quality. It is going to take 
all of us working together, across political party and health 
policy philosophy, from rural and urban communities alike, to 
fix it.
    You have the support of the American public as you work to 
address these issues. Ninety-three percent of Americans agree 
that our country is paying too much for the quality of health 
care we receive, and more than half of adults in that same poll 
said that their most recent health care experience was not 
worth the cost.2 The majority of Americans now rate 
the quality of health care as subpar, including 31% saying it 
is `only fair' and 21% calling it `poor.'3 Recent 
polling shows that almost 90% of voters say it is important for 
this Congress to take action to reduce high health care prices, 
particularly hospital prices, including 95% of Biden voters and 
85% of Trump voters.4

The U.S. Health System in Crisis: Harming Families, Workers, 
Employers, and Taxpayers

    The United States is in the midst of a health care 
affordability and quality crisis. High and rising health care 
prices, particularly for hospital stays and prescription drugs, 
are a direct threat to the health and wellbeing of every 
American, negatively impacting our access to health care, our 
ability to earn a living wage, and the health of our national 
and local economies. At its core, this crisis is driven by a 
fundamental misalignment between the business interests of the 
health care sector and the health and financial security of our 
nation's families - a business model that allows industry to 
set prices that have little to do with the quality of the care 
they offer.
    Broken incentives within our current system reward building 
local monopolies and price gouging instead of rewarding success 
in promoting the health, wellbeing and financial security of 
families and communities.5 This is particularly 
acute when looking at the shifting role of hospitals in our 
economy over the last 60 years.6 What were once 
local charitable institutions built to serve the community have 
now become large corporate entities focused on maximizing 
revenue rather than improving health.7 Americans in 
far too many communities have watched as their local hospitals 
became health systems, and those health systems were bought by 
large health care corporations. What many in the public and 
policymaking community are beginning to realize is how much 
this has destroyed any real competition in our health care 
sector, allowing hospitals to dramatically increase their 
prices every year with little to no transparency into the true 
costs associated with delivering care.8 And health 
care consumers have been left holding the bag.

Impact on Families and Workers

    More than 100 million Americans face medical debt; a 
quarter of all Americans forgo needed medical care due to the 
cost; and a third of Americans indicate that the cost of 
medical services interferes with their ability to secure basic 
needs like buying groceries and paying rent.9 In 
addition, more than a quarter of older Americans, who spend 
more on health care than any other age group, report being very 
concerned they will be unable to pay for lifesaving health care 
in the future.10
    Not only do consumers and patients experience high health 
care prices in the form of expensive medical bills, but high 
health care costs also affect the economic vitality of middle-
class and working families by crippling the ability of working 
people to earn a living wage. Rising prices are a major 
contributor to skyrocketing health insurance costs, which come 
directly out of workers' paychecks as annual increases in 
premiums and cost sharing.11 This results in 
stagnating wages, rising income inequality, and ultimately 
leaves workers with less in take home pay over time, making it 
more difficult for them to afford housing, pay their regular 
expenses, send their children to school, and 
retire.12
    Today's real wages - wages after accounting for inflation - 
are roughly the same as four decades ago, yet employer health 
insurance premiums have risen dramatically.13 The 
total cost of a family employer-sponsored insurance (ESI) plan 
increased an astounding 272% in the past two decades, rising 
from $6,438 annually in 2000 to $23,968 in 2023.14 
As a result, a U.S. family of four with a median income of 
roughly $95,000 annually is estimated to have lost more than 
$125,000 in wages over roughly the same time 
period.15 A recent analysis by Families USA found 
that if policymakers do not take action to rein in high and 
rising hospital prices and the harmful business practices of 
large heath care corporations, low- and middle-income workers - 
a group that disproportionately includes people of color - 
could lose another $20,000 in wages by 2030.16 At 
the same time, nearly 90% of large employers say that rising 
health care costs will threaten their ability to provide health 
care benefits to employees over the next five to 10 years if 
costs are not lowered.17 The rising costs of health 
care have already contributed to record numbers of businesses 
no longer providing critical worker benefits, including retiree 
health benefits, disproportionately harming older adults who 
rely on these benefits during retirement. As a result, older 
Americans are increasingly exposed to high and rising health 
care costs. In fact, out-of-pocket health care spending for 
older Americans grew a staggering 41% between 2009 and 
2019.18
    To make matters worse, workers are increasingly subjected 
to health insurance plans with larger cost-sharing 
requirements, including higher-deductible health plans, in an 
effort to contain rising health care spending and costs. 
Deductible-related costs for workers have grown significantly, 
with the average annual deductible for an individual employee's 
coverage nearly doubling in just a decade, from $1,025 in 2010 
to $2,004 in 2021.19 Importantly, the 153 million 
Americans who rely on ESI for health insurance cannot always 
access the care they need, with more than a quarter putting off 
or postponing needed medical care due to the high 
cost.20

Impact on Taxpayers and Our Economy

    High and rising health care costs not only threaten the 
health and financial security of American individuals and 
families but are also a critical problem for the federal 
government, state governments, and taxpayers. National health 
expenditures (NHE), which includes both public and private 
spending on health care, have grown from $27.1 billion in 1960 
to nearly $4.5 trillion in 2022.21 Relative to the 
size of the economy, NHE grew from 5% of gross domestic product 
(GDP) in 1960 to 17.4% in 2022.22 The largest 
proportion of this spending is on hospital care, which accounts 
for a 30 percent share at a whopping $1.4 trillion 
annually.23
    The situation is expected to get much worse, with NHE 
projected to climb to $7.2 trillion by 2031, and high and 
rising health care costs projected to continue to grow faster 
than the economy, hitting nearly 20% of GDP by 
2031.24 That means a fifth of our economy will be 
spent on health care. This far outpaces what similarly situated 
countries spend on health care: On a per capita basis, the U.S. 
spent $12,555 in 2022 - over $4,000 more per person than any 
other peer nation.25
    Notably, the excessive cost of health care does not 
generally buy Americans higher-quality care or even higher 
volumes of care. In fact, the opposite is true. Despite 
spending two to three times more on health care than other peer 
countries, the United States has some of the worst health 
outcomes, including some of the lowest life expectancy and 
highest infant mortality rates.26 These health 
outcomes are even worse for people of color who experience 
higher rates of illness and death across a range of health 
conditions compared with their white counterparts.27 
And the vast majority of our nation's seniors have at least one 
chronic health condition, with many dealing with multiple 
health issues.28
Lack of Transparency Provides Cover to Medical Monopolies and 
their Unjustifiably High Prices

    Importantly, America's health care affordability crisis 
stems from high, rising, and variable prices across a wide 
range of health care goods and services, particularly for 
hospital care and prescription drugs. For example, the price of 
Humira - a drug used to treat arthritis - is more than four 
times as expensive in our country as in the United Kingdom and 
almost twice as expensive as in Germany.29 The 
average price of a hospital-based MRI in the United States is 
$1,475,30 while that same scan costs $503 in 
Switzerland and $215 in Australia.31
    What's more, health care is one of the only markets in the 
U.S. economy in which consumers are blinded to the price of a 
service until they receive a bill after the services are 
delivered.32 Consumers and employers, who are the 
ultimate purchasers of health care, have limited insight into 
what the prices of health care goods and services are. For the 
majority of Americans (66%) who receive health care through 
private insurance, health care prices are established in 
closed-door negotiations between large hospital corporations 
and health plans based on who has more market 
power.33 These health care prices, often referred to 
as the negotiated rate, are buried in proprietary contracts 
without insight into or oversight over the price of health care 
services by the public and policymakers.34
    These exorbitant, opaque, and unjustifiable prices are 
largely due to trends in health care industry consolidation 
across the U.S. that have eliminated healthy competition and 
allowed monopolistic pricing to flourish.35 This 
consolidation has taken place without meaningful regulatory 
oversight or intervention, and is becoming more 
acute.36
    The end result is a system with few truly competitive 
health care markets left: 95% of metropolitan statistical areas 
(MSAs) having highly concentrated hospital markets, nearly 80% 
of MSAs having highly concentrated specialist physician 
markets, and 58% of MSAs having highly concentrated insurer 
markets.37 Consolidation has been particularly 
pronounced among hospitals, drug companies, and pharmacy 
benefit managers and is made worse by the increasingly harmful 
role of private equity firms in the U.S health care system:

      	Hospitals, health systems and other providers have 
rapidly consolidated, via horizontal and vertical integration, 
into large health care corporations, amassing outsized market 
power in order to increase prices for hospital care year after 
year. In fact, over 1,500 hospital mergers have occurred 
between 1998 and 2017, with an estimated 40% of those mergers 
taking place from 2010 to 2015.38 Moreover, between 
2013 and 2021, the percentage of physician practices that were 
hospital-owned rose from 15% to 53%, and the percentage of 
physicians employed by a hospital rose from 27% to 
52%.39
      	Drug manufacturers have increasingly engaged in anti-
competitive behavior and transactions to similarly amass 
significant market power, regularly buying up or paying off 
their competition in order to game the U.S. patent system and 
price gouge our nation's families for prescription medications. 
The vast majority (70%) of drug industry profits now go to only 
a small number (25) of the top prescription drug companies in 
the country.40
      	Pharmacy benefit managers, as third-party administrators 
designed to serve as middlemen between health insurers and drug 
makers, have increasingly merged with insurers and pharmacies 
to increase their own market power to negotiate pricing 
structures that serve their financial interests, often to the 
detriment of securing more affordable prescription medicines 
for consumers. This has led to the top three PBMs controlling 
80% of the PBM market.41
      	Health insurers are increasingly consolidated. Between 
2006 and 2014, the four-firm concentration ratio - the extent 
of market control held by the four largest firms, Aetna, Anthem 
Blue Cross Blue Shield, UnitedHealthcare and Cigna - for the 
sale of private insurance increased from 74% to 
83%.42 This results in monopolistic health care 
prices that lead to unaffordable health care and poorer 
quality.43 There is also growing vertical 
integration between insurers and health care providers; 
UnitedHealthcare for instance now employs almost 50,000 
physicians as of 2021, and their reported share of medical 
expenses that flow to employed providers or other related 
businesses increased nearly 250% between 2016 and 
2019.44

    Widespread consolidation across the health care system has 
been compounded by the growing role of private equity (PE) 
firms over the last decade. Once largely uninvolved in the U.S. 
health care system, PE firms are increasingly purchasing and 
reselling a variety of health care provider organizations in 
order to make short term profit, largely to the detriment of 
the financial wellbeing of those providers and ultimately to 
health care access and affordability in a community. In 2020, 
health care became the second largest sector for private equity 
investment, accounting for 18 percent of all reported deals, up 
from 12 percent in 2010.45 Private equity investors 
spent more than $750 billion on health care acquisitions 
between 2010 and 2019.46
    The business model of private equity firms is fundamentally 
misaligned with ensuring that our nation's families have the 
high-quality, affordable, and equitable health care they need 
and deserve. PE firms often apply a very short-term profit 
driven business model (a three-to-seven- year period) to their 
investment strategy, characterized by buying a health care 
entity that is struggling financially or offers short-term 
growth potential, investing in it, saddling it with debt, and 
then selling their stake to generate profit.47
    Further, recent studies show that PE ownership was 
associated with a number of harmful health care impacts, 
including but not limited to:

      	Decreases in health care quality and patient safety: PE 
owned hospitals experience a 25% increase in hospital-acquired 
conditions, including a 27% increase in patient falls and an 
almost 38% increase in infections.48 Researchers say 
that these outcomes may be partially due to "decreased 
staffing, changes in operator technique, poorer clinician 
experience," among other potential causes;49
      	Increases in health care prices and charge-to-cost 
ratios: PE owned hospitals charge $400 more per inpatient day 
on average compared to non-PE owned hospitals;50 and
      	Increased out-of-network costs due to PE firms buying up 
specialty physician staffing firms.51

    Without question, widespread and largely unchecked health 
industry consolidation has led to the deterioration of healthy 
competition across and within U.S. health care markets and has 
had a significantly negative impact on the affordability and 
quality of American health care.52 Importantly, most 
health care consolidation has not resulted in reduced costs 
through economies of scale, improved care coordination or 
quality oversight as industry proponents have 
argued.53 In fact, the evidence overwhelming 
confirms that consolidation has produced exploitative markets 
that drive high prices and costs without improving the quality 
of care.54
    In many cases, consolidation is actually associated with 
reductions in health care quality.55 For instance, 
one study found that mortality risk among heart attack patients 
is significantly higher in more concentrated hospital 
markets.56 On top of that, consolidation often leads 
to reduced geographic access to needed providers, which can 
contribute to longer travel times and serious health 
consequences, particularly for rural communities.57 
For example, rural hospitals that merge with larger hospital 
systems are more likely to eliminate key service lines in 
primary care, maternal and neonatal health, surgery, mental 
health, and substance use disorder services post-merger, 
significantly reducing access to critical health care services 
and threatening the health and wellbeing of rural 
communities.58 Moreover, increasing the distance to 
the nearest site of health care can result in people living in 
all types of communities not getting the care they need due to 
a lack of transportation or the time needed to get there, 
disproportionally affecting older Americans, racially and 
ethnically marginalized groups, those with low incomes, and 
people with disabilities.59

A Closer Look at Hospital Consolidation

    Nowhere is the negative impact of consolidation more 
evident than the rising cost of hospital stays and services, 
which have increased dramatically in the last decade and make 
up a large portion of increasing health care costs 
overall.60 These cost increases have occurred 
despite lower hospital utilization and are largely due to 
escalating prices, which are the result of hospitals buying 
other hospitals and community doctors to eliminate competition 
and form big health care corporations and medical 
monopolies.61
    Between 1990 and 2023, hospital prices increased 600%, and 
just since 2015, hospital prices have increased as much as 31% 
nationally, now accounting for nearly one-third of U.S. health 
care spending, and growing more than four times faster than 
workers' paychecks.62 Importantly, hospital prices 
are not only high, but have become essentially irrational:

