Marilyn Bartlett is a CPA and a senior policy advisor with the National Academy for State Health Policy, where she developed and continues to work on its Hospital Cost Tool. She was 64 and ready to retire when Montana asked her to run its state employee health plan, which was headed into insolvency. In under three years she moved its projected reserves from minus $9 million to a positive $112 million, without raising employee premiums and while improving benefits. Before that she was controller for a Blue Cross Blue Shield plan and CFO of a regional third-party administrator.
This conversation follows the healthcare dollar from the employer, through carriers and middlemen, to the hospital. Marilyn explains how Montana moved its hospitals to Medicare-based reference pricing, why most self-funded employers never see the claims data that shows where their money landed, and how Medicare cost reports show what a hospital spends to deliver care. Listeners come away knowing which contract clauses to question, what claims data to demand from a TPA, and where to start when a plan is losing money.
In this episode
- From gold mining and utilities, where every cost was visible, to a Blue Cross Blue Shield controller’s desk where prices were hidden
- Taking over a 30,000-life plan projected to lose $28 million, starting with the 11 acute care hospitals that made up 87% of Montana hospital spend, and one paid an average of 611% of Medicare for outpatient care
- Why employers rarely get their full claims data, how float and cross-plan offsetting work, and why every payment has to be reconciled to where it landed
- Bringing employees and the union on board, and the last hospital holdout that cited a most favored nation agreement
- How NASHP’s Hospital Cost Tool uses Medicare cost reports, including a hospital’s claimed 40% Medicaid loss that its cost report put at 18%
- Shifting the hospital conversation from revenue adequacy to revenue efficiency, and the employer data provisions in the Patients Deserve Price Tags Act
- Where hospital price transparency compliance stands, and what the updated Transparency in Coverage rules mean for employers
- Where a benefits director with a money-losing plan should start, the $5.5 million in wellness vendors Montana cut, and how HIPAA’s need-to-know standard keeps claims details away from the employer
Figures cited in this episode
Marilyn cites a handful of numbers on tape. Here they are checked against the primary sources.
Marilyn puts hospital price transparency compliance at about 20% before the rules allowed pricing algorithms, and in the 40% range now. PatientRightsAdvocate.org’s reviews of 2,000 hospitals match: its previous report found 21.1% in full compliance, and its eighth report, released in September 2026, found 49.4%, the highest it has recorded.
Marilyn said the updated Transparency in Coverage rules should be out in early October. CMS finalized them on October 5, 2026, and they take effect December 7, 2026.
Marilyn describes a $4 million out-of-network payment where the provider received about $875,000, the repricer about $700,000 and the carrier $2.1 million. The claim is documented in Chris Deacon’s July 2024 testimony to the Senate Special Committee on Aging: the plan paid $4,078,652, of which $875,810 went to the provider, $677,944 to MultiPlan and $2,524,899 to Cigna in fees. The carrier’s share was larger than the figure cited on tape.
Transcript
Andrew Gordon: Welcome to The Price of Healthcare. I’m your host, Andrew Gordon. On this show, we sit down with the executives, operators, and advocates working to build a functional healthcare market. Every episode, we’re unpacking what’s broken, what’s working, and what it takes to buy healthcare with informed choice. My guest today is Marilyn Bartlett, a certified public accountant by training. Marilyn is a senior policy advisor with the National Academy for State Health Policy, also known as NASHP, where she developed and continues to work on its Hospital Cost Tool. The tool takes the Medicare cost reports that every hospital already files and turns them into something a state or an employer can use when negotiating what they pay hospitals.
Andrew Gordon: She’s also researching how efficiently hospitals use the money they bring in, working with Patient Rights Advocate on policy, and working with employer group health plans to address their costs. Before that, Marilyn ran the Montana State Employee Health Plan, taking it from projected reserves of minus $9 million to a positive $112 million in under three years while improving benefits. She’s also been controller for a Blue Cross Blue Shield carrier, chief financial officer for a regional third-party administrator, and special projects coordinator for the Montana Commissioner of Securities and Insurance. In 2019, Fortune named her number 13 on its list of the world’s 50 greatest leaders, one spot ahead of Apple’s Tim Cook. Marilyn, welcome to The Price of Healthcare.
