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Health Affairs This Week places listeners at the center of health policy’s proverbial water cooler. Join host Jeff Byers, editors from Health Affairs Publishing, and guests as they discuss health policy’s most pressing news and trends.
Hello and welcome to Health Affairs This Week. I'm your host Jeff Beyers. We are recording on 04/22/2026. As a heads up, we have an insider event I wanted to point everyone to on May 13. We have an event on Understanding ICHRAs with Urban Institute's Jason Lovitis.
Jeff Byers:I hope you'll join us. Today on the program, we have Stacey Pogue Stacey and colleagues wrote in forefront an article titled Taking Stock of Proposed Updates to Health Plan Price Transparency Rules. Price transparency has been a large multi year effort, so we thought now is a good time to check-in and take stock of where things stand in that regard. Stacey, welcome to the program.
Stacey Pogue:Thank you, Jeff. It's lovely to be here.
Jeff Byers:In your you know, you wrote the forefront article. We encourage people to check it out. If they don't get the what they need here for that, As this could be someone's first introduction into price transparency, like, can you give us some quick background on these efforts?
Stacey Pogue:So in the last few years, there's been a lot of interest at the federal level in advancing price transparency. We've seen efforts both from the administration and from congress. So so two big pushes that have come through rule from the administration were in the first Trump administration. They had a rule for hospital price transparency and another for health plan price transparency. That one's called the transparency and coverage rule.
Stacey Pogue:And they both have two parts. They require essentially a consumer facing piece, like a price lookup tool that hospitals and health plans have to give so you could figure out what something will cost or what your out of pocket cost will be. But they also have another piece called machine readable files, where hospitals and health plans have to disclose all their prices in these big complex files. And those are not consumer facing. Those are meant for, people with a requisite experience, people who can parse data to pull down so that employers, regulators, policymakers can be informed, right, of of what's going on with health care prices.
Stacey Pogue:And we've also seen congress interested in price transparency. They passed a number of provisions in the Consolidated Appropriations Act of 2021 that related to price transparency. One was telling, health plans and providers they need to work together to give patients an upfront disclosure of how much their scheduled health care will cost. It's called the advanced explanation of benefits. It has not been implemented.
Stacey Pogue:And another was to give employers some more information. Employers sponsor health plans that cover, you know, roughly half of working age adults, and they don't get the information they want from their third party administrators on the the health care that they are purchasing. So congress has been active. The administration's been active. And as you said, it's been a multi year, you know, journey trying to to make some progress on this front.
Jeff Byers:Yeah. And it has been a journey. So at least in the hospital side, those price charges have been kinda opaque and murky. Is that correct?
Stacey Pogue:Yeah. So I think that's the the complaint and concern all around is that patients are expected to pay prices that they cannot know generally in advance. And so hospitals have been moving forward on their requirements, but there's been some compliance issues on the hospital side. There's been some data standardization issues. And there's been there's been roadblocks on the health plan, price transparency side too, but all moving towards this idea that both consumers need information for decision making.
Stacey Pogue:And outside of consumers, policymakers, regulators, other stakeholders need information, that they can use to help kinda hold down health care cost growth.
Jeff Byers:And so I think a lot of the media coverage that, at least from what I've seen, has focused more on the hospital compliance side. Your forefront article focuses more on the plan side. So I am kinda curious, like, is there any notable difference between, you know, compliance and, like, where we are in these efforts from plans versus hospitals?
Stacey Pogue:Yeah. So those the two efforts are very similar, but they've rolled out somewhat differently. What I'll say, you you have seen a lot of compliance attention on the hospital side. There's been a lot of it in part because it's it's frankly easier to measure. It's pretty hard to figure out if health plans are complying and to what degree they're complying because the files are so much more complex.
Stacey Pogue:So part of it is just that it's it's easier to measure on the hospital side. The health plan side, how it's rolled out is where we've hit big roadblocks is with a starting point on the Ground Floor is access to the data. So health plans have been posting data, mountains of data every month, but in large part, they're not, very accessible and very usable. They are unwieldy, they're giant, but they're full of redundant data and they're full of irrelevant data. And the size alone, apparently there's about a trillion prices posted a month, means that very few users have the infrastructure and the knowledge to work with data sets that big and frankly that messy to clean them.
