Put Doctors Back in Charge

• Reduce administrative overhead as a share of total healthcare expenditure from approximately 34% to below 20%—closing the gap between the United States and peer nations and redirecting hundreds of billions of dollars annually toward actual patient care. [1]
• Reduce prior authorization turnaround times to a maximum of 48 hours for all non-emergency requests, eliminating the weeks-long delays that currently force physicians to choose between treating patients and fighting paperwork.
• Restore physicians’ administrative burden to pre-HMO levels.  Before managed care, physicians spent the substantial majority of their working hours with patients, not on documentation.  That ratio has inverted; we intend to invert it back. [2]
• Eliminate non-clinical waiting for hospital beds.  When a physician determines a patient needs admission, administrative and insurance pre-clearance processes should not be the bottleneck.
• Ensure that cost reductions flow to patients, not exclusively to insurer margins.  Administrative savings that disappear into earnings reports have not solved the problem.

These goals describe outcomes, not mechanisms.  The specific legislative and regulatory pathway is under active development and will be published separately.  Where our initial approach proves wrong, we will say so plainly and revise.

Administrative overhead reduction alone does not go far enough.  We are actively researching additional sources of meaningful cost reduction—not pennies on the dollar, but dimes, and multiple dimes—including the crisis of hospital bankruptcy and closure that is leaving entire communities without access to care, and refinements to the overall concept that reflect what we have learned since this page was first published.  This section will be updated as that work progresses.

1. Administrative overhead ratio:
   1. Administrative costs as a percentage of total national health expenditure, measured against the CMS National Health Expenditure Accounts baseline. [1]
   2. Insurer medical loss ratios (the share of premiums spent on actual care versus administration and profit), reported quarterly under existing ACA requirements.
2. Prior authorization:
   1. Median and 90th-percentile turnaround time for prior authorization requests, measured from submission to determination.
   2. Denial rate and overturn-on-appeal rate.  A high overturn rate is evidence that initial denials are functioning as delay, not as clinical judgment. [3]
3. Physician time allocation:
   1. Ratio of direct patient-care hours to documentation and administrative hours per physician, tracked via time-motion studies modeled on existing AMA survey methodology. [3]
   2. Physician burnout rates as reported in annual Medscape or AMA surveys, used as a lagging indicator of administrative burden.
4. Hospital bed access:
   1. Median time from physician admission order to patient placement in a bed, excluding periods where the delay is clinical (e.g., awaiting test results).
   2. Number of documented cases per quarter in which administrative or insurance pre-clearance delayed an admission the treating physician had ordered.
5. Cost pass-through:
   1. Average out-of-pocket healthcare spending per household, adjusted for inflation, tracked against the Bureau of Labor Statistics Consumer Expenditure Survey.
   2. Premium growth rate relative to administrative cost reduction—if overhead falls but premiums do not, the savings are not reaching patients.

• CMS already publishes the National Health Expenditure Accounts annually.  The administrative overhead ratio should be broken out as a headline figure in that report, not buried in supplementary tables.
• The ACA’s medical loss ratio reporting requirement provides a quarterly data stream for insurer-level administrative spending.  No new reporting infrastructure is needed.
• Prior authorization turnaround and denial data should be reported by all insurers participating in federal programs (Medicare Advantage, Medicaid managed care, ACA marketplace) on a quarterly basis, with public dashboards.
• Physician time-allocation surveys should be conducted annually by HHS or by contract with an existing medical society (AMA, ACP), with results published and compared to the pre-reform baseline.
• Congressional review through the Senate HELP Committee and House Energy and Commerce Committee no less than annually for the first five years following enactment.

• Prior authorization reform can proceed independently of broader structural changes to the managed care system.  Bipartisan prior authorization bills have already advanced in multiple recent Congresses.
• The 48-hour turnaround requirement can be implemented by CMS rule for federal programs without waiting for legislation covering commercial insurers.
• Hospital bed access reforms are separable from insurance-side reforms and can be pursued through hospital accreditation standards (via CMS Conditions of Participation) as well as legislation.
• Administrative overhead reduction targets and cost pass-through requirements are interdependent—one without the other allows savings to be captured by intermediaries rather than patients.  These should move together.
• Physician time-allocation improvements follow naturally from prior authorization reform and administrative simplification, but explicit reporting requirements should be enacted separately to ensure the data exists regardless of which reforms pass.

• The right to have medical decisions made by physicians rather than insurance administrators is not a temporary policy experiment.  Core protections should be permanent law.
• The 48-hour prior authorization mandate should be reviewed after five years to determine whether the timeline should be shortened further or whether prior authorization for specific categories of routine care should be eliminated entirely.
• Administrative overhead reporting requirements and public dashboards should be permanent.  Transparency does not expire.
• The cost pass-through provisions should include a ten-year review to assess whether market dynamics have internalized the incentive or whether ongoing regulatory enforcement remains necessary.
• Physician time-allocation surveys should continue indefinitely as a public health workforce indicator, regardless of the status of any specific reform.