Grief is also common. While we may not like to talk about it, 37% of Americans are grieving a recent death. The U.S. averaged 3.26 million deaths per year over the last five years and data suggests that an average of nine people grieve a single death. The CDC started measuring bereavement for the first time in 2021, but most health plans aren’t yet measuring the incidence or cost of grief.
So we decided to take a look. Here’s just some of what we found.
When a member is bereaved, health plans — especially those serving older adults — see significant jumps in utilization and costs across multiple claims categories. Examples include:
These increases lead to escalating claims costs that add up quickly, especially in populations 65+. But what are these costs? And what can insurers do to mitigate them?
To make these hidden costs visible, my team at Help Texts created a tool that health plans can use to model bereavement’s financial impacts. With just member numbers, the Bereavement Cost Calculator from Help Texts will estimate a health plan’s:
● Projected Per Member Per Month (PMPM) cost increase after bereavement ● Total cost impact of grief when no intervention is provided ● Estimated savings when plans provide Help Texts’ clinically sound, scalable, grief support for bereaved members
Consider a Medicare Advantage Plan with 250K members ages 65+. It should expect: ● Potential year one cost reduction (with intervention): $22.8M ● 11,500 members to be grieving the death of a partner or child ● 81,500 members to be grieving other losses (eg. parent, sibling, friend) ● Average PMPM increase (without intervention): $120 ● Total estimated year one cost impact (without intervention): $134M *
What can a health plan do to save money and improve care and outcomes for its members? The numbers are powerful, showing that grief is expensive, but also that bereavement presents a clear opportunity to provide an impactful upstream intervention that can save millions, while also caring for people during what is often the loneliest time in their lives.
Help Texts is a clinically sound, scalable, bereavement intervention. With subscribers in 59 countries and all 50 states, Help Texts delivers affordable, multilingual grief support via text message. With extraordinary acceptability (95%) and 6-month retention (90%) rates, Help Texts’ light-weight solution makes it easy for health plans and others to improve health and community outcomes, while also realizing significant cost savings for those in their care.
Health Plans, particularly Medicare Advantage plans, can use the new bereavement cost calculator from Help Texts to estimate the true cost of bereavement and their cost savings when grief support is provided. The Bereavement Cost Calculator from Help Texts uncovers the savings potential when caring for grieving members. In less than a minute, you can start to see how much bereavement is costing, and how much could be saved by supporting members grieving the loss of a loved one.
Because the true cost of bereavement isn’t only emotional, it’s also financial. And for health plans, addressing both is the smartest investment you can make.
In late July the UN International Court of Justice (ICJ) announced its long-awaited and highly-anticipated climate advisory opinion. The ICJ ruling represents an historic moment in climate accountability.
“Obligations of States in Respect of Climate Change”
In a rare unanimous decision, the ICJ opinion concluded “a clean, healthy and sustainable environment” is in part a precondition for the enjoyment of human rights including the right to life and the right to health. Consequently, the ICJ ruled states including their private actors are obligated to ensure the climate is protected from anthropogenic greenhouse gas emissions (GHGs) and can be held legally culpable by other harmed or unharmed states, groups and individuals for failing to protect the climate.
The 140-page opinion is the result of a 2023 UN resolution that requested the ICJ produce an advisory opinion answering two questions: what are states’ obligations under international law to ensure protecting the climate and what are the legal consequences for causing significant climate harm? In a failed attempt the US State Department opposed the resolution arguing the ICJ can only consider applicable climate treaties such as the 2015 Paris Agreement and to the exclusion of other rules of international law.
In sum, the ICJ found states have substantive, urgent and enforceable obligations under UN climate treaties and international laws to prevent significant harm to the environment from GHG emissions that includes those resulting from fossil fuel use. The court broadly defined fossil fuel use as the adoption of laws, regulatory policies and programs that promote fossil fuel production and consumption via leases, licenses and subsidies.
States must act using “all means at their disposal” that includes adopting appropriate legal and regulatory measures, acquiring and analyzing scientific and technological information and risk and impact assessments, meeting a duty of cessation and acting in good faith that includes a duty to cooperate and collaborate internationally. The ruling also allows for legal action to protect future generations. The court rejected the argument attributing harm on a case-by-case basis is unachievable stating it is “scientifically possible” to determine each state’s current and historical emissions. Without naming the US, the ICJ affirmed states not party to UN treaties must still meet their equivalent responsibilities under international law. (Columbia’s Sabin Center Climate Change Law Blog has examined at length the ICJ opinion.)