Stacey Pogue:So there's just less information coming out of the health plan files because of the the barriers to entry to even opening them up and using them. And and there's a new rule that's trying to to address some of those issues.
Jeff Byers:Yeah. So HHS did release a proposed rule with comments due in March, so that that was last month, you know. Walk us through what did that proposal
Stacey Pogue:Alright. So this proposal is kind of a response to the data users who've been complaining, right, that there's some real issues with with the data. I think the proposal is pretty narrow in scope and pretty technical, but the changes fall into four big buckets. One is an effort to reduce the file sizes. So first, they cut out redundant data.
Stacey Pogue:The way that is organized is that there's a lot of duplicates. Each employer who uses the same network. For example, you might have a bakery next to a school, and they both might use Acme Insurance Premier Network, but they'll show up in the data today duplicated. And so there's an effort to change how the data is organized so that it's per network, and that should cut out some of duplication. Another issue that's written about a lot with these data are ghost codes.
Stacey Pogue:Another colorful name for it are zombie rates, but these are clinically implausible rates. So it's the rate for a dermatologist to do a triple bypass. Right? It's not gonna be billed in the real world, but there's still a negotiated rate for it. So to remove those ghost codes that we're not gonna see billed.
Stacey Pogue:And the agencies estimate this change alone will reduce file sizes by 70%. So that's the first big bucket. The second one is that the agencies wanna give data users more context. So add information to the price files that isn't a price. Like, how many people are enrolled in each plan, which providers have billed for a certain service.
Stacey Pogue:So there's some additional context. The third bucket is improving access. So sometimes these files are spread across each insurer's website or each TPA's website all over the place. So they have a requirement to provide, like, a a digital pathway to help people find the files. And the last piece is to to reduce the reporting cadence.
Stacey Pogue:Right now, health plans have to post this information every month, and the proposal will move that back to quarterly, which will reduce some of the administrative burden.
Jeff Byers:So all of this is very, very technical and wonky. So, like, how does this fit into price transparency efforts in the health care space in general? Like, what, you know, what does it all mean?
Stacey Pogue:Because I think what this is is this is the agencies saying we had a vision for how accessible price information would be back in 2019 and 2020, and that just hasn't materialized because there's just some fundamental structural issues with how these files are built. Some of which we can't fix because the the files are complex, because pricing is complex, because it's so granular. Right? There's so many services, so many codes, so many providers. But some of it they can fix.
Stacey Pogue:They can change how the files are structured. So I think it's a realization that the kind of information, actionable information they wanted out in the universe isn't coming from these files today. But they can make some changes to make them a little easier to access, a little easier to use, a little cheaper to use. They're pretty expensive now to be able to clean and get the data in a way that they can be used. So try to increase access, so that eventually we'll get more actionable information out of these price files.
Jeff Byers:Yeah. So in your view, is this like an intermediary step to an end goal or like where where are we on this journey?
Stacey Pogue:Oh, wow. That's a good question. Yeah. I think it's an intermediary step. So I think we've been since 2019, 2020 with these rules in a long and iterative implementation process.
Stacey Pogue:So where the agencies are addressing, you know, groups of problems at a time, you know, for hospitals as first with standardization is compliance, they're still working on those. But for the health plan side, again, they're still at a somewhat early step of trying to increase access just to the price files, there will have to be more steps that aren't in this rule to clean up some issues with data accuracy, compliance. There's nothing in here about compliance checks for health plans. So all of that is probably, you know, forthcoming. So it's gonna be a multiyear effort still to to get from the initial requirement several years ago to a vision where health price data is available for decision making for policymakers or consumers.
Jeff Byers:Yeah. So, you you know, what's the over under? Are we looking at 2040? Or like, if I when I need a hip replacement, I can figure out what the what the cost is?