      	In 2020, across all hospital inpatient and outpatient 
services, employers and private insurers paid on average 224% 
of what Medicare pays for the same services.63:
      	Prices at hospitals in concentrated markets are 12% 
higher than those in markets with four or more rivals without 
any demonstrated improvement in quality or access to 
care.64
      	Prices for the exact same service vary widely, sometimes 
even within a single hospital system:
          	A colonoscopy at a single medical center in 
Mississippi can range from $782 to $2,144 depending on 
insurance.65
          	At one health system in Wisconsin, an MRI costs 
between $1,093 and $4,029 depending on level of 
insurance.66
          	Across the country, the average price for a knee 
replacement ranges from $21,976 in Tucson, Arizona to $60,000 
in Sacramento, California.67
          	The price of an MRI at Mass General Hospital in 
Boston Massachusetts ranged from $830 to $4,200, depending on 
the insurance carrier.68

    Importantly, America's health care workers are also 
suffering ill-effects of being trapped in this greed-driven 
system. Following hospital mergers, wages for nurses and 
skilled workers stagnate: Wage growth was found to be 1.7% 
below the average national wage growth for these workers 
following horizontal mergers.69 Research on high-
impact mergers shows that over the four years post-merger, 
wages might be 6.8% lower for nurses and pharmacy workers and 
4% lower for other skilled workers, in comparison to what wages 
could have been without the merger.70 This is 
compounded in rural areas: Research from 2015 showed that after 
a merger some rural hospitals decreased their spending on 
employee salaries by more than $1000 per full-time equivalent 
employee.71 Hospital consolidation has also been 
shown to have negative impacts on staffing ratios. Following an 
acquisition in North Carolina by HCA Healthcare in 2019, nurses 
in that system experienced nurse-to-patient ratio changes and 
staffing cuts, in addition to closures of primary care offices 
and cutbacks of other services.72 This left nurses 
and other health care workers caring for more patients with 
less time and fewer resources, which the Federal Trade 
Commission (FTC) cautioned would lead to patient harm in the 
form of "higher health care costs, lower quality, reduced 
innovation and reduced access to care."73

    Congress Should Root Out Corporate Greed and Fix our Broken 
System

    It does not have to be this way. We know what the major 
drivers of high and irrational health care prices are, and we 
know how to fix them. This Committee has previously examined 
potential abuses in health care and taken steps to conduct 
oversight over the quality of care delivered in nursing homes 
and explore root causes of high prescription drug prices. Since 
the late 1800's Congress has leveraged its power to break up 
harmful monopolies, rein in corporate abuses and drive improved 
transparency across a wide array of other industries and 
sectors, ranging from big oil to big tobacco to big banks to 
big tech.74 Last year the Senate even examined how 
to promote healthy competition in entertainment and protect 
consumers from the monopolistic pricing practices exhibited by 
Ticketmaster.75 Now is the time to turn full 
attention to the health care industry and ask the hard and 
necessary questions about the impacts of medical monopolies on 
health care affordability that pose a direct threat to the 
health and wellbeing of every American.
    The House of Representatives has already advanced well-
vetted, bipartisan, and commonsense legislation that would 
remedy some of the most obvious health system failings. The 
Lower Costs, More Transparency Act, which passed the House in 
an overwhelming bipartisan vote in December 2023, would make 
crucial progress by codifying and strengthening price 
transparency rules, expanding site neutral payments, and 
advancing billing transparency, among other reforms. Several 
Members of Congress have introduced other meaningful solutions, 
including Ranking Member Braun's legislation: S. 3548, the 
Health Care PRICE Transparency Act 2.0 and S. 1869, the Site-
based Invoicing and Transparency Enhancement (SITE) Act. Some 
of these provisions, in addition to other important policy 
solutions, are discussed in further detail below.

Strengthen Price Transparency

    Unveiling prices is a critical step towards achieving truly 
affordable health care, improved health, and more competitive 
health care markets across the U.S. health care system. Price 
transparency pulls back the curtain on prices so that 
policymakers, researchers, employers, and consumers can see how 
irrational health care prices have become and take action to 
rein in pricing abuses.76 Further, unveiling prices 
can specifically inform where the highest and most irrational 
prices are occurring in the health care system, so policymakers 
can implement targeted policy solutions to bring down the cost 
of health care.77 All Americans, and particularly 
older Americans who heavily rely on the health care system, 
should be able to easily access the price of health care 
services at a hospital or health care facility before they 
receive care.
    Consumer advocates have long sought transparency in health 
care prices. Following years of consumer advocacy, the Center 
for Medicare and Medicaid Services (CMS) finalized the Hospital 
Price Transparency Rule and the Transparency in Coverage Rule, 
which require hospitals and insurers respectively to disclose 
health pricing information, including their negotiated rates, 
and to provide consumer-friendly online tools to allow 
consumers to compare prices and estimate out-of-pocket 
costs.78 But many large hospital corporations have 
bucked the federal requirements and are actively working to 
keep their prices hidden.79
    The Lower Costs, More Transparency Act makes clear, without 
any exception, that all hospitals and insurers are required to 
post the underlying price of health care services, in a machine 
readable and consumer-friendly format. The Health Care PRICE 
Transparency Act 2.0 would advance transparency by taking bold 
steps to:80

      	Impose data sharing standards.
      	Require machine-readable files of all negotiated rates 
and cash prices between plans and providers, not estimates.
      	Expand price transparencyquirements to clinical 
diagnostic labs, imaging centers, and ambulatory surgical 
centers.
      	Require pricing data standards including all billing 
codes for services.
      	Require actual prices for 300 shoppable services with 
all services by 2025.
      	Require attestation by executives that allices are 
accurate and complete.
      	Increase maximum annual penalties to $10,000,000 
(includes specific minimum and maximum penalties according to 
number of hospital beds in the facility).
      	Prevent pre-emption of state price transparency laws, 
except for ERISA group health plans.
      	Codify the Transparency in Coverage (TIC) rule.
      	Provide group health plans the right to access, audit, 
and review claims encounter data.

    The American public is in broad agreement about the need 
for action on price transparency, with polling showing that a 
large majority (95%) of the public say it is important for 
Congress to pass a law to make health care costs more 
transparent to patients, including 60% who call this a top 
priority.81

Enact Site Neutral Payment and Billing Transparency

    Market inefficiencies that stem from site-specific payment 
rates in Medicare are a significant problem which, if 
addressed, could save American families and health care payers 
billions of dollars.82 Since commercial insurance 
and Medicaid often adopt Medicare payment policies, the broken 
payment incentives in Medicare are amplified across payers. 
These site-of-service payment differentials drive care delivery 
from physician offices to higher-cost hospital outpatient 
departments.83 This shift is a major driver of 
higher spending on health care services which require lower 
resources such as office visits and minor 
procedures.84 Importantly, these payment 
differentials create a financial incentive for hospitals to 
consolidate by buying physician offices and rebranding them as 
off-campus outpatient hospital departments (HOPDs) and 
facilities in order to receive higher payments.85 
This type of consolidation - vertical integration between 
hospitals and physicians - leads to a growingly anticompetitive 
market where hospitals increase market power to demand even 
higher prices from commercial payers.86 These higher 
commercial prices are then passed on to American families and 
come directly out of workers' paychecks, typically as monthly 
health insurance premiums.87
    Currently, hospitals that own doctors' offices that have 
been rebranded as off-campus HOPDs are allowed to charge a 
"facility fee" in addition to the higher fees they bill for the 
physician services they provide.88 The result is 
that consumers not only receive a bill for the visit with the 
physician but also for the use of the hospital facility where 
the visit occurred.89 These bills together (the 
physician fee and the facility fee) amount to a higher total 
cost for the consumer than if the service was provided in the 
physician's office.90
    We are encouraged that Members of Congress are working to 
address payment differentials across sites of service that 
incentivize further consolidation and are a major driver of 
unaffordable care for America's families. The Lower Costs, More 
Transparency Act takes important steps toward fostering 
healthier competition in health care markets by advancing 
billing transparency reforms and expanding site neutral 
payments for drug administration services to help ensure 
consumers pay the same price for the same service regardless of 
where that service is performed. It would enact billing 
transparency reforms so that off-campus hospital outpatient 
departments are required to use a separate identifier when 
billing to Medicare or commercial insurers to ensure large 
hospital systems do not overcharge for the care they deliver in 
outpatient settings. It would also enact site neutral payments 
for physician-administered drugs in outpatient settings, which 
is estimated to save the highest-need chemotherapy patients 
more than $1,000 on cost sharing a year.91 The 
Congressional Budget Office (CBO) estimates that site neutral 
payments for physician-administered drugs and billing 
transparency reforms would generate $3.74 billion and $403 
million in savings, respectively, over ten years.92 
These policies are welcome first steps to addressing misaligned 
payment incentives that lead to higher costs for patients 
without meaningfully improving quality.
    Bipartisan legislation introduced by Ranking Member Braun, 
S. 1869 Site-based Invoicing and Transparency Enhancement 
(SITE) Act, would go even further to expand site neutral 
payments for outpatient services, end exemptions in Medicare 
billing rules that keep many facilities from having to charge 
the same price for the same service, and require that health 
systems establish and bill using a unique National Provider 
Identifier number for each and every off-campus outpatient 
department.93 The bill is projected to save the 
government as much as $40 billion based on previous CBO 
estimates.94
    Ultimately, Congress could make significant strides in 
addressing medical monopolies by implementing comprehensive 
site-neutral payment policies as recommended by MedPAC in 2023, 
and eliminating site-dependent reimbursement distortions that 
indirectly incentivize acquisition of non-hospital patient 
access points.95 CBO estimates that this policy 
could save Medicare approximately $140 billion over the next 
decade.96 And the Committee for a Responsible 
Federal Budget projects that these policies could reduce health 
care spending by $153 billion over the next decade, including 
lowering premiums and cost-sharing for Medicare beneficiaries 
by $94 billion and for those in the commercial market by $140-
466 billion.97

    Ban Anticompetitive Contracting Practices

    We also urge Congress to take a close look at 
anticompetitive practices and clauses in health care 
contracting agreements between providers and insurers that give 
large entities in highly consolidated markets the upper hand in 
contract negotiations to build networks and set prices. Many of 
these contracts include terms that limit patient access to 
alternative sources of higher-quality, lower-cost care. 
Congress made important progress by banning gag clauses in 
executed contracts between insurance plan issuers and providers 
or provider networks as part of the Consolidated Appropriations 
Act of 2021. This policy has the potential to enable consumers 
and employers to be more informed purchasers of health care and 
to unveil fundamental information that policymakers, employers, 
researchers and other stakeholders need to identify health care 
markets with the highest prices and build policy that 
encourages healthier competition.
    Congress should further prohibit large hospital systems 
from using their monopoly power to employ anti-competitive 
contracting practices when negotiating with insurers and other 
health care providers, as this is one of the primary ways 
medical monopolies are able to charge high and rising 
prices.98 These prohibitions should include the use 
of "all-or-nothing," "anti-steering," and "anti-tiering" 
clauses in contracts between health care providers and 
insurers. "Anti-tiering" and "anti-steering" clauses restrict 
the plan from directing or incentivizing patients to use other 
providers and facilities with higher quality and lower prices; 
and "all-or-nothing" clauses require health insurance plans to 
contract with all providers in a particular system or none of 
them.ese contracting terms too often limit consumers from 
accessing higher-quality and lower-cost care.99
    Bipartisan legislation led by Senate HELP Committee 
Chairman Sanders, S.2840, the Bipartisan Primary Care and 
Health Workforce Act,100 includes provisions to ban 
anticompetitive terms in facility and insurance contracts, 
estimated by CBO to increase revenues by $3.2 billion over a 
10-year window.101

Ensure Transparency in Ownership

    Additionally, we urge the Committee to continue to explore 
opportunities to improve transparency around the ownership 
interest of health care corporations, particularly when it 
comes to private equity. We support legislative provisions 
considered by committees of jurisdiction in the U.S. House of 
Representatives that would require providers to annually report 
changes in ownership, and hope that Congress will consider 
integrating these or similar provisions back in to any final 
health care transparency legislation that is sent to the 
President's desk. Without insight into how profits from health 
systems are ultimately being funneled it is very difficult to 
identify potential abuses, leaving private equity firms free to 
purchase health systems in order to drive profits through 
upcoding, surprise billing, and other questionable business 
practices.

    Strengthen FTC Oversight Authority

    Policymakers should prevent future horizontal, vertical, 
and cross-market mergers that undermine healthy competition in 
health care markets and drive unaffordable care by ensuring the 
Federal Trade Commission (FTC) and the U.S. Department of 
Justice (DOJ) are fully applying federal antitrust laws to 
horizontal integration, such as mergers between hospitals and 
other health systems, pharmacy benefit managers and drug 
companies; and vertical integration, such as mergers between 
physician practices and hospitals, health plans and pharmacy 
benefit managers. Specifically, Congress should improve the 
infrastructure needed to monitor anti-competitive mergers and 
contracting practices among health care corporations by 
increasing FTC and DOJ funding for anti-trust enforcement, and 
by giving the FTC authority to investigate and rein in anti-
competitive practices by non-profit health care entities, 
including non-profit hospitals. Special attention should be 
given to PE firms and the smaller transactions that may 
traditionally fall below existing thresholds of review. 
Congress should increase the number of health care transactions 
reported to FTC and DOJ and subject to anti-trust review and 
enforcement by reducing the Hart-Scott-Rodino Act reporting 
threshold.102

Congress has the Power to Fix our Broken System - And Families 
Can't Afford to Wait

    Over the last year there has been growing bipartisan 
momentum in Congress to advance policies that improve health 
care system transparency, end pricing abuses, and deliver on 
promises to make health care more affordable. Congress has a 
clear and immediate opportunity to put the needs of families 
ahead of the demands of corporate greed, and people all across 
the country are desperately awaiting action.
    Consider the story of Ben Los from Colorado, whose 
encounter with our health care system's lack of transparency 
came at the most vulnerable time for his young family:

      In September of 2022, Ben Los's 5-year-old son began 
experiencing seizures. After rushing him to the doctor, Ben and 
his wife were referred to a specialist within their insurance 
network, an hour and a half away from their Colorado Springs 
home. They got the EEG scan for their son and were in and out 
of the specialist's office in 45 minutes where they were 
assured, "yes, absolutely this is covered."t two months later, 
the Los family received a bill for $2,518 for the appointment. 
After calling the hospital to find out why they were being 
charged for something they had confirmed multiple times was 
covered, the hospital claimed this was for "facility fees." The 
appointment itself was covered, but now the hospital was 
defending the charge stating, "Well, you paid the clinic staff, 
but now you also have to pay the hospital."

