Imagine this: You need an MRI. The hospital quotes you $1,200. The next morning, you find the same MRI advertised for $700—if you book it that day. No change in insurance, location, or quality. Just a change in timing.
It sounds like surge pricing for airline tickets. But this is the new frontier: dynamic pricing in healthcare. It’s controversial. It’s disruptive. And it’s happening now.
This week, three major developments made headlines: a lawsuit backed by the Department of Justice against pricing algorithms, New York City’s launch of an Office of Health Care Accountability, and growing pressure on PBMs to eliminate spread pricing in favor of transparent models.
Together, these stories tell us that healthcare is no longer insulated from real-time pricing innovation—but it also isn't ready to embrace it blindly.
Why Dynamic Pricing Matters Right Now
Dynamic pricing refers to adjusting the cost of a product or service in response to real-time market factors like demand, supply, or resource availability.
In sectors like travel, energy, and e-commerce, it's standard. But in healthcare, it’s a revolutionary—and potentially volatile—concept.
Why now?
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Rising costs: U.S. healthcare spending exceeded $4.5 trillion in 2023. Patients, payers, and employers are looking for solutions that match cost with value.
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Underutilized resources: Studies show that many outpatient facilities operate at only 60–70% capacity during off-peak hours. That’s lost revenue and delayed care.
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Consumer demand for transparency: Patients want to know why costs vary—and are demanding more flexible, value-driven choices.
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Digital health platforms: Online schedulers and third-party networks are making real-time pricing implementation possible.
Still, the risks are real. Surge pricing without ethical safeguards can lead to inequity, confusion, and lawsuits.
The Regulatory Trigger: This Week’s Breaking News
Let’s look at what’s making headlines—and why healthcare executives should pay attention:
1. DOJ Supports Algorithm Pricing Lawsuit
On March 27, 2025, the U.S. Department of Justice filed a Statement of Interest in a lawsuit alleging that MultiPlan (now Claritev) and insurers used shared pricing algorithms to underpay out-of-network providers. The DOJ warned that algorithmic coordination could violate antitrust laws even if parties never formally agreed on pricing.
Takeaway: Your pricing system can be legal—but if it's perceived as collusive, expect scrutiny.
2. NYC Creates Office of Health Care Accountability
On March 23, 2025, Mayor Eric Adams signed legislation creating the Office of Health Care Accountability. It will benchmark hospital pricing and publicly name facilities charging more than 150% of Medicare rates. The move is intended to combat opaque and variable charges faced by city employees and retirees.
Takeaway: Dynamic pricing must come with clear benchmarks. Transparency isn’t optional anymore.
3. PBM Pricing Models Under Pressure
A June 2025 Drug Topics interview with pharmacy benefit leaders revealed a shift from traditional rebate-driven models to cost-plus, pass-through, and unbundled structures. Plans are pushing for pricing transparency that reflects real-time inventory, patient benefit tiers, and utilization.
Takeaway: Healthcare pricing—especially in pharmacy—is being forced into daylight.
Three Expert Perspectives on What’s Coming
Dr. Larragem Raines, MPH – Health Technology Assessment Analyst
“Traditional ICER models assume pricing is fixed, but biologic and specialty drug prices can drop by 40–60% within three years of launch,” says Raines. “Failing to include price lifecycle modeling leads to distorted reimbursement recommendations.”
Scott Halperin, PharmD – PSG Consultant
“Innovative employers are seeking direct contracting, pass-through rebate clarity, and real-time utilization controls,” Halperin said. “PBMs are being forced to evolve into platforms, not black boxes.”
DOJ Antitrust Division – Legal Watchdog
Their warning is clear: “When multiple entities use the same pricing algorithm or coordinate pricing logic, it could violate Section 1 of the Sherman Act, even without direct collusion.”
Real-World Story: How One Patient Saved $500
Hope is a 52-year-old public school teacher in Michigan. During a lapse in insurance coverage, she was quoted $1,200 for a brain MRI. A digital health platform offered the same scan for $700—if she booked at 11 a.m. on a Wednesday.
Same hospital. Same machine. Same staff. The only difference: time slot.
She got the scan. The hospital explained it was part of a pilot to fill capacity gaps and reduce idle technician time.
