Economist Vivian Ho has been researching the U.S. health care system for four decades. These days, she\u2019s focused on what she thinks are the biggest burdens on the average American: runaway hospital prices and rising health insurance premiums.<\/p>\n
She has developed a strategy for addressing high insurance premiums \u2014 one that\u2019s based on giving patients reliable information about how much they, and their insurer, would have to pay for care. The system is already working in Massachusetts. Could it be a model for the rest of the country?<\/p>\n
Ho explains to Dan Weissmann, host of \u201cAn Arm and a Leg,\u201d why she thinks this approach could help curb high prices and how listeners can help prove it by sharing their medical bills.<\/p>\n
\tDan Weissmann<\/p>\n
\t\t\t \t\t\tHost and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago’s WBEZ. His work also appears on “All Things Considered,” Marketplace, the BBC, “99 Percent Invisible,” and “Reveal,” from the Center for Investigative Reporting.\t\t<\/p>\n \tEmily Pisacreta \tClaire Davenport \tAdam Raymonda \tEllen Weiss \t\t\t\t\tClick to open the Transcript\t\t\t\t<\/p>\n \t\t\t\t\t\tTranscript<\/strong>: This Health Economist Wants Your Medical Bills<\/strong>\t\t\t\t<\/p>\n Note: \u201cAn Arm and a Leg\u201d uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.<\/em><\/p>\n Dan:<\/strong> Hey there\u2013<\/p>\n Vivian Ho is a health economist at Rice University and the Baylor College of Medicine in Houston. And since early 2024, she\u2019s been giving talks at\u2026 HR conferences. Which is not a typical gig for an economist.<\/p>\n Vivian Ho: Um, yes. Economists don\u2019t usually do that. We love to go talk at our own conferences.<\/strong><\/p>\n Dan:<\/strong> But she\u2019s been eager to spread a pretty big message.<\/p>\n Vivian Ho: There\u2019s a potential to save workers, um, you know, and employees a lot of money.<\/strong><\/p>\n Dan:<\/strong> And a few weeks ago, she sent me an email asking for help with what she\u2019s trying to do:\u00a0<\/p>\n She\u2019s wants folks to send her hospital bills for a study she thinks could be part of saving people a lot of moneys. She wondered if I\u2019d encourage people to pitch in.<\/p>\n And honestly, I wanted to say yes before I even really knew anything specific about the study.<\/p>\n I should say: Vivian Ho has been a donor to this show. That\u2019s actually how I met her and learned about her work. And became kind of a fan.\u00a0<\/p>\n Over the last few years, she\u2019s been digging up and publishing evidence we need, to push back against the way health care keeps getting more and more expensive.<\/p>\n This is stuff a lot of us suspected, to say the least \u2014 stuff reporters have documented examples of \u2014 but she\u2019s demonstrated they\u2019re actual trends, not one-offs.\u00a0<\/p>\n For instance: When nonprofit hospitals make big profits \u2014 and they often do \u2013 they call them surpluses\u2013 they don\u2019t generally use that money to help patients, by giving more charity care to reduce people\u2019s bills.\u00a0<\/p>\n In one study, she compared hospital finances in the early 2010s and near the end of the decade. As the decade was ending, she found nonprofit hospitals were a LOT more profitable than they\u2019d been before.\u00a0<\/p>\n And they\u2019d gotten a lot richer, with like seventy percent more cash in the bank than they\u2019d had earlier.\u00a0\u00a0<\/p>\n But they were actually giving out less<\/em> charity care.\u00a0\u00a0<\/p>\n \u00a0She told me she ran that down after she got help understanding a big set of data that helped her see what hospitals actually do with their money\u2013 and started to poke around in it.<\/p>\n Vivian Ho: I say, well, I\u2019m just gonna go have a look at, you know, one of the local hospitals and see what it says and then I pull it up and I go, oh wow.<\/strong><\/p>\n Dan:<\/strong> She took a peek at one hospital\u2019s \u201cfund balance\u201d \u2014 that\u2019s non-profit speak for an institution\u2019s savings, like for a rainy day.\u00a0<\/p>\n Vivian Ho: The fund balance for one of the hospitals across the street from Rice University is five and a half billion dollars. And so, you know, then it\u2019s like, well, I need to take a closer look at this.<\/strong><\/p>\n Dan:<\/strong> Here\u2019s a couple things she found: That fund balance \u2014 the \u201crainy day fund\u201d \u2014 was enough to run the hospital for more than two years. And it runs a healthy profit margin.