      After extensive efforts, Ben was able to speak to 
somebody near the top of the hospital's administration, who 
negotiated the bill down to a 75% reduction under a 
classification of charity care. During this time Ben engaged 
with an investigative journalist in Denver and found out the 
hospital is owned by one company, which is owned by another 
company, and so on. When they finally identified the 
overarching owners of the health system, they discovered those 
owners profited billions of dollars in the first nine months of 
2022 alone. "You can't tell me that there is no way for the 
hospitals to pay their employees when they're raking in the 
kinds of net profits that they're claiming every single year," 
said Ben.103

    Patients experience egregious price hikes for the very same 
services they've previously received in the very same 
outpatient settings. For instance, Kyunghee Lee, a then 72-
year-old retiree who lives in Mentor, Ohio:

      Kyunghee Lee has arthritis and once a year she would go 
to a rheumatologist for a steroid injection in her hand to 
relieve pain in her knuckles. For a few years, each round of 
injectionspara.st her $30. In 2021, she arrived at her usual 
office and the rheumatologist she regularly saw had moved to a 
new floor of the building - just one floor up. She didn't think 
anything of it, as the rest of the appointment went as usual, 
until she received a bill for $1,394. The infusion clinic that 
Lee went to had been moved from an office-based practice to a 
hospital-based setting, and as a result the price of the same 
service she had been relying upon increased a staggering 
4,546%. Lee's bill had a $1,262 facility fee attached, making 
up the majority of the increase in cost, even though she saw 
the same doctor and received the same treatment as the years 
prior. Lee and her family didn't know what they would do about 
the shot in the following year when the story was 
reported.104

    In some cases, patients receive bills for facility fees 
when they never even set foot inside a medical facility of any 
kind. Take the story of Brittany Tesso and her then 3-year-old 
son Roman from Aurora, Colorado:

      In 2021, Roman's pediatrician referred him to Children's 
Hospital Colorado to receive an evaluation for speech therapy. 
With in-person visits on hold due to the COVID-19 pandemic, the 
Tessos met with a panel of specialists via videoconference. The 
specialists, who appeared to be calling from their homes, 
observed Roman speaking, playing, and eating. Later, Mrs. Tesso 
received a $700 bill for the one-hour video appointment. Then, 
she received another bill for nearly $1000. Thinking it was a 
mistake, Mrs. Tesso called to question the second bill. Despite 
the fact that the Tessos never set foot inside the hospital, 
she was told the bill was a "facility fee" designed to cover 
the costs of being seen in a hospital-based 
setting.105

    In addition to jeopardizing financial security for 
individual patients and their families, widespread health 
system consolidation risks the health and economic security of 
entire communities:106

      Hahnemann University Hospital opened in Philadelphia, 
Pennsylvania in 1885. For more than 130 years, it served 
primarily lower income residents, until 2018 when it was 
purchased by Paladin Healthcare, a private equity firm. Over 
the course of about 18 months, Paladin Healthcare laid off 
physicians, nurses, and other workers, while steering the 
hospital towards bankruptcy and closure.107 
Questions and concerns were raised by local, state, and 
national officials as to whether the motivation for these 
decisions came from the value of the land on which the hospital 
sat being seen as more valuable to the private equity firm than 
the nearly 500-bed charity hospital itself.108 
Despite the local community's longstanding reliance on this 
centrally located hospital, Hahnemann University Hospital 
closed its doors in August 2019. Shortly thereafter, the land 
was put up for sale. addition to residents losing access to 
care, thousands of employees lost their jobs and 550 medical 
residents were displaced.109

    A broad range of stakeholders have endorsed and supported 
critical policy solutions to address consolidation and improve 
transparency, including organizations representing consumers, 
patients, workers, small and large employers, and primary care 
clinicians.110 Large majorities of voters support a 
range of policies to lower prices. Voters from both sides of 
the aisle broadly support:111

      	Requiring hospitals to provide real prices in advance, 
not estimates (93%)
      	Limiting outpatient fees to the same price charged by 
doctors in the community (85%)
      	Preventing hospitals from engaging in business tactics 
that reduce competition (75%)
      	Limiting mergers and acquisitions (74%)

    Beyond these immediate steps, policymakers should focus on 
a broader redesign of the economic incentives of the health 
care sector to align with consumers and families. Ultimately, 
policy solutions should reorient health care payment and 
delivery to the goal that we all have - improved health for 
ourselves and our families that is affordable and economically 
sustainable.
    Thank you again for holding this hearing today and for your 
leadership in addressing the challenges posed to older 
Americans and their families by our health care system's lack 
of transparency and affordability. Congress should seize this 
momentum to immediately implement commonsense policies that 
rein in abusive health care prices and make health care more 
affordable for everyone: patients, workers, and taxpayers 
alike. The journey to fully transform our health care system is 
long, but Congress holds the power to take the next critical 
steps. Families USA stands ready to support you in this 
essential and urgently needed work.

                          Footnote References
                          
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]   
      
=======================================================================


                        Questions for the Record

=======================================================================

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                        Questions for the Record

                            Dr. Chris Whaley

                       Senator Kirsten Gillibrand

    Question:

    A recent report showed that less than 36 percent of 
hospitals were fully compliant with transparency requirements 
issued by the Centers for Medicare and Medicaid Services 
Hospital Price Transparency Rule. Dr. Whaley, what should the 
Federal government do to increase and enforce compliance?

    Response:

    Starting in 2021, hospitals have been required to post 
negotiated rates for 300 shoppable services. However, 
compliance with this policy has been low, in part due to lax 
enforcement. To date, fewer than 20 hospitals have been 
penalized for not posting prices.\1\ To further increase 
compliance, an immediate step for CMS is to fully enforce 
penalties for non-compliance. Ensuring compliance through 
complete enforcement will provide a greater degree of 
transparency and accountability around U.S. healthcare prices.
---------------------------------------------------------------------------
    \1\ Centers for Medicare & Medicaid Services (CMS). Enforcement 
Actions . www.cms.gov. Published September 10, 2024. www.cms.gov/
priorities/key-initiatives/hospital-price-transparency/enforcement-
actions

---------------------------------------------------------------------------
    Question:

    How would increased transparency in healthcare pricing 
specifically benefit small employers who struggle the most to 
access their data? What impact could this have on their ability 
to provide competitive benefits?

    Response:

    Health care costs come directly from worker paychecks and 
other benefits, employers who provide health benefits to their 
workforce have a legal and moral fiduciary obligation to be 
responsible fiduciaries and purchasers. It is not possible to 
fulfill this fiduciary obligation without insight into prices 
and contracts negotiated on behalf of employers and purchasers. 
Access to both medical claims data and contract information is 
the clearest way for employers and purchasers to ensure prices 
align with received value.
    With access to their data, employers and purchasers have 
innovated, including:

        	 The California Public Employees Retirement System 
(CalPERS), which uses targeted financial incentives to steer 
patients to lower-priced, high-quality providers. For a range 
of shoppable services, my work shows that this program reduces 
spending by approximately 20% and leads to quality 
improvements.\2\
---------------------------------------------------------------------------
    \2\ Robinson JC, Brown TT, Whaley C. Reference Pricing Changes The 
Choice Architecture Of Health Care For Consumers. Health Affairs. 
2017;36(3):524-530. doi:doi.org/10.1377/hlthaff.2016.1256
---------------------------------------------------------------------------
        	 The of Oregon public employees and school teacher s 
plan, which limits hospital prices to 200 percent of Medicare. 
By limiting hospital prices, this program reduced annual 
spending by approximately four percent for the plan.\3\
---------------------------------------------------------------------------
    \3\ Murray RC, Brown ZY, Miller S, Norton EC, Ryan AM. Hospital 
Facility Prices Declined As A Result Of Oregon s Hospital Payment Cap. 
Health Affairs. 2024;43(3):424-432. doi:https://doi.org/10.1377/
hlthaff.2023.01021

---------------------------------------------------------------------------
    Question:

    The average drug price increase between January 2022 and 
2023 was 15.2 percent. The Capping Prescription Costs Act of 
2024 would cap individual cost-sharing for prescription drugs 
to help those with limited incomes and high costs. Dr. Whaley, 
which sector of the health care market has benefitted the most 
from higher drug prices? Which sector has suffered the most? 
Which sector would a patient out-of-pocket cap affect?

    Response:

    Many studies show high patient out-of-pocket costs for 
prescription drugs reduce adherence to medication management. 
Particularly for chronic conditions, reductions in medication 
management due to cost leads to increases in hospitalizations, 
emergency department visits, and overall healthcare 
spending.\4\ \5\ Thus, policies, including limits on out-of-
pocket costs for chronic condition medications, that limit 
patient financial burden for medication management can improve 
health and reduce spending. These policies are particularly 
important for lower-income Americans and those with multiple 
chronic conditions. However, a key challenge with these 
programs that limit patient out-of-pocket burden is that they 
are borne by a patient s pharmacy benefit, while savings due to 
improved health accrue to a patient s medical insurer. Aligning 
incentives between prescription drug and medical insurance 
coverage could spur programs that reduce patient financial 
burden for chronic condition medications.
---------------------------------------------------------------------------
    \4\ Congressional Budget Office (CBO). Offsetting Effects of 
Prescription Drug Use on Medicare's Spending for Medical Services.; 
2012. www.cbo.gov/sites/default/files/cbofiles/attachments/43741-
MedicalOffsets-11-29-12.pdf
    \5\ Goldman DP, Joyce GF, Zheng Y. Prescription Drug Cost Sharing: 
Associations With Medication and Medical Utilization and Spending and 
Health. JAMA. 07;298(1):61 69. doi:10.1001/jama.298.1.61
---------------------------------------------------------------------------

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                        Questions for the Record

                              Cora Opsahl

                       Ranking Member Mike Braun

    Question:

    As detailed in the Wall Street Journal, the 32BJ Health 
Fund's decision to remove a large hospital system, New York-
Presbyterian, from its network in 2022 and the subsequent 
payment demands made by New York-Presbyterian are emblematic of 
the outsized market influence of hospitals. As you state in 
your testimony, these contracting practices ultimately impact 
not just cost, but transparency and the member experience. Can 
you describe how the events reported by the Wall Street Journal 
influenced the health fund's ability to select a benefit 
administrator, and any other consequences that resulted?

    Response:

    New York-Presbyterian's demands as described in the Wall 
Street Journal article limited the 32BJ Health Fund's ability 
to select a third part administrator (TPA) vendor during a 
standard procurement process. This is the latest example of New 
York-Presbyterian's anti-competitive practices, which the 32BJ 
Health Fund has been challenging for years.
    As our testimony references, in 2018, we sought to tier our 
network after our claims data showed certain hospitals, 
including New York-Presbyterian, charged significantly more for 
some services without relation to quality. The Health Fund's 
TPA at the time indicated their contract with New York-
Presbyterian prohibited the tiered arrangement. After a public 
campaign, New YorkPresbyterian agreed to be placed in a non-
preferred tier with a significant copay differential.
    In 2021 New York-Presbyterian informed the 32BJ Health 
Fund's TPA that the TPA would have to reduce its non-preferred 
co-pay structure. Targeted programs accessible through 
hospitals selected on the basis of competitive bidding and 
superior quality performance, including our Maternity Program 
could not be continued in their current design. In 2022, the 
32BJ Health Fund was able to remove New York-Presbyterian from 
its network after their refusal to negotiate directly with the 
Health Fund to provide participants with high-quality care at 
affordable prices and another public campaign.
    In 2023, the 32BJ Health Fund embarked on a standard 
procurement process to select a TPA vendor that could 
administer the 32BJ Health Fund's hospital and medical 
benefits.
    In April 2024, after months of deliberation, the 32BJ 
Health Fund Trustees terminated final contract negotiations 
with its newly selected TPA vendor after the vendor reported 
they could no longer maintain New York-Presbyterian as an out-
of-network facility unless the 32BJ Health Fund complied with 
New YorkPresbyterian's demand for additional payments amounting 
to tens of millions of dollars that New York-Presbyterian 
claimed it was owed for out-of-network emergency services 
provided to 32BJ Health Fund participants in 2023. No 
documentation or list of claims was provided at that time with 
this demand, and the 32BJ Health Fund's review of its records 
determined that the payment demand was without merit, and no 
additional payment was made.
    Instead of using the arbitration processes that the federal 
law provides through the No Surprises Act to resolve this type 
of payment disputes, New YorkPresbyterian attempted to make 
this additional payment part of the contract negotiations 
between the TPA vendor and the 32BJ Health Fund.
    After this demand by New York-Presbyterian, the 32BJ Health 
Fund terminated its contract negotiations with that TPA vendor. 
This left the 32BJ Health Fund no choice other than selecting 
the only TPA vendor with an existing agreement with New York-
Presbyterian to be out-of-network for the 32BJ Health Fund. The 
Health Fund has been told that New York-Presbyterian intends to 
remove this provision in the agreement when its contract with 
the newly selected TPA vendor is up for renewal in 2025.