Marilyn Bartlett: Well, thank you, Andrew. It’s good to be here.
Andrew Gordon: So today we’re going to be talking about the work that it takes to understand where your healthcare dollars go and how to track the numbers behind them. Marilyn spent a large part of her career doing exactly this. I’d love to start the conversation kicking things off with the finance work that you did before you came into healthcare. Tell us a little bit about what that was like, and when you did make the transition into healthcare, what jumped out at you?
Marilyn Bartlett: Oh, that’s a good question. I think that as a CPA, of course, I held financial positions. I had worked in the mining area with coal mining. I had worked for a utility company, and I had worked for a gold mining company, and I was in controller positions, administrative superintendent positions, and I really focused on the financial side. And it was really great. I put cost accounting systems in so we could look at every single cost through the mining process for gold.
Marilyn Bartlett: So you knew exactly the assay costs, you knew every single cost that went along. We also were really good at purchasing the different supplies and contracts. Everything was transparent, absolutely transparent. You knew the costs you were paying. You could compare it to a contract, market pricing. You could compare it to the market. And it was really good. It was really, you know, definitely the CPA work. And then I entered healthcare and I entered healthcare as a controller at a Blue Cross Blue Shield plan. And I was really, really surprised at the lack of transparency. The inability to really verify prices and even to get ahold of contracts to verify prices.
Marilyn Bartlett: Things were very segmented, things were not transparent, and you would receive a number from the association that you were to book on your financial statements for different BlueCard or FEHBP program. But no detail behind it. So that was very, very hard. And then we also invoiced the employer group health plans. And so following the claims costs, and that was just really — that was like night and day to me, the lack of transparency in healthcare, to be able to get to the different contracts, to be able to understand the pricing, to see that pricing was negotiated, but not public, that it was just, it was different. You didn’t know really what you were paying for most of the time.
Andrew Gordon: I want to dive into when you talk about following the dollar, I’d love to sort of work through an example or just get some additional clarity from you on what does that look like and what does that mean? You know, in general, maybe when you sit down with a set of financials, but then also if there’s any thoughts or examples that you can give relative to the healthcare space when it comes to really following the dollar all the way through and what that looks like.
Marilyn Bartlett: Following the dollar is really basically you’re incurring expenses for inputs that you’re bringing in, and then you’re receiving revenue for outputs that you’re sending out. And so on the inputs alone, to try to figure out what are the components of that price, and you surely find very quickly in healthcare, it’s pretty much going to be a middleman in there somewhere. And so trying to decipher those costs, it’s difficult because you can’t get to the underlying contracts and … where are you? Both areas I was in had the provider network negotiations.
Marilyn Bartlett: So there was certain people that negotiated prices with the network, and that was all very secretive, and you couldn’t see the underlying components of that negotiation, and you couldn’t understand why maybe sometimes a particular price for a service was at one amount, then it was another amount. I naively thought, well, the price of fixing a broken leg’s going to be the same across the board, but it’s not. It depended on that negotiation and how much power those negotiation teams had.
Marilyn Bartlett: And so every employer had a different price usually, and then there were add-ons if they had a point solution involved in it. And then we started getting into shared savings and value-based was just starting to come in. And you could see the spread that was really being held for value-based for the providers to meet certain targets. And it’s very, very hard because one, there are a lot of little add-ons. And number two, it’s not transparent. You have to really dig to try to find it and find the underlying document or price that supports it. And that’s near impossible in healthcare, but it wasn’t in mining and it wasn’t in the utilities.
Marilyn Bartlett: And the interesting thing there too, and I know I’m jumping around, but the interesting thing there is I realized that in mining, the market set the price. So in gold mining, it’s a commodity and the market sets the price. You’ve really got to know your costs. That’s your only leverage you have. In the utility area, the regulatory body sets the rate. And yes, you could market and try to sell more, but in healthcare, trying to figure out what the price of healthcare was, whether it be a hospital, a doctor’s office, a device, a supply, that is opaque. And that was really a transition.
