What is healthcare price transparency?
Hospital vs. health plan price transparency
What does the health plan price transparency data reveal?
Vertical integration and rate negotiation
Physician employment and rate variation
How are stakeholders engaging with price transparency data?
In 2024, U.S. healthcare spending reached $5.3T, or $15,474 per person and 18.0% of GDP. Private businesses, largely employers sponsoring coverage for their workers, are responsible for 18.3% of that spending.1 Yet unlike purchasers in every other sector, employers and patients have historically paid for healthcare services without knowing their price. In healthcare, negotiated rates between health plans and providers were historically confidential, protected by contract terms and shaped by antitrust guidance that discouraged public disclosure of pricing information and thwarted value-based competition.
Federal rules have now changed that. Hospitals have been required to publish negotiated rates since 2021, and most commercial health plans since 2022. While these initiatives were intended to help consumers shop for care, the data itself are too large and complex for most consumers to use. Their value has instead emerged among the organizations that buy, sell and finance care. For the first time, employers, payers, providers and policymakers can see what is paid for most services, across plans, providers and markets, and they can bring that evidence to contracting, network design and benefit decisions.
This report provides a detailed overview of Federal price transparency rules, compares hospital- and health plan-reported data, examines what the data show about price variation and its relationship to quality and evaluates how different stakeholders are putting the data to work.
Over the past 40 years, the Federal government has incrementally tried to address the high and growing cost of healthcare (Figure 1). The Federal government has the most direct influence over prices in Medicare and Medicaid, which account for 38.8% of national health expenditures (NHE).2 In 1983, Medicare began paying hospitals prospectively using diagnosis-related groups (DRGs). In more recent years, Federal regulators and policymakers addressed affordability and spending through the Affordable Care Act (ACA) and the testing of value-based care models, most of which have not generated savings.3 While commercial spending falls outside the federal government’s direct control, a 2022 Congressional Budget Office (CBO) report identified three approaches Congress could use to reduce the prices commercial insurers pay for hospital and physician services: promoting competition among providers, capping prices and increasing price transparency.4
Commercial negotiated rates are set through private negotiations between health plans and providers, and they remained confidential until recently. Contracts between health plans and providers commonly included confidentiality provisions, sometimes called gag clauses, that barred disclosure of negotiated rates. Federal antitrust guidance issued in 1996 by the Department of Justice (DOJ) and the Federal Trade Commission (FTC) also discouraged sharing current price information. However, the Consolidated Appropriations Act of 2021 prohibited gag clauses in contracts between health plans and providers, and the DOJ and FTC withdrew the 1996 guidance in 2023.
In November 2019, the Centers for Medicare & Medicaid Services (CMS) finalized hospital price transparency requirements alongside the calendar year (CY) 2020 Hospital Outpatient Prospective Payment System (OPPS) Rule, effective January 1, 2021. The rule requires U.S. hospitals to publish a machine-readable file (MRF) of standard charges for all items and services, including gross charges, discounted cash prices, payer-specific negotiated charges and deidentified minimum and maximum negotiated charges. Hospitals must also make these same charge types public in a consumer-friendly format for at least 300 shoppable services, 70 of which are specified by CMS. As an alternative to the consumer-friendly display, hospitals may offer an internet-based price estimator tool that provides real-time, personalized out-of-pocket (OOP) cost estimates for the same set of services.5,6
Following this, the Departments of Health and Human Services (HHS), Labor and the Treasury (“the Departments”) jointly finalized the Transparency in Coverage (TiC) rule in 2020, requiring health plans to publish MRFs of in-network rates and out-of-network allowed amounts for all covered items and services beginning July 1, 2022. The rule also requires health plans to provide enrollees with an internet-based self-service tool for personalized OOP cost estimates, phased in over two plan years, starting with 500 shoppable items, services and drugs for plan years beginning on or after January 1, 2023, and expanding to all covered items, services and drugs for plan years beginning on or after January 1, 2024.7 A related requirement to publish a prescription drug MRF has been enforced on a case-by-case basis since September 2023. The Departments plan to develop a schema for the drug MRF beginning in November 2026 and expect plans to begin publishing it using that schema in December 2027, with monthly updates thereafter.8
On October 5, 2026, the Departments finalized amendments to the TiC rule intended to improve the standardization, accuracy and accessibility of health plan MRFs. The amendments require plans and insurers to exclude provider-rate combinations for services a provider is unlikely to render (i.e., “zombie rates”), to report in-network rates by provider network rather than by plan, to attest to the accuracy and completeness of each file and to update the in-network and out-of-network files quarterly rather than monthly. The rule also adds context files, including a taxonomy file and a utilization file, and requires plans to make cost-sharing information available by phone for plan years beginning on or after January 1, 2027. The file amendments will be introduced in phases, beginning in March 2027 for the in-network and out-of-network files and September 2027 for the new context files.