\u00a0<\/p>\n And her study showed when she zoomed out: This is not a one-off. Among hospitals that do well, it\u2019s the norm.<\/p>\n And this kind of data \u2014 this kind of EVIDENCE of how things work, of who benefits, and how much, from the totally unfair and unaffordable prices we\u2019re all up against \u2014 it\u2019s ammunition.\u00a0<\/p>\n Vivian Ho is looking for people to share their hospital bills with her, in order to build up her arsenal of information .\u00a0<\/p>\n She\u2019s got a strategy in mind for how to deploy that information to save a lot of people a ton of money. It\u2019s interesting.<\/p>\n And: I have no idea if this specific strategy will pay off.<\/p>\n But here\u2019s what I do think: ?If we\u2019re going to fight against the greed and exploitation that make our health care system so unhealthy \u2014 so deadly \u2014 we\u2019re gonna need all the fighting power we can get.<\/p>\n So, I\u2019ve sent Vivian Ho a hospital bill. And at the end of this episode I\u2019ll encourage you to do the same.\u00a0<\/p>\n This is An Arm and a Leg \u2014 a show about why health care costs so freaking much, and what we can maybe do about it. I\u2019m Dan Weissmann. I\u2019m a reporter, and I like a challenge. So the job we\u2019ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you a show that\u2019s entertaining, empowering and useful.<\/p>\n Dan:<\/strong> Vivian Ho has been a health economist for like 40 years. And you could say she has mixed feelings.<\/p>\n Vivian Ho: Health economists, they work on so many different things and they are all important and interesting. But I do think the issue of the cost of healthcare and the cost of health insurance premiums is the biggest problem putting a burden on the average American citizen. And I don\u2019t think as a profession that we spend enough time on that basic issue. I feel kind of \u2013 well, it does make me quite sad because here I am, I\u2019ve worked in this career for this entire time, and things aren\u2019t getting better. They\u2019re actually getting much worse.<\/strong><\/p>\n Dan:<\/strong> And that, she says, is why she does things like go to HR conferences these days. She\u2019s got the motivation and she\u2019s got the freedom to do it.\u00a0<\/p>\n Vivian Ho: So I\u2019m super lucky. I\u2019ve got tenure at Rice and you know, I\u2019m a member of National Academy of Medicine. I\u2019ve sort of achieved everything that I wanted to achieve, and now it\u2019s, it\u2019s all about, well, what can we do?<\/strong><\/p>\n Dan:<\/strong> She\u2019s decided to go after what she now sees as the biggest problem. Not the ONLY problem, but the biggest driver in prices that only seem to go up more every year.<\/p>\n Hospital systems are consolidating \u2014 gobbling each other up. So they get more bargaining power with insurers. They get higher prices without necessarily delivering more value.<\/p>\n Which isn\u2019t what economists always expect. Bigger can mean better, more efficient. That\u2019s what Vivian Ho used to expect.<\/p>\n Vivian Ho: I started this whole research agenda sort of 10-15 years ago, and I thought bigger was going to be better. I thought because of economies of scale and that if you allowed hospitals to acquire physician practices, there would be less duplication of services, you\u2019d save money. But then the problem is there\u2019s no mechanism that forces a provider to pass any savings onto the consumer. So there may be economies of scale, it\u2019s just you and I as consumers aren\u2019t able to enjoy any of those benefits.<\/strong><\/p>\n Dan:<\/strong> That\u2019s something we\u2019ve talked about on this show. Like a lot. But what Vivian Ho has been able to demonstrate is: At this point, the average profit margins for hospitals \u2014 including \u201cnon-profit\u201d hospitals \u2014 are actually higher than average profit margins for insurance companies.<\/p>\n Vivian Ho: There\u2019s plenty of rural hospitals and smaller hospitals that lose money, but net, when you average on just how much profits the consolidated systems are making and you add them up all over the country, it\u2019s much higher than what you get for the total profits of insurers.<\/strong><\/p>\n Dan:<\/strong> Which isn\u2019t to say that insurance companies don\u2019t have a BIG role to play in our suffering.\u00a0<\/p>\n Vivian Ho: Insurers are, in many ways, not doing what they should be for customers. Certainly the show demonstrates that in many ways and that they are earning high profits. I\u2019ve just looked at the data and concluded that the hospitals are earning much higher profits than the insurers are, and that\u2019s where we\u2019ve gotta focus our attention.