Andrew Gordon: You were close to retirement when Montana called. What made you say yes?
Marilyn Bartlett: Yeah, that was really interesting. I was 64 years old, ready to head to retirement. And the state of Montana reached out to me to ask me about applying for the position of the administrator over the employee self-funded plan, that it was headed into insolvency. They wanted a financial look at that. And so at that point in time, the financial reports, all the meeting notes, everything was online. They published it on their site, so I was able to pull it up and look at the trends, look at the prices. I was able to look at the number of point solutions they had, which is a typical thing that will happen when a plan seems to be struggling. They think, oh, our problem is drug costs.
Marilyn Bartlett: We’re going to hire a different company to look at our pre-auth side of care. Oh, our problem is musculoskeletal. We’re going to hire somebody else to take care of the musculoskeletal area. And so I could see which is that stacking of vendors, which adds costs. And they may be very helpful, but you got to measure that. You got to measure the outcome. Is it helping us for that cost?
Marilyn Bartlett: So it may be what you need. But my focus had always been hold the TPA accountable. They’re the ones doing the prior auth. Your PBM’s doing the prior auth. Why aren’t you holding them accountable? Musculoskeletal, you’re paying for some care coordination programs within your TPA contract, hold them accountable. So anyway, I looked at that and I thought, oh, this plan is in trouble. It was spiraling down and you could see they were projected to lose $28 million that year. That is a lot for a plan of 30,000 lives and the whole state of Montana and its taxpayer money and member money.
Marilyn Bartlett: So I thought, man, I had been thinking about this with, well, there was a broker at the TPA, Sandra Hartman, and she had been explaining to me a lot about how we price as a discount off a chargemaster, which makes no sense to an accountant because you don’t know the chargemaster and then you negotiate a discount. And then there was threshold pricing that came in and there were a lot of things.
Marilyn Bartlett: And so as accountant, we had brainstormed cost plus because that’s what we do as an accountant. So we had talked a lot about using Medicare price as a reference point. So I studied that a little bit more and I decided that that would be a better way to go because if you’re losing, losing, losing money, you can’t bring on another point solution. You can’t just tweak a little benefit. You’re left with either shifting major costs to the employees or really cutting their benefits. And I didn’t want to do either.
Marilyn Bartlett: So I thought, how can we leave premiums where they’re at and not take away benefits? Well, the only choice is get the money out of the system. And the biggest spend, 43% of our spend were in the Montana hospitals. So we had to go there first, and we had to go to the 11 acute care hospitals because they comprised 87% of the total Montana spend. So we had to go there first.
Marilyn Bartlett: And we did an RFP. We found a vendor, Allegiance Benefits Management, and they had been studying this for quite a while. They really had knowledge in this area. They knew about reference-based pricing. They had worked with a third party on repricing claims. So we worked together to model the program. And it was a tough year. It was a tough year negotiating with the hospitals to get those prices down. We had just two years to do it till the legislature came back. And they had said there’d be no pay raises unless we could get the prices down.
Marilyn Bartlett: And we were under the microscope to get it done. So that’s what we did. Plus, we cut out a lot of the point solutions. We enhanced the primary care at the onsite health centers. We renegotiated — well, we actually did a new RFP for a new PBM. We changed consulting firms. We did a lot. We just changed the whole thing. Now, there are some things out there now that we didn’t have 10 years ago when I did this that are great. And that are payment integrity vendors that will come in and take a look at your claims data and be able to see how the claims were paid.
Marilyn Bartlett: And they have been able to save anywhere from 5% to 10% and recover funds from overpayments, missed payments, and also give you some transparency into that data. The other thing that is absolutely great is now we’re getting the transparency and coverage files. The TiC files, and we’re getting the hospital price transparency files. And we have great firms that are out there really getting that information in usable form for us.