Effective January 1, 2022, the No Surprises Act added a further consumer protection, requiring providers to give uninsured and self-pay patients a Good Faith Estimate (GFE) of expected charges for scheduled services. A parallel requirement under the No Surprises Act, in which providers would give insured patients a GFE that health plans then use to generate an Advanced Explanation of Benefits (AEOB) before scheduled care, has not been implemented.9 The Departments have deferred enforcement of the AEOB and insured-patient GFE requirements pending future rulemaking, and no compliance deadline has been set.
FIGURE 1. Timeline of Select Federal Efforts to Contain Healthcare Costs
Medicaid law is amended to require all managed care capitation rates to be set on an actuarial basis
Tax Equity and Fiscal Responsibility Act of 1982 establishes capitated payments in Medicare
HCFA adopts DRGs with prospective payments anchored by base rate
HCFA implements Physician Fee Schedule for physicians and other professionals
DOJ releases guidance on exchange of price and cost information for healthcare providers
Medicare Prescription Drug, Improvement and Modernization Act creates prescription drug benefit (Part D) and MA
Affordable Care Act requires insurers submit prospective rate hikes for review, establishes CMMI, etc.
CMMI introduces value-based payments
Patient Right to Know Drug Prices Act and the Know the Lowest Price Act prohibit “gag clauses” that conceal lower prescription drug prices at pharmacy
White House announces price transparency for healthcare
June: Executive Order 13877 directs agencies to require hospitals to disclose prices and health plans to give patients out-of-pocket cost information
November: CMS finalizes the Hospital Price Transparency rule, requiring hospitals to post standard charges in machine-readable files and a consumer-friendly display of 300 shoppable services
HHS, Labor and Treasury finalize the Transparency in Coverage rule, which requires health insurers to provide clear and easy-to-understand information about pricing and coverage details and to offer online tools so consumers can estimate cost sharing within an enrollee’s own plan.
Hospital Price Transparency takes effect
January 1: No Surprises Act takes effect, limiting surprise out-of-network bills and requiring Good Faith Estimates for uninsured and self-pay patients
July 1: Health Plan Price Transparency takes effect
August 16: Inflation Reduction Act sets deadlines for cost sharing and spending caps and authorizes Medicare to negotiate drug prices starting in 2023 and effective in 2026.
September 29: CBO report identifies price transparency as one of three approaches to reduce commercial prices.
January 1: TiC consumer tool requirement begins, requiring plans to offer an online tool with out-of-pocket estimates for 500 shoppable services
February: DOJ withdraws 1996 safe harbor for healthcare pricing
April: CMS hospital price transparency enforcement process updates (shortened CAP timelines)
January 1: TiC consumer tool expands to cover all covered items and services
February: Executive Order 14221 directs agencies to require disclosure of actual prices, not estimates, and to strengthen enforcement of hospital and health plan price transparency rules
December 23: CMS, Labor and Treasury propose amendments to the TiC rule to improve the standardization, accuracy and usability of health plan MRF data
January 1: OPPS/ASC rule takes effect to standardize hospital MRF data by requiring hospitals to report median, 10th percentile and 90th percentile allowed amounts.