US Healthcare’s Contribution to Anthropogenic Warming
Because the ICJ recognizes an inherent link between anthropogenic warming and human rights, the opinion implies the right to health cannot be secured without addressing US health care’s own climate obligations. Meeting these pose a substantial challenge for the industry for several reasons.
US health care significantly contributes to anthropogenic warming. Per Northeastern Professor Matthew Eckelman, the industry accounts for a growing amount GHG emissions currently at over 600 million metric tons of carbon dioxide equivalents (CO2e), or 9-10% of total US emissions and 25% of global healthcare emissions. If US healthcare was its own country it would likely rank 9th, less than Saudi Arabia but more than Germany.
Two reasons largely explain US healthcare’s carbon footprint. The industry is immense. Despite providing care for 4% of the world’s population, last year it constituted a $5.3 trillion market or roughly half of total global healthcare spending. The industry wastes an enormous amount of energy. Despite spending over $5 billion annually on energy, equivalent to at least 15% of profits, hospitals are significantly energy inefficient because they continue to consume fossil fuels to first generate heat to produce electricity that is dramatically less efficient than using renewable resources that directly generate electricity or work demand. End-use energy inefficiency compounds the problem. For example, only a trivial number of hospitals are EPA Energy Star certified for energy efficiency. For the ten-year period ending in 2024, 85 or 1.4% of over 6,000 hospitals were on average certified.
A little-noticed telehealth safe harbor provision tucked inside the One Big Beautiful Bill was a significant milestone in virtual care. Though it specifically addresses pre-deductible telehealth services in high-deductible health plans, the legislation has far wider implications for both care delivery and insurance design, especially in the commercial insurance market. In fact the permanent extension of a pandemic-era policy is a clear signal to health insurers that a new era of virtual care is under way.
The provision, which permanently extended an expired pandemic-era policy, is a win for employers and workers. After five years of uncertainty, employers are now empowered to provide telehealth services to their entire workforce at little or no cost, which has been shown to reduce access barriers and close gaps in care. For self-funded employers in particular, this flexibility in cost-sharing — combined with an increasingly sophisticated ecosystem of virtual care providers — will further accelerate innovation in benefits strategy and workforce well-being.
Less obviously, this employer-led innovation is also changing the virtual care landscape for a key partner: health plans. Though 20% of employers contract directly with specialized telehealth vendors, 78% rely on their health plan partners — and their vendors — to provide telehealth services for employees. As employers revisit their long-term virtual care strategy with new assurance in the wake of the safe harbor provision, health plans have an important seat at the table.
That seat is heating up, however. In a year when employer healthcare costs are projected to increase by more than 9%, employers are scrutinizing their partnerships and plan design to ensure that virtual care solutions are delivering meaningful value to their employees and their bottom line.
In a new annual survey from the Business Group on Health (BGH), more than three-quarters of employers said they are actively eliminating underutilized programs and underperforming vendors, or are considering doing so. Employers are also stepping up expectations in RFPs, evaluating potential healthcare partners on a growing list of factors and capabilities including performance guarantees, product and network design, reporting and analytics, and member experience.
In this light, the safe harbor provision is a call to action for health plans to evaluate their own virtual care strategy and partnerships through an employer’s lens. Three areas are especially important:
1. Quality
In the BGH survey, employers cited navigation to higher-quality providers and better quality transparency as top priorities — and virtual care is no exception. In last year’s survey, half of all employers expressed concerns about the quality of virtual care.
I have been on a quest to try to understand why I am being charged $34.95 by Labcorp for some lab tests that I think should be free under the ACA preventative care statutes, and for which my insurer Blue Shield of Californian has issued me an EOB with a $0 co-pay.
It’s been a microcosm of the chaos of American health care so far, If you want to catch up here’s part 1, part 2, part 3 and part 4
You may recall that I had paid a $50 co pay for the lab tests connected to my preventative annual wellness visit in 2024 (and I didn’t pay attention) but that when I got a $34.94 charge from Labcorp in 2025 and found that Blue Shield said my copay was $0, I decided to investigate.
