By JASON HINES
On August 1, 2025, Capital Girls’s Care (CWC), one of many largest OB/GYN practices within the Mid-Atlantic area went out-of-network with UnitedHealthcare, affecting tens of hundreds of ladies throughout Maryland, Virginia, Pennsylvania, and Washington D.C. The contract dispute between Capital Girls’s Care (CWC) and UnitedHealthcare provides an enchanting case examine in how value transparency information can illuminate the actual dynamics behind these high-stakes negotiations.
The Public Battle
Capital Girls’s Care, with greater than 250 physicians and healthcare professionals, confirmed that its settlement with UnitedHealthcare would lapse regardless of ongoing negotiations. The observe urged sufferers to contact UHC to voice their issues about shedding entry to their suppliers.
UnitedHealthcare fired again with detailed public claims on their web sitealleging that CWC “refused to maneuver off its calls for for double-digit value hikes” and is “considerably increased price at present in comparison with peer suppliers all through Maryland and Virginia”. UHC offered particular examples, claiming {that a} vaginal supply from CWC would price “greater than 120% increased – or over $2,600 extra – than the common price of different OB/GYN suppliers”.
However what does the precise value transparency information reveal about these competing claims?
What the Transparency Knowledge Reveals
Utilizing Capital Girls’s Care’s negotiated charges from UnitedHealthcare’s personal machine-readable information, we analyzed a pattern of frequent OB/GYN procedures from Maryland fee information. Whereas this represents solely a subset of all procedures and focuses particularly on Maryland charges, it gives helpful insights into the actual cost dynamics between these organizations. The info paints a extra nuanced image than both occasion’s public statements recommend.
Knowledge Methodology Observe: Our evaluation examined negotiated charges for Capital Girls’s Care from publicly obtainable machine-readable information, specializing in Maryland suppliers and filtering out statistical outliers (charges beneath 50% or above 500% of Medicare). We analyzed charges for each UnitedHealthcare and CareFirst throughout three frequent OB/GYN procedures the place each payers had enough information.
CWC’s Charge Place vs Different Payers
Our evaluation of three frequent OB/GYN procedures in Maryland reveals that CWC’s charges with UnitedHealthcare have been really fairly aggressive in comparison with different main payers:
For the three procedures the place each UHC and CareFirst have negotiated charges with CWC:
- CPT 56515 (Vulvar Lesion Destruction): UHC paid $401 vs CareFirst’s $617 (53.9% distinction)
- CPT 57288 (Sling Operation): UHC paid $1,163 vs CareFirst’s $1,254 (7.8% distinction)
- CPT 58558 (Hysteroscopy): UHC paid $2,294 vs CareFirst’s $2,318 (1.0% distinction)
This pattern information suggests UnitedHealthcare was already getting favorable charges from CWC in comparison with different main payers, calling into query UHC’s claims about CWC being “considerably increased price.”
The Medicare Benchmark Actuality
Each UHC and CareFirst have been paying CWC charges properly above Medicare in our pattern:
- UnitedHealthcare: 143-175% of Medicare charges
- CareFirst: 166-220% of Medicare charges
Whereas CareFirst paid increased charges, UnitedHealthcare’s charges have been nonetheless substantial premiums over authorities reimbursement, suggesting the “double-digit will increase” CWC requested could have been makes an attempt to align with market charges different payers have been prepared to pay.
Necessary Limitation: This evaluation relies on a pattern of three procedures in Maryland solely. A complete evaluation would require inspecting all process codes throughout all markets the place CWC operates to completely validate these patterns.
The Strategic Context: Market Share Issues
Understanding why CWC may need walked away requires inspecting UnitedHealthcare’s place within the Maryland market. Based on KFF information, UnitedHealthcare holds solely 9% of Maryland’s massive group market share as of 2023. This comparatively small market place gave CWC vital leverage.
The Math of Strolling Away:
- UHC represents a small portion of CWC’s affected person base
- CWC has contracts with bigger payers (Aetna, CareFirst, Cigna) paying increased charges
- The observe serves over 250 suppliers throughout a number of states
- Strolling away from 9% of the market to ascertain fee precedent makes strategic sense
Evaluating UnitedHealthcare’s Public Claims
UHC’s web site makes a number of particular claims that we are able to consider towards transparency information:
Declare 1: “CWC is considerably increased price in comparison with peer suppliers”
Evaluation: Partially Deceptive
Whereas CWC could cost greater than some suppliers, our evaluation exhibits UHC was paying aggressive charges in comparison with different main payers for a similar companies. The “peer supplier” comparability lacks context about geographic market charges and supplier high quality variations.
