Tireless Price Transparency Advocate Shows No Sign of Slowing Down

Meet the self-described “accounting nerd" who used to be the controller for Blue Cross Blue Shield of Montana and CFO of Employee Benefit Management Services.

Marilyn Bartlett, now a senior policy fellow with the National Academy for State Health Policy (NASHP), began her groundbreaking work to advance hospital price transparency when she was Montana Employee Benefit Plan (MEBP) administrator. Her work for state-run employee health plans to secure transparent and reasonable prices from hospitals through reference-based pricing (RBP) garnered national attention. A self-described “accounting nerd,” who on occasion dons debit-and-credit earrings, Bartlett could never understand why anyone would agree to discounts off a hospital charge description master.

“I’m a CPA, and we do cost-plus,” she explains, referencing the RBP approach of pegging prices to a modest percentage of Medicare rates to control rising health care costs.

From Big Sky to the Beltway

Bartlett’s Montana experience turned around a program teetering on the brink of insolvency, eventually leading to various collaborations on a national stage. Chief among them was the development of a cost tool for NASHP that uses Medicare cost reports to identify a hospital’s financial condition and the multiple of Medicare rates that would be a break-even point for each facility. Since 2019, it has been used by other states, employer groups and academic researchers to better understand hospital costs and finances – with version 4.0 ready to roll out.

Another key role for Bartlett has been consulting with Patient Rights Advocate since 2020 on transparency in hospital prices and health insurance coverage. The nonprofit seeks to empower health care consumers with upfront prices that will reduce their costs through a functional, competitive market.

Over the past two years, she joined forces with congressional staffers, U.S. representatives and senators on efforts to pass the Health Care Prices Revealed and Information to Consumers Explained Transparency Act (S. 3548). The bill – which has been referred to the Senate Health, Education, Labor and Pensions Committee – would require that employer-provided group health plans have access to their own data, underlying contracts, and some files that contain health claim information.

Marilyn Bartlett, senior policy fellow with the National Academy for State Health Policy (NASHP).

While the Consolidated Appropriations Act of 2021 (CAA) directed employer group health plans to remove gag clauses from their contracts and provide cost and quality data access, Bartlett cautions that service providers still have not provided all the data under this law. She works closely with law firms that assist employer-provided group health plans in their quest to gain access to data as well as identify fraud, waste and abuse in financial transactions.

Employers face an uphill battle in addressing group health plan contracting and costs, she says, noting that the administrative services only (ASO) plans – employee benefit plans administered by outside vendors – are dominated by Big Insurance carriers, pharmacy benefit managers (PBMs) and large consulting firms. She believes high-profile lawsuits against Johnson & Johnson and others will help move the dial on employer engagement with fiduciary responsibility to provide better stewardship of health and welfare benefit plans.

Spreading Messages and Cracking Codes

Since Bartlett’s stint with MEBP, Oregon, Nevada and North Carolina have adopted Medicare-based pricing models. She surmises the change isn’t more widespread because it requires considerable political will in the face of resistance from hospitals and large health insurance carriers, as well as brokers and consultants who earn generous commissions off group health insurance products.

“It bothers me to see middlemen between the patient and provider sucking money out of the system,” she says, noting that effect intensified when carriers devised strategies in response to the Affordable Care Act’s minimum loss ratio, which requires that at least 80% of premium revenue be spent on medical claims and quality improvement rather than administrative costs and profits.

After Bartlett started at MEBP in 2014, she led efforts to move it from projected reserves of minus $9 million to a $112 million surplus in less than three years. Among her accomplishments in Montana was firing the state’s PBM, one of the Big Three that now dominate about 80% of the market, and negotiating a contract that ensured the health plan would reap any drug cost savings, which turned out to be 23% at $7.4 million. One goal was to help rural pharmacies, many of which struggled to compete with national retail chains. 

RBP and other initiatives she helmed resulted in flat rates for members and the state since 2016, as well as an overfunded reserve that provided more than $52 million in employer premium holidays. Since her departure, Montana has changed third-party plan administrators and hospital payment methods, which she fears may roll back payment transparency. “In my opinion, the decision makers didn’t fully understand the RBP contracts and the potential impacts to plan members and the state budget with this change,” she said.

No Rest for the Weary

Before Bartlett made her most significant mark in Big Sky country, she was controller for Blue Cross Blue Shield of Montana, chief financial officer for the regional third-party administrator Employee Benefit Management Services, special projects coordinator for the Montana Commissioner of Securities and Insurance, and worked with the RAND Corp. The itch to fix systemic problems that lead to needlessly expensive health care kept pulling her back in.

At 74, she finds that a new issue surfaces every time she thinks about retiring. One issue she cites: Audits have shown that billions of dollars are leaking from the fully insured Federal Employees Health Benefit program.

However, Bartlett has commitments that include serving as a board member for the Midwest Business Group on Health and working with the National Alliance of Health Care Purchaser Coalitions as well as employer group health plan administrators to track health system and hospital financial performance, 340B programs and application of NASHP’s hospital cost tool.

The closest she has come to riding off into the Montana sunset, she reports with a wry smile, is finding an attorney and CPA who are willing to take over some of her contracts. Until that time comes, health care payers and consumers will have a formidable ally working tirelessly to make high-quality medical care more accessible and affordable.

Bruce Shutan is a Portland, Oregon-based freelance journalist who has written about employer-provided group health benefits for 36 years. He is the former managing editor of Employee Benefit News and a regular contributor to The Self-Insurer magazine, published by the Self-Insurance Institute of America.