Written by: Robert Mitchell | Producer

Reference-based pricing (RBP) is a pricing strategy gaining popularity in the healthcare and insurance industries as an alternative to traditional fee-for-service models. RBP sets a maximum limit on what an insurance plan will pay for a particular medical service or procedure, often referencing a benchmark price based on market rates or Medicare reimbursement rates. This approach aims to control healthcare costs while promoting transparency and fairness in pricing. In this article, we will delve into the origins, pros and cons of RBP, and identify the types of groups that are well-suited for its implementation.

Origins of Reference-Based Pricing

The concept of reference-based pricing emerged as a response to the rising healthcare costs and the lack of transparency in traditional pricing models. Historically, fee-for-service models led to varying prices for the same medical services, making it difficult for patients to understand the actual cost of care. RBP, influenced by principles of value-based care and cost containment, sought to address this issue by establishing a clear reference point for pricing.

Pros of Reference-Based Pricing

  1. Cost Control: RBP offers an effective way to control healthcare costs. By setting a maximum limit on reimbursements, insurance companies can negotiate favorable rates with providers, reducing the overall expenditure.
  2. Transparency: Patients and providers benefit from increased transparency. With a predetermined reference price, patients can better understand the potential costs associated with a procedure, and providers have a clear benchmark for negotiations.
  3. Market Competition: RBP can encourage competition among healthcare providers. Providers may be motivated to offer quality services at competitive prices to attract patients.
  4. Flexibility: Reference prices can be set based on multiple factors, such as Medicare rates or market averages. This flexibility allows for customization to suit the specific needs of different plans or populations.

Cons of Reference-Based Pricing

  1. Provider Relations: Some healthcare providers may be hesitant to accept reimbursements that are significantly lower than their usual charges, potentially leading to strained relations between providers and payers.
  2. Access to Care: If reference prices are set too low, it may lead to a limited choice of providers for patients, especially in regions where providers are less inclined to accept lower reimbursements.
  3. Balance Billing: Patients might face unexpected balance billing if the reference price falls short of the actual provider charges. This can result in financial hardships for patients who are unaware of the potential discrepancy.
  4. Complexity: Implementing RBP requires careful consideration and communication, as understanding the concept of reference pricing can be challenging for both patients and providers.

Appropriate User Groups for Reference-Based Pricing

Not all groups may benefit equally from RBP. Certain groups are more likely to find RBP advantageous based on their characteristics:

  1. Self-Insured Employers: Large companies that self-fund their employee health plans can benefit from RBP by having more control over healthcare costs and the flexibility to tailor reference prices to their specific employee demographics.
  2. Value-Conscious Consumers: Individuals who are comfortable comparing healthcare prices and are willing to make informed decisions regarding their healthcare choices can benefit from the transparency that RBP provides.
  3. Network Flexibility: Individuals residing in regions with a variety of healthcare providers are better positioned to benefit from RBP, as they have more options to choose from.
  4. Healthcare Navigators: Organizations or individuals that assist patients in making healthcare decisions can help educate patients about RBP, enabling them to make cost-effective choices.


Reference-based pricing has emerged as a potential solution to address the escalating healthcare costs and lack of pricing transparency. By setting a clear reference point for reimbursements, RBP aims to balance cost control and fair compensation for healthcare services. While it comes with its share of challenges, RBP can be a valuable pricing strategy for certain user groups, especially self-insured employers and individuals who prioritize value-conscious decision-making. As the healthcare landscape continues to evolve, reference-based pricing presents an innovative approach to reshaping the way we think about medical pricing and cost containment.

IMA will continue to monitor regulator guidance and offer meaningful, practical, timely information.

This material should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. These materials are not exhaustive and are subject to possible changes in applicable laws, rules, and regulations and their interpretations.