I have had a lot of help from Rhea, a senior customer service rep at Labcorp who I think is having nearly as much fun with this as I am. She told me that the co-pay Labcorp tries to collect is the lower of $50 or whatever the total bill is. For the 5 tests I had, Labcorp’s agreed rate with Brown and Toland Physicians (the Blue Shield-owned IPA that contracts with their HMO, of which I am a member) was $34.94. So that is the answer as to that charge.
But it still doesnt answer a couple more questions.
Why was a subsequent lab test I had as a follow up also shown by Blue Shield as a $0 copay on the EOB?
Why weren’t the lab tests I had considered preventative under the ACA and therefore also free?
Rhea’s guess for the first answer is that Labcorp receives a capitated amount for lab tests from Blue Shield or Brown and Toland, and that the second test was somehow covered under that. Maybe, but then why wasn’t the first one?
The second question takes me further down a rabbit hole. Rhea dug out the order from One Medical to Labcorp. You can see below that the CPT codes are on it (what the tests actually are) and also what the related diagnosis codes are.
I of course asked chatGPT what those diagnosis codes were and the answer is E78.5 = Hyperlipidemia (i.e. high cholesterol) R73.03 = PreDiabetes E66.811 = Obesity class 1 M10.9 = Gout
As you might suspect as a pretty typical 60+ year old American, I fit the bill for all those diagnoses. The CPT codes for the tests I had are complete blood count, Metabolic Panel, Hemoglobin (A1C), Lipid Panel, and Uric Acid (which causes gout).
Presumably all of those, with the possible exception of the Gout/Uric Acid, could be seen to be preventative. After all the CMS web site explains that preventative screening is free for “Annual Wellness Visits and Physical Exams, for instance with a primary care doctor and Health Screenings for blood pressure, cholesterol, blood sugar for diabetes, and various cancer screenings such as colonoscopies and mammograms”.
So why is this not free to me? Rhea from Labcorp suggests that Blue Shield initially issued me a $0 copay EOB but later should have reprocessed that when it got the bill from Labcorp, and told me to pay the $39.94. She also found that in addition to CMS suggesting what should be called preventative, Blue Shield of CA has a very long document with what it thinks is preventative care. You can see and download it here.
I asked ChatGPT to read it for me and after a bit of looking around we (that’s me and ChatGPT) concluded that E78.5 is in the list of applicable ICD-10 diagnoses codes for Annual health appraisal visits, which are a (free) covered service. So my high cholesterol should be screened for free.
On the other hand there’s a whole section on Page 28 of the document discussing pre-diabetes education but it doesn’t explicitly say that an A1C test is covered under the annual wellness visit. And if you go way down, to page 116, there’s a table that suggests that last year a Blue Shield review removed several of the diabetes codes, including R73.03.
Now I am not going to pretend that I understand what the hell is going on in this document, and why (or whether) Blue Shield is able to change what CMS says it should do–if that is what in fact is happening. But it does seem weird.
And again, because there are no actual costs per test from Labcorp (there are charges per test but they are bundled and discounted on the bill), it’s impossible to tell what the contracted cost for each test was, and therefore whether I got some for free (as I think I should have) and what I was actually charged for.
Finally, I got very excited as Blue Shield sent me a message tonight which had an attachment which I think is a response to the grievance that was somehow filed for me by someone from their executive offices in part 2. But the attachment wasn’t properly formatted. So I don’t know what it says!
No less than I’d expect on this adventure.
But hopefully we are close to finding out who is charging whom for what and why!
UPDATE. I called Blue Shield’s grievance line and a nice customer service rep read me the letter that I couldn’t see online. Essentially Blue Shield has asked Brown and Toland to explain what happened. That grievance will take another 30 days! The rep wasn’t able to send it to me in my portal, but she could send me an email (It will be one of those secured ones that are super annoying to open). She told me it was sent while she was on the phone but 30 mins later, it’s not here!
