Coverage authority, payment authority, audit and appeals sit in separate bodies, because concentrating them would make a coverage mistake, a payment mistake and a governance mistake mutually reinforcing. The cost brake runs in two stages and both read access-adjusted spending, so a fall caused by undelivered care never registers as a saving. Prior authorization is abolished and replaced by retrospective, collective review. Durability is engineered: universality, mandatory appropriation, ring-fenced capital, insulated rate-setting.
Prior authorization is abolished, so something has to replace it. The substitute is retrospective and collective rather than permission-based, and it addresses over-provision through three instruments matched to its three drivers.
Upcoding is a billing problem handled by payment design. Over-provision is clinical, larger, and needs defensive medicine, demand-driven provision and self-referral tackled separately.
Defensive medicine is ordering to avoid a lawsuit rather than to answer a question. Patient-satisfaction scoring tied to reimbursement pays physicians to say yes, and the research linking higher satisfaction to higher spending and worse mortality is consistent. Self-referral turns clinical discretion into a revenue channel.
None of these is solved by making clinicians ask permission first. Prior authorization is expensive, universally resented, and aimed at the wrong target.
Federal liability preemption makes guideline adherence an affirmative defence, administered through an administrative compensation system on the vaccine-injury model. State tort-reform evidence shows modest, low-single-digit spending effects — this is worth doing because it purchases the price reduction and because clinicians deserve it, not because it pays for itself.
Satisfaction scores are barred from payment adjustment on any procedural, imaging or prescribing decision. They are retained and strengthened for access, communication, respect and dignity — what patients are uniquely positioned to judge — and removed from every domain where refusal is the correct clinical answer.
Physician self-referral closes completely. No in-office ancillary services exception, no whole-hospital exception. The exceptions that swallowed the original rule are removed rather than narrowed.
None of this is needed inside an Authority under a global budget, because nobody there profits from the unnecessary procedure. The share of care delivered under salaried, budgeted arrangements is itself an anti-over-provision metric and is tracked as one; it crosses half of all care by Year 15.
Retrospective review examines patterns, not permission slips. Risk-adjusted practice above the 95th percentile triggers professional examination and does not establish wrongdoing. The sequence is explanation, peer review, education, corrective plan; financial consequences follow only persistent unexplained variation. Fraud and deliberate miscoding are separate enforcement matters.
Abolishing prior authorization means some unnecessary care gets paid for.
Yes, and that is the accepted price. Retrospective review finds patterns after they occur, which means the first instance is always paid. The trade is a system that stops spending billions on an arms race in which payers automate denials and providers automate appeals.
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.
- Federal tort preemption has failed for forty years, and it is what purchases the price cut.