Marilyn Bartlett: And so now there is pricing information out there where there wasn’t 10 years ago, and pricing information that can compare the price you’re paying to Medicare. And so, you know, when we looked at our claims when we first did this, we saw on an average one hospital we were paying 611% of Medicare for outpatient. So we decided we have a range that we wanted the hospitals to get to.
Marilyn Bartlett: And we negotiated with every hospital to come down to this range. Some it took a couple of years to get there. So you have to kind of work with the providers.
Andrew Gordon: We talk about the importance of getting claims data. What does that process just in general kind of look like? And are people getting their claims data by default, or is that something they have to ask for and demand?
Marilyn Bartlett: That’s a really good question. I find in general, they’re not getting their claims data. They may say, oh yes, we get our claims data, but the key to it, which I’m not finding many employers doing, is typically you get a claims funding report, and the TPA wants to hold the cash. So they will — the larger, the carriers, the TPAs, the larger ones will hold it in their bank account.
Marilyn Bartlett: So they’ll send you a claims run, and that claims run should show you the claim number, and it should show you the amount. And I like it if it shows you who it’s being paid to, but it doesn’t always do that because that claims amount may be paid to several parties. But you’ve got that claim amount and the claim at a minimum. You know the date you funded it. I really find that employers, what they need to do is then reconcile it on the back end. I paid $2,000 on this claim on September 12th. Oh, it’s over here, end of the year, and it didn’t come through on my claims run.
Marilyn Bartlett: So there’s a lot of float that goes on. So why isn’t it there? And then you find out, oh, it was cross-plan offsetting. It’s in your contract. It means we can use your money to pay another employer’s claims, but you, the employer, are still liable. You’ve got to reconcile, and you’ve got to reconcile in total. You’ve got to reconcile on this day, I paid this much, and you’ve got to make sure every one of those claim payments got paid.
Marilyn Bartlett: For instance, on out-of-network claims, we’ve got an example where the employer paid $4 million. This came out of a court case in California. The employer paid $4 million for residential addiction treatment care. And you can see on the employer’s records, they paid the $4 million, but they didn’t get their claims data. But when the court got the claims data, you could see that the provider was paid $875,000. The repricer that comes in to negotiate was paid about $700,000, but $2.1 million went to the carrier because they have a clause that they can keep 30% of savings, sometimes 50% of savings. And savings is what you were billed less what they negotiated.
Marilyn Bartlett: Now that needs to be in your claims run. So maybe you’re going to see over here, I paid $4 million, and you say, oh, this claim says $4 million was paid. You need the fields behind that to know who was paid what. And I’ll tell you, we’re having a hard time getting the claims data. Employers will say, we get the claims data. In some cases, their consultant broker gets that claims data, but they’re under a contract with the carrier, not to share the data further.
Marilyn Bartlett: So they’re locked down on the data. You don’t always get all the fields. It takes a lot of reconciliation to make sure you got all the fields. Now, you have seen the court cases of employer group health plans, and I’ve been expert witness on a couple of them, where you support the employer to get their claims data, and the carrier, TPA says, no, it’s proprietary and confidential. You can’t have the claims data.
Marilyn Bartlett: But when we get the data, we’re able to see some of these payments to the carrier’s subsidiary, to other parties. We’re able to see what makes up that claim. And I would say, as an employer, when you say you get your claims data, do you reconcile what went out to where it landed specifically? Who received those payments? And to do that, you’re going to need the detailed claims file. Detail. And we’re working with employers to try to get the data that goes from the TPA to the provider, because that’s where you can track the payments. So getting down to follow the money and all that accounting.
Andrew Gordon: Yeah, it’s a lot of really, really important activity that needs to happen. And I think there are certainly a lot of folks that, to your point, they’re not getting that level of visibility. And the thoughts around information being proprietary, why wouldn’t both employees and employers be on board with kind of doing this? And how do people maybe navigate, or how have you seen companies navigate this notion of we’re going to keep the network that you’ve had, but we’re also going to do some additional work to substitute out certain partners or just to figure out how we can better procure or put into place direct contracts or whatever that may be while, I guess, minimizing disruption?