You’ll recall we left it with a mystery $34.94 bill which didn’t either fit the official $50 copay amount I have, nor the $0 patient responsibility in my EOB. I got a call from Rhea Fleming, an experienced customer rep at Labcorp, on whose virtual desk this has been dumped. We had a lovely conversation in which we agreed that the co-pay should either have been $50 or $0 but that it’s possible that the co-pay is the lower of $50 or the amount Labcorp was trying to collect.
She had previously called the Blue Shield of California provider line to try to figure this out. Blue Shield had indeed kicked this claim from Labcorp to Brown and Toland the IPA I am assigned to in the HMO product I bought. The charges from Labcorp were $322.28 and the response from B&T was that the contractual price (i.e. what they agreed to pay Labcorp for those tests) was $34.94, hence the “adjustment” of $287.34. However in Labcorp’s system the algorithm interpreted B&T’s response as saying 1) the agreed payment is the $34.94 according to the contract and 2) they were not going to pay so the patient owes the difference. When Rhea Fleming asked Blue Shield’s rep why the patient owed payment on this, the Blue Shield rep said that the procedure code and diagnosis code from my PCP (One Medical) did not count as preventative care. In other words Labcorp has not got paid at all for running these tests so far, because they are according to B&T “not preventative”. Although IMHO, CMS says that they are. And of course as it says my copay is $0 I’m interpreting Blue Shield of California’s EOB as saying that to me!
Hence Labcorp generated the bill for the $34.94 and sent it to me. Which started this whole telenovela.
BTW Rhea’s conclusion was that as none of the tests were “preventative,” Labcorp billed me the $34.94 as that was the total it was contractually owed rather than the $50 copay I am supposed to pay for lab work. I actually checked back in my Labcorp account and found that last year I did in fact pay $50 so perhaps last year I had different tests or somehow they have changed the algorithm. I checked the EOB for that 2024 bill and the total charge was $445.20 of which Blue Shield paid $28.07. No I couldn’t find the Labcorp bill on their system, presumably because I have paid it! Given that I paid $50 for services from Labcorp on that date (yes, it took me 7 months to pay up!), it’s likely that the agreed payment was $78.07 ($50+$28.07) of which I unthinkingly paid the $50 copay. And yes that should have been preventative too. (Perhaps I should ask for that $50 back!!)
BRIEF UPDATE: Rhea from Labcorp looked into this 2024 bill and that is exactly what happened
Then, I had another thought.
It turns out that the lab results this year generated a further concern in my doctor’s mind. (Bear in mind I had the lab tests before the office visit so that we could discuss the results). It seems that my iron levels were a little low, so while I was in the doctor’s office he ordered some more tests specifically about that. As One Medical has techs on site they drew my blood then and there and shipped it to Labcorp.
According to my EOB, Labcorp’s charge for those new tests was $60.79 of which Blue Shield or rather Brown and Toland again paid $0 and created an EOB which again said my patient responsibility was $0. I asked Rhea to check that bill in her system and it turns out that I do NOT owe Labcorp anything on that set of tests. Maybe they were coded as preventative? I tried to find the bill on my patient portal at Labcorp but because I don’t owe anything I haven’t been sent an invoice and without an invoice number you cannot check the bill!
When Rhea ended the call with me, her next move was going to enquire of Blue Shield and Brown and Toland what the reason was for me owing $0 on that bill!
Meanwhile I await the result of the official Blue Shield investigation with interest. Of course this might just have come down to Amazon One Medical coding the tests incorrectly. But it’s all fun and games if you have unlimited patience in American health care.
There is no doubt Robert F. Kennedy, Jr. is sincere about wanting to make the world a better place. The Hudson River cleanup, which he helped lead, is one of the most successful environmental achievements in the United States. It had bipartisan support, set global standards, and earned the highest compliment: imitation.
It was quite reasonable to believe Mr. Kennedy could use those same skills and passion to lead Health and Human Services (HHS). He has a proven track record with complex systems, scientific evidence, and protecting public welfare. Even skeptics of his appointment want him to succeed.
But skill sets in one domain do not always translate to another domain—no matter how strong that skillset is. And it can be very difficult to realize this until the effects of the Law of
Unintended Consequences start to complicate things—as is now happening with Mr. Kennedy’s approach to public health. I know the feeling — because I had made the very same mistake.
Lessons from Databases
I had over fifteen years of experience with databases in auto parts, newspapers, manufacturing, and insurance before I started working with healthcare databases. Each domain had its own complex logic but I could adapt from one domain to another relatively easily.
