By NextBestFitFixed budget share for program integrity
Reserve a share of administrative spending (e.g., 0.3% of benefits) for fraud detection, audits, and prosecutors.
Fixed budget for program integrity.
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This path
Fixed budget share for program integrity
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Reserve a share of admin spending for program integrity
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- One payer becomes one target
Reserving administrative funding for fraud detection, audits, and prosecutors deters fraud; the cited control program recovers more than it spends.
- Fraud and improper payments
Dedicated funding for fraud detection, audits, and prosecutors supports deterrence and recovery of fraudulent payments.
What it creates or worsens
- About $1 trillion a year in administrative cost
Reserving funding for fraud detection, audits, and prosecutors adds administrative cost.
21 paths soften this
One claims system and standard rulesAbout $1 trillion a year in administrative costChosenStandardize across many payersAbout $1 trillion a year in administrative costChosenSingle public payer for everyoneTens of millions of people have no coverageChosenRegulated multi-payer: everyone must have a non-profit or tightly regulated planTens of millions of people have no coverageRejectedPublic option alongside private insuranceTens of millions of people have no coverageRejectedContinuous eligibility (12-month or multi-year) in Medicaid and CHIPPeople lose coverage when their life changes (churn)ChosenCoverage tied to residence, not job or incomePeople lose coverage when their life changes (churn)ChosenNo cost sharing at the point of careUnderinsurance: covered, but can't afford to use itChosenEvery licensed provider is in-networkNarrow networks and out-of-network surprisesChosenPrevent new debt by ending point-of-care billsMedical debt affects about 100 million peopleChosenEliminate out-of-network statusSurprise billing and a runaway arbitration systemChosenEliminate prior authorization except for a short listPrior authorization delays and blocks careChosenPublic administration with a cost targetInsurer overhead and profitChosenPublic review of hospital budgetsExecutive pay and nonprofit statusChosenCut documentation and billing burdenClinician burnout from paperwork and EHR workChosenGlobal budgets for hospitalsU.S. prices are far higher than in other countriesChosenLower costs for clinicians, not only payProviders leave, retire, or go cash-only if pay dropsChosenFast transition in one or two yearsTransition disruption: jobs, companies, and familiar coverageRejectedAutomatic exemptions and annual collection through taxesCopays keep billing systems alive and still deter poorer patientsChosenDrop point-of-care charges entirelyCopays keep billing systems alive and still deter poorer patientsChosenReport measures publicly without tying pay to themTargets and quality metrics invite gamingRejected - Adds paperwork, coordination, or complexity
Fraud detection and audits can also burden honest providers.
Who's affected
Who gains
- Taxpayers and public budgets
- One payer becomes one target: A single national payer concentrates fraud and cyber risk.
- Fraud and improper payments: Fraud and improper payments consume public funds and premiums.
- People with employer coverage
- Fraud and improper payments: Fraud and improper payments consume public funds and premiums.
- Health insurers, brokers, and their shareholders
- About $1 trillion a year in administrative cost: Insurers, billing firms, and clearinghouses earn from the complexity.
- Insurance and billing workers
- About $1 trillion a year in administrative cost: Their jobs exist because of the complexity.
Who loses
- Fraudulent operators and cybercriminals
- One payer becomes one target: Concentrated national payments provide a single fraud target.
- Fraud and improper payments: Fraudulent providers receive improper health payments.
- Doctors, nurses, and other clinicians
- About $1 trillion a year in administrative cost: Time goes to billing and insurer rules instead of patients.
- People with employer coverage
- About $1 trillion a year in administrative cost: Premiums pay for the administration.
- Taxpayers and public budgets
- About $1 trillion a year in administrative cost: Public programs pay for it too.
Where it has been tried
- U.S. Health Care Fraud and Abuse Control Program: Recovers several dollars per dollar spent.