Marilyn Bartlett: It’s a really good question. And I faced this when I went to the state of Montana employee health plan because the employees were told you’re getting very minimal raise and you may not get one unless you can get those health plan costs down. And purchasing healthcare from the employee side or from a consumer side is emotional. It’s an emotional decision. It’s not a commodity. It’s not a, I can go without buying this book this week, or I can go without this latte this week. It’s emotional. It’s your life. It’s your family’s life. It’s your health.
Marilyn Bartlett: So it brings in different issues. And I think employees were mad. The union was mad. The union was mad, feeling that the plan had not been managed well. And that anger has to come out somewhere. So we made the commitment, we’re not going to raise premiums and we’re going to give you better care and we need your help. And I was very fortunate that the governor at the time and my department of administration, or the lead of it, the department head, and the budget director were all on board, and they had very close relationships with the union leadership, and they were able to actually mobilize the employees to help.
Marilyn Bartlett: So we made sure the members knew we were doing something and making promises to them. And then we also knew on the legislative side, we were not going to set price caps. We were not doing price fixing. We were changing the method of reimbursement, and we were negotiating with each hospital to come up with a rate that would set them. So we were able to mesh and get a lot of support from both sides. And it is hard for an employer. I was very fortunate that my focus is financial and we had the governor’s office staff that was really able to help more with the other side, the employee side and messaging.
Marilyn Bartlett: But it is tough. It is tough. But the best part of it is that you talk from the viewpoint of we’re going to get the money out of the system and we’re going to get the money back to you and the taxpayers. So with even enhanced benefits. And I’m sure glad we did it because here they — boy, look what we’ve taken on. But we knew the numbers. We knew the leverage points.
Marilyn Bartlett: And the Allegiance team had great provider network contracting and negotiating skills. But it is hard on employees because if you face that you can barely make ends meet now, now you have a higher premium. You’re not going to get to see the same providers that you used to. That’s a horrible position to be in, to care for your family or to care for yourself. It’s a horrible position.
Marilyn Bartlett: And I think that puts the employer group health plan in a tough position. But I think the untapped area is getting the money out of the system and learning that you can do a lot of this yourself. You don’t need that expensive broker. You don’t need these things. You need to get into those contracts. You need to see what’s going on. Some of the congressional testimony that’s come up in the Senate on some of the bills in the House, and one of the pieces of testimony included a clause from a current contract with a PBM and a brokerage firm, and that its current contract and that contract says, for every employer group you sign up, broker, and we’re going to give you $7 per 90-day script.
Marilyn Bartlett: Did we know this was going to work? No. When we started off on this path, we had the data. It all made sense. It all seemed to work. Everything was going to go live on July 1st, and of the large hospitals, June 15th, five aren’t signed on. So what are we going to do? And we weren’t going to blink. We were going to stick with it. And we had come up with travel benefit options. We had worked through a lot. And in that last week, three more hospitals came on, and they slowly came on.
Marilyn Bartlett: And then it was July 1st, and one hospital had not signed on and refused to. And unfortunately, or fortunately, they did say in the press that they could not give us the pricing that we wanted because it was lower than Blue Cross Blue Shield, and they had an agreement with Blue Cross Blue Shield that they would get the lowest price. So a most favored nation arrangement. And our comeback on that was that this is taxpayer money, these are state employees. And that’s when I dug into the financial statements and could see how much the hospital had in reserves, what the large salaries were that we could really look — that they were capable of taking.
Marilyn Bartlett: And we knew how much the revenue would go down for them. And we continued to negotiate, but we put in travel benefits and it’s a town that has two hospitals, fortunately. One is very small, but we were able to route some of the cancer care there. We were able to bring people to Helena to the onsite health center. We were creative and they signed on August 6th.
Marilyn Bartlett: So yeah, you don’t know, but you’ve got to take those steps. And the interesting thing is, as you take those steps, you learn more. You just keep learning more and maybe alter your course a little bit. But our — we had our goal in mind was to have reference-based pricing contracts with the hospitals in Montana and not increase employee premiums, not decrease benefits, in fact enhance them.