When I started at the University of Iowa’s Department of Anesthesia, I was confident I could make a smooth transition to a new domain as I always had.
My first assignment was simple: create a report of the active prescription medications listed for a patient at a given appointment. It didn’t take very long to figure out how to find patient data, appointment data, and prescription data. My expertise in databases was transferring to a new domain quite smoothly!
All I had to do was use a chart I had and see how to make the connections.
I can read…how hard could that be?
Not only was it harder than I expected it to be, but I also didn’t immediately recognize why.
Parallel Paths
Mr. Kennedy took a similar path with vaccines and autism. He could see patient data. He could see vaccine data. He could see autism data. The connections seemed clear.
In my case, a researcher at Iowa had a theory that the length of a clinical appointment could be predicted by the number of prescriptions a patient was taking. My job was to combine all of the relevant data. He would then use that for his calculations.
I built a dataset. Everything looked right. But I was so new I didn’t realize there were hidden flags that identified appointment types. And flags for prescriptions that were active on the date of the visit. I didn’t even know there was a database flag that identified them. Flag is an oversimplification; it was far more complex than that.
Kennedy thought he had confirmation of his theory in 1998, when Andrew Wakefield and colleagues published a study in The Lancet suggesting a link between the MMR vaccine and autism. It looked right. It seemed obvious. A lot of people believed it. But like my report, it was flawed — a small sample size, uncontrolled design, and speculative conclusions. My initial dataset had “false” data because I missed some flags. My mistake was caught long before the data ever got close to any kind of study. Not only did the Wakefield study include falsified data, it made it to the publication stage.
My researcher kindly showed me my errors and I was fortunate it was early on in the process. Meanwhile, epidemiologists and clinicians have repeatedly shown Mr. Kennedy where his conclusions don’t stand up. Yet, like a friend of mine who once argued astronomy with Dr. James Van Allen — yes, the Van Allen Belts Van Allen — some convictions are hard to let go of, no matter how authoritative the counterevidence.
Three Questions for Transferring Expertise
I have learned to ask myself three questions whenever I enter a new domain — and I think they apply to all of us…including Mr. Kennedy.
So some of the more outspoken employees have written a letter. That should do the trick.
The letter, which they call the FEMA Katrina Declaration, was signed by almost two hundred current and past employees (although only three dozen allowed their names to be public). They charge:
Since January 2025, FEMA has been under the leadership of individuals lacking legal qualifications, Senate approval, and the demonstrated background required of a FEMA Administrator. Decisions made by FEMA’s Senior Official Performing the Duties of the Administrator (SOPDA) David Richardson, Former SOPDA Cameron Hamilton, and Secretary of Homeland Security Kristi Noem erode the capacity of FEMA and our State, Local, Tribal, and Territorial (SLTT) partners, hinder the swift execution of our mission, and dismiss experienced staff whose institutional knowledge and relationships are vital to ensure effective emergency management.
The letter goes on to list “Six Statements of Opposition,” calling to reverse various actions the Administration has taken that they believe impairs FEMA’s ability to fulfill its mission. Each seems perfectly reasonable, and none seems likely to result in action, at least unless/until disasters strike enough red states to force action.
FEMA spokesperson Daniel Llargues was not impressed, responding: “It is not surprising that some of the same bureaucrats who presided over decades of inefficiency are now objecting to reform. Change is always hard. It is especially for those invested in the status quo. But our obligation is to survivors, not to protecting broken systems.”
I probably wouldn’t have paid much attention to the letter, except it comes two months after some 90 NIH scientists issued their “Bethesda Declaration” to protest what has been happening to the NIH so far in the Trump Administration. Addressed to Director Jay Bhattacharya, it declared:
For staff across the National Institutes of Health (NIH), we dissent to Administration policies that undermine the NIH mission, waste public resources, and harm the health of Americans and people across the globe. Keeping NIH at the forefront of biomedical research requires our stalwart commitment to continuous improvement. But the life-and-death nature of our work demands that changes be thoughtful and vetted. We are compelled to speak up when our leadership prioritizes political momentum over human safety and faithful stewardship of public resources.