September: OPPS/ASC proposed rule / RFI seeks public feedback on how to improve readability of hospital MRF data
October 5: TiC amendments are finalized, requiring plans to exclude unlikely provider-rate combinations, report rates by network, attest to file accuracy and update files quarterly
| Note: HCFA denotes Health Care Financing Administration; CMS denotes Centers for Medicare & Medicaid Services; DRG denotes diagnosis-related groups; DOJ denotes Department of Justice; CMMI denotes Center for Medicare & Medicaid Innovation; MA denotes Medicare Advantage; TiC denotes Transparency in Coverage; MRF denotes machine-readable files; RFI denotes request for information; HHS denotes Department of Health and Human Services; CBO denotes Congressional Budget Office. Source: Centers for Medicare & Medicaid Services; Congressional Budget Office. |
Hospital and health plan price transparency rules share a common policy objective of making the negotiated rate between a specific payer and a specific provider for a specific service easily available to consumers. However, the 2019 CMS hospital price transparency rule and the 2020 TiC rule produced two separate datasets, one published by hospitals and one published by health plans, which differ in data architecture, update frequency, schema requirements and enforcement mechanisms (Figure 2). Hospital MRFs cover hospital care, are updated at least annually and include gross charges, discounted cash prices and negotiated rates for commercial, Medicare Advantage and managed Medicaid plans. Meanwhile, health plan MRFs cover only commercial plans; they include in-network negotiated rates for all care settings including outpatient offices, ambulatory surgery centers, labs and imaging centers, and are updated monthly, though this will switch to quarterly beginning in March 2027. Given the higher update frequency and breadth of health plan price transparency data, it is generally considered a more reliable source compared to hospital price transparency data. Currently, neither dataset reports service volume, so neither shows which rates are paid most often. For this reason, transparency data are often paired with claims data.
FIGURE 2. Comparison of Hospital and Health Plan Price Transparency
| Components | Hospital Price Transparency | Health Plan Price Transparency |
|---|---|---|
| Regulatory background |
November 2019 The CY 2020 Hospital Outpatient Prospective Payment System Rule, finalized in November 2019, CMS began requiring hospitals to publish:
Updates: July 2024: Made pricing files more standardized but allowed hospitals to report percentages and algorithms instead of dollar-and-cents prices. January 1, 2026 (enforced April 1, 2026): Strengthened standardization and readability by requiring more information on MRFs. Requires median, 10th and 90th percentile allowed amounts, Type 2 National Provider Identifier (NPI) and named attester. |
November 2020 HHS, the Treasury Department and the Department of Labor finalized the Transparency in Coverage Rule, requiring health plans to publish:
Updates: October 5, 2026: Final rule (CMS-9882-F) amending TiC, following a December 23, 2025 proposed rule (90 FR 60432) |
| Data frequency |
Hospitals must update their MRF at least annually at any point during the year. CY 2024 template requires a “last updated on” date. |
Currently, payers must update data monthly and it must reflect current contractual payment information as of the month of publication. |
| Business lines |
Hospitals must publish all negotiated rates, including rates with commercial plans (group and individual), Medicare Advantage plans and managed Medicaid plans. |
Commercial group (self-insured and fully insured) and individual market plans; excludes grandfathered plans (those in place before March 2010 that have not significantly changed) and excepted benefits (e.g., dental/vision). |
| Primary intended user |
The consumer-friendly display is designed for patients. MRFs are designed for researchers, regulators, employers and third-party vendors. |
The self-service cost estimator tool is designed for patients. MRFs are designed for researchers, regulators, employers and third-party vendors. |
| Readability |
Initially, hospitals were allowed to publish the negotiated rates for each payer and network combination using their own naming convention and were not required to state which line of business each network reflects. The CY 2024 OPPS final rule requires hospitals to post the payer and plan name (as specified in the contract). |
Within the payer files, the data are clearly labeled as either group or individual, although the network name may not always be clear. Once the final rule applies, payers will be required to provide network-level files, product type and network identifiers, a single JSON format and the new taxonomy and utilization files. |
| Billed charges and negotiation rates |
Data include the negotiated rate, or the allowed amount, for each service by billing code, with negotiated rate reported as a specific dollar amount; includes billed charges and cash prices in addition to the negotiated rates. The data contain information about the specific rate methodology that applies to each negotiated rate. In May 2025, CMS guidance required a new data element on encoding “allowed amounts” in hospital MRFs. |
