By Julie Wasserman
Reference Based Pricing is gaining traction, but with it, we are seeing a handful of hospitals pushing back by refusing access. Ironically, some of the most recognizable non-for-profits are leading the charge against RPB.
Hospitals with a mission to serve their community will flat out refuse to see patients using an RBP plan. When a hospital uses patients as leverage to demand higher reimbursement, it becomes less about cost and more about ethics.
When a hospital system refuses to treat patients covered by a Reference-Based Pricing (RBP) plan, it will cause disruption and frustration. Members will complain about their plan and HR teams are managing the backlash. But who is the real villain here?
If a hospital system is billing commercial payers at several multiples of its costs and receiving reimbursement far above Medicare rates, why should patients be denied access to care when their plan pays 150% to 200% of Medicare?
The real victims in this debate are not hospitals or health plans. They are patients who have done everything right by enrolling in their employer’s health plan, paying their premiums, and seeking care when needed. Only to be told they are not welcome because reimbursement rates do not meet revenue expectations. And let’s be clear, those expectations are, on average, 350% of Medicare.
In virtually every other industry, businesses compete for customers. Imagine a grocery store, airline, or auto repair shop announcing that it will refuse service unless customers agree to pay double what is considered fair and reasonable. There would be anarchy. Yet in healthcare, many hospital systems, and even physician offices, will refuse access to care because they want reimbursement levels that exceed what most would consider reasonable payment.
Reference-Based Pricing was created to bring transparency and reasonability to healthcare pricing. Whether one agrees with the model or not, healthcare provider flat out denying patients access over money raises some serious ethical concerns. Patients should not become bargaining chips in reimbursement disputes.
There are a handful of hospitals/hospital systems that are notorious for denying access to members using an RBP plan. As you can see from the illustration below, the hospitals at large are billing at egregious rates relative to self-reported costs.
Data pulled from NASHP Hospital Costs Tool Downloadable data last updated on December 30, 2025, and cross-referenced with Sage Transparency data. Both resources are publicly available.
These are all non-for-profit hospitals, by the way. So, while they demand ridiculously inflated payments, most of them report a dismal amount of charity care. Let’s get a quick refresher on the expectations of NFP hospitals:
Not-for-profit hospitals receive significant tax advantages in exchange for providing a community benefit. In return, they are generally expected to:
Serve the healthcare needs of their communities.
Improve access to care.
Provide charity care and financial assistance to those who qualify.
Reinvest surplus revenues into facilities, services, staff, technology, and community health initiatives rather than distributing profits to shareholders.
Act as community stewards, balancing financial sustainability with their mission to serve.
How can any hospital justify denying care, but especially those whose mission is specifically to serve the needs of their community.
Companies across the country are getting crushed trying to maintain a comprehensive and competitive health benefit offering for their employees. At the same time, employees are struggling to afford healthcare, with medical debt contributing to more than 25% of personal bankruptcies.
Reference Based Pricing can provide significant relief for both plan sponsors and employees, but it isn’t without hurdles. The reality is that employers and employees are often frustrated with the wrong party. Reference Based Pricing didn’t create the problem. It’s one of the few solutions that directly challenges it. If hospitals were pricing services fairly and transparently, there would be no need for alternative reimbursement models in the first place.
HOMEWORK READING ASSIGNMENT: The Power of Free Market Choice
The Power of Free Market Choice
Sorry, We Don’t Take That Insurance