The Declaration lists five categories of cuts the Administration has taken, about which they warn: “Combined, these actions have resulted in an unprecedented reduction in NIH spending that does not reflect efficiency but rather a dramatic reduction in life-saving research.”
Amen to that.
Director Bhattacharya was somewhat more respectful than Mr. Llargues in his response, claiming: “The Bethesda Declaration has some fundamental misconceptions about the policy directions the NIH has taken in recent months, including the continuing support of the NIH for international collaboration. Nevertheless, respectful dissent in science is productive. We all want the NIH to succeed.”
I don’t believe him. This Administration does not recognize any dissent as “respectful.”
This is Part 2 of Jason and Gigasheets’ investigation into the Capital Women’s Care vs UnitedHealthcare contract dispute in which (partially at my request) he expanded the investigation to look at other providers in the same market. Revealing stuff!–Matthew Holt
While Capital Women’s Care (CWC) battles UnitedHealthcare over contract terms, a deeper look at Maryland’s OBGYN market reveals a complex competitive landscape where negotiated rates vary dramatically across providers and procedures. By analyzing price transparency data from both UnitedHealthcare and CareFirst BlueCross BlueShield, we can see exactly what each insurer pays CWC’s competitors. The results are eye-opening.
The Players in Maryland’s OBGYN Market
Our analysis focuses on four OBGYN providers in Maryland that have contracts with both UnitedHealthcare and CareFirst. These four practices were selected as a representation of the broader market because they have published rate data with both insurers, allowing for direct comparisons. However, Maryland’s OBGYN landscape includes dozens of additional providers, from solo practitioners to hospital-based practices, each with their own negotiated rates that may follow different patterns.
The four providers in our analysis include:
Capital Women’s Care – The large practice at the center of the UHC dispute, with multiple locations across the region
St Paul Place Specialists (Mercy Medical Center) – Baltimore-based OBGYN practice with established market presence
Maryland Physicians Edge – Women’s health group with OBGYN services, now part of Advantia
Simmonds, Martin & Helmbrecht – Established OBGYN practice, also under the Advantia umbrella
The four-provider sample provides valuable insights into competitive dynamics among major market players and helps contextualize the CWC-UHC dispute within broader industry patterns.
Following our analysis in Part 1, we examined negotiated rates for three common gynecologic procedures:
Code 56515: Destruction of cervical lesion (treatment following abnormal Pap smears)
Code 57288: Sling operation for stress incontinence (surgical procedure)
Code 58558: Hysteroscopy with sampling (diagnostic procedure for abnormal bleeding)
The Rate Comparison: UHC vs CareFirst
Rate variations in the price transparency data reveals a complex competitive landscape where UHC pays 200-500% more than CareFirst for hysteroscopy procedures across all providers in our sample, while Capital Women’s Care shows mixed positioning. Sometimes Capital Women’s Care commands premium rates from UHC (codes 56515, 57288), other times they’re receiving comparable rates to smaller competitors (code 58558). The data suggests both sides in the CWC-UHC dispute have legitimate arguments: CWC already receives competitive or premium compensation, while rate inconsistencies across procedures indicate room for negotiation.
Extreme rate variations (up to 519%) between UHC and CareFirst reveal market complexity, with Capital Women’s Care showing mixed competitive positioning that supports both sides’ arguments in their contract dispute.
Key Findings: A Tale of Two Insurance Strategies
UHC Generally Pays More Than CareFirst
Across 12 provider-procedure combinations, UnitedHealthcare pays higher rates than CareFirst 75% of the time. This suggests CareFirst has been more aggressive in negotiating lower rates across the Maryland market.
Hysteroscopy Shows the Most Dramatic Differences
For Code 58558 (hysteroscopy with sampling), the rate differences are staggering:
UHC pays 203-519% more than CareFirst across all providers
Average UHC rate: ~$2,200 vs CareFirst rate: ~$510
This represents the largest systematic difference across procedures
Capital Women’s Care Commands Premium Rates
CWC’s rates relative to competitors reveal why UHC may be resistant to further increases:
Code 58558: CWC’s UHC rate ($2,384) is already comparable to competitors, despite CWC’s larger scale
Code 56515: CWC gets slightly better terms from UHC ($581) vs competitors ($352-411)
Code 57288: CWC receives significantly higher rates from UHC ($1,685) vs most competitors ($1,008-1,258)
Wide Rate Variations
The most extreme example: Simmonds Martin & Helmbrecht receives 519% more from UHC than CareFirst for hysteroscopy procedures (a difference of nearly $1,700 per procedure). These patterns suggest that while some procedures have established market rates, others (particularly diagnostic procedures like hysteroscopy) lack standardized pricing, contributing to the complexity of provider-insurer negotiations like the CWC-UHC dispute.