Data include the negotiated rate, or the allowed amount, for each service by billing code, and negotiated rates can be reported as the specific percentage rate (rather than a negotiated dollar amount) for services that are reimbursed as a percentage of billed charges (or the gross amount). Additionally, the fee schedule for each negotiated rate is included. However, the in-network file does not include billed charges, while the out-of-network file does. |
| Network information |
The data only contain in-network negotiated rates. |
Payers are required to publish two MRFs an in-network: negotiated rate file and an allowed amount file with out-of-network rate information. However, the allowed amount MRFs do not include information that is as comprehensive as the in-network MRF. Once the final rule takes effect, out-of-network files will need to be aggregated by market type, with the claims threshold lowered from 20 to 11. |
| Covered services |
Standard charges for all chargemaster items |
The data include all provider types, including professional practices, specialty groups, standalone radiology centers, labs and other provider types. |
| Capitation/ bundled payments |
Hospitals are not required to report and identify bundled payment and capitated rates with the applicable billing codes. |
Payers are required to report and identify bundled payment and capitated rates with the applicable billing codes. |
| Schema |
Since July 2024, hospitals have been required to use a standard CMS template. The CY 2026 OPPS/ASC rule added further hospital-side standardization, and an August 2026 CMS request for information (RFI) (CMS-2026-2344) is soliciting public comment on how to improve MRF comparability. |
CMS maintains a required schema and a website with formatting examples and a channel for questions. |
| Limitations/ compliance |
As of August 2026, 49.4% of hospitals are compliant with posting MRF and prices for the 300 most common shoppable services.10 |
The files contain large numbers of “zombie rates.” Over 300 entities have contributed data, and very few have not posted. |
| Data limitations |
Conflicting rates: Posted rates diverge from the health plan’s rate for the same payer and procedure. Rate-type mix: Files may report percentages or algorithms in place of dollar amounts, limiting comparability. |
Conflicting rates: A single service can carry multiple distinct rates with no indication of which is correct. Rate-type mix: Files mix dollar amounts, percentages of billed charges, per diem rates and bundled or capitated arrangements. Zombie rates: Rates listed for providers or organizations that do not provide a given service, along with duplicate and invalid entries. The October 2026 TiC final rule requires that unlikely provider-rate combinations be excluded and that each file carry an attestation. |
| Enforcement mechanism |
If hospitals are not in compliance, CMS can require corrective actions, issue a civil monetary penalty or both. Penalties range from $300 per day for hospitals with 30 or fewer beds to $5,500 per day for larger hospitals, before inflation adjustment. |
CMS enforces TiC for issuers and nonfederal governmental plans. Labor and Treasury enforce for Employee Retirement Income Security Act (ERISA) plans, including penalties of up to $100 per day per affected individual for noncompliant plans. |
In practice, health plan-reported and hospital-reported commercial negotiated rates can differ. For example, Aetna-reported rates are consistently higher than hospital-reported Aetna rates for endoscopy CPT codes, with hospital-to-health plan rate ratios averaging 0.6 for CPT 43239 (esophagogastroduodenoscopy with biopsy), CPT 45380 (colonoscopy with biopsy) and CPT 45385 (colonoscopy with snare polypectomy) (Figure 3). This indicates that health plan-reported rates are, on average, 1.7x the hospital-reported rate for these procedures. For CPT 47562 (laparoscopic cholecystectomy) and CPT 49650 (laparoscopic inguinal hernia repair), the average ratios are closer to parity at approximately 1.0 and 0.9, respectively. For UnitedHealthcare (UHC), average ratios are near or slightly above 1.0 for the same endoscopy procedures and slightly below 1.0 for the laparoscopic procedures.
The largest single-hospital discrepancy where the health plan-reported rate is higher than the hospital-reported rate is an Aetna rate for CPT 45380, with an observed difference of $11,001. The largest single-hospital discrepancy where the hospital-reported rate is higher than the health plan-reported rate is a UHC rate for CPT 47562, with an observed difference of $31,048. Across all hospital-payer-procedure combinations, 10.8% have an exact match between the health plan-reported rate and hospital-reported rate, and 41.7% fall between 0.9x and 1.1x. However, 17.9% have a hospital-to-health plan ratio below 0.5x or above 1.5x, a level of discrepancy between the two sources that limits the comparability and usability of the data.
