The American Healthcare Quality Board publishes national coverage indications; a service inside an indication is paid on the clinician's attestation. Congress sets the ethical frame and the numbers encoding it, and AHQB applies them — an unelected board choosing a value threshold would be illegitimate, while the same board applying one set by statute is not. The cost-effectiveness corridor governs end-stage life-prolonging therapy only; the rest of the floor is a clinical determination on evidence of benefit, with price disciplined by procurement and negotiation.
AHQB determines whether a drug, device, procedure, diagnostic or model of care is payable from the floor, and in which clinical situations. Permanent professional staff conduct comparative assessment; conflict-screened expert panels receive evidence, hear patients and clinicians, deliberate in public and recommend. Recommendations are advisory. AHQB is legally accountable, issues the final national determination, and publishes evidence, methodology, indication, exclusions and reconsideration date.
It does not approve products for sale, license clinicians, or prohibit lawful self-paid care.
Insurer medical-necessity review is case-by-case discretion exercised by a party with a financial interest in the answer. Replacing it with a published national rule does not remove judgement; it moves the judgement into the open, applies it once rather than millions of times, and makes it appealable.
The FDA analogy is incomplete and worth stating precisely. FDA answers whether a treatment works, which is evidentiary. AHQB answers whether it is worth paying for, which requires a threshold — and a threshold is a value judgement. An unelected board choosing that threshold would be illegitimate. The same board applying a threshold set by statute is not.
Members serve fixed terms with removal only for cause, on the Federal Reserve model. Political officials may change the law and the budget; they may not direct an individual coverage determination.
A covered indication creates an entitlement. The clinician attests; the claim is paid. Claims may still be rejected for fraud, duplication, ineligibility, or a service outside the indication.
Published for every determination: the full economic model and its inputs, the reference case as applied, the deliberation record including dissents, conflict declarations, and the reconsideration date. Confidential commercial pricing is permitted only where it produces a net-lower price than public listing, with the net price disclosed to the relevant congressional committees.
AHQB also supervises supplemental tier standardization and rating rules, and runs the annual one-way ratchet review.
Coverage authority, payment authority, audit and appeals sit in separate bodies. Concentrating them would make a coverage mistake, a payment mistake and a governance mistake mutually reinforcing.
- Coverage standard
- Congress sets the perspective, corridor, modifiers and safeguards; AHQB applies them.
- Review and appeal
- Determinations are petitionable by societies, patient groups, manufacturers, Authorities and clinicians.
AHQB will be staffed by people learning on the job — roughly 3,000 health-technology-assessment analysts, in a labour market that has never produced them.
True and unresolved. A rate-setting body finding its feet is how a price glide path gets set wrong in the direction that cannot be undone. Fixed terms, public panels, statutory methodology, published dissents and judicial review reduce the risk without eliminating it.
Honesty about gaps. Distributed Healthcare has more unresolved specification than other Engines because operational complexity is higher; the items below are flagged for v10.2 specification or for outside expert review.
- Analyst supply is a five-year-plus problem and is on the critical path.
- Whether the ratchet review can resist becoming an annual lobbying event.