By NextBestFitRegional administrators under national rules
Split claims processing among regional administrators (public or contracted) that compete on integrity metrics.
Regional administrators under national rules.
Review ledgerHow this path connects
Addresses
One payer becomes one targetThis path
Regional administrators under national rules
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Split claims processing among regional administrators
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
Dividing claims processing among regional administrators avoids a single point of failure and permits comparisons of integrity across regions.
What it creates or worsens
- About $1 trillion a year in administrative cost
Splitting claims processing among regional administrators adds overhead.
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 - Targets and quality metrics invite gaming
Making regional administrators compete on integrity metrics puts those measures at the center of performance comparisons.
Who's affected
Who gains
- Taxpayers and public budgets
- One payer becomes one target: A single national payer concentrates fraud and cyber risk.
- Health administration and software vendors
- One payer becomes one target: Dividing claims processing among regional administrators avoids a single point of failure and permits comparisons of integrity across regions.
- 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.
- Hospitals, clinics, and care organizations
- Targets and quality metrics invite gaming: They can benefit by changing referral dates, avoiding sick patients, or upcoding.
Who loses
- Fraudulent operators and cybercriminals
- One payer becomes one target: Concentrated national payments provide a single fraud target.
- 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.
- People with ongoing or specialist care needs
- Targets and quality metrics invite gaming: Gaming wait-time and quality measures undermines their intended protection.
Where it has been tried
- U.S. Medicare MACs: Regional contractors process claims.
- Canada: Each province runs its own plan.
- United States: In FY 2024, 12 regional A/B and 4 DME Medicare Administrative Contractors processed over 1.1 billion fee-for-service claims and paid $459.7 billion in benefits for 33.9 million beneficiaries under national rules.