A common recommendation to combat the current opioid epidemic is to provide physicians with opioid prescribing guidelines. Opioid guidelines synthesize the available research to inform judicious prescribing behaviors and safe dosages when opioids are needed. Given the seriousness of the opioid epidemic, it is not surprising that multiple organizations currently produce opioid prescribing guidelines. Opioid guidelines are based on evaluations of the research, but the guidelines themselves need to be evaluated critically, as well. Guideline Evaluation Fortunately, there are multiple standards currently available to evaluate guidelines, including AGREE (Appraisal of Guidelines, Research and Evaluation), IOM (Institute of Medicine), GRADE (Grading of Recommendations Assessment, Development and Evaluation) and AMSTAR (A Measurement Tool to Assess Systematic Reviews). For example, the AGREE consortium’s latest standard (AGREE II) provides a 23-point checklist covering six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability and editorial independence. While some AGREE II domains are obvious criteria including “rigor of development” and “editorial independence,” other domains such as “applicability” are less obvious but important. See also: Who’s Going to Pay for the Opioid Crisis?   For example, one part of “applicability” is about providing advice or tools for translating recommendations into practice. This point is important considering opioid prescribing guidelines will only work if practitioners can integrate use of the guidelines into their workflow and can apply them effectively to the appropriate individuals. Most chronic opioid users’ first exposure to opioids is through a physician’s prescription, and physicians’ opioid-prescribing patterns have been shown to be associated with opioid abuse and deaths. Therefore, preventing unnecessary first exposure to opioids is crucial. Guideline standards have shown that not all opioid treatment guidelines are of equal quality. For example, Nuckols et al. (2014) assessed 13 opioid guidelines using the AGREE II and AMSTAR instruments. The authors found AGREE II scores ranged from 3.00 to 6.20 on a 1 to 7 scale, and AMSTAR ratings ranged from poor to high. Four of the guidelines were “recommended against using … because of limited confidence in development methods, lack of evidence summaries or concerns about readability.” This research proves that the quality of opioid guidelines does vary. The National Guidelines Clearinghouse (www.guideline.gov) is a publicly available resource that provides summaries of guidelines that comply with IOM standards. Although not all guidelines are available free on the National Guidelines Clearinghouse website, it could be a good starting point for finding organizations with guidelines that adhere to a guideline standard. Jim Smith’s Story Jim Smith’s occupational injury provides a useful example of how being prescribed opioids contrary to high-quality treatment recommendations may lead to serious health and economic consequences. Jim is a 38-year-old construction worker who suffered an extremely painful lower back strain while attempting to lift a heavy box. Against most guidelines’ recommendations, he was treated from the start with a long-acting opioid, on which he became first dependent and then addicted, taking increasingly higher doses. Even on doses exceeding most guidelines’ recommendations, Jim still suffered from pain and limited mobility. In addition, he began to require supplemental medication to treat the side effects of his opioid use, such as constipation. He subsequently underwent surgery on his lumbar spine, which did not provide him relief from his pain, and he ended up a chronic user of opioids, permanently disabled and housebound. If Jim had been treated according to any of the current, high-quality opioid treatment guidelines, he would not have received a prescription for an opioid as an initial measure. He would have been counseled to try over-the-counter medications such as ibuprofen or acetaminophen, sent to physical therapy, prescribed exercise and perhaps offered a course in cognitive behavioral therapy (CBT). If opioids had been truly necessary in the acute phase of Jim’s injury, he would have been prescribed a limited course and then been gradually tapered off. See also: 3 Perspectives on Opioid Crisis in WC   Conclusion It is very important to find guidelines that both reduce initial use of opioids and serve to guide the physician in tapering chronic opioid users off these drugs. For someone who has been on opioids for a long time, the tapering process could take many months or years, and there could be both physical and psychological complications during the taper. The process for weaning someone off chronic opioid usage will be discussed in the next article in this series. In conclusion, users of treatment guidelines put a lot of trust into the recommendations provided. Using only opioid treatment guidelines with sound quality and content helps keep that vital trust so clinicians can continue to use guidelines in combating the prescription opioid epidemic.

