THE VALUED VOICE

On Sept. 10, Wisconsin Health News hosted a panel in Milwaukee to discuss the evolving issue of health care price transparency. The panel explored the impact and evolution of recent federal hospital and health insurer transparency regulations, including how private sector data analysts like Turquoise and Milliman are aggregating and using that data. Additionally, the panelists shed light on future directions policymakers might take to further enhance transparency in health care, including middlemen in the health care system that are significantly driving up the cost of health care.

The event brought together a diverse group of experts to discuss these issues, including Eric Borgerding, president and CEO of the Wisconsin Hospital Association (WHA); Phillip Blair, human resources director at Gamber Johnson; Sen. Mary Felzkowski (R-Tomahawk); Michael Finley, director of revenue cycle at Emplify Health; Mike Gaal, principal at Milliman; and Robert Van Meeteren, CEO of Reedsburg Area Medical Center. Each panelist provided a unique perspective on the current state of health care price transparency and what it means for different stakeholders.
 

The Evolving State of Health Care Transparency
Sen. Felzkowski opened the discussion by describing hospital price transparency as a “two-pronged approach,” involving both machine-readable files (MRFs) and tools that allow consumers to shop for health care services. She emphasized that transparency is vital not only for consumers, but also for employers who use the data to build cost-effective health plans.
 
Phillip Blair echoed Felzkowski's sentiments, explaining how Gamber Johnson has successfully integrated transparent pricing into its employee health plans. “We have access to actual bundled prices for our employees,” Blair noted, adding that this transparency allows the company to steer employees toward lower-cost providers.
 
Borgerding recognized the efforts of employers like Gamber Johnson but pointed to a larger issue that emerged from a legislative hearing on transparency last year. "Hats off to Gamber Johnson for doing some pretty impactful things, particularly with the data that's available…it seems to be working," Borgerding said. However, he emphasized that a key, and for him unexpected, takeaway from the October hearing on Sen. Felzkowski’s bill was the frustration employers voiced over their inability to obtain their own data from third-party administrators (TPAs), even backing Sen. Felzkowski’s legislation because it would be the only way to get their own data.
 
"The frustration seemed to be channeled at hospitals through this legislation, but the real issue was the inability to get data that is rightfully theirs," Borgerding explained. According to Borgerding, there are employers across the country now suing their TPAs over access to their own data, with some lawsuits outright claiming that TPAs are purposely withholding information to obscure the real value they provide to employers as middlemen. 
 
Blair weighed in on this issue, stating, “If there are any employers in the room and you don’t have access to the data that you’re legally required to have, switch your partner. Get access to the data. It is your responsibility to have access to that information.”
 
This frustration has led to ongoing conversations about hospital price transparency, but Borgerding warned that focusing solely on hospitals ignores other significant drivers of health care costs. "There’s almost no information about the middlemen in health care—like TPAs and networks—and their impact on costs," he said.
 
Borgerding emphasized the need for transparency across the entire system to ensure that both consumers and policymakers can make informed decisions. “We do not have a line of sight into many other significant elements of the health care system that contribute to the overall cost," Borgerding stated. "When I think of health care transparency, I think of what consumers and policymakers need to know to address rising health care costs."
 
Mike Gaal is a principal at Milliman who specializes in supporting health plans, employer-sponsored health plans, and employers in creating actionable insights from publicly available health care price transparency data. He added that in 2022, a transparency rule went into effect for health insurers that “effectively required all payers to basically post all rates for every type of service, not just hospital-based services."  
 
Gaal compared the compliance burden and usefulness of the federal hospital transparency rule to the federal health insurer transparency rule, noting that the “schema that was written into the [health insurer transparency] rule was much more clear than the scheme written into the hospital rule.” Gaal said that the health insurer rule “was just a lot easier to interpret,” but the challenge for users of that data was that it is “massive in scale” and a challenge to be consumable by humans or companies.
 
Nevertheless, Gaal said that having both the hospital transparency rule and the health insurer transparency rule enabled organizations to compare the data produced by both hospitals and payers for accuracy.  Gaal said the data is “exactly the same, which means it’s working.”
 
The Patient-Centric Focus of Price Transparency
WHA members Robert Van Meeteren and Michael Finley reinforced the importance of maintaining a patient-focused perspective when it comes to price transparency. Van Meeteren highlighted the efforts his hospital makes to ensure patients receive clear, personalized information about the cost of their care.
 
“We’re fully compliant with federal transparency regulations, but what our patients really appreciate is being able to talk to a human being,” Van Meeteren shared. While technology plays a significant role in compliance, Reedsburg Area Medical Center remains focused on direct communication to enhance patient understanding.
 