Negotiated rates vary nationally, even within a single payer. UHC negotiated rates for MS-DRG 236 (coronary bypass without cardiac catheterization or major complications/comorbidities (MCC)) at short-term acute care hospitals range from $28,861 to $195,609, a factor of 6.8x (Figure 4). Negotiated rates for MS-DRG 331 (major small and large bowel procedures without complications/comorbidities (CC) or MCC) and MS-DRG 470 (major hip and knee joint replacement or reattachment of lower extremity without MCC) also range by a factor of 6.8x, from $11,595 to $78,588 and $13,290 to $90,076, respectively.
Negotiated rates also vary within and across markets. Across select CBSAs, median negotiated rates for MS-DRG 470 range from $24,134 in Dallas-Fort Worth-Arlington, TX, to $43,655 in Phoenix-Mesa-Chandler, AZ (Figure 5). Within a single market, negotiated rates can also vary substantially. For example, in Dallas-Fort Worth-Arlington, TX, negotiated rates for MS-DRG 470 range by 3.0x from $21,604 to $64,637.
Negotiated rates vary not only geographically but also by payer, even within the same facility. Nationally, Aetna negotiated rates for MS-DRG 470 range from $13,290 to $117,081, a factor of 8.8x, while UHC negotiated rates for the same procedure range from $13,290 to $90,076, a factor of 6.8x (Figure 6). Nationally, the median UHC commercial negotiated rate for MS-DRG 331 is $4,064 higher than the median Aetna rate, $29,336 and $25,272, respectively. Within a single hospital, negotiated rates can vary substantially by payer. At Tufts Medical Center, the UHC negotiated rate for MS-DRG 331 is 1.6x the Aetna negotiated rate. At Robert Wood Johnson University Hospital New Brunswick, the Aetna negotiated rate is 2.6x the UHC negotiated rate.
Negotiated rates for the same service also vary by care setting. For many procedures, negotiated rates are higher at hospital outpatient departments (HOPDs) than at ambulatory surgery centers (ASCs), while rates at ASCs vary more widely. For example, the national median UHC HOPD negotiated rate for CPT 29827 (rotator cuff arthroscopy) is $13,477, while the median ASC rate is $5,492 (Figure 7). UHC commercial negotiated rates at HOPDs for CPT 29827 range from $7,437 to $59,816, a factor of 8.0x, compared with $3,697 to $35,196 at ASCs, a factor of 9.5x.
In many markets, negotiated rates are growing faster than general inflation. Between 2024 and 2026, average commercial negotiated rates for CPT 19307 (modified radical mastectomy) grew faster than the 6.6% increase in the Consumer Price Index for All Urban Consumers (CPI-U) in 26 of 47 CBSAs and faster than the 9.9% increase in the national hospital CPI in 12 of 47. Rate change for this procedure ranged from -24.5% in Oklahoma City, OK to 45.4% in San Francisco-Oakland-Fremont, CA (Figure 8).
Across the hospitals analyzed, negotiated rates for common inpatient conditions show little correlation with quality. While the median negotiated rate for MS-DRG 280 (acute myocardial infarction) in Los Angeles-Long Beach-Anaheim, CA is $32,858, the hospital receiving the highest rate ($63,622) also has the fifth-highest mortality rate (12.5%) of the hospitals analyzed (Figure 9). For four common medical MS-DRGs (chronic obstructive pulmonary disease, pneumonia, acute myocardial infarction and heart failure), the correlation coefficient between negotiated rate and mortality rate ranges from r=-0.30 (heart failure) to r=0.25 (chronic obstructive pulmonary disease). If higher price and better quality were perfectly correlated, the correlation coefficient would be r=-1.
