PDF(Pubmed)
Abstract：
US health care administrative spending is approximately $1 trillion annually. A major operational area is the financial transactions ecosystem, which has approximately $200 billion in spending annually. Efficient financial transactions ecosystems from other industries and countries exhibit 2 features: immediate payment assurance and high use of automation throughout the process. The current system has an average transaction cost of $12 to $19 per claim across private payers and providers for more than 9 billion claims per year; each claim on average takes 4 to 6 weeks to process and pay. For simple claims, the transaction cost is $7 to $10 across private payers and providers; for complex claims, $35 to $40. Prior authorization on approximately 5000 codes has an average cost of $40 to $50 per submission for private payers and $20 to $30 for providers. Interventions aligned with a more efficient financial transactions ecosystem could reduce spending by $40 billion to $60 billion; approximately half is at the organizational level (scaling interventions being implemented by leading private payers and providers) and half at the industry level (adopting a centralized automated claims clearinghouse, standardizing medical policies for a subset of prior authorizations, and standardizing physician licensure for a national provider directory).
摘要：
美国每年的医疗行政支出约为1万亿美元。一个主要的业务领域是金融交易生态系统，每年有大约2000亿美元的支出。来自其他行业和国家的高效金融交易生态系统表现出两个特点：即时支付保证和整个过程中高度使用自动化。目前的系统在私人付款人和提供者之间，平均每笔索赔的交易成本为12至19美元，每年超过90亿笔索赔;每个索赔平均需要4至6周的时间来处理和支付。对于简单的索赔，私人付款人和提供者的交易成本为7到10美元；对于复杂的索赔，35到40美元。对大约5000个代码的事先授权，私人付款人每次提交的平均费用为40至50美元，提供者每次提交的平均费用为20至30美元。与更有效的金融交易生态系统相一致的干预措施可以减少400亿美元至600亿美元的支出；大约一半是在组织层面（由领先的私人付款人和提供商实施的扩展干预措施），一半是在行业层面（采用集中的自动化索赔交换所，为先前授权的子集标准化医疗政策，并将医生执照标准化为国家提供者目录)。