    Question:

    You mention in your testimony that hospitals use their 
market power to make contract demands that impact the ultimate 
terms agreed upon between your third-party administrator of the 
medical and hospital benefits provided by your health fund. 
Based on the news reported by the Wall Street Journal, is this 
essentially what happened with New YorkPresbyterian? Can you 
share more about the impact of this on the Fund?

    Response:

    Yes, the demands made by New York-Presbyterian impacted the 
32BJ Health Fund's ability to select a vendor during our 2023 
medical and hospital benefit third party administrator (TPA) 
procurement. New York-Presbyterian demanded additional payments 
they claimed they were owed for out-of-network emergency 
services provided to 32BJ Health Fund participants in 2023 with 
no documentation or list of claims provided at that time. In 
April 2024, the 32BJ Health Fund's newly selected TPA vendor 
reported they could no longer maintain New York-Presbyterian as 
an out-of-network facility unless the 32BJ Health Fund complied 
with this additional payment demand by New York-Presbyterian. 
This left the 32BJ Health Fund no choice other than selecting 
the only TPA vendor with an existing agreement with New York-
Presbyterian to be out-of-network for the 32BJ Health Fund.

    Question:

    What further policy recommendations do you have beyond 
transparency proposals?

    Response:

    Prohibiting anti-competitive contracting practices in 
hospital provider contracts is an important step to realign 
healthcare system incentives to enable employer-sponsored 
health plans like 32BJ Health Fund to better steward their 
resources for the benefit of plan participants.
    The 32BJ Health Fund recommends Congress expand on recent 
legislation that bans certain anti-competitive contracting 
clauses in hospital provider contracts. In the Consolidated 
Appropriations Act (CAA) of 2021, Congress enacted a 
prohibition of gag-clauses that restrict certain information 
sharing with health plans and health insurance issuers.\1\ 
While the CAA enactment of the gag-clause prohibition was a 
positive step forward, more action is needed to regulate other 
common anti-competitive contracting practices.
---------------------------------------------------------------------------
    \1\ Rochman, Harvey. (November 29, 2023). The Gag Clause 
Prohibition Compliance Deadline Is Approaching: What Plans and Issuers 
Need to Know. https://www.manatt.com/insights/newsletters/health-
highlights/the-gag- clause-prohibition-compliancedeadline-is
---------------------------------------------------------------------------
    State legislatures have also made attempts to ban or 
regulate anti-competitive contracting practices but have 
encountered resistance from the hospital lobbies when proposals 
are filed. The Hospital Equity and Affordability Legislation 
("HEAL") Act, which passed in New York State in 2022, bans 
health plan and provider contract provisions that restrict the 
disclosure of provider claims cost, price, or quality 
information. However, other anti-competitive contracting 
practices -- "all-or-nothing" and "anti-tiering" clauses -- 
were removed from the final version of the HEAL Act following 
opposition by the Greater New York Hospital Association.
    Congress should pursue enacting Federal regulations to 
prohibit "most favored nation, "anti-tiering/anti-steering," 
and "all-or-nothing" clauses in provider and insurer contracts. 
Given the opposition experienced in State legislatures, further 
action is needed by Congress to protect employers and self-
funded plans from these anti-competitive contracting practices 
by providers and carriers that impact the ability to steward 
health plan resources effectively. We strongly encourage 
Congress to continue advancing proposals that ban anti-
competitive contracting practices.

    Question:

    What actions can we take to decrease health costs?

    Response:

    There is no silver bullet for decreasing health care costs, 
but rather targeted policies that can help to lower healthcare 
costs. One policy in particular that would provide constructive 
relief for employer-sponsored health is enacting site neutral 
payment policies.
    Under current Medicare fee schedules, reimbursement is 
typically higher for routine procedures provided at a hospital 
outpatient department versus a freestanding doctors' office. 
Site-neutral payment policies seek to eliminate downstream 
incentives for hospital acquisition and mergers by instituting 
price regulation on routine services that are safe to be 
delivered at a freestanding doctor's office.
    There are multiple site-neutral proposals before Congress 
today. Introduced in the U.S. Senate in June 2023, the Site-
based Invoicing and Transparency Enhancement Act (the SITE 
Act), proposes updating Medicare reimbursement at off-campus 
hospital outpatient departments to follow site-neutral 
requirements these facilities were previously exempted from in 
the 2015 Bipartisan Budget Act.\2\ Also in the current session, 
in December 2023, the U.S. House of Representatives passed the 
Lower Costs, More Transparency Act, which would ensure Medicare 
pays the same prices for physician-administered drugs in 
different settings.\3\ However, in March 2024, the bipartisan 
legislation stalled in Congress.\4\
---------------------------------------------------------------------------
    \2\ Key Takeaways from the Site-based Invoicing and Transparency 
Enhancement (SITE) Act-2023-06-13 (crfb.org)
    \3\ Lower Costs, More Transparency Act (2023). House Committee on 
Energy and Commerce. https://energycommerce.house.gov/LCMT
    \4\ Sullivan, P. (March 5, 2024). Hospitals and PBMs seem to have 
dodged big federal reforms, for now. Axios Health. https://
www.axios.com/2024/03/05/hospitals-pbms-dodge-reforms-congress
---------------------------------------------------------------------------
    There are potential savings across commercial payers if 
site-neutral payments were enacted beyond Medicare fee 
schedules. The Committee for a Responsible Federal Budget 
estimates commercial payors could save between $140 and $466 
billion in the next 10 years if a site-neutral payment policy 
were implemented nationwide.\5\
---------------------------------------------------------------------------
    \5\ Equalizing Medicare Payments Regardless of Site-of-Care 
(February 21, 2021). Committee for a Responsible Federal Budget. 
https://www.crfb.org/papers/equalizing-medicare-payments-regardless-
site-care
---------------------------------------------------------------------------
    We strongly encourage Congress to continue advancing 
proposals that enact siteneutral payment policies for Medicare 
and commercial insurers and self-funded plans.

    Question:

    What impacts have you experienced because of health care 
consolidation?

    Response:

    As the hospital markets where 32BJ Health Fund 
participants' care is provided are becoming increasingly 
consolidated, participants are experiencing shifts in where 
their routine care is provided.
    New York State and City, where a majority of 32BJ Health 
Fund participants' healthcare is provided, has experienced 
hospital market consolidation. One 2018 study reviewing 
hospital consolidations in New York State found the 12 largest 
systems now control half of all the acute care hospitals in New 
York and 70 percent of the inpatient acute care beds.\6\ New 
York hospitals continue to pursue consolidation. In February 
2024, Northwell Health announced a proposal to acquire the 
Nuvance Health system, which operates seven hospitals in 
Connecticut and New York State. The proposed merger would 
expand the Northwell System to include 28 total hospitals 
valued at $20 billion.\7\
---------------------------------------------------------------------------
    \6\ Uttley, L., Hyde, F., HasBrouck, P. and Chessen, E. (May 2018). 
Empowering New York Consumers in an Era of Hospital Consolidation
    \7\ Gagne, M. (March 4, 2024). Will patient care, costs in CT 
improve with Nuvance-Northwell merger? `Cautiously optimistic.' 
Newstimes. https://www.newstimes.com/news/article/danbury-norwalk-
hospital- nuvance-northwell-merger18695997.php.
---------------------------------------------------------------------------
    While large hospital systems are merging in New York, their 
net financial assets are also growing. From 2016-2022, 
collectively, six academic medical centers in the New York City 
region (New York-Presbyterian, Northwell Health, New York 
University Langone, Mount Sinai Hospital, Catholic Health 
Services of Long Island, and Montefiore Health System) 
increased its total net assets from $16 billion to $24 billion. 
New York-Presbyterian recorded the highest total net assets 
among these hospitals in 2022 at nearly $11 billion.\8\
---------------------------------------------------------------------------
    \8\ Audited Financial Statements for FY 2022, as posted on 
Electronic Municipal Market Access (https://emma.msrb.org/)
---------------------------------------------------------------------------
    At the same time net financial assets increased for large 
hospital systems in the New York City region, the site of care 
for some routine procedures also shifted for 32BJ Health Fund 
participants. The 32BJ Health Fund reviewed its claims to 
examine changes in billing from office settings to hospital 
outpatient departments. The analysis showed a shift over time 
in the site of care for many routine procedures like allergy 
shots, acupuncture, and glaucoma screenings from doctors' 
offices to hospital outpatient departments. In 2016, 29% of 
nonemergency CT scans for 32BJ Health Fund participants in New 
York were conducted in hospital outpatient departments, meaning 
71% took place in doctors' offices. By 2022, the number of 
these CT scans conducted in hospital outpatient departments 
rose by 12 percentage points, and the number in doctors' 
offices decreased by the same amount.
    Without further regulatory action from Congress to reduce 
incentives for hospital consolidation, 32BJ Health Fund 
participants may continue to experience changes in their 
location for routine care and navigate concentrated hospital 
markets.

                       Senator Kirsten Gillibrand

Medicare for All Act

    The current medical system is complicated and is not 
patient friendly. The Medicare for All Act would simplify this 
process and ensure every American has access to quality, 
affordable health care regardless of income.

    Question:

    Ms. Opsahl, would Medicare as a uniform health care 
insurance plan simplify the health care process for union 
members and their families?

    Response:

    The 32BJ Health Fund strives to simplify access to and 
maintain affordable healthcare for our plan participants. We 
also value efforts to do the same for all working Americans. 
Containing hospital prices is a critical prerequisite for 
success in any global healthcare delivery, access and cost 
reform effort. Policies to maintain affordable healthcare for 
both the payer or purchaser and the patient, like regulating 
inflated hospital prices, is a foundational step to achieving 
broader healthcare reform.

Capping Prescription Costs Act of 2024

    The average drug price increase between January 2022 and 
2023 was 15.2 percent. The Capping Prescription Costs Act of 
2024 would cap individual cost-sharing for prescription drugs 
to help those with limited incomes and high costs.

    Question:

    Ms. Opsahl, how much of the overall Health Fund costs do 
prescriptions contribute to the 32BJ Health Fund?

    Response:

    In 2023, the 32BJ Health Fund spent $1.4B in total on 
medical and pharmacy benefits. Of the $1.4B the 32BJ Health 
Fund spent in 2023 on medical and pharmacy benefits, 18% 
($262M) was spent on pharmacy benefit costs.

    Question:

    How would a cap on out-of-pocket costs affect the union 
members'and their family's health care costs?

    Response:

    Price caps, and other drug pricing mechanisms, are but one 
way for the 32BJ Health Fund to manage prescription costs. The 
32BJ Health Fund is responsible for creating and implementing a 
cost-effective plan design that offers plan participants 
accessible and affordable prescription drug benefits. We 
contract with vendors, such as pharmacy benefit managers (PBMs) 
to provide benefits to plan participants. Maintaining 
affordable prescription drug benefits for our participants is a 
guiding principle in our vendor partnerships. In 2021, the 32BJ 
Health Fund transitioned our PBM vendor to OptumRx with the 
CoreTrust Group Purchasing Coalition. After the first year of 
this change, the 32BJ Health Fund saved 15% on prescription 
drug cost spend and 10% in the second year. The 32BJ Health 
Fund will continue to prioritize access and affordability in 
the prescription drug benefits provided to our participants.

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                        Questions for the Record

                             Sophia Tripoli

                       Senator Kirsten Gillibrand

Compliance

    A recent report showed that less than 36 percent of 
hospitals were fully compliant with transparency requirements 
issued by the Centers for Medicare and Medicaid Services 
Hospital Price Transparency Rule.

    Question:

    Ms. Tripoli, how would patients benefit from hospitals 
posting price transparency data in a standardized format?

    Response:

    The United States is in the midst of a severe health care 
affordability and quality crisis, stemming from high, rising, 
and variable prices across a wide range of health care goods 
and services, particularly for hospital care.\1\ Large health 
care corporations have destroyed competition in the health care 
sector, and hospitals are dramatically increasing their prices 
year after year without any oversight from policymakers.\2\ 
This practice has become a central strategy in the business 
model of health care corporations: generate profit by buying up 
other hospitals and doctors' offices to become large corporate 
health care systems that can increase health care prices, and 
then block policymakers and the public from seeing those 
prices, while maximizing service volumes of the highest-priced 
services.\3\ The ability of hospitals to increase prices year 
over year is the direct result of their ability to keep the 
underlying price of health care service hidden from public 
oversight and scrutiny.
---------------------------------------------------------------------------
    \1\ Robert A. Berenson et al., Addressing Health Care Market 
Consolidation and High Prices, The Urban Institute https://
www.urban.org/sites/default/files/publication/101508/addressing--
health--care--market--consolidation--and--high--price s--1.pdf. See 
also, Naomi N. Levey, "100 Million People in America are Saddled with 
Health Care Debt," Kaiser Health News, June 16, 2022, Health https://
khn.org/news/article/diagnosis-debt-investigation-100-million-
americans-hidden-medical-debt/
    \2\ Health Care Cost Institute, 2020 Health Care Cost and 
Utilization Report, May 2022. https://healthcostinstitute.org/images//
pdfs/HCCI--2020--Health--Care--Cost--and--Utilization--Report.pdf; The 
Impact of Hospital Consolidation on Medical Costs. NCCI Insights. 2018. 
https://www.ncci.com/Articles/Pages/II--Insights--QEB--Impact-of-
Hospital-Consolidation-on-Medical-Costs.aspx
    \3\ Sophia Tripoli, Frederick Isasi, and Eliot Fishman, Bleeding 
Americans Dry: The Role of Big Hospital Corporations in Driving Our 
Nation's Health Care Affordability and Quality Crisis (Washington, DC: 
Families USA, September 2022), https://familiesusa.org/wp-content/
uploads/2022/09/People-First-Care--Role-of-Hospitals.pdf.
---------------------------------------------------------------------------
    Health care is one of the only markets in the U.S. economy 
in which consumers are blinded to the price of a service until 
they receive a bill after the services are delivered. For the 
majority of Americans (66%) who receive health care through 
private insurance, health care prices are established in 
closed-door negotiations between large hospital corporations 
and health plans based on who has more market power.\4\ These 
health care prices, often referred to as the negotiated rate, 
are buried in proprietary contracts without insight into or 
oversight over the price of health care services by the public 
and policymakers.\5\
---------------------------------------------------------------------------
    \4\ Katherine Keisler-Starkey and Lisa N. Bunch. "Health Insurance 
Coverage in the United States: 2020." United States Census Bureau. 
September 2021. https://www.census.gov/library/publications/2021/demo/
p60-274.html. See also, Sarah Kliff and Josh Katz. "Hospitals and 
Insurers Didn't Want You to See These Prices. Here's Why." The Upshot: 
The New York Times. August 21, 2021. https://www.nytimes.com/
interactive/2021/08/22/upshot/hospital-prices.html
    \5\ Jaime S. King. "Examining State Efforts to Improve Transparency 
in Healthcare Costs for Consumers: Testimony before the House Committee 
on Energy and Commerce and Subcommittee on Oversight and 
Investigations." U.S. House of Representatives. July 17, 2018. https://
docs.house.gov/meetings/IF/IF02/20180717/108550/HHRG-115-IF02-Wstate-
KingJ-20180717.pdf
---------------------------------------------------------------------------
    It is critical that we achieve meaningful price 
transparency to infuse healthy competition back into the health 
care system and not allow large hospital corporations to 
secretly set their prices to price gouging levels at the 
expense of the health and financial security of our nation's 
families. Price transparency pulls back the curtain on prices 
so that policymakers, researchers, employers, and consumers can 
see how irrational health care prices have become and take 
action to rein in pricing abuses.\6\ Further, unveiling prices 
can inform where the highest and most irrational prices are 
occurring in the health care system, so policymakers can 
implement targeted policy solutions to bring down the cost of 
health care.\7\ All Americans, and particularly older Americans 
who heavily rely on the health care system, should be able to 
easily access the price of health care services at a hospital 
or health care facility before they receive care.
---------------------------------------------------------------------------
    \6\ Robert A. Berenson, Jaime S. King, and Katherine L. Gudiksen, 
et al., "Addressing Health Care Market Consolidation and High Prices," 
The Urban Institute, January 2020, https://www.urban.org/sites/default/
files/publication/101508/addressing--health--care--market--
consolidation--and--h igh--prices--1.pdf.; See also, Jaime S. King, 
"Examining State Efforts to Improve Transparency in Healthcare Costs 
for Consumers: Testimony before the House Committee on Energy and 
Commerce and Subcommittee on Oversight and Investigations," U.S. House 
of Representatives, July 17, 2018, https://docs.house.gov/meetings/IF/
IF02/20180717/108550/HHRG-115-IF02-Wstate-KingJ-20180717.pdf
    \7\ Phillip Longman and Harris Meyer, "Why Hospitals Keep Their 
Prices Secret," Washington Monthly, July 6, 2020, https://
washingtonmonthly.com/2020/07/06/why-hospitals-keep-their-prices-
secret/
---------------------------------------------------------------------------
    Consumer advocates have long sought transparency in health 
care prices. Following years of consumer advocacy, the Center 
for Medicare and Medicaid Services (CMS) finalized the Hospital 
Price Transparency Rule and the Transparency in Coverage Rule, 
which require hospitals and insurers respectively to disclose 
health pricing information, including their negotiated rates, 
and to provide consumer-friendly online tools to allow 
consumers to compare prices and estimate out-of-pocket 
costs.\8\ But many large hospital corporations have bucked the 
federal requirements and are actively working to keep their 
prices hidden.\9\ The Lower Costs, More Transparency Act and 
the Health Care PRICE Transparency Act 2.0 make clear, without 
any exception, that all hospitals and insurers are required to 
post the underlying price of health care services, in a 
standardized machine readable and consumer-friendly format.
---------------------------------------------------------------------------
    \8\ "Transparency in Coverage Final Rule Fact Sheet (CMS-9915-F)," 
Centers for Medicare & Medicaid Services, October 29, 2020, https://
www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rule-fact-
sheet-cms-9915-f.
    \9\ PatientsRightsAdvocate.org, "The Fifth Semi-Annual Hospital 
Price Transparency Compliance Report," PatientsRightsAdvocate.org, July 
2023, https://www.patientrightsadvocate.org/july-semi-annual-
compliance-report-2023; See also, PatientsRightsAdvocate.org, "The 
Fourth Semi-Annual Hospital Price Transparency Compliance Report," 
PatientsRightsAdvocate.org, February 2023, https://
www.patientrightsadvocate.org/february-semi-annualcompliance-report-
2023; See also, Justin Lo, Gary Claxton, Emma Wagner, et al., "Ongoing 
Challenges With Hospital Price Transparency," Peterson-KFF Health 
System Tracker, February 10, 2023, https://www.healthsystemtracker.org/
brief/ongoing-challenges-with-hospital-price-transparency/.
---------------------------------------------------------------------------
    The American public is in broad agreement about the need 
for action on price transparency, with polling showing that a 
large majority (95%) of the public say it is important for 
Congress to pass a law to make health care costs more 
transparent to patients, including 60% who call this a top 
priority.\10\
---------------------------------------------------------------------------
    \10\ Shannon Schumacher, Kunna Lopes, and Grace Sparks, et al., 
"KFF Health Tracking Poll December 2022: The Public's Health Care 
Priorities For The New Congress," KFF, December 20, 2022, https://
www.kff.org/mental-health/poll-finding/kff-health-tracking-poll-
december-2022/

---------------------------------------------------------------------------
Medicare for All Act

    The current medical system is complicated and is not 
patient friendly. The Medicare for All Act would simplify this 
process and ensure every American has access to quality, 
affordable health care regardless of income.

    Question:

    Ms. Tripoli, how would a system with one insurance plan 
improve the issues that health care consumers currently face?

    Response:

    Every individual and family throughout the nation should 
have access to the best health and health care, regardless of 
who they are, where they are from, or how much money they make. 
This includes putting in place a sustainable, competitive, and 
affordable system of health care and coverage for all. There 
are a number of pathways to achieve universal health coverage. 
In all of them, it is critical to address the underlying 
drivers of our nation's health care affordability and quality 
crisis, including reining in the impact of unchecked health 
care industry consolidation on health care prices. Policymakers 
should enact a range of bipartisan, commonsense policy 
solutions to address high and rising health care prices 
including strengthening and codifying hospital price 
transparency rules,\11\ so that hospitals provide real prices 
(in dollars and cents) to consumers in advance of delivering 
care; enacting comprehensive site neutral payments as 
recommended by MedPAC that ensures consumers pay the same price 
for the same service regardless of where that care is 
delivered,\12\ as well as billing transparency reforms that 
ensure large hospital systems do not overcharge for the care 
they deliver in outpatient settings; banning anti-competitive 
contracting terms in health care provider and insurer contracts 
- such as "all-or-nothing," "anti-steering," and "anti-tiering" 
clauses - and in clinician and health care worker employment 
arrangements - such as "non-compete" clauses; and requiring 
meaningful ownership transparency and strengthening FTC 
authority to effectively oversee health care markets.
---------------------------------------------------------------------------
    \11\ Gallup, Record High in U.S. Put Off Medical Care Due to Cost 
in 2022, January 2023. https://news.gallup.com/poll/468053/record-high-
put-off-medical-care-due-cost-2022.aspx. See also, NORC at the 
University of Chicago and West Health, Americans' Views on Healthcare 
Costs, Coverage and Policy, March 2018 https://www.norc.org/
NewsEventsPublications/PressReleases/Pages/survey-finds-large-number-
of-people-skipping-necessarymedical-care-because-cost.aspx; Naomi N. 
Levey, 100 Million People in America are Saddled with Health Care Debt, 
Kaiser Health News, June 16, 2022, https://khn.org/news/article/
diagnosis-debt-investigation-100-million-americans-hidden-medical-debt/
; Robert A. Berenson et al., Addressing Health Care Market 
Consolidation and High Prices, The Urban Institute https://
www.urban.org/sites/default/files/publication/101508/addressing--
health--care--market--consolidation--and--high--prices--1.pdf
    \12\ Medicare Payment Advisory Commission, "Medicare and the Health 
Care Delivery System, Report to the Congress," MedPAC, June 2023, 
https://www.medpac.gov/wpcontent/uploads/2023/06/Jun23--MedPAC--
Report--To--Congress--SEC.pdf; H 
     
=======================================================================


                        Statement for the Record

=======================================================================

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                        Statement for the Record

            Statement of 75 Alliances, Unions, and Employers

    We write asking you to support the bipartisan Senate Bill 
3548, The Health Care PRICE Transparency Act 2.0, introduced by 
Senate Health Education Labor and Pensions (HELP) Committee 
Chairman Bernie Sanders and Committee member Senator Mike 
Braun. The transparency provisions in this bill will empower 
employers and unions like ours, which provide coverage to 
nearly 160 million Americans, to greatly reduce our health plan 
costs, improve our business competitiveness, and share savings 
with employees through higher wages and lower premiums.
    Currently, employers and unions nationwide are blocked from 
accessing, auditing or leveraging their own health claims data. 
The situation is so dire that many have had to sue their own 
insurers and third-party administrators (TPAs) to gain access 
to their own data and fulfill their fiduciary duty.
    The Health Care PRICE Transparency Act will, among other 
priorities, empower us as employers to access our claims data 
through a daily data transaction set. This data feed acts as a 
daily receipt for our plan payments to providers, allowing us 
to confirm that the claim amounts match both the payments by 
the TPA and the negotiated prices. It will enable the 
identification and remedy of overcharges and erroneous billing, 
allowing us to perform the fundamental oversight of our health 
plan spending. The bill also removes anti-audit and similar 
obstacles currently rampant in health plan administrator 
contracts, making it easier for employers to audit and oversee 
our plan spend effectively.
    By building on the existing Transparency in Coverage (TiC) 
regulation, this bill strengthens consumer access to health 
plan pricing data with all billing and coding elements, helping 
us protect our employees from overcharges and assess the value 
and performance of our plan. Seeing systemwide prices across 
all plans will empower us to negotiate higher quality, lower 
cost care, as we do for every other aspect of our supply 
chains.
    This bill also requires disclosure of all hospital pricing 
data including all negotiated rates and discounted cash prices 
not estimates, averages, or percentages. This price disclosure 
will enable us to identify wide price variation, steer 
employees to lower priced facilities, and compare our plans 
negotiated prices with others.
    Finally, the bill expands price disclosure requirements to 
laboratories, imaging centers, and ambulatory surgical centers, 
informing consumers of alternatives to high-priced hospital 
systems.
    On behalf of the over 21 million employees we collectively 
represent, we ask you to please support the Braun-Sanders 
Health Care PRICE Transparency Act 2.0 in the reconciliation 
process. By bringing systemwide transparency and accountability 
to healthcare, this bill provides employers and unions with the 
necessary tools to lower our healthcare costs, with no added 
cost to the government. The significant savings can then be 
used to increase earnings and wages, ultimately improving 
competitiveness and stimulating the American economy.

    Sincerely,

    75 Alliances, Unions and Employers Nationwide

    CC: United States Senate

Alliances

Alabama Employer Health Consortium
Dallas-Fort Worth Business Group on Health
Employers' Advanced Cooperative on Healthcare
Employers' Forum of Indiana
Florida Alliance for Healthcare Value
Greater Philadelphia Business Coalition on Health
HealthCareTN
Houston Business Coalition on Health
Independent Colleges and Universities Benefits Association 
(ICUBA)
Kansas Business Group on Health
Lehigh Valley Business Coalition on Health
MidAtlantic Business Group on Health
Midwest Business Group on Health
Nevada Business Group on Health
Oklahoma Business Collective on Health
Rhode Island Business Group on Health
Texas Business Group on Health
Texas Employers for Affordable Healthcare
The Alliance - Midwest
Washington Health Alliance

Unions

32BJ SEIU
International Union of Bricklayers and Allied Craftworkers 
Local 1 CT
National Association of Police Organizations
New Jersey State Policemen s Benevolent Association
Teachers Health Trust

Employers

Agra Industries, Wisconsin
American Licorice, Indiana
Applied Laser Technologies, Wisconsin
Broadway Metal Works, Virginia
Conner Insurance, Indiana
Consolidated Scrap Resources, Inc., Pennsylvania
Curran Group, Illinois
Dick Myers, Inc., Virginia
Diversified Industrial Service Company, Texas
Dupre Logistics, Louisiana
Dynamic Aviation Inc., Virginia
Enerquip, Wisconsin
Faulks Bros Construction, Wisconsin
Frank Blum Construction, North Carolina
Glass and Metals Inc., Virginia
Harman Construction, Inc., Virginia
Health Rosetta, Washington
Hospice of Wichita Falls, Texas
Hyster-Yale, Ohio
InterChange Group; Inc., Virginia
Lantz Construction Company, Virginia
LD&B Insurance & Financial Services, Virginia
Lincoln National Bank, Kentucky
Lynch Companies, Wisconsin
Mayville Engineering Company, Inc., Wisconsin
Menasha Joint School District, Wisconsin
Meshoppen Stone, Pennsylvania
Midwest Carriers, Wisconsin
Mitchell Metal Products, Wisconsin
Moose Pharmacy, North Carolina
Myers Ford Co., Inc., Virginia
Nolato Contour, Wisconsin
Nordic Group of Companies, Wisconsin
Pacific Steel & Recycling, Montana
Partners Excavating Company, Virginia
Ponsse North America, Wisconsin
Railside Enterprises, Inc., Virginia
Rockingham Cooperative, Virginia
Rosen Hotels & Resorts, Florida
SavATree, New York
Second Harvest Food Bank of Central Florida, Florida
SFS Tools & Safety, LLC, Virginia
Shickel Corporation, Virginia
Synthomer, Ohio
Team Schierl Companies, Wisconsin
The Frazier Quarry, Inc., Virginia
The Weber Group, Wisconsin
Valley Engineering, PLC, Virginia
Vero Orthopaedics, Florida
Walker Forge, Inc., Wisconsin

