The national Consumer Price Index for All Urban Consumers (CPI-U) is one of the most widely used indicators of inflation in the economy and can be used to contextualize changes in the cost of healthcare services. Since July 2022, health plan price transparency data – published monthly under the Transparency in Coverage (TiC) final rule – has enabled the measurement of negotiated rates for specific procedures, markets and payers along with changes in these rates over time. Given the documented variation in negotiated rates that exists across procedures and markets, service line level rates of change can materially impact self-funded employers, especially within expensive clinical areas like oncology.1
National healthcare spending on cancer-related diagnosis and treatment is projected to reach $246B by 2030, an increase of more than 30% from $183B in 2015.2 The ultimate cost of cancer-related diagnosis and treatment is influenced by trends in both cancer incidence and procedure cost (i.e., the amount reimbursed for the procedure).
While spending on cancer care has continued to increase, overall cancer incidence has remained relatively stable, although underlying incidence trends differ meaningfully across cancer types. Breast cancer incidence increased 1% per year from 2013 through 2022, with a steeper increase among women younger than 50 (1.4% per year) and among Hispanic (1.8% per year) and Asian American, Native Hawaiian and Pacific Islander (2.7% per year) populations, even as breast cancer mortality continued to decline, down 44% from its 1989 peak through 2023.3 Colorectal cancer follows a different pattern, with overall incidence declining by about 1% per year over the past decade, but incidence among adults younger than 50 increased 2.9% per year, and colorectal cancer moved from the fifth-leading cause of cancer death in adults under 50 in the early 1990s to the leading cause in 2023.
Employers underwrite the majority of private health insurance in the United States, financing more than $1.4T in healthcare spending in 2024.4 Because a single cancer diagnosis can generate reimbursement claims well in excess of a typical stop-loss threshold, cancer is also consistently identified as a leading driver of high-cost, catastrophic claims for the self-funded employer health plans that cover the majority of the commercially insured population. Notably, 88% of employers cited cancer as a top condition driving health plan costs in 2025.5
Employer-sponsored health insurance is a welfare plan under the Employee Retirement Income Security Act of 1974 (ERISA), under which plan sponsors have a fiduciary duty to administer benefits solely in the interest of participants and beneficiaries. Under Delaware law, the state in which more than 300 Fortune 500 companies are incorporated, corporate officers are subject to a duty of care requiring informed business decisions based on information relevant to the decision at hand. Historically, employers and their brokers have relied on national CPI benchmarks as a proxy for a healthcare cost trends; however, with the implementation of the TiC rule, whether a benefit decision meets the fiduciary standard under Delaware law now depends in part on analyzing the difference in actual procedure-level negotiated rates between payers at the market level. Said differently, it is now possible to measure longitudinal trends in negotiated rates for cancer-related procedures directly, rather than relying on an aggregate carrier trend figure or a national CPI benchmark.
To this end, this study examines the extent of the difference between national CPI benchmarks and CBSA-level percent change in commercial negotiated rates for cancer-related procedures.
Using Trilliant Health's health plan price transparency (HPPT) dataset, 2024 and 2026 average commercial negotiated rates for 11 cancer-related CPT codes were calculated and compared across a select group of 49 core-based statistical areas (CBSA). Negotiated rates included in the analysis equaled or exceeded the respective Medicare base rate. Three analyses are presented. The first aggregates across the 11 CPT codes associated with the diagnosis, treatment and surgical management of cancer: CPT 19303 (simple, complete mastectomy), CPT 19307 (modified radical mastectomy with axillary lymph node dissection), CPT 44204 (laparoscopic partial colectomy with anastomosis), CPT 55866 (robotic-assisted laparoscopic radical prostatectomy), CPT 58150 (total abdominal hysterectomy), CPT 58571 (laparoscopic total hysterectomy for a uterus 250 g or less), CPT 71271 (low-dose CT lung cancer screening), CPT 74178 (CT of the abdomen and pelvis without and with contrast), CPT 77373 (stereotactic body radiation therapy delivery per fraction), CPT 78816 (whole-body PET/CT) and CPT 96413 (initial-hour intravenous chemotherapy infusion). The second analyzes CPT 19307 to assess discrete rate changes. The first two analyses are limited to a single payer, UnitedHealthcare (UHC). The third analysis isolates CPT 19307 by individual payer, Aetna and UHC, across 30 CBSAs between 2025 and 2026. In all analyses, the CBSA-level percent change is benchmarked against the national Urban Consumer CPI (CPI-U) and the national Hospital CPI (the BLS Hospital Services component of the medical care CPI), along with the Hospital Cancer Producer Price Index (PPI) and the Pharmaceutical Cancer Producer Price Index (PPI), which are producer price indexes specific to hospital-based and pharmaceutical cancer care over the same period.
For the 11 cancer-related CPT codes, percent change in rates across the 49 CBSAs ranged from -4.6% in Kansas City, MO-KS to 46.4% in Seattle-Tacoma-Bellevue, WA (Figure 1). Notably, average rates increased in every CBSA except Kansas City, MO-KS. Across the CBSAs included in the analysis, the average increase across the 11 CPT codes in commercial negotiated rates exceeded the national CPI-U (6.6%) in 27 out of 49 markets (55.1%). Additionally, the average increase in commercial negotiated rates exceeded the national Hospital CPI (9.9%) in 17 markets (34.7%). It exceeded the Hospital Cancer PPI (11.0%), the highest of the four benchmarks, in 14 of 49 markets (28.6%) and exceeded the Pharmaceutical Cancer PPI (4.6%), the lowest of the four benchmarks, in 38 of 49 markets (77.6%).