While negotiated rates and quality are generally not correlated, the availability of health plan price transparency data has the potential to motivate value-based competition. Between 2024 and 2026, the correlation between 30-day heart failure mortality and negotiated rate strengthened in Chicago-Naperville-Elgin, IL-IN, decreasing from r=-0.26 to r=-0.32 (i.e., lower rate, higher quality) (Figure 10). While the median negotiated rate increased from $16,689 in 2024 to $19,105 in 2026, the median mortality rate improved from 10.3% to 8.9%. The range of negotiated rates widened from 2.5x to 3.3x, while the mortality rate range narrowed slightly from 2.4x to 2.3x, indicating that prices diverged even as quality converged.
When a payer and a provider share a parent organization, the rate between them is not negotiated through the same competitive process as rates negotiated between unaffiliated organizations. UHC and Kelsey-Seybold Clinic, a provider group within UnitedHealth Group's Optum subsidiary, illustrate this situation. UHC's negotiated rates with Kelsey-Seybold for evaluation and management (E/M) CPT codes (99211-99215) are consistently higher than UHC's negotiated rates with other providers in Houston-Pasadena-The Woodlands, TX for the same E/M codes, ranging from approximately 5% higher at the lowest-complexity code (99211) to nearly 70% higher at the highest-complexity code (99215), relative to the average market rate (Figure 11).
Negotiated rates also differ by physician employment status. Across various specialties, blended E/M rates for hospital-employed physicians are higher than those of their independent peers in Chicago-Naperville-Elgin, IL-IN. Hospital-employed physicians average $239 for the blended E/M rate, compared with $147 for independent physicians, a difference of $92 (Figure 12). The difference in commercial reimbursement varies by specialty type, ranging from $42 in primary care ($196 vs. $154) to $122 in urology ($263 vs. $141).
Federal price transparency data have created a new category of analytical capability – benchmarking an organization's own contracted rates against those of competitors or peers. Employers, hospitals, payers and researchers each use this capability differently, while state policymakers and consumers engage with the data in other ways.
Employers are well-positioned to demand value for enrollees. Private businesses, mainly employers sponsoring coverage for their workers, are responsible for 18.3% of all healthcare spending, with employers covering 180.7M individuals, or 53.5% of the insured population.11,12 However, employers often fail to exert the leverage that comes with their purchasing power. TiC data, paired with publicly available quality benchmarks, should allow employers to understand the price differences for the same service within a market and assess whether providers in that market offer good value. Under the Employee Retirement Income Security Act of 1974 (ERISA), private-sector plan sponsors have a fiduciary duty to act “solely in the interest of participants and beneficiaries” based on the information available to them. Some large employers have started using TiC data to identify underperforming carrier relationships and benchmark specific contracts ahead of renewal. One employer with staff across 20 regions used price transparency data to determine that its carrier’s rates were as much as 12% higher than those of competing carriers in eight metropolitan markets and held costs flat the following year by switching carriers in those markets. A separate employer used the same type of analysis to negotiate an orthopedic contract $3M to $4M lower than it otherwise would have paid.13 While price transparency can help employers design high-value benefits for their employees, only 18% of large firms (200 or more workers) have conducted or received analyses using price transparency data as of 2025, with use increasing with employer size (Figure 13).
Hospitals and health systems can use TiC and hospital price transparency data to understand their price position relative to competitors ahead of payer contract negotiations. Hospital MRFs show the rates a competing hospital has negotiated with each payer, and TiC files show the rates a given payer has negotiated with other providers in the market. Together, the files allow a hospital to see where its rates for the same services fall above or below those of competitors and to compare what a single payer pays across hospitals. In addition, price transparency may incentivize hospitals to lower charges if enough patients are likely to compare prices and switch to a competitor.14 The usefulness of this comparison is limited by the same data quality issues that affect other stakeholders. Zombie rates and conflicting rates in payer files can make a competitor’s posted price unreliable. The mix of rate types (e.g., percentages, dollar amounts) can make rates difficult to compare across organizations.
The share of hospitals complying with the hospital transparency rule has increased from 14.3% in February 2022 to 49.4% in August 2026 (Figure 14). However, following a rule update in July 2024 requiring stricter reporting data, the share of compliant hospitals decreased to 21.1%.15 Although compliance has improved since the rule took effect, more than half of hospitals are still not fully complying with transparency requirements, indicating that enforcement has not yet driven full compliance.