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                        Statement for the Record

            Statement of Patient Rights Advocate.Org Letter

    Thank you for holding a hearing on health care price 
transparency, lowering costs, and empowering patients. As a 
nonprofit advocating for systemwide price transparency in 
healthcare, we believe that empowering consumers and employers 
with actual, upfront prices will create a functional, 
competitive market, protect patients from overcharges, and 
greatly reduce healthcare costs.
    We strongly endorse the bipartisan Senate Bill 3548, The 
Health Care PRICE Transparency Act 2.0, introduced by Senate 
Health Education Labor and Pensions (HELP) Committee member 
Senator Mike Braun and Committee Chairman Bernie Sanders. 
Earlier this year, 75 alliances, unions and employers from 
across the country, representing more than 21 million 
employees, also endorsed this bill in the attached letter sent 
to bipartisan Senate leadership.
    The price transparency provisions in this bill will empower 
employers and unions like them to greatly reduce their health 
plan costs, improve their business competitiveness, and share 
savings with employees through higher wages and lower premiums. 
Currently, employers and unions nationwide are blocked from 
accessing and analyzing their own health claims data to 
identify overcharges and savings opportunities. Many have had 
to sue their own insurers and third-party administrators (TPAs) 
to gain access to their own data and fulfill their fiduciary 
duty.
    The Health Care PRICE Transparency Act 2.0 will, among 
other priorities, empower self-insured employers and union 
health plans to access their claims data through access to a 
daily transaction data set. This data feed will act as a daily 
receipt of plan payments to providers, allowing employers to 
confirm that the claim amounts match both the payments by the 
TPA and the negotiated prices. It will enable employers and 
union health plans to identify and remedy overcharges and 
erroneous billing, allowing them to perform the critical 
oversight of their health plan spending. The bill also removes 
anti-audit and similar obstacles rampant in health plan 
administrator contracts, making it easier for employers to 
audit and oversee their plan receipts for payment.
    This bill also requires transparency of all hospital 
pricing data including all negotiated rates and discounted cash 
prices not estimates, averages, or percentages. This price 
disclosure will enable consumers to identify wide price 
variation, find lower priced care, and compare their plan s 
negotiated prices to those of other plans. The bill requires 
increased enforcement for noncompliant hospitals, at a time 
when only 34.5% of hospitals reviewed are fully compliant and 
the Centers for Medicare and Medicaid Services (CMS) has only 
penalized fifteen hospitals for noncompliance.
    By building on the existing Transparency in Coverage (TiC) 
regulation, this bill strengthens consumer access to health 
plan pricing data with all billing and coding elements, helping 
employers protect their employees from overcharges and assess 
the value and performance of their health plan. Seeing 
systemwide prices across all plans will empower employers to 
negotiate higher quality, lower cost care, as is the case for 
every other aspect of supply chains.
    Finally, the bill expands price disclosure requirements to 
laboratories, imaging centers, and ambulatory surgical centers, 
informing consumers of alternatives to high-priced hospital 
systems.
    By bringing systemwide transparency and accountability to 
healthcare, this bill provides employers and unions with the 
necessary tools to lower our healthcare costs, with no added 
cost to the government. The significant savings can then be 
used to increase earnings and wages, ultimately improving 
competitiveness and stimulating the American economy.

    Sincerely,

    Cynthia Fisher
    Founder & Chairman PatientRightsAdvocate.org

    CC: United States Senate

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                        Statement for the Record

               Statement of Leukemia and Lymphoma Society

    On behalf of the more than 1.5 million Americans living 
with a blood cancer diagnosis, The Leukemia & Lymphoma Society 
(LLS) appreciates the opportunity to provide recommendations to 
address the nation's rising healthcare costs and improve 
transparency in our healthcare system. As an organization that 
has invested in the fight to cure cancer, LLS knows that the 
cost of care associated with a blood cancer diagnosis is too 
high and continues to rise. We receive over 20,000 calls to our 
Information Resource Center (IRC) annually, the vast majority 
of which pertain to the cost burden of cancer.
    In response to cost growth in recent years, payers and 
policymakers have often passed the burden to patients in the 
form of increased cost-sharing and changes that erode the 
quality of care accessible to cancer patients. In 2019, the 
national patient economic burden associated with cancer care 
was over $21 billion, including direct patient out-of-pocket 
costs of more than $16 billion.\1\
---------------------------------------------------------------------------
    \1\ K. Robin-Yabroff, PhD, Angela Mariotto, PhD, et al., Annual 
Report to the Nation on the Status of Cancer, Part 2: Patient Economic 
Burden Associated With Cancer Care, JNCI: Journal of the National 
Cancer Institute, Volume 113, Issue 12, December 2021, Pages 1670-1682, 
https://doi.org/10.1093/jnci/djab192
---------------------------------------------------------------------------
    LLS launched our Cost of Cancer Care initiative in 2017 to 
address this growing issue, and we continue to advocate for 
aggressive but feasible cost-cutting policy solutions that 
would not sacrifice quality of care.\2\ We offer the following 
policy recommendations for the Committee to consider to help 
lower healthcare costs, incentivize high-quality care, and 
increase healthcare transparency.
---------------------------------------------------------------------------
    \2\ The Leukemia & Lymphoma Society. Cost of Cancer Care 
Initiative. Accessed at www.lls.org/CancerCost

---------------------------------------------------------------------------
Expand Site-Neutral Payments

    LLS encourages Congress to pursue expanding site-neutral 
payments in Medicare. Expanding site-neutral payment-the 
practice of paying equally for services whether they are 
associated with a physician practice or an outpatient hospital 
setting-has the potential to lower patient out-of-pocket costs, 
reduce unnecessary Medicare spending, and reduce incentives for 
hospitals to participate in anticompetitive practices (such as 
buying up physician practices).
    Vertical consolidation between hospital and physician 
office settings continues to rise, driven in part by the 
ability of hospital entities to receive higher hospital 
outpatient reimbursements for services performed at the 
facility that had previously been considered a physician 
office. According to the Government Accountability Office 
(GAO), between 2007 and 2013, the number of vertically 
consolidated physicians nearly doubled from 96,000 to 
182,000.\3\ Further, a 2016 study found that the proportion of 
chemotherapy infusions delivered in a hospital increased from 
15.8 percent in 2004 to 45.9 percent in 2014 in the Medicare 
population.\4\
---------------------------------------------------------------------------
    \3\ GAO (2015) Increasing Hospital-Physician Consolidation 
highlights Need for Payment Reform. Accessed at https://www.gao.gov/
assets/680/674347.pdf
    \4\ Milliman (2016) Cost Drivers of Cancer Care: A Retrospective 
Analysis of Medicare and Commercially Insured Population Claim Data 
2004-2014. Accessed at https://www.communityoncology.org/wpcontent/
uploads/sites/20/2018/07/Trends-in-Cancer-Costs-White-Paper-FINAL-
20160403.pdf
---------------------------------------------------------------------------
    We urge the Committee to consider implementing site-neutral 
payment policies as outlined in H.R. 5378, the Lower Costs, 
More Transparency Act, which passed the House of 
Representatives on an overwhelmingly bipartisan basis last 
year. The site-neutral policies included in this bill take 
steps to adjust incentives by expanding existing site-neutral 
payments for drug administration services. LLS strongly 
supports advancing this policy and looks forward to working 
with Congress to advance and expand site-neutral payments or 
other payment changes intended to address the ways in which 
consolidation negatively impacts patients.
    Experts have repeatedly identified site-neutral payments as 
an opportunity to save money for Medicare. The Congressional 
Budget Office (CBO) estimated that the site-neutral policies in 
the Lower Costs, More Transparency Act would result in over 
$3.7 billion in Medicare savings.\5\ More importantly, these 
policies also reduce cost-sharing for beneficiaries and limit 
non-clinical incentives to provide services in more expensive 
settings - without compromising beneficiary access to care or 
health outcomes. Research commissioned by LLS has demonstrated 
that requiring site-neutral payment for drug administration 
services can result in significant out-of-pocket savings for 
patients. A patient with multiple myeloma, for example, could 
save $1,200/year under this policy.\6\ In addition to saving 
taxpayer dollars and reducing patient out-of-pocket costs, 
equalizing payments between these sites of service would weaken 
the incentive for provider consolidation, which would also 
produce long-term cost savings and provide patients with 
additional options for their care.
---------------------------------------------------------------------------
    \5\ Congressional Budget Office. (2023) "Estimated Direct Spending 
and Revenue Effects of H.R. 5378, the Lower Costs, More Transparency 
Act." Accessed at: hr5378-DS-and-Revs--12-2023.pdf (cbo.gov)
    \6\ Stewart, R. (2023) "Site Neutral Payment Reform Has the 
Potential to Significantly Reduce Out-Of-Pocket Patient Spend" Wakely. 
Accessed at: Site Neutral Payment Reform has the Potential to 
Significantly Reduce Out-of-Pocket Patient Spend (lls.org)

---------------------------------------------------------------------------
Unique Identifiers

    Medicare payments to providers currently include limited 
information about where the service is provided. For example, 
codes do not distinguish if services are delivered on a 
hospital campus or at an affiliated provider, such as a primary 
care doctor or infusion center that may be geographically 
separate from the primary hospital's physical campus. Because 
Medicare payments for hospital outpatient departments (HOPDs) 
are reimbursed at a higher rate than physician's offices, 
hospitals are incentivized to purchase smaller providers and 
reclassify them as HOPDs.
    In addition to site-neutral reforms, several proposals 
under consideration in Congress would, if passed, require 
hospitals and providers to report more granular data regarding 
where services are being provided-at a hospital's primary 
facility or at a provider beyond the boundaries of the 
hospital's physical campus. These simple transparency 
requirements would provide data that would help policymakers 
and researchers better understand hospital revenue cycles and 
consolidation trends, as well as their implications on patients 
and national budget outlays. LLS strongly supports legislation 
that would improve site-of-service transparency to better 
understand if healthcare systems are using consolidation and 
other anti-competitive behaviors to game federal payments.

Enforce Provider Price Transparency Rules

    One crucial way this Congress can address provider 
consolidation and encourage competition in the healthcare 
system is through price transparency. While multiple federal 
rules are in effect requiring disclosure of negotiated prices 
between health plans, physicians, and hospitals, compliance is 
lacking. Price transparency is a means to an end, and 
stakeholders must be able to access and analyze data to 
identify cost drivers and make informed healthcare policy 
decisions. Congress should direct the Centers for Medicare and 
Medicaid Services (CMS) to provide hospitals and health plans 
with better datareporting standards and usability guidelines to 
ensure that transparency leads to the goal of a more cost-
efficient healthcare system.

Bring Transparency to Pharmacy Benefit Managers (PBMs)

    Given the nature of blood cancers, many patients rely on 
prescription drugs as their primary therapy. As a result, blood 
cancer patients often access their cancer therapy via their 
insurance plan's pharmacy benefit-typically managed by their 
plan's contracted pharmacy benefit manager (PBM). LLS believes 
that the healthcare system needs greater transparency, 
oversight, and guardrails in order to ensure that PBM financial 
incentives are aligned with the goals of both plans and 
patients.
    Congress should require that PBMs provide comprehensive 
quarterly reporting to plan sponsors, including details about 
the list and net prices for drugs accessed through the pharmacy 
benefit as well as comprehensive rebate information for each 
drug. Additionally, PBMs should be required to provide 
important information related to the inflated out-of-pocket 
costs paid by plan enrollees utilizing a drug whose enrollee 
cost-sharing is based on its list price rather than net price. 
Plan sponsors should be aware of the impact on enrollees of 
choosing to base cost-sharing on an inflated list price, which 
dramatically increases the cost burden for patients who rely on 
drugs with high list prices in order to provide a small amount 
of savings either to plan cost or enrollee premiums. This 
trade-off has significant consequences for plan enrollees with 
blood cancer and other chronic and/or life-threatening 
conditions, and plan sponsors should be aware of the impact on 
these enrollees.
    Congress should also prohibit spread pricing-a practice 
that positions a PBM's financial incentives in opposition to 
the incentives of the plan sponsor for whom they are managing 
the prescription benefit. Spread pricing describes the practice 
of PBMs administering a plan's drug benefits charging a plan 
sponsor far more for a drug than the drug's pharmacy 
acquisition cost, with the potentially vast difference between 
the two costs going to the PBM's bottom line. This practice 
prevents plan sponsors, enrollees, and patients filling their 
prescriptions from experiencing the financial benefits of 
generic competition, and it serves no purpose other than to 
reward PBMs for behavior contrary to the interests of the 
entities on whose behalf they are contracted to work.

Facilitate Competition through Consumer-Friendly Plan 
Transparency

    When shopping for coverage during enrollment periods, 
consumers do not have access to clear and transparent 
information about the amount they would be required to pay as 
their share of the cost of a medication. This is due largely to 
the prevalence of coinsurance, a cost-sharing technique that 
requires consumers to pay a percentage of a drug's total cost. 
Plan formularies typically represent coinsurance as a 
percentage only - e.g. "30%" or "45%" - with no accompanying 
information that consumers can use to translate that percentage 
to an actual dollar amount. Thus consumers must select and 
enroll in a plan without a full understanding of the 
affordability of one plan's drug benefit versus another.
    This lack of transparency poses a real threat to patient 
well-being: patients are more likely to abandon treatment when 
the cost of their care is high, a dynamic that is exacerbated 
when patients are unable to anticipate and plan for the precise 
out-of-pocket cost of their care. This lack of transparency is 
harmful to the marketplace as well, as it diminishes 
competition among plans.
    In order to facilitate greater transparency regarding cost-
sharing for medications:
      -Congress should require CMS to improve Medicare Plan 
Finder to convey important information on out-of-pocket drug 
costs so that consumers can judge their health care options 
based on complete information about the impact of their 
decision on their financial and physical health, and
      -Congress should require qualified health plans (QHPs) to 
provide transparency regarding the plan's prescription drug 
formulary, including meaningful cost-sharing information, to 
consumers during the open enrollment process. At a minimum, 
QHPs should be required to include for every covered drug a 
range of out-of-pocket spending for the prescription (e.g. $-
$$$$ OR $010, $11-25.$500+, etc.)

