by Peter Pitts
The most important healthcare document released this year wasn’t another regulation, another Inspector General report, or another congressional hearing. It was a list. Roughly 500 hospitals spread across 45 states and the District of Columbia were publicly identified by the Trump Administration as failing to comply with the Hospital Price Transparency Rule. Five years after hospitals were required to disclose what they charge, hundreds still aren’t following the law.
Tennessee hospitals were among them.
At this point, we’re no longer debating transparency. We’re debating accountability. For years the explanation has been the same. Healthcare is complicated. Hospital billing is complicated. Insurance contracts are complicated. All true. But complexity is no longer a persuasive excuse.
Anyone who has spent time inside a hospital finance department knows these organizations possess extraordinarily sophisticated revenue-cycle systems. They know what Blue Cross pays for an MRI, what Medicare reimburses for a hip replacement, what a self-pay patient owes after meeting a deductible, and how each payer contract differs from the next. The information hospitals have been asked to disclose isn’t missing. It already exists.
That’s why the conversation in Tennessee needs to change. This is not an information technology problem. It is not a software problem. It is an incentives problem. Hospitals have every technical capability necessary to comply. The real question is whether current public policy makes transparency a better business decision than secrecy. At the moment, the answer is too often no.
Price secrecy has economic value. It protects negotiating leverage with insurers. It shields reimbursement differences from Tennessee employers shopping for healthcare coverage. It makes meaningful price comparisons more difficult for patients and weakens one of the most important forces in any competitive marketplace: informed buyers.
Economists have understood this dynamic for decades. Organizations respond to incentives. Healthcare is doing exactly what economics predicts it will do.
The Trump Administration deserves credit for recognizing that reality. Rather than issuing another guidance document or quietly negotiating corrective action plans, CMS publicly identified hospitals it believes remain out of compliance with federal law.
Naming institutions that fail to meet transparency requirements is more than a communications strategy. It changes the conversation from regulatory process to public accountability.
Hospital boards pay attention to reputation. Donors pay attention. Tennessee employers negotiating health benefits pay attention. Patients pay attention. Public scrutiny often succeeds where another warning letter does not. And Tennessee should pay particular attention.
The fact that Tennessee hospitals continue appearing on federal enforcement lists despite years of regulatory guidance and repeated opportunities to comply should concern policymakers in Nashville. Tennessee is hardly alone. Hospitals in North Carolina, Texas, Maryland, Kansas, and many other states face the same problem. Different legislatures, different governors, different healthcare markets—but remarkably similar results.
That consistency tells us something important. The challenge isn’t regional, partisan, or ideological. It’s structural.
But Tennessee does not need to wait for Washington to solve every part of the problem.
State policymakers should ask a straightforward question: What can Tennessee do to make compliance with existing hospital price-transparency requirements the economically rational choice?
Too much of the discussion still treats price transparency as merely a consumer issue. It is certainly that, but it is much more. Transparent pricing is essential to competitive markets.
Tennessee employers cannot negotiate intelligently if they have no meaningful way to compare hospital prices. Patients cannot make informed financial decisions if the bill arrives long after the care has been delivered. Researchers and policymakers cannot accurately study Tennessee’s healthcare markets if pricing information remains incomplete or inaccessible.
Markets don’t become inefficient because consumers make poor decisions. They become inefficient when one side controls information the other side cannot obtain. Congress has already established the legal framework for transparency. CMS has spent years developing regulations, refining reporting requirements, and expanding enforcement authority. The Administration has now publicly shown the country which hospitals are complying, and which are not.
The next step should not be another round of stakeholder meetings or another lengthy debate about implementation. It should be consistent, credible enforcement that changes behavior. Tennessee policymakers should also examine what other states have done. Texas, Colorado, North Carolina, and others have begun experimenting with stronger accountability measures that connect transparency with governance, consumer protection, and institutional reputation.
Tennessee can learn from those experiences without simply copying them. The principle is what matters: organizations change when incentives change. Federal enforcement should become faster, more predictable, and more consequential. At the state level, Tennessee should consider ways to reinforce federal requirements and ensure that hospitals serving Tennessee communities understand that transparency is not an optional administrative exercise.
Large health systems should not be able to treat delayed penalties as simply another cost of doing business.
Justice Louis Brandeis famously observed that “sunlight is said to be the best of disinfectants.” More than a century later, his observation has particular resonance. But sunlight only works when it is allowed in. Congress opened the blinds more than five years ago. Washington has now begun identifying the hospitals that keep pulling them shut.
Tennessee should help make sure they stay open.
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Peter J. Pitts, a former FDA Associate Commissioner, is President of the Center for Medicine in the Public Interest.