Payers both use and publish price transparency data. As users, payers can compare the rates they have negotiated against those of competitors, which are visible in other payers’ TiC files, and against the rates hospitals report having negotiated with other payers in hospital MRFs. Payers are also the publishers of TiC data, and the usefulness of the data for other stakeholders depends on the quality of the MRF files, which varies considerably by payer. The completeness of negotiated rate data is one measure for gauging a payer’s adherence to price transparency mandates. An analysis published in The American Journal of Managed Care assessed the share of commonly billed codes that had negotiated rates in the 2025 TiC files for Aetna, Cigna and UHC.16 The study examined the most common Healthcare Common Procedure Coding System (HCPCS) codes for three specialties (i.e., cardiology, family practice and orthopedic surgery) and for hospital outpatient settings, as well as the most common DRG codes for hospital inpatient care. Completeness was highest for physician specialties and lowest for hospital settings, with the weakest setting differing by payer (Figure 15). UHC’s physician group data were nearly complete, but its median hospital inpatient data had rates for only 2% of common DRG codes. Cigna’s physician and inpatient data were highly complete, but for the median hospital outpatient department, its data had rates for only 4% of common codes. Aetna’s hospital outpatient data fell in the middle. The October 2026 amendments to the TiC rule address some of these issues, such as by requiring payers to exclude unlikely provider-rate combinations and to attest to the accuracy and completeness of each file.17
Researchers have previously studied commercial price variation using claims data contributed by participating employers and insurers, such as RAND’s hospital price studies and Health Care Cost Institute research. However, TiC and hospital price transparency changed data accessibility, making negotiated rates public for every payer, network and provider type, and researchers no longer need a claims contribution or restrictive data use agreement to study them. An early peer-reviewed study using TiC data analyzed Humana’s negotiated rates for seven common services and found wide variation across geography, even within one insurer.18 Another study found that UHC’s negotiated commercial rates with hospitals for hip and knee replacements ranged from $11,203 to $106,427 nationally, with substantial variation by hospital and payer in the Chicago area.19 Researchers have also begun using the data for questions beyond price variation. One study examined how health system concentration and insurer concentration relate to negotiated prices for outpatient procedures.20 The data also make it possible to compare what a payer pays a provider group it owns with what it pays other providers. The main methodological challenge researchers report is that TiC files include zombie rates, or rates for providers who do not provide the service. Studies therefore link the files to claims data in order to identify the providers who actually deliver each service. For example, one study linked insurer-posted data to claims for approximately 270M people to improve the data’s usability.21
States have also begun supplementing Federal price transparency requirements. Arizona's Department of Health Services is responsible for monitoring hospital compliance with Federal requirements and publicly posting the names of noncompliant hospitals.22 Arkansas imposes state-level penalties on hospitals that do not comply with Federal requirements.23 Texas has codified the Federal hospital price transparency rule into state law with enhanced state-level penalties for noncompliance, and has extended TiC-style disclosure requirements to health plan types not covered by Federal rules, such as short-term limited duration plans, for which the state has issued its own data schema and standardization guidance.24 Colorado passed HB22-1285 in 2022, adding state-level consumer protections when hospitals are found out of material compliance with Federal hospital price transparency rules, and SB24-080 in 2024 requiring insurers, carriers and pharmacy benefit managers to submit Colorado-specific pricing data to the state's Division of Insurance.25,26 Colorado's state-specific MRF went live on August 15, 2025, and updates every six months.27 Colorado's Department of Health Care Policy and Financing separately publishes its own hospital compliance evaluation, independent of Federal tracking, which found that the share of Colorado hospitals rated Good or Fair rose from 73.5% in November 2022 to 84.2% in 2024.28 States also use price transparency data as plan sponsors. In 2023, North Carolina’s State Health Plan for Teachers and State Employees released a report analyzing hospital prices for 16 shoppable services at 140 North Carolina hospitals and found median prices up to 1,120% above Medicare rates for some routine services.29 Another potential explanation is the limited options available to consumers, who are constrained by insurance networks, highly concentrated markets and provider shortages.30,31
Consumers can use price transparency data to “price shop,” or find and compare the price of healthcare services across providers before receiving care.32 Price shopping is most relevant for patients who pay a meaningful share of the cost themselves, such as uninsured patients or those who have not yet met their deductible. Price transparency is effectively irrelevant to emergent patients, who represent approximately 50% of hospital admissions.33 Patients presenting at the emergency department rarely know their diagnosis, making it impossible to search for specific procedure costs. Even for truly shoppable services where patients theoretically have time and options to compare prices, the complexity of understanding how deductibles, copays, coinsurance and OOP maximums interact with both cash and negotiated rates creates cognitive barriers that prevent informed decision-making.