Andrew Gordon: We want to pay attention to the health of everybody that’s involved, including these excellent, excellent providers that are serving our communities and are absolutely doing amazing work.
Marilyn Bartlett: Oh, I think you’re absolutely right. We need our hospitals. And our critical access hospitals in Montana are only 13% of that hospital spend, just 13%. And there are 60 critical access hospitals. Montana is a big state. We weren’t going to hurt them at all. In fact, some of them received increases in rates. And the one hospital that had probably the higher critical care of patients, we did the glide path, three years to get down there.
Marilyn Bartlett: And we worked with them. We worked with them very, very closely. And some procedures that they do very, very well and were cost-effective for us, we could channel members to them. So we worked with them. We didn’t want any hospital to close. We wanted to kind of just make it better for everyone.
Andrew Gordon: In terms of the, the Hospital Cost Tool, I’d love to just dive into the why a bit behind that and, you know, what you built it to solve and how it works and how folks have used it, who’s using it, that kind of stuff.
Marilyn Bartlett: Certainly. It was actually born out of my work in Montana because as we negotiated with hospitals, I needed to understand their financial condition. I needed to understand. So I’m familiar with audited financial statements. We all love those, but they’re at the system level. And so they’re going to bring in everything that they own. There might be some schedules at the back that carve them into smaller groups, but you couldn’t get to that actual hospital.
Marilyn Bartlett: So I started off with wanting to know the hospital’s costs. And the Medicare cost reports are really the only source, public source, of being able to get to hospitals’ actual costs. So I studied the Medicare cost reports, the Medicare pricing, the methodology that is used. And it’s basically their methodology is to get a hospital to close to break even. So they didn’t want to give them surplus because they want the hospital to become more — continue to be efficient.
Marilyn Bartlett: But a relatively efficient hospital will break even or make a slight margin. So in my mind, that came to be pretty much close to cost. So I studied the reports and I learned a lot that you could get from them. So I used them when we were negotiating. For instance, we were negotiating with one hospital that said, you can’t lower the prices, we are losing 40% on Medicaid.
Marilyn Bartlett: So I thought, oh, I need to figure that out. So I went to the hospital cost report and I came back and I said, you know, last year you lost 18% on Medicaid. On Medicaid, but it’s only 9% of your payer mix. That’s not by revenue, that’s by care. So that’s a different story than if you lost 40% and it was 50% of your payer mix. Losing 18% and 9%, yes, you know, that’s not good for you, but that margin to make up isn’t a huge spread.
Marilyn Bartlett: So I thought when I went to the National Academy of State Health Policy, states were struggling with how do we know the hospital’s costs? They were all working with the audited financial statements, days cash on hand, debt coverage service ratio, some of those very common metrics that we all use. And I thought, we need to go deeper. You need to go deeper. You need to get into the cost. You need to get in the revenue. You need to know the payer mix. You need to learn everything.
Marilyn Bartlett: And the Medicare cost reports will do it. So I’ve completed an Excel worksheet that you could go to a Medicare cost report and you could put numbers in certain fields and it would calculate all of this for you. So you could know those results and you could go talk to a hospital and policymakers and states could use it as a tool to better understand the hospital’s financial condition.
Marilyn Bartlett: So how states have used it is numerous. We’re seeing states use it a lot, Washington, other states, that have used it for their state employee health plan to go to reference-based pricing. We’ve used it a lot in Indiana to really show how much — where the hospitals maybe are having payment issues, where they’re not.
Andrew Gordon: I wanted to ask you, relative to the Hospital Cost Tool numbers and then looking at audited financial statements from a hospital, sometimes there could be different narratives or stories told between those two things. Wondering what should purchasers believe? How should people discern the difference between those two things? How would you unpack that for us?
Marilyn Bartlett: Yeah, I think you need both. I use both. I use the 990, the Medicare cost report, public things, because I love to make organizational charts. Haven’t automated that yet because you need to see all the entities that are owned, the for-profit entities, the tax-exempt entities, the offshore entities. But the audited financial statement is going to show you that whole thing. It’s going to show you all the revenue of everything owned under that entity, and that’s good to know.