\u00a0<\/strong><\/p>\n Dan: I mean, there\u2019s so much to unpack there, right? One is, wow, the hospitals are earning higher profits than insurance companies, and the insurance companies, by and large, are publicly traded entities that answer to shareholders. And the majority of hospitals in the United States are, as far as the IRS is concerned not-for-profit entities.<\/strong><\/p>\n Vivian Ho: Exactly. We\u2019ve been doing research lately that unfortunately shows that our not-for-profit hospitals behave a lot like for-profit companies.<\/strong><\/p>\n Dan: So, okay, how do we get at that?\u00a0<\/strong><\/p>\n Vivian Ho: Oh, uh, how do we change the behavior of what\u2019s going on?\u00a0<\/strong><\/p>\n Dan: Yeah.<\/strong><\/p>\n Vivian Ho: Yeah. So\u2026<\/strong><\/p>\n Dan:<\/strong> Here\u2019s Vivian Ho\u2019s game plan. It\u2019s complicated, and I\u2019m not in a position to say, \u201cthis\u2019ll totally work\u201d \u2014 but there\u2019s a lot that\u2019s worth knowing here.<\/p>\n Especially this:<\/p>\n When Vivian Ho talks to business executives or HR managers, she brings out another set of data. And this is data that\u2019s only become available in the last few years.\u00a0<\/p>\n Insurers now have to show what they pay hospitals. Not the sticker price, the negotiated price.<\/p>\n So, Vivian Ho\u2019s talk includes a slide showing some details from three Houston hospitals. Blue Cross pays one of them about 22 thousand dollars for spinal fusion surgery. Another one gets 66 thousand \u2014 three times as much..\u00a0<\/p>\n And the slide shows: That math is similar for other procedures.\u00a0<\/p>\n Vivian Ho: Employers didn\u2019t realize how different the prices could be at their local hospitals. They thought, you know, anyone would think, oh, the prices couldn\u2019t be that different. And now that some of the data is starting to make it out there, it\u2019s becoming clear you really could save a lot of money.<\/strong><\/p>\n Dan:<\/strong> I mean, you MAYBE could \u2014 if you could give your workers a good reason to go to the hospital that charges less.<\/p>\n Vivian Ho has a model for how that could work. It\u2019s \u2014 based in part on a story I call Once Upon a Time in Massachusetts.\u00a0<\/p>\n That\u2019s next.<\/p>\n This episode of An Arm and a Leg is produced in partnership with KFF Health News. They\u2019re a nonprofit newsroom covering health issues in America. Their reporters do amazing work. They win all kinds of awards every year. We\u2019re honored to work with them.\u00a0<\/p>\n So, here\u2019s our story \u2014 Once Upon a Time in Massachusetts \u2014 straight from the story\u2019s author.<\/p>\n Elena Prager: I am Elena Prager. I\u2019m an assistant professor of economics at the Simon Business School at the University of Rochester.<\/strong><\/p>\n Dan:<\/strong> And while doing her dissertation, she came across a very unusual set of data.\u00a0<\/p>\n Elena Prager: I was like, wow, goldmine.<\/strong><\/p>\n Dan:<\/strong> Here\u2019s the story: Massachusetts has an agency that basically runs employee health benefits for all state employees, and a lot of local-government workers too.<\/p>\n And once upon a time \u2014 starting in 2010\u2013 they tried something unusual.\u00a0<\/p>\n Elena Prager: Possibly because they were lucky, possibly because they were smart, they designed their health insurance plans \u2013 at least when it came to hospital care \u2013 based everything on copays. And what that means is that you are given a dollar number. Let\u2019s say $250 or $500 and like that\u2019s it. That\u2019s the number. If you go to hospital A, you pay 250, you go to hospital B, you pay 500. The end.<\/strong><\/p>\n Dan:<\/strong> Which is totally different from how we\u2019re used to looking at hospitals, right? I mean, regular insurance plans typically say, \u201cYou\u2019ll pay like 10 percent, or 20 percent or 30 percent of whatever the total bill turns out to be.\u201d\u00a0<\/p>\n Elena Prager: And the patient is left scratching their head being like, well, how do I know what the total bill is gonna be? Even if the hospital tells me something. Like, what if something goes wrong with the anesthesia? They have to call in an extra specialist. There\u2019s a complication. More stuff gets done. Like it\u2019s very, very hard to, for a patient and even really a provider, to predict in advance what\u2019s gonna be done to them and therefore what the price is going to be.