In the CPT 19307-specific analysis, percent change across the CBSAs analyzed ranged from -24.5% in Oklahoma City, OK to 45.4% in San Francisco-Oakland-Fremont, CA (Figure 2). For example, in San Francisco-Oakland-Fremont, CA, the average negotiated rate increased from $16,325 to $23,731, or 45.4%. Notably, two CBSAs, Oklahoma City, OK and Indianapolis-Carmel-Greenwood, IN, had a negative percent change. Of the 47 CBSAs with CPT 19307 rates, the average increase in commercial negotiated rate exceeded the CPI-U in 25 markets (53.2%). Additionally, the average increase in commercial negotiated rate exceeded the Hospital CPI in 12 markets (25.5%). It exceeded the Hospital Cancer PPI (11.0%), the highest of the four benchmarks, in 10 of 47 markets (21.3%), and exceeded the Pharmaceutical Cancer PPI (4.6%), the lowest of the four benchmarks, in 34 of 47 markets (72.3%).
Thirty of the 49 studied CBSAs had a negotiated rate for both UHC and Aetna. Among those 30 CBSAs, the average negotiated rate for CPT 19307 increased by an average of 3.3% for both UHC and Aetna. The average absolute difference between the two payers' percent change within the same CBSA was 3.2 percentage points, larger than the 2.6 percentage point range between the lowest and highest of the four benchmarks shown (Pharmaceutical Cancer PPI, 2.5%; National CPI-U, 4.2%; Hospital CPI, 5.8%; Hospital Cancer PPI, 6.8%). In a comparison of the two payers, UHC had a higher percent change in a slight majority of markets (56.7%). The largest payer differences occurred in Chicago-Naperville-Elgin, IL-IN, where Aetna's percent change (10.9%) exceeded UHC's (2.7%) by 8.2 percentage points, and in San Jose-Sunnyvale-Santa Clara, CA, where UHC's percent change (3.8%) exceeded Aetna's (-4.1%) by 7.9 percentage points. Relative to the four benchmarks, nine of 30 CBSAs (30.0%) had an Aetna percent change that exceeded the national CPI-U, and 10 (33.3%) had a UHC percent change that exceeded it. Fewer CBSAs exceeded the higher benchmarks, with four (13.3%) for Aetna and two (6.7%) for UHC exceeding the Hospital Cancer PPI. More than half of CBSAs exceeded the Pharmaceutical Cancer PPI, with 18 (60.0%) for Aetna and 17 (56.7%) for UHC. Just five (16.7%) CBSAs for Aetna and four (13.3%) for UHC exceeded the Hospital CPI.
A national benchmark describes an average. By definition, the more variation that exists, the less informative a national benchmark becomes for localized decision making.
Aggregate carrier trend figures and national CPI benchmarks, both of which smooth over market-level variation, emerged as proxies because direct measurement was historically unavailable. However, health plan price transparency data removes that constraint, making it possible to measure percent change in negotiated rates at the CBSA level and the facility level rather than approximating it at the national level. As these data expand to cover additional procedures and longer time periods, the same method can be applied to any high-cost, high-acuity procedure category in which market-level variation is material to total cost.
In the majority of CBSAs analyzed, the percent change in average negotiated rate differed substantially from the national CPI benchmarks for the national CPI-U, Hospital CPI, Hospital Cancer PPI and Pharmaceutical Cancer PPI. In both the composite analysis and the single CPT code analysis, the range in percent change, 51.0 and 69.9 percentage points respectively, exceeded the 6.4 percentage-point range across the four benchmarks by a factor of at least seven. Although the Pharmaceutical Cancer PPI grew more slowly than the Hospital Cancer PPI over the period, oncology drugs remain a substantial and growing share of total cancer spending in absolute terms.
At a minimum, the divergence in the market-level price trends from government-endorsed measures of pricing confirms the axiom that healthcare is local. The question is whether that variation is stochastic or instead reflective of a lack of attention to detail by brokers, payers and self-insured employers.
Given the stakes, self-funded employers would logically be the most self-interested stakeholder to utilize TiC data to constrain the increase in healthcare benefit costs, particularly for care that is clinically complex and high cost. In turn, almost every employer would logically be curious to benchmark their self-funded plan costs at the market, service line and payer level. If they did, they would discover that national benchmarks are poorly suited to meet a self-funded plan’s fiduciary duty under ERISA and Delaware law.
It is clear that benefits advisors, consultants and the actuaries who set trend assumptions can substitute market-specific percent change for a national benchmark when projecting cost and structuring network, steerage and stop-loss decisions. It is unclear why they do not and, in contrast, continue to create notional “percent of Medicare” benchmarks instead of utilizing actual price signals, as economists would predict.
Similarly, the information is available for health plans and third-party administrators to identify the markets and facilities in which negotiated rate change diverges most from the national benchmark. In theory, health plans and third-party administrators would leverage that information to implement benefit design changes that incentivize commercial insureds to utilize providers that deliver value for money. If they did, health systems would be effectively forced to compete to deliver cancer services in the context of value for money, which exists at the intersection of cost and quality.
No question is more urgent for health economy stakeholders than to understand why self-funded employers are not utilizing TiC data to inform healthcare benefit strategy and design. For a company to act in its financial self-interest is not only seemingly obvious but required as a matter of law in every state and under ERISA. A benchmark that was once defensible as the best available proxy becomes impossible to justify once procedure-level, market-level data are published monthly that reveal a material difference from a national benchmark.