Despite these barriers, public support for price transparency is high. Nearly all Americans surveyed (96%) believe they deserve to know the price of healthcare before they receive it, and 89% support the Federal government requiring hospitals and health insurance companies to provide actual prices of healthcare, not estimates (Figure 16).34 This support holds across sex, age, education status and political affiliation. Despite the availability of pricing data since 2021, most consumers do not price shop. A 2022 survey found that 64% of Americans had never tried to look up the price of a healthcare service. Price shopping varied by age, with 45% of adults ages 18 to 34 having researched healthcare prices, compared with 27% of adults ages 55 and older.35 Limited awareness may partly explain low use of transparency data. A 2025 survey found that only 20% of American voters believed that patients currently have access to actual prices for healthcare services.36
Federal price transparency requirements took effect in 2021, and two datasets now describe the same negotiated rates, with one published by hospitals and one published by health plans. They were created under separate rules, on separate schedules and for different audiences. Across the outpatient procedure codes examined in this report, the hospital-to-health plan rate ratio was above 1.5x or below 0.5x in 17.9% of hospital-payer-procedure combinations, and the two sources matched exactly in only 10.8%. Health plan price transparency data are often considered more reliable since they are updated more frequently and cover more provider types and care settings.
The data reveal that negotiated rates differ by payer, facility, site of care and geography. Commercial rates for several MS-DRGs varied by 6.8x to 8.8x nationally, and between 2024 and 2026 rates for one procedure grew faster than general inflation in most markets analyzed. Notably, observed differences in rates do not align with differences in quality. Negotiated rate and mortality rate were not meaningfully correlated across the inpatient conditions examined, and in at least one market, rates moved further apart between 2024 and 2026 while a quality measure for the same condition improved. Ownership is also associated with higher rates. When a payer and provider share a parent organization, the rate between them is not set through the same competitive process as rates between unaffiliated organizations. In Houston-Pasadena-The Woodlands, TX, UHC's rates with Kelsey-Seybold Clinic, a provider group within UnitedHealth Group's Optum subsidiary, were higher than its rates with other providers. Because no quality measure exists for these services, the rate differences cannot be evaluated against quality differences. Post-discharge mortality reporting – required since 2007 – has become less complete over time, which limits price and quality analyses more broadly.37
Price transparency data are already being used in several ways. Employers have used health plan data to review carrier relationships and negotiate lower rates. Hospitals and payers use them to benchmark their rates before contract negotiations. Researchers use them to study commercial price variation across every payer and provider type. Some states, including Colorado, have added their own disclosure rules and compliance tracking to Federal requirements.
Use of price transparency data remains limited by variable data quality, uneven enforcement and low public awareness. Only 18% of large firms report having conducted or received a price transparency analysis as of 2025, even though ERISA requires employers to act in the interest of plan participants. Compliance varies among payers subject to Federal rules, including in the share of files that are machine-parsable and the share of rates reported in conflict with one another. Hospitals and payers cite administrative burden as a main concern with current and proposed requirements, and CMS enforcement so far has focused mostly on small and rural hospitals. Among the public, 96% of Americans surveyed believe they deserve to know prices before receiving care and 89% support a Federal requirement that actual prices be disclosed, yet only 20% believe actual prices are currently available to them.
Price transparency has expanded considerably since 2021. Whether that expansion lowers costs or improves value depends on who uses the data, how completely they are reported and what quality information is available for comparison.