Rate variations reveal dramatic pricing inconsistencies across Maryland’s OBGYN market, with hysteroscopy procedures showing the most extreme disparities difference between the highest and lowest negotiated rates for identical services.
What This Means for the CWC-UHC Dispute
CWC Already Commands Premium Rates
The data reveals a key insight: Capital Women’s Care isn’t necessarily getting unfair treatment from UHC. In fact, CWC often receives higher rates than competitors from both insurers:
For hysteroscopy (58558), CWC gets comparable UHC rates despite being a larger practice that should theoretically have less negotiating leverage
For cervical procedures (56515), CWC receives 40-65% higher rates from UHC than smaller competitors
For sling operations (57288), CWC’s UHC rate ($1,685) significantly exceeds most competitors
This pattern suggests UHC’s resistance to further rate increases may be economically rational rather than punitive.
Industry-Wide Rate Fragmentation
The massive variations between UHC and CareFirst rates across all providers highlight fundamental pricing inefficiencies in healthcare. However, within each insurer’s network, CWC consistently commands premium rates, suggesting their market position is already strong.
Scale vs. Negotiating Power
Conventional wisdom suggests larger practices should receive lower per-unit rates due to volume efficiencies. The data shows the opposite: CWC often receives higher rates than smaller competitors, indicating they’ve successfully leveraged their size for premium pricing rather than volume discounts.
The Broader Market Dynamics
CareFirst’s Market Power
CareFirst BlueCross BlueShield appears to have leveraged its position as Maryland’s dominant insurer to negotiate significantly lower rates across the board. With roughly 50% market share in Maryland, CareFirst can drive harder bargains with providers who can’t afford to lose access to half their potential patient base.
UHC’s Perspective Becomes Clearer
UnitedHealthcare’s position in the dispute gains context when viewed against competitor rates. UHC is already paying CWC premium rates compared to other Maryland OBGYN providers. From UHC’s perspective, further rate increases would create an even larger gap between what they pay CWC versus smaller practices.
The Economics of Provider Consolidation
The data illustrates a key tension in healthcare consolidation: large practices argue their size justifies higher rates due to quality and convenience, while insurers worry about paying premium prices for what should be commodity services. CWC appears to have successfully established premium pricing, making UHC’s resistance to further increases economically understandable.
Looking Forward: What This Means for Healthcare Costs
The Price Transparency Revolution
This analysis is only possible because of federal price transparency requirements that took effect in 2021. For the first time, we can see exactly what insurance companies pay different providers for the same services, revealing the massive hidden variations in our healthcare system.
Market Efficiency Questions
The data raises fundamental questions about market efficiency:
Why does the same procedure vary by 500% between insurers at the same provider?
Are patients getting better care when insurers pay more, or are some insurers simply paying inflated rates?
How can patients make informed decisions when rate variations are this extreme?
Regulatory Implications
These findings may attract regulatory attention, particularly around:
Whether rate variations this extreme serve any legitimate purpose
How to ensure patients aren’t penalized for insurance-provider rate disputes
Whether price transparency alone is sufficient to drive market efficiency
Conclusions: Both Sides Have Valid Arguments
The Capital Women’s Care vs UnitedHealthcare contract dispute becomes more nuanced when viewed through competitive rate data. Our analysis reveals that both sides can point to legitimate evidence supporting their positions:
Capital Women’s Care’s Case:
Rate Inconsistencies: For some procedures like hysteroscopy (58558), CWC receives similar UHC rates to much smaller competitors, despite CWC’s larger scale and presumably higher overhead costs.
CareFirst Comparison: CWC’s significantly higher rates from CareFirst for certain procedures (like sling operations at $2,245 vs UHC’s $1,685) suggest room exists for UHC rate increases.