Declare 2: “Double-digit value hikes that may make them 30% increased than common”
Evaluation: Lacking Context
This declare doesn’t account for:
- How UHC’s present charges in comparison with different payers
- Whether or not the “common” contains lower-quality or otherwise positioned suppliers
- Regional price variations within the costly Mid-Atlantic market
Declare 3: Particular process price comparisons
Evaluation: Doubtlessly Correct however Incomplete
UHC’s claims about supply prices could also be correct, however they don’t present the complete market context. The transparency information exhibits vital fee variation throughout payers and procedures, suggesting that “costly” is relative to the comparability set chosen.
How Worth Transparency Modifications the Recreation
This dispute illustrates how value transparency information is reshaping healthcare negotiations in a number of methods:
Knowledgeable Leverage
Suppliers like CWC can now see precisely how their charges evaluate throughout payers, enabling extra strategic negotiations. CWC knew they have been giving UHC favorable charges in comparison with CareFirst.
Public Accountability
Each events made public claims that may now be fact-checked towards precise negotiated charges. UHC’s claims about CWC being “considerably increased price” are extra nuanced when seen towards the complete payer panorama.
Market Benchmarking
The transparency information reveals that:
- Regional markets have substantial fee variations
- Supplier high quality and market place justify fee premiums
- “Costly” is relative to the comparability being made
Strategic Positioning
For a observe with CWC’s market place, sustaining fee self-discipline throughout payers turns into essential. Accepting below-market charges from one payer can undermine negotiations with others.
The Actual Winner: Market Transparency
Whereas sufferers are caught in the midst of this dispute, the broader healthcare market advantages from the transparency this battle gives. The general public availability of precise negotiated charges means:
- Sufferers could make extra knowledgeable decisions about suppliers and plans
- Employers can higher consider insurance coverage plan worth propositions
- Suppliers can benchmark their charges towards precise market information
- Payers should justify fee choices with actual information moderately than selective comparisons
Wanting Ahead: Classes for Healthcare Negotiations
The CWC-UHC dispute provides a number of classes for future healthcare contract negotiations:
- Worth transparency information is now a negotiating instrument – Each side can and can use precise fee comparisons to help their positions
- Market share issues in fee negotiations – UHC’s 9% Maryland market share restricted their leverage towards a big, established supplier
- Public relations battles require information backing – Claims about “costly” suppliers can now be fact-checked towards precise negotiated charges
- Supplier consolidation creates negotiating energy – Giant practices like CWC can afford to stroll away from unfavorable contracts
The Path to Decision
For this particular dispute, the transparency information suggests each events have cheap positions:
- CWC was certainly giving UHC favorable charges in comparison with different payers, justifying their request for will increase
- UHC faces strain to regulate prices for members whereas sustaining an sufficient supplier community
A decision seemingly requires:
- UHC acknowledging that their present charges have been beneath market
- CWC accepting that dramatic fee will increase have an effect on affected person prices
- Each events discovering center floor that displays true market positioning
The supply of precise negotiated fee information ought to, in principle, make these conversations extra productive by establishing shared details about market charges and supplier positioning.
Conclusion
The Capital Girls’s Care vs UnitedHealthcare contract dispute demonstrates how value transparency is essentially altering healthcare negotiations. Whereas each events made public claims supporting their positions, our evaluation of precise negotiated fee information from Maryland reveals a extra complicated story the place market dynamics, strategic positioning, and regional components all play essential roles.
Key takeaways from our information evaluation:
- UHC was paying aggressive charges in comparison with different main payers for the procedures we examined
- CWC’s choice to stroll away makes strategic sense given UHC’s restricted 9% Maryland market share
- Each payers have been paying properly above Medicare charges, suggesting room for negotiation
Necessary caveats: Our evaluation examined solely three frequent procedures from Maryland information. A complete analysis would require analyzing all process codes throughout all markets the place CWC operates to completely validate these patterns.
As extra stakeholders achieve entry to this beforehand hidden pricing data, we are able to count on healthcare contract negotiations to turn into extra data-driven, clear, and in the end extra rational. The true winners shall be those that can successfully analyze and act on this new transparency to make higher choices about healthcare protection, supplier choice, and contract phrases.
I’ll be again on THCB to take a look at the remainder of the context for this dispute partly 2. What was the price of these companies from different suppliers available in the market?
Jason Hines is CEO of Gigasheet which delivers AI-powered value transparency market intelligence.. This was first posted on their company weblog