A win for Hope—and a signal that dynamic pricing could solve real problems. But payers flagged the inconsistency and demanded an audit.
This story illustrates both opportunity and risk.
Tactical Playbook for Health Leaders
If you're exploring dynamic pricing in your practice, system, or network, here’s a proven step-by-step:
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Start with high-volume, elective services (imaging, physical therapy, dermatology).
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Test off-peak discounts: Offer lower prices during underutilized periods (Tuesdays, after 6 p.m., holidays).
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Bundle services: Combine labs, imaging, or procedures into packages with price transparency.
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Use AI to predict no-show risks, and offer last-minute discounts to fill them.
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Audit pricing variance by ZIP code, race, age, and payer type monthly.
Transparency is key. Without it, you’ll face patient confusion—or worse, legal action.
What Not to Do: 3 Failures to Avoid
1. Hourly CT Scan Pricing
One urban hospital rolled out an hourly pricing model: scans at 5 p.m. cost 15% more. Patients accused the hospital of price gouging. Local media picked it up. The model was pulled in under 10 days.
2. ZIP Code-Based Tiering
An insurer used income data to set pricing tiers, which led to higher deductibles in predominantly minority neighborhoods. State regulators imposed fines and forced a rollback.
3. Broken PBM Rollout
A regional PBM launched a pass-through pricing model without IT support. Claims failed to adjudicate. Pharmacists were flooded with calls. After 45 days, the PBM reverted to its old system.
Bottom line: Test, learn, but avoid surprises. Keep the patient experience front and center.
Frequently Asked Questions
Is dynamic pricing legal in the U.S. healthcare system?
Yes, but it must be implemented with transparency, fairness, and without coordination between competitors.
Can dynamic pricing help reduce costs for patients?
If done right, yes. It can offer lower prices during off-peak times, encourage better scheduling, and allow uninsured patients to access care.
What’s the biggest risk?
Perceived unfairness or discrimination. If algorithms lead to higher prices for low-income or minority patients, legal and reputational risks skyrocket.
Do I need to disclose variable pricing to patients in advance?
Absolutely. Lack of price visibility is a key driver of distrust in U.S. healthcare.
Can payers participate in dynamic pricing?
Yes. Insurers can build tiered benefit structures or use real-time co-pay modeling. But coordination with other payers must be avoided.
What’s Coming Next?
Expect the following developments in the next 12–24 months:
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CMS may issue guidance on dynamic pricing in federally subsidized plans.
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More municipalities will follow NYC’s lead with price transparency offices.
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Litigation will increase, especially as pricing data becomes more discoverable.
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Third-party platforms (GoodRx, Sesame, Amino) will offer “healthcare flash sales” and off-peak scheduling discounts.
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Providers will move from “chargemasters” to transparent, benchmarked price bands.
Updated References
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PBM Pricing Trends Shift Toward Transparency
Published by Drug Topics on June 24, 2025, this interview explores how PBMs are moving toward unbundled, transparent pricing due to employer and regulatory pressure. -
DOJ Supports Lawsuit Against Healthcare Pricing Algorithms
On March 27, 2025, the DOJ filed a Statement of Interest asserting that shared pricing algorithms could violate federal antitrust laws. -
NYC Launches Healthcare Pricing Review Office
The NYC.gov announcement outlines legislation creating a watchdog office to cap hospital prices at 150% of Medicare.
Final Thoughts: The Future is Flexible—But It Must Be Fair
Dynamic pricing in healthcare is here. It can deliver value, access, and efficiency—if executed with transparency, ethics, and smart regulation.
The line between innovation and exploitation is thin. Every algorithm, every pilot program, and every price variation must be anchored in one question: Does this help patients and providers equally?
Whether you're a physician, policy expert, tech founder, or healthcare executive, you are in the room where pricing decisions are made. Help ensure that data doesn't replace discretion—and that technology empowers, rather than exploits, our healthcare system.
About the Author
Dr. Daniel Cham is a physician and medical consultant with expertise in healthcare technology, billing systems, and medical operations strategy. He works with practices, startups, and healthcare systems to make innovation safe, scalable, and equitable.
Connect on LinkedIn: linkedin.com/in/daniel-cham-md-669036285
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