Conclusion

    LLS stands ready to work with you and your colleagues in 
Congress to advance the solutions we have outlined above and 
other proposals that would achieve savings without sacrificing 
patient access to appropriate cancer care. We share your belief 
that we are at a crucial juncture in our healthcare system, and 
we urge you and your colleagues to capitalize on this real 
opportunity to make the reforms necessary to promote patient 
access to appropriate care while eliminating incentives that 
drive unnecessary spending. We are grateful for your 
leadership.

    Sincerely,

    Brian Connell
    Executive Director of Federal Affairs

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                        Statement for the Record

               Statement of American Hospital Association

    On behalf of our nearly 5,000 member hospitals, health 
systems and other health care organizations, our clinician 
partners - including more than 270,000 affiliated physicians, 
two million nurses and other caregivers - and the 43,000 health 
care leaders who belong to our professional membership groups, 
the American Hospital Association (AHA) writes to share the 
hospital field's comments on health care costs and 
transparency.

OVERVIEW OF NATIONAL HEALTH SPENDING

    America's hospitals and health systems - physicians, nurses 
and other caregivers - understand and share concerns regarding 
the high cost of health care and are working hard to make care 
more affordable by transforming the way health care is 
delivered in our communities. Real change will require an 
effort by everyone involved, including providers, the 
government, employers and individuals, device makers, drug 
manufacturers, insurers and other stakeholders.
    The AHA's most recent "Cost of Caring" report provides 
greater details on the challenges hospitals face with respect 
to treating patients with higher acuities while dealing with 
financial instability. The issues include workforce shortages 
and increasing supply chain costs, coupled with inadequate 
reimbursement from government payers and increased 
administrative burden related to commercial insurance efforts 
to reduce compensation. Taken together, these factors create an 
environment of financial uncertainty in which many hospitals 
and health systems are operating with little to no margin.
    For this statement, we highlight two of the cost drivers 
incurred by hospitals and health systems: commercial insurer 
operating methods and prescription drug costs.

Commercial Insurer Practices

    To truly reduce health care costs, we urge Congress to 
address practices by certain commercial health insurers. For 
example, additional oversight is needed to ensure that Medicare 
Advantage (MA) plans can no longer engage in tactics that 
restrict and delay access to care while adding burden and cost 
to the health care system.
    While MA plans were designed to help increase efficiency in 
the Medicare program, data from the Medicare Payment Advisory 
Commission (MedPAC) found that MA plans will be responsible for 
$88 billion in excess federal spending this year, due in part 
to inappropriate upcoding practices, whereby plans report 
enrollees as having more health conditions and being sicker 
than they are to receive higher reimbursements. At the same 
time, health insurance premiums continue to grow - in fact, 
annual insurance premiums increased nearly twice as much as 
hospital prices over a 10-year period.\1\
---------------------------------------------------------------------------
    \1\ https://www.medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-
status-report-Jan-2024.pdf
---------------------------------------------------------------------------
    Additionally, inappropriate denials for prior authorization 
and coverage of medically necessary services remain a pervasive 
problem among certain MA plans. A 2022 report from the 
Department of Health and Human Services (HHS) Office of 
Inspector General found that MA plans are denying at a high 
rate medically necessary care that met Medicare criteria.\2\ 
The report highlights that 13% of prior authorization denials 
and 18% of payment denials met Medicare coverage rules and 
therefore should have been approved. In a program this size - 
covering more than half of all Medicare beneficiaries - 
improper denials at this rate are unacceptable. However, 
because the government pays MA plans a risk-adjusted per-
beneficiary capitation rate, there is a perverse incentive to 
deny services to patients or payments to providers to boost 
profits.
---------------------------------------------------------------------------
    \2\ https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf
---------------------------------------------------------------------------
    These practices delay access to care for seniors and add 
financial burden and strain on the health care system through 
inappropriate payment denials and increased staffing and 
technology costs to comply with plan requirements. They also 
are a major burden to the health care workforce and contribute 
to provider burnout. To address these issues, the AHA supports 
regulatory and legislative solutions that streamline and 
improve prior authorization processes, including the Improving 
Seniors' Timely Access to Care Act (S. 4532), which would 
codify many of the reforms in the Interoperability and Prior 
Authorization Final Rule.
    Though issues with denials are often felt most acutely with 
MA and Medicaid managed care plans, these practices also are 
followed by other commercial payers, where claims denials 
increased by 20.2% in 2023. Moreover, the time taken by 
commercial payers to process and pay hospital claims from the 
date of submission increased by 19.7% in 2023, according to 
data from the Vitality Index. For hospitals and health systems, 
these practices, which require hospitals to divert dollars away 
from patient care to instead focus on seeking payment from 
commercial insurers, result in billions of dollars in lost 
revenue each year.\3\ Without further intervention, these 
trends are expected to continue and worsen. National 
expenditures on the administrative costs of private health 
insurance spending alone are projected to account for 7% of 
total health care spending between 2022 and 2031 and are 
projected to grow faster than expenditures for hospital 
care.\4\
---------------------------------------------------------------------------
    \3\ https://www.ama-assn.org/practice-management/prior-
authorization/health-systems-played-payer-takeback-schemes
    \4\ AHA analysis of NHE projections of 2022-2031 expenditures.

---------------------------------------------------------------------------
Prescription Drug Prices

    Congress also should address the high costs of prescription 
medications, given the regular increases in costs, as this 
impacts expenses for all providers, including hospitals. For 
instance, a report from earlier this year noted pharmaceutical 
companies raised list prices on 775 brand name drugs during the 
first half of January 2024, with a median increase of 4.5%, 
though the prices of some drugs rose by 10% or higher.\5\ These 
increases were higher than the rate of inflation, which was 
3.4% in December. A report by the HHS Assistant Secretary for 
Planning & Evaluation (ASPE) found that between 2022 and 2023 
drug companies increased drug prices for nearly 2,000 drugs 
faster than the rate of general inflation, with an average 
price hike of 15.2%.\6\
---------------------------------------------------------------------------
    \5\ https://www.wsj.com/health/pharma/drugmakers-raise-prices-of-
ozempic-mounjaro-and-hundreds-ofother-drugs-bdac7051
    \6\ https://aspe.hhs.gov/reports/changes-list-prices-prescription-
drugs
---------------------------------------------------------------------------
    Moreover, recent drug shortages also have fueled further 
expense growth. An ASPE report found up to a 16.6% increase in 
the prices of drugs in shortage; in many cases, the increase in 
the price of substitute drugs were at least three times higher 
than the price increase of the drug in shortage.\7\ The costs 
incurred as a result of drug shortages are compounded by staff 
overtime needed to find, procure and administer alternative 
drugs, to manage the added challenges of multiple medication 
dispensing automation systems and changing electronic health 
records and to undergo training to ensure medication safety 
using alternative therapies.\8\
---------------------------------------------------------------------------
    \7\ https://aspe.hhs.gov/reports/drug-shortages-impacts-consumer-
costs
    \8\ https://link.springer.com/article/10.1007/s13181-023-00950-
6:text=shortages%20compromise%20or%20delay%20medical,morbidity%20%5B1%2C
%202%5D.

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MEDICAL DEBT

    Hospitals and health systems are very concerned about 
patients' medical debt, which is a consequence of patients not 
paying some or all their health care bills. While health 
insurance is intended to be the primary mechanism to protect 
patients from unexpected and unaffordable health care costs, 
for too many that coverage is either unavailable or falling 
short.
    Trends in health insurance coverage that are driving an 
increase in medical debt include inadequate enrollment in 
comprehensive health care coverage, growth in highdeductible 
and skinny health plans that intentionally push more costs onto 
patients and misleading health plan practices that confuse 
patients' understanding of their coverage. These gaps in 
coverage leave individuals financially vulnerable when seeking 
medical care. The primary causes of medical debt are:

      -There are still too many uninsured Americans. 
Affordable, comprehensive health care coverage is the most 
important protection against medical debt. While the U.S. 
health care system has achieved higher rates of coverage over 
the past decade, gaps remain.
      -High-deductibles subject many Americans to cost-sharing 
they cannot afford. High-deductible plans are designed to 
increase patients' financial exposure through high cost-sharing 
in exchange for lower monthly premiums. Yet many individuals 
enrolled in high-deductible plans find they cannot manage their 
portion of health plan expenses. A Federal Reserve report found 
that 37% of adults would not be able to afford a $400 
emergency,\9\ an amount $1,000 less than the average general 
annual deductible for single, employer-sponsored coverage.
---------------------------------------------------------------------------
    \9\ https://www.federalreserve.gov/publications/2023-economic-well-
being-of-us-households-in-2022expenses.htm
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      -Certain health plans provide inadequate benefits and 
frequently lead to surprise gaps in coverage. Short-term, 
limited-duration health plans and health sharing ministries 
cover fewer benefits and include few to no consumer 
protections, such as required coverage of pre-existing 
conditions and limits on out-of-pocket costs. Patients with 
these types of plans often find themselves responsible for 
their entire medical bill without any help from their health 
plan, including for critical services such as emergency medical 
and oncology care. These denials can lead to an accumulation of 
significant medical debt.\10\
---------------------------------------------------------------------------
    \10\ https://kffhealthnews.org/news/sham-sharing-ministries-test-
faith-of-patients-and-insurance-regulators/
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      -Complex health plan benefit design and misleading 
marketing can expose patients to unexpected costs. Many health 
plans have complex benefit designs that are not transparent to 
patients, such as what is covered predeductible, the 
interaction between point-of-service copays, coinsurance and 
deductibles and poor communication and education about what the 
plan covers. For example, a recent National Association of 
Insurance Commissioners report found significant gaps and 
inconsistencies with the way that insurers share information 
about pre-deductible, no cost-sharing preventive services with 
their members, resulting in a "meaningful barrier to effective 
understanding and use of preventive service benefits."\11\
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    \11\ https://healthyfuturega.org/ghf--resource/preventive-services-
coverage-and-cost-sharing-protectionsare-inconsistently-and-
inequitably-implemented/

    Hospitals are the only part of the health care sector that 
provide services to patients regardless of their ability to 
pay. They underscore that commitment by offering financial and 
other assistance, including helping patients qualify for 
federal and state health care programs, such as Medicaid. In 
doing so, patients can receive regular preventive care, not 
just episodic care for serious injuries or illness. In 
addition, hospitals absorb billions of dollars of losses for 
patients who are unable to pay their bills, mainly due to 
inadequate commercial insurance coverage; in 2020, the latest 
figure available, hospitals provided more than $42 billion in 
uncompensated care.\12\
---------------------------------------------------------------------------
    \12\ https://www.aha.org/system/files/media/file/2020/01/2020-
Uncompensated-Care-Fact-Sheet.pdf
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    This is why hospitals are staunch supporters of ensuring 
everyone is enrolled in some form of comprehensive coverage. 
However, we appreciate that closing the remaining coverage gaps 
may be a longer-term solution and that more immediate steps can 
be taken. To that end, the AHA has routinely developed patient 
billing guidelines to help prevent patients from incurring 
medical debt. The AHA's Board of Trustees adopted the most 
recent set of guidelines in 2020, which reaffirm the hospital 
field's commitment to:

      -Treating all people equitably, with dignity, respect and 
compassion.
      -Serving the emergency health care needs of all, 
regardless of a patient's ability to pay.
      -Assisting patients who cannot pay for part or all the 
care they receive.

    Notably, several of the guidelines directly address medical 
debt, including encouraging hospitals to forego adverse credit 
reporting of medical debt, so far, nearly 2,800 hospitals and 
health systems have affirmed their commitment to the 
guidelines, and the AHA revisits them regularly for updating.

PRICE TRANSPARENCY REQUIREMENTS

    We appreciate Congress' ongoing interest in hospital price 
transparency to provide consumers with the price information 
they need specific to their course of treatment.
    Hospitals and health systems have invested considerable 
time and resources to comply with the Hospital Price 
Transparency Rule, which requires online access to both a 
machine-readable file and a list of shoppable services. Recent 
data from Turquoise Health shows that 93.4% of hospitals have 
met the requirement to post a machinereadable file.
    We are concerned, however, with recent legislative efforts 
to no longer recognize price estimator tools as a method to 
meet the shoppable services requirement. This change would both 
reduce access to a consumer-friendly research tool and unfairly 
penalize hospitals that have spent significant capital to 
comply with the regulation. These facilities would instead need 
to develop and maintain a shoppable services spreadsheet, which 
may be difficult for consumers to navigate and will not reflect 
the different policies that their insurer may apply to 
determine the final price for a service. Price estimator tools 
offer consumers an estimate of their out-of-pocket costs based 
on their insurance benefit design, such as cost-sharing 
requirements and prior utilization, as well as the patient's 
annual deductible. This is an important feature of these tools 
that is not available from a shoppable services spreadsheet. 
Eliminating the use of price estimator tools as a method to 
meet the shoppable services requirement of the Hospital Price 
Transparency Rule would therefore reduce price transparency for 
patients. We urge Congress to reject this potential change.
    As Congress seeks to make statutory changes to price 
transparency standards, it is important for legislators to take 
into consideration the adjustments to the Hospital Price 
Transparency Rule made by the Centers for Medicare & Medicaid 
(CMS) on a regular basis. These include changes related to 
standardization, new data elements, file accessibility, an 
accuracy and completeness affirmation, as well as changes to 
CMS' monitoring and enforcement processes. Most notably, CMS 
now requires hospitals to use a standard format to comply with 
the machine-readable file requirement, which includes new data 
elements such as negotiated rate contracting type or 
methodology, an accuracy and completeness affirmation and (as 
of January 1, 2025) an "estimated allowed amount." CMS also now 
requires that hospitals' price transparency information be more 
easily found on their websites.
    Regarding compliance and enforcement, hospitals may be 
required to have an authorized hospital official certify the 
accuracy and completeness of the hospital's machine-readable 
file during the monitoring and enforcement process. CMS also 
can require hospitals to provide additional documentation at 
the agency's request, including contracting documentation 
needed to validate the hospital's negotiated rates and 
verification of the hospital's licensing status.
    In addition, CMS increased its efforts to publicize 
hospital-specific information on all compliance assessment and 
enforcement activity, which it now updates regularly on a 
public website. This includes details related to CMS' 
assessment of hospital compliance, any compliance actions taken 
against a specific hospital, the status of the compliance 
action(s) and the outcome of the action(s). A list of the civil 
monetary compliance notices and fines issued to date is 
available on the CMS website. The fines vary in scope, from 
$55,000 to nearly $1 million, for those hospitals that have 
been deemed out of compliance with the Hospital Price 
Transparency Rule. CMS clearly has the authority and 
willingness to enforce compliance with the rule and assess 
significant fines, regardless of statutory activity.