It all began with reports of eroding books of business, price wars and marketing dollars not accounting for conversions of prospects into customers (or not in any visible manner, anyway). Then the CEO made that big "I’m back from a conference speech" and wanted to share. Suddenly, we’ve established a deadline to implement Net Promoter Score (NPS) at the enterprise level, and a whole playbook is being designed. Sound familiar? NPS can be used to gauge the loyalty of a firm’s customers. It measures who is promoting our brand versus who is likely to detract and therefore take their business elsewhere. We soon realize that the costs of exceeding customer expectations are high, while the payoffs are minimal. We know from experience that customers are much more likely to punish bad service than to reward good service. Having your problems resolved easily is a much better predictor for satisfaction than the exceeding of expectations. Improving the customer experience by making the customer journey easy is of greater significance to any brand. This philosophy requires different measurements, like the Customer Effort Score (CES), which is superior to Customer Satisfaction (CSAT) and Net Promoter Score (NPS) in predicting consumer behavior. See also: What Is the Right Innovation Process?   In the end, consumers to have a job done and will back brands that help them get the job done faster, better and cheaper. Achieving this for your consumers not only requires meeting current needs but anticipating future needs by inventing a future that is interesting and sexy and serves a purpose. This requires moving from data to analytics, customer segmentation to ease of doing business and ideas that sell to ideas that are bought. We have started shifting the paradigm, mental models and mindsets. The future is in its making, and the applications are only limited by our imagination. In the world of innovation, which lies at the fringes of most organizations or fills the gaps in between, we keep asking all the wrong questions. We all want frictionless technology solutions, but the focus can't be on which technologies are enabling us or who we’ve partnered with. The focus needs to be on why we are innovating and at what scale. Let’s consider the value proposition for transporting people from A to B. We must ask ourselves, what are the jobs to be done before that journey, during that journey and after that journey from the consumer’s point of view. I call this exercise wearing the "Uber Hat." The jobs to be done before the journey may include finding a driver nearby, knowing how long it’ll take for the driver to arrive and figuring out if the fare is coming out of personal or business expenses. Once on the journey, the jobs to be done may include picking up a friend or colleague, knowing how long the journey will take in real-time or sharing the ride. After the journey, the jobs are knowing how much it cost, receiving a receipt for payment (especially for expense claims on business trips) and recovery of items left behind in the car. Uber has thought about everything! It's even started services that assist people in emerging markets to hail a ride without the app or the need for credit card payments. Who would want to take a taxi when you’ve experienced Uber’s service and quality of care? See also: Is Insurance Having an Uber Moment?   When we are wearing the Uber Hat, we think and act like Uber. We are able to design solutions that are globally relevant, apply to any business or market and withstand the challenges in our way, no matter how big they may seem to others. Throw creative thinking and industry expertise into the mix, and you’ve got a winning formula for the application of human-centered design that has proven its success across borders. This is the difference between a market leader and a follower. I’m only here to present concepts. The choice is yours. If you don’t make that choice, ultimately the consumer will.

Significant numbers of insurance startups are emerging in the market today, and many are providing brilliant tech-based solutions. Insurtech startups have shown so much promise that venture capital firms are starting to invest heavily in them. In fact, between 2011 and 2017, VC funding for insurtech companies grew 31% annually. Between Series B and Series D funding, $2 billion to $3 billion is being directed to insurance startups annually. Here is a look at some of the most exciting insurtech startups that are receiving significant funding. Lemonade Lemonade is a home and renters insurtech company that is making a lot of waves. The company launched in New York in 2016 but now is planning to expand into California. Lemonade uses artificial intelligence and behavioral economics to optimize accuracy and efficiency. After its latest round of funding, Lemonade has generated $60 million in total. This makes it one of the biggest players in the insurtech startup space. Lemonade’s funding is not coming from average VC firms; it is coming from high-level sources, such as General Catalyst, GV (Google Ventures) and Sequoia. See also: Let’s Make Lemons Out of Lemonade   Friendsurance Friendsurance received $15.3 million in its latest round of funding. The majority of the money invested in this round came from the Hong Kong-based Horizons Ventures. Friendsurance is a sophisticated peer-to-peer insurance startup that has its headquarters in Berlin. Originally, it was only a national company, but it is now expanding internationally. In addition to Horizons Ventures, Friendsurance has received funding from Otto Group Eventures, the European Regional Development Fund and the German Startups Group. With so much financial backing, and a steadily growing customer base, Friendsurance looks poised to succeed internationally. Amodo Amodo is a Croatian insurtech that helps insurance companies get the most out of connected devices. The company lets customers build profiles and provide data, which helps insurance companies address the specific needs of each customer much better. For example, with Amodo