Marilyn Bartlett: And the expenses, the footnotes are great. They tell you definitely where the money’s going, assets that are retired, if they merged, what happened was, did they gain money on it or lose money on it? And so there’s a lot there, and I think they’re good for looking at the whole corporation, especially since we’ve had so much consolidation.
Andrew Gordon: For sure. So with the latest update of the tool, you said version 6, right? Or what would — it covers close to, I think, 5,000 hospitals or so through 2024. What showed up in that data that you didn’t expect? Was there anything that kind of jumped out at you just thinking about the evolution of it?
Marilyn Bartlett: Yeah, I think we’re going to be rolling it out. Version 6 will have 2025 in it. I think one of the things that I have found as I use the data or the graphs from the tool too, we’re able to see that since COVID things have really gone up. But we’re also now able to compare how much of it is salaries, wages, how much of it is direct patient care, how much of it is administration.
Marilyn Bartlett: We’re able to see drug costs compared to drug charges, and we see that spread, not so much in the cost, but definitely higher. So we’re able to see kind of what you hear in the market. We’re able to see a little bit deeper what’s going on there. And I’m kind of excited because one of the things that we’re starting to work on, and this came through the times that we’re facing now, is we keep hearing from the providers, we need more revenue.
Marilyn Bartlett: We’re getting revenue cut from Medicaid, Medicare, government programs. We’re getting revenue cut. We need the revenue. We need the revenue. So we’re trying to switch the conversation from — we’ve always looked at revenue adequacy. Do I have enough revenue to cover my expenses? We’re trying to look at efficiency now. And we’re just starting to dig into that. How can you become more efficient? And we’ve talked about you and I have shared the story about the hospital that has been able to manage to Medicare rates. They determined how could we become more efficient? Where can we pick up efficiencies?
Marilyn Bartlett: And the hospital CEO knows way more about building hospital efficiency than I do, and definitely the hospital staff. But how can they build more efficiency if they’re not going to get that revenue? We’re really, through Patient Rights Advocate, strongly advocating for Senate Bill 2355, which is the Price Tags Bill, where hospital prices will be posted dollars and cents, imaging centers, labs. But even more important from where I come from, Sections 7 and 8 requires that the employer group health plan receive all their data, including the transaction data that goes to the provider and what they were billed. It’s adding transparency so you really can manage that plan.
Andrew Gordon: It’s important, very much so needed. And to build on that work that you’re doing with patient rights advocacy and thinking about policy, would love to get your read on where we stand in the push for the compliance relative to this information. Obviously, these are things that have been kept secret for a while until all the legislation started to emerge 2019, 2020, and beyond with the hospital machine-readable files, the transparency and coverage files. Where do we stand when it comes to compliance and the ability for this information to get into as many hands as possible?
Marilyn Bartlett: Well, I’m going to talk about the two separate. One is the hospital price transparency files. And what we saw was very low compliance with it, maybe around 20%. But then some of the rules got changed. And you were allowed to do some algorithms, which are really hard to work through to try to come up with what a price is. So now you could say the compliance is up in the 40%, but is the data usable?
Marilyn Bartlett: So I think that’s what we’re working on heavily with Patient Rights Advocate is get that data useful. But compliance has been very, very low. Now, TiC files, transparency and coverage files, and those have to be produced by the plan, the insurance carrier, if you’re, you know, on that, or if you’re an employer group health plan. Those have been difficult, massive amounts of data and ghost data. The data now we’re actively watching because the updated TiC regulations should be out in early October, and the updated regulations will spell out what has to be complied with.
Marilyn Bartlett: And I think those would be very useful for the employer group health plan. I just want to be able to compare it to other payers. I don’t want just mine as an employer. I don’t want to see what just my TiC file is. I want to see what a Cigna, an Aetna, an EBMS, whatever is paying in the market too. So I’m anxious to see what those TiC files come out because we’re trying to move this to that marketplace where people can see the costs and get transparency that we can move to more of an industry that’s not opaque.