<\/strong><\/p>\n Dan:<\/strong> So there\u2019s no way for me to take price into account if I need to go to the hospital.<\/p>\n But Once Upon a Time in Massachusetts, there was. It was a co-pay. Whatever insurance plan you were on, it worked the same way:<\/p>\n Go to hospital A \u2014 where prices are generally higher \u2014 your copay might be five hundred dollars.<\/p>\n Go to hospital B \u2014 that charges the insurance plan less for stuff \u2014 you\u2019d pay two-fifty.<\/p>\n And Elena Prager found the data that showed what happened next.<\/p>\n Long story short, she found that over three years, patients started using lower-priced hospitals more often. Patients saved money, and so did the health plan.\u00a0<\/p>\n And actually, Massachusetts still runs its health plans this way, but\u2013\u00a0<\/p>\n \u00a0Vivian Ho doesn\u2019t think other employers can just get their insurance companies to adopt this same model.\u00a0<\/p>\n VIVIAN HO:<\/strong> It\u2019s actually a fair amount of work.<\/p>\n DAN:<\/strong>\u00a0 Work for the insurance company. Doing the math to figure out which tier is which, and what the copays would be.<\/p>\n Vivian Ho:<\/strong> and of course it gets the hospitals really upset.<\/p>\n Dan:\u00a0 The folks in Massachusetts had a ton of leverage that most employers don\u2019t have:\u00a0\u00a0<\/p>\n Elena Prager says they represented a huge chunk of the insurance market like a twelfth of it. Enough business that it was worth insurance companies\u2019 while to put in the work.<\/p>\n But now, Vivian Ho has her eye on a couple of new services that are promising to do something similar.<\/p>\n One is actually a subsidiary of everybody\u2019s favorite insurance company: United Healthcare. They make an app called Surest.<\/p>\n Surest Ad: It\u2019s easy to shop for a vacation rental or your next flight, but when it comes to something like healthcare, not so easy. That\u2019s why Surest is a health plan, designed to be simple with clear upfront costs.<\/strong><\/p>\n Dan:<\/strong> Here\u2019s how Vivian Ho describes the mechanics of this kind of app.<\/p>\n Vivian Ho: Doctor tells you you need to go get an MRI, you punch an MRI, the app knows where you live, and it says, here\u2019s a list of providers where you can go get an MRI. And then if you go to this particular place, there\u2019s no copay and there\u2019s actually no deductible, and then if you go to this MRI place, well, you know, there\u2019s gonna be a $25 copay or a $50 copay. Yeah. Isn\u2019t that kind of mind blowing?<\/strong><\/p>\n Dan:<\/strong> I tell her: That sounds like I would want that if I trusted that the place that costs my employer less is, you know, gonna take good care of me.<\/p>\n Vivian Ho: Right. Well that\u2019s why I\u2019m trying to get funding to do an analysis to look at the spending and quality implications of using one of these apps.<\/strong><\/p>\n Dan:<\/strong> That is: Do people using these apps end up choosing lower-cost providers? AND: Do they get good care when they do?<\/p>\n Vivian Ho wants to study that. But first she needs to study something else.\u00a0<\/p>\n Vivian Ho: All of these apps and price shopping applications, they all depend on having the correct data. Now, the insurers are required to disclose this information by federal rules. It is slowly coming out. It\u2019s not all there yet, but no one\u2019s actually looked to see whether it\u2019s accurate.<\/strong><\/p>\n Dan: Oh.<\/strong><\/p>\n Vivian Ho: So there\u2019s been a lot of focus on, is the price there or is it not there, but not is it the price that the patient is actually getting billed.<\/strong><\/p>\n Dan:<\/strong> And this is why Vivian Ho wants our hospital bills.\u00a0<\/p>\n Because: Whether or not one particular strategy is gonna pan out, the data itself contains ammunition. One hospital gets paid twice as much as the ones across the street?\u00a0<\/p>\n I mean, that\u2019s information I want out in the open, and getting put to use.\u00a0<\/p>\n But that information can\u00a0 only be useful if we know the data is accurate. And right now, there\u2019s no way to know.\u00a0<\/p>\n Insurers are publishing big data sets, but how\u00a0 do we *know* somebody at the insurance company didn\u2019t just go to Chat GPT and say, \u201cMake me a giant spreadsheet with these fields on it?\u201d<\/p>\n Vivian Ho says if she has enough ACTUAL bills \u2014 a thousand would be good, three thousand would be great \u2014 she can check.