CONCLUSION

    Thank you for your consideration of the AHA's comments on 
issues related to health care expenditures. We look forward to 
continuing to work with you to address these important topics 
on behalf of our patients and communities.

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                        Statement for the Record

                           Statement of AHIP

    AHIP is the national association that represents health 
insurance plans that provide coverage, services, and solutions 
for over 205 million Americans through public programs such as 
Medicare and Medicaid, employer-sponsored insurance, and the 
individual insurance market.
    We appreciate the Committee's attention to the issue of 
health care transparency and encourage efforts to increase 
transparency and accessibility of health care for older 
Americans. We share the Committee's goal of achieving better 
health outcomes and more affordable health care, and increased 
price transparency is a step in the right direction.
    Our statement for the Committee's July 11 hearing outlines 
several policy considerations and highlights the ways health 
insurance plans are implementing innovative solutions to 
increase access and transparency for older Americans, such as 
providing clear information on coverage options, strengthening 
Medicare, and addressing the cost of high-priced prescription 
drugs.

Commitment to Price Transparency

    AHIP and our member health insurance plans fully support 
the goals of providing actionable information about the cost 
and quality of health care services to enable older Americans 
to make better-informed decisions.
    Health insurance plans are often the best resource for 
providing consumers with personalized and accurate cost 
information, offering tools that enable consumers to obtain 
specific data about their coverage while protecting the privacy 
and security of their personal health information. For example, 
consumers use these tools to understand their benefits and 
provider networks, and cost sharing.
    Health insurance plans continue to work to increase 
consumer awareness and use of these tools through, among other 
methods, member portal messages, outreach efforts, and text 
messaging campaigns. Older Americans deserve to know how much 
their care and prescriptions will cost before they receive 
them, as well as how to access the highest value services. 
Health insurance plans are committed to empowering seniors with 
the information they need, when they need it, so they can make 
health care decisions that are right for them.

Medicare Advantage Provides Choice, Value and Transparency for 
Older Americans

    More than 33 million seniors and people with disabilities 
actively choose Medicare Advantage (MA) for their Medicare 
coverage. MA offers high-quality care and support, financial 
protections, and affordable coverage options so enrollees can 
pay less and receive better care.

MA Empowers Choice

    MA offers a market-based framework that encourages 
competition and provides seniors and people with disabilities 
with options for finding a package of benefits that best meets 
their needs. An average Medicare beneficiary in 2024 has access 
to 43 MA plans, with specialized plans also available to 
certain populations such as retirees or individuals who also 
have Medicaid coverage.1
    These different options provide enrollees with the same 
basic covered benefits available in feefor-service (FFS) 
Medicare. However, unlike FFS, all MA plans are required to 
limit annual outof-pocket spending, with most offering a wide 
range of extra benefits, called supplemental benefits. These 
benefits can include reduced cost sharing for basic Medicare 
benefits and offer important benefits unavailable in FFS such 
as dental, vision, and hearing services; innovative telehealth 
options; wellness programs; and nutrition, transportation, and 
in-home caregiver services. The Medicare Payment Advisory 
Commission (MedPAC) reports that in 2024, MA enrollees on 
average have access to more than $2,100 in added 
benefits.2 In addition, most MA enrollees can obtain 
Part D drug coverage through an MA plan for no additional 
premium.
    To obtain similar financial protection or supplemental 
benefits, individuals in FFS Medicare must purchase coverage at 
an additional monthly premium. One analysis found that "MA 
enrollees spent, on average, $2,541 less on healthcare costs 
(spending on premiums and out-ofpocket expenses) than FFS 
Medicare enrollees in 2021."3 Another analysis found 
that a 65-yearold retiree who chooses to enroll in MA needs 
more than 40% less in savings to cover health care costs over 
their remaining lifetime as a person who chooses FFS 
Medicare.4

Transparency Aids Consumer Decision-Making and Program Analysis

    Medicare beneficiaries have access to information about the 
plans available to them through a variety of sources, including 
the Medicare program's Medicare Plan Finder. This tool provides 
data to beneficiaries, researchers, and others so they can 
understand Medicare coverage options and benefits available 
under each available plan in a particular service area.
    In addition, significant data on MA supplemental benefits 
is currently available and additional data will soon be 
available. The Centers for Medicare & Medicaid Services (CMS) 
requires supplemental benefits data reporting through plan 
Medical Loss Ratio (MLR) reporting. Effective for plan year 
2024, CMS is collecting additional data through annual 
reporting requirements and "encounter data", including use and 
cost data. CMS typically posts public use files of plan-
reported data, which can be used by researchers and other data 
analysts.5 Beginning in 2026, MA plans will be 
required to send mid-year notices to enrollees regarding unused 
supplemental benefits.
    MA plans also submit details to CMS on every claim they 
receive from providers, including demographic information, 
diagnoses, and descriptions of services provided. This 
"encounter data" is made publicly available for analysis by 
researchers and analysts, and detailed "landscape" files are 
released in advance of the annual Medicare open enrollment 
period to allow analysts to identify key trends in the program.
    In summary, whether it's more choices for the health plan 
that fits a person's needs, more widespread availability of 
high-quality, integrated health coverage, and greater access to 
health plans with $0 premium and drug coverage, MA is helping 
drive immense value for the millions of older Americans the 
program serves.

      -Recommendation: AHIP urges lawmakers and regulators to 
invest resources to make further improvements to the comparison 
functionality on certain benefits (including supplemental 
benefits) and to make other changes based on public input. Q05
The Importance of Transparency in Reducing Drug Prices

    Rising drug prices impose a heavy burden on all Americans, 
especially older adults living on fixed incomes. This situation 
is a direct result of high list prices determined solely by 
drug companies. Due to the high prices manufacturers set in the 
U.S., twenty-two cents of every health care dollar go toward 
prescription drugs - with drugs contributing more to health 
care costs and growing at a rate faster than any other type of 
health care service.6
    AHIP looks forward to working with the Committee to advance 
market-based solutions that hold drug makers accountable for 
setting high list prices and provide relief to American 
families.

Manufacturers Set High Drug Prices

    Any assessment of prescription drug affordability must 
start with the root causes of high drug prices: drug 
manufacturers often hold monopoly power over medicines and 
continue to prevent and undermine competition to keep drug 
prices as high as possible in the U.S. This anticompetitive 
dynamic has a profound impact on older Americans. For instance, 
over the 2009-2018 period, the average price of a brand-name 
drug prescription more than doubled in the Medicare Part D 
program and increased by 50% in Medicaid.7
    To make prescription drugs available and affordable for 
patients, health insurance plans and their pharmacy benefit 
manager (PBM) partners negotiate with drugmakers. These savings 
are passed along to patients and consumers through lower 
premiums and out-of-pocket costs. However, the lack of 
transparency on how drugmakers' set prices or why they 
routinely increase prices on Americans multiple times a year 
creates a barrier to developing new solutions to lower drug 
prices.

Solutions to Enhance Drug Pricing Transparency and Reporting

    Consumers and taxpayers should have access to information 
on manufacturing and research and development costs, net 
profits, and marketing and advertising costs for expensive 
medications and manufactures should publicly justify price 
increases.

      -Recommendation: AHIP urges Congress to consider policies 
that would require drugmakers to publicly justify high prices 
and report pricing information. Congress should advance S.1218, 
the Fair Accountability and Innovative Research (FAIR) Drug 
Pricing Act, to apply basic transparency to drug pricing and 
require drug manufacturers to justify price increases.

Disclosure of Drug Prices in Direct-to-Consumer (DTC) 
Advertising

    Greater transparency is a crucial component of the broad-
based strategy by lawmakers that is needed to provide consumers 
with relief from prescription drug prices.

      -Recommendation: Congress should pass S. 1250, the Drug-
Price Transparency for Consumers Act, which would require 
drugmakers to disclose list prices in DTC advertisements and 
provide disincentives for them to continue price gouging 
patients.

Accessing Affordable Alternatives

    Older Americans should be able to get the medications they 
need at costs they can afford, including more affordable 
generics and biosimilars. However, drug companies are regularly 
abusing the patent system to keep lower-cost generic drugs from 
reaching the market. AHIP supports supports a number of 
bipartisan Senate legislative proposals to promote more 
competition and reduce drug costs, including:

      -S.79, the Interagency Patent Coordination and 
Improvement Act, which would establish an inter-agency 
cooperative task force to spur more collaboration in patent-
related functions.

      -S.142, the Preserve Access to Affordable Generics and 
Biosimilars Act, which would prevent anticompetitive "pay-for-
delay" deals that delay and prevent the introduction of more 
affordable alternatives.

      -S.148, the Stop STALLING Act, which would authorize the 
Federal Trade Commission (FTC) to take action against drug 
companies when they game the patent system by filing frivolous 
petitions with the Food and Drug Administration (FDA).

      -S.150, the Affordable Prescriptions for Patients Act, 
which would begin to limit drug manufacturers' anti-competitive 
tactics such as product hopping and manipulating the patent 
litigation process.

      -Recommendation: AHIP recommends the Committee work with 
the House of Representatives to advance these pieces of 
legislation expeditiously and create a more competitive drug 
market and lower costs for older Americans and all consumers.

    Our members are fully committed to advancing solutions that 
provide relief to the American people from out-of-control 
prescription drug prices. Common-sense steps are needed to 
ensure that people have access to affordable medications. With 
solutions that deliver real competition, create more consumer 
choice, and reduce drug prices, we can deliver more savings.

Additional Considerations

Impact of Concentrated Health Systems and Private Equity
    A growing body of research consistently finds that the 
consolidation of health care providers into health systems with 
market power is a primary driver of the high costs of health 
care in the United States.8 Concentrated health 
systems often stifle competition and limit the ability for 
health insurance plans to negotiate lower prices for patients.
    Private equity's growing influence over portions of the 
provider market - from nursing homes to ambulance providers to 
important specialties - has also resulted in higher costs for 
the same, or worse, care resulting in higher out-of-pocket 
costs and higher premiums.9 Additional growth of 
private equity ownership focused on extracting short-term 
profits, could further inflate health care costs.

      -Recommendation: AHIP urges the Committee to prioritize 
policies that remove the incentives and opportunities for 
private equity firms focused on extracting short term patients 
to exploit patients by acquiring specialty practices, ambulance 
providers, and other portions of the system vulnerable to such 
abuses.

Improving Hospital Transparency by Advancing Site-Neutral 
Payments

    Advancing site-neutral payments is a competition-enhancing 
approach that would improve affordability and access for older 
patients and all Americans. Medicare's outdated payment 
structure has created an incentive for hospitals to acquire 
physician practices and superficially convert them to off-
campus, provider-based hospital outpatient departments. This 
loophole allows providers to charge patients substantially more 
for the same services and outcomes.
    Expanding site-neutral payment reforms would require 
transparency of these locations and improve payment accuracy in 
the Medicare program. Solutions that permit comparable payment 
for comparable services would protect consumers from hidden 
fees and encourage a more efficient and competitive market. An 
industry analysis found that if enacted site-neutral payments 
would save patients and taxpayers close to $500 billion over 
ten years.10

      -Recommendation: We urge the Senate to advance the 
bipartisan S. 1869, SITE Act, which would reduce costs for 
consumers and the system by expanding site-neutral payments and 
billing transparency.

Conclusion

    Consumers need access to reliable estimates and 
explanations of their health care costs. Health insurance plans 
will continue to help older Americans can get the information 
they need to make important decisions about their coverage and 
care. Through meaningful collaboration with the Committee, we 
believe we can achieve such a framework and help older 
Americans make wellinformed health care decisions aided by 
transparent information. 
[GRAPHIC] [TIFF OMITTED] T7076.010

                 U.S. Senate Special Committee on Aging

   "Health Care Transparency: Lowering Cost and Empowering Patients"

                             July 11, 2024

                        Statement for the Record

         Statement of Healthsystem Association of Pennsylvania

    We are concerned that individual examples cited do not 
provide full information and do not accurately reflect hospital 
pricing. The Committee should undertake a holistic discussion 
about health care costs for patients, providers, and others in 
the health care system. A recent report from the Pennsylvania 
Health Care Cost Containment Council (PHC4) found that more 
than half of Pennsylvania general acute care hospitals are 
operating in the red. As you continue to evaluate opportunities 
for health care reform, HAP strongly encourages you to address 
the underlying challenges facing hospitals in Pennsylvania and 
across the nation, including inadequate reimbursement for the 
cost of care, outdated regulations that drive administrative 
burden and cost, and continuum-wide workforce shortages. HAP 
and Pennsylvania's hospital community are committed to working 
with you to address these core challenges.

                               [all]`