Stacey Pogue:Maybe maybe when you and I need hip replacements, we can easily figure out what the cost is. I think it's gonna be a while. But I also think I can't fully integrate, like, how technology is changing and how AI can change, you know, what is available and what's not. I think, you know, I think the the ground is shifting at the same time. So maybe things happen faster, but, you know, something that seems so easy on its face, telling you the price of something isn't.
Stacey Pogue:It just isn't because of how complex pricing is in health care. So it we're still a ways away from letting consumers know upfront what their care will cost.
Jeff Byers:Yeah. That's that's the story of health care. Right? Something should be so simple and then, you know, you start getting into the to the little details. So back to the rule, you know, what has been the reaction from insurers?
Jeff Byers:Are they on board with this generally or is there a general pushback of
Stacey Pogue:Yeah. That so it's it's both both and. So I've read through a bunch of comments from the insurers who create the files and the file users. So the insurers say in general, we support the streamlining, we're on board, but all this extra ancillary information you want, we don't wanna do that. That's just too far.
Stacey Pogue:And the other thing that they have said is that the rule requires us to change our files too quickly. That they can't come into compliance as quick as quickly as the rule envisioned, is twelve months after the rule is finalized. They say, no. No. No.
Stacey Pogue:We'll need twelve to eighteen months after the technical guidance is finalized, which will come even after the rule is finalized. So they want more time. But if you read the comments on the other side from the file users, so employers, researchers, these data firms that are the ones that are each actually able to use the data today and try to clean the data today, they all say, hey, the streamlining is good. The ancillary information is great, but you didn't go far enough. You need to do more CMS.
Stacey Pogue:You need to clean up the data accuracy issues. You need to require more information on utilization in the files, and you need to create a central repository for links to all the files because they're really hard to find. And you try to make it easier in the in the rule, but it's not it won't be easy enough. So the users want more, the insurers want less, you know, what you'd expect.
Jeff Byers:So you're right that these changes will change the use of transparency and coverage data. So, that was a new term to me. So what does this mean, and how will this change?
Stacey Pogue:Yeah. So transparency and coverage data are nominally free and publicly available. Right? That's what the rule back from 2020 requires. But in practice, to the degree that people can get insights from these price files, it's mostly coming from data firms that specialize in ingesting these gigantic quantities of data and cleaning this really messy, really complex data and parsing it all.
Stacey Pogue:And so it's hard to get. It's expensive to access. It's expensive to use. And these third party data vendors are nimble, right? They are overcoming these challenges, but that's at a cost.
Stacey Pogue:You know, all of these data challenges drive up the cost of collecting the data and synthesizing the data. And what that means is that better resource stakeholders can access data extracts. They can access insights from the data, and and then other folks can't. Right? So some researchers can and some researchers can't.
Stacey Pogue:And some industry players can and some state regulators can't access the information they want. So the rule does two things. By making the data files easier to access, easier to clean, easier to manipulate, cheaper to store, they're gonna reduce the costs. The costs for these big firms or other users to be able to get the data and make it available. And that'll help improve availability of the information, and hopefully, the availability of actionable insights from the data.
Stacey Pogue:And the other thing is there's this new ancillary information in these files. So enrollment information, some very limited utilization information, provider taxonomy information. These new data, if they are finalized, could open up some new, avenues for analysis and answer some different new research questions.
Jeff Byers:Okay. Yeah. So what should we expect next? When will the rule be finalized?
Stacey Pogue:I don't know.
Jeff Byers:You know? Yeah. Yeah.
Stacey Pogue:Yeah. That's a good question. I know that that price transparency is clearly a priority of the Trump administration. So I am sure they've got resources going into finalizing this rule and then steps that come after it. But they also have a lot of other work that they are trying to juggle at the same time.
Stacey Pogue:So so we will see.
Jeff Byers:Well, with that, Stacey Pogue, thanks again for joining us today on Health Affairs This Week. The forefront article, again, is titled taking stock of proposed updates to health plan price transparency rules. If you, the listener, enjoyed this, send it to the actuary in your life, and we will see you next week. Thanks all.