\u00a0<\/p>\n Actually, even better: She wants your itemized bill and, if she can get it, the paperwork you get from your insurance company about what they paid. The thing that says \u201cThis is not a bill.\u201d It\u2019s an \u201cexplanation of benefits\u201d \u2014 or EOB for short.<\/p>\n And, she recognizes, this isn\u2019t a TINY ask.<\/p>\n Vivian Ho: I realize it\u2019s time consuming. It does, you know, because you gotta sit down. It\u2019s like, what\u2019s my password and log in, and then you\u2019ve gotta, you know, find one of these EOBs.<\/strong><\/p>\n Dan:<\/strong> Oh, and you\u2019ve gotta cover up all your personally identifying information.<\/p>\n Vivian Ho: We don\u2019t wanna see your your name and address and so, you know, it takes time to you, you can sort of print these out and use a Sharpie and cross them out.<\/strong><\/p>\n Dan:<\/strong> It does sound like a huge drag, but I\u2019m here to tell you: I did it. And it took me maybe five minutes.<\/p>\n I don\u2019t know how Vivian Ho\u2019s specific strategy will play out, and honestly, neither does she.<\/p>\n Vivian Ho: You know, I am going at this at sort of like many different angles.<\/strong><\/p>\n Dan: Yeah.<\/strong><\/p>\n Vivian Ho: So just trying to raise people\u2019s awareness of there are huge price differences. This is, this is what it takes to address the issue.\u00a0<\/strong><\/p>\n Dan:<\/strong> If you\u2019ve gotten a hospital bill in the last year or so, and you\u2019ve got five minutes \u2014 maybe set a note on your calendar for when you DO have five minutes? \u2014 I\u2019d love it if you gave this a shot.\u00a0<\/p>\n Grab a sharpie, fire up your printer, dig up your login. Print out a bill and an EOB, scratch out your identifying information, take a picture on your phone \u2014 wow, this is sounding long, but honestly, it took me five minutes \u2014 so do those things, and send the images to pricecheck@rice.edu.\u00a0<\/p>\n Vivian Ho\u2019s got researchers standing by.<\/p>\n Coming up on this show: We\u2019re gonna take some time as the year ends, to look at some things that DIDN\u2019T suck in 2025.\u00a0<\/p>\n Which basically means: Places where state governments stepped in to protect us from ripoff prices. Which, it turns out, happened!\u00a0<\/p>\n News archive 1: Oregonians burdened by medical bills may soon get a break on their credit scores.<\/strong><\/p>\n News archive 2: New law aimed at protecting Maine consumers from the impacts of medical debt goes into effect.<\/strong><\/p>\n News archive 3: Tonight Indiana governor Mike Braun signs 10 health care-related bills into law.<\/strong><\/p>\n Dan: <\/strong>Happened enough that it\u2019ll take more than just one episode to give you a good sample.<\/p>\n That\u2019s next time on An Arm and a Leg.<\/p>\n Till then, take care of yourself.\u00a0<\/p>\n This episode of An Arm and a Leg was produced by me, Dan Weissmann, with help from Emily Pisacreta \u2014 and edited by Ellen Weiss. Adam Raymonda is our audio wizard.<\/p>\n Our music is by Dave Weiner and Blue Dot Sessions. Bea Bosco is our consulting director of operations.\u00a0<\/p>\n An Arm and a Leg is produced in partnership with KFF Health News. That\u2019s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.<\/p>\n \u00a0Zach Dyer is senior audio producer at KFF Health News. He\u2019s editorial liaison to this show.<\/p>\n An Arm and a Leg is distributed by KUOW, Seattle\u2019s NPR news station.<\/p>\n And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.<\/p>\n They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.<\/p>\n Finally, thank you to everybody who supports this show financially.<\/p>\n You can join in any time at arm and a leg show, dot com, slash: support.<\/p>\n \u201cAn Arm and a Leg\u201d is a co-production of KFF Health News and Public Road Productions.<\/p>\n For more from the team at \u201cAn Arm and a Leg,\u201d subscribe to its weekly newsletter, First Aid Kit<\/a>. You can also\u00a0follow the show on\u00a0Facebook<\/a>\u00a0and\u00a0the social platform X<\/a>. And if you\u2019ve got stories to tell about the health care system, the producers\u00a0would love to hear from you<\/a>.<\/p>\n To hear all KFF Health News podcasts, click here<\/a>.<\/em><\/p>\n And subscribe to \u201cAn Arm and a Leg\u201d on Spotify<\/a>, Apple Podcasts<\/a>, Pocket Casts<\/a>, or wherever you listen to podcasts.<\/em><\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\n
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