Andrew Gordon: There’s a benefits director that might be listening to this right now. They have a plan that’s bleeding money. Where should they start?
Marilyn Bartlett: Oh, that’s a really good point. I think that they need to start with their contracts. I think you need to go back and read your contracts, and there are plenty of sources out there that will be more than ready to help you. Get your contract. Look for clauses in there that may say you may pay more than billed. If it’s an out-of-network claim and we reprice it, we get 30% of the savings. What does that mean? Really get in there and look at your contract and understand that and push back.
Marilyn Bartlett: The second thing is I think you need to really get your data. You need to get your data and have a really strong analytics capability look at that and really figure out what that data is saying. You need to really question all the middlemen, look at the return on investment of every one of them and see what they’re doing. When I stepped into the state of Montana, I got rid of all of the wellness vendors except the one program that was driven out of our health centers. And saved $5.5 million. And I was really worried about that. How’s that going to impact the employees? And we, because of HIPAA, of course, I didn’t know who the employees were.
Marilyn Bartlett: I relied on our third-party address for them to go out and reach out to every single employee and redirect them. And we had a nurse on staff who did that too. I never got one complaint. In fact, it was interesting. What we heard back from the union was that they really appreciated it, that we cared enough about the person that they were being taken care of, and we followed up with them. Not we. I didn’t have access to the information, nor should I, but I think you can work with employees to get that done.
Marilyn Bartlett: But I think look at your contract, see these clauses in there that might be a problem, demand to find out. What are all the middlemen making as far as compensation? Even if it’s paid to their firm, even if it’s a wellness vendor, what is the payment and what is the payment that they’re sending back to the TPA for getting them a referral? So try to start flushing this out to try to follow the money a little bit where you can. And don’t be afraid. Don’t be afraid to do something really different, really different because the same old thing is just getting us the same old thing. Prices continue to go up. Employees continue to lose benefits. And employers continue to lose money.
Marilyn Bartlett: So I think just try something different, something I’ve never thought of. Great minds out there. You guys know your people. You know your vendors. You know your providers. Look at direct contracting. Just go for it.
Andrew Gordon: When we’re talking about the visibility, the accountability, and the flow of data and information, what exactly should employers be accessing? And then to your point, there’s some things that maybe you want to lean on those partners to manage from a healthcare journey and coordination standpoint, not just costs.
Marilyn Bartlett: Yeah, it’s a really good question. And it’s a topic that’s being discussed quite a bit now. And I think the HIPAA rules really apply and really do protect. The HIPAA rules basically say that an employer group health plan needs to have a privacy officer. And that privacy officer really determines who has the need to know. I didn’t have the need to know. I needed to know the claim number and the dollars and cents. I needed to know those things. I didn’t need to know the person. I didn’t need to know their care plan.
Marilyn Bartlett: But the privacy officer knew that our data analyst who was working in the claims data needed access, our nurse that was care management nurse needed access to the data. And then we had a very small appeals team of just those two, and then we added two more people if something went in for appeals. And the employee had to sign that it was okay to give the data to that appeals team.
Marilyn Bartlett: So it’s very, very restricted. You only see the data if you have the need to know. So the employer doesn’t see the data. The group health plan has a need-to-know basis and very, very strict penalties if you ever violate that. So we always required the employee approval if anyone was to know the data other than the data analyst and the nurse and the TPA.
Andrew Gordon: Important distinctions for sure. Thank you for that clarity. For those who are interested in reaching out to you after this episode, where would you direct them?
Marilyn Bartlett: I would direct them to — actually, you know, I don’t really have a social profile, which is probably good. But I am on LinkedIn, so you can find me there. You could reach out to me there. That would be good.
Andrew Gordon: Excellent. Marilyn, thank you so much for joining us on The Price of Healthcare.
Marilyn Bartlett: Thank you.
Andrew Gordon: And that’s a wrap for this episode of The Price of Healthcare. We’ll see you on the next one. Thanks so much for listening.