Market Position Justification: As Maryland’s largest OBGYN practice, CWC can argue their scale, convenience, and comprehensive services warrant premium compensation.
UnitedHealthcare’s Case:
Already Premium Rates: Across multiple procedures, CWC receives higher rates from UHC than smaller competitors (40-65% higher for cervical procedures), indicating UHC already recognizes CWC’s value.
Economic Reasonableness: Further rate increases would create an even larger premium gap between CWC and other providers, potentially making UHC’s network economics unsustainable.
Mixed Performance: The inconsistent pattern across procedures suggests CWC’s premium positioning isn’t uniformly justified across all services.
The Complexity of Healthcare Negotiations:
Rather than a clear case of unfair treatment, the data reveals the inherent complexity of healthcare rate negotiations. Both parties can legitimately point to specific procedures and comparisons that support their position, while the overall picture remains genuinely mixed.
This analysis suggests the dispute reflects broader challenges in healthcare pricing: How do you fairly compensate scale and market position while maintaining reasonable cost structures? The competitive data shows there’s no obvious “right” answer; just different ways to interpret the same complex market dynamics.
The real insight isn’t that one side is clearly right, but that healthcare rate negotiations involve legitimate competing interests where reasonable people can look at the same data and reach different conclusions about fair compensation.
Jason Hines is CEO of Gigasheet which delivers AI-powered price transparency market intelligence.. This was first posted on their corporate blog
Note: This analysis is based on a sample of price transparency data filed by UnitedHealthcare and CareFirst BlueCross BlueShield, as mandated by federal regulations. The rate calculations are aggregations of data from multiple contracts and locations within each provider organization. To expand our rate analysis from Part 1, we resolved EINs to organization names using public data sources.
(I copied this here from Linked in where it 65+ comments just so I can find it when the story continues) Too painful to write up fully but I am on my 4th transfer in one phone call to MarinHealth trying to get an echocardiogram (EDIT-not an EKG as I originally wrote). They have lost the referral from One Medical twice. I had to download the referral and email it to them (Lucky it’s on the One Medical system). Every person has asked for my DOB and phone number. The guy who got the email, read the referral and transferred me. The latest guy appears very puzzled & wants me to fax him the referral. Eventually he gets me to his supervisor who says that radiology & cardiology are separate and they can’t receive an email because it’s a HIPAA violation. (I claimed to be Lucia Savage & laughed at him). Now I have to figure out how to fax it to them and the supervisor promised to call me back. He had to ask for my phone number….
Oh and I can’t book a echocardiogram on MyChart, but I can book a mammogram.
I’ll follow up in the comments. BTW that phone call was 19 minutes
UPDATE: OK, so I faxed them via a dodgy efax company whose “free trial” I need to remember to cancel. The supervisor did call me back, but for some reason my phone didn’t ring! He left a message and booked an appointment for me. But not in their Marin facility. In the next county over! (And Sonoma is very lovely). A 45 min drive rather than a 10 min drive from my house. I can SEE the appointment in the UCSF MyChart, and I can cancel it. but I cannot request a change or see when I could book one closer to me (presumably at a later date). So I guess I will call back on Monday….
UPDATE: So I called back today and got the appointment changed to the closer location. I had to wait one more day… I know you are all on tenterhooks so I will tell you if my heart works in 2 weeks!
UPDATE to the Update. A human called me and cancelled my appointment. Apparently the tech was out sick. Still no word on whether I have a heart or just a black pit inside my chest
UPDATE: I finally got in and had the Echocardiogram. Marin Health had an iPad based fast check in (well done). I didn’t recognize whose software it was. The echocardiogram took 45 minutes and was a bit like having somone stick their finger in your chest the whole time. Yes I do have a heart! More to come
My friend Rosemarie Day joins me to talk about the Healthcare Leaders for Democracy session coming up on September 4 (Thursday) at 8pm ET 5pm PT. It’s a one hour session with Atul Gawande as the keynote speaker, joined by Don Berwick and John McDonough. It’ll be a fascinating discussion and it’s a fundraiser for Movement Voter Project, but it’s free to sign up.
Rosemarie and I talked about how we work on getting grassroots mobilization for the mid-terms and beyond, and we hope people will come and join.