Michael Finley echoed this sentiment, explaining that Emplify Health goes beyond compliance by providing resources to help patients navigate their price estimates and understand available financial assistance options. Emplify Health, he said, also works closely with local businesses to provide transparent pricing and quality data directly, removing the need for intermediaries.
 
“We’re removing the middleman and working directly with our community partners, which has led to greater success,” Finley noted.
 
Costs of Compliance for Hospitals
Both Van Meeteren and Finley shared that the addition of new transparency requirements for hospitals does not come without new costs on hospitals. They noted new costs when the federal government added new requirements last year in an update to the hospital transparency rule. Van Meeteren pointed out that as a small, rural hospital, with limited resources to serve its community, Reedsburg Area Medical Center spent almost an equivalent of a full-time certified nursing assistant salary to meet the updated federal hospital transparency requirements last year. 
 
Finley added that Emplify Health had dedicated over 180 hours to comply with federal requirements. He explained that is not a one-time cost but is an ongoing cost as significant resources are expended by Emplify Health to update its publicly available machine-readable file every time a payer changes its payment policies.   
 
Borgerding emphasized that while price transparency is crucial, it represents just one piece of a much larger impact that insurance companies’ polices that impede and deny care have on health care costs, yet are completely absent from legislation and devoid of scrutiny. "Hospitals spend significant time and resources complying with these federal transparency laws," he said. "But that pales in comparison to the time and effort spent complying with other regulations just to get paid or obtain permission to provide care." Numerous recent studies have started to quantify the billions of dollars in funding and resources the so-called “Middleman Industrial Complex” is siphoning out of health care.
 
“We are focusing on one element of health care that is important but ignoring many other factors driving up the cost of care, which is why we need comprehensive health care transparency,” Borgerding said.
 
Employers Steering Care Away from Hospitals
A major concern raised during the panel was the trend of employers diverting care away from hospitals and toward lower-cost alternatives such as independent surgical centers and direct primary care providers. John Nygren, executive director of the Wisconsin Association of Health Plans brought attention to the increasing burden on hospitals where closures and service reductions are becoming more common due to financial strain. Nygren pointed out that hospitals often face unsustainable payer mixes, with a disproportionate share of patients covered by Medicaid, Medicare and charity care, all of which reimburse well below the actual cost of care.
 
Borgerding confirmed that this issue is exacerbating financial challenges for hospitals across Wisconsin, particularly for those providing essential services like labor and delivery, mental health care and substance use disorder treatment—services that many hospitals offer at a loss and that no one else will sustain. He pointed to Eau Claire as a prime example, where nonprofit hospitals carry the bulk of Medicaid and Medicare patients while employers increasingly steer their employees to independent providers.
 
"The notion that there is a free market in health care is misguided and misleading," Borgerding said, stressing that hospitals are shouldering the financial burden of being the safety net for the health care system while others cherry pick the best reimbursing patients.
 
Blair acknowledged this tension from the employer’s side, stating that while employers are increasingly steering their employees toward lower-cost providers, they also recognize the need for strong hospital systems, particularly for emergency services.
 
“It’s naive to think employers don’t need strong hospital systems. We absolutely do,” Blair stated. However, he noted that employers feel they are becoming too much of the "safety net" for health care costs, and this frustration is driving many to seek alternatives.
 
Blair further explained that employers are now directing care to independent providers and bypassing hospitals, which only worsens the financial challenges faced by hospitals. "We’re on an unsustainable path," Blair warned. He emphasized the need for “good faith discussions” between all stakeholders—hospitals, employers, insurers and policymakers—to address the issue. If these discussions do not happen, he argued, more hospitals will face closures or be forced to eliminate critical services.
 
Looking Ahead:  The Future of Health Care Transparency
Sen. Felzkowski pledged to continue pushing for state-level transparency legislation focusing on hospitals in the next legislative session. She expressed concerns about the constantly shifting federal requirements, stating, “We’ve heard from hospitals that the federal standards keep moving the needle.” Her approach, she said, would focus on requiring machine-readable files and bundled pricing, while working collaboratively with the Wisconsin Hospital Association to ensure the legislation addresses the realities hospitals face.
 
Borgerding also highlighted a key challenge in health care transparency—the lack of information about intermediaries in the system, such as TPAs and networks. "There’s no information about the middlemen in health care, almost zero," he said, stressing that these entities play a significant role in driving up costs.
 
In closing, Borgerding reaffirmed the ongoing need for health care transparency, but called for a broader, more inclusive approach that captures all aspects of the health care system, not just hospitals. "If we don’t tackle what’s going on between patients and providers, we are ignoring the hundreds of millions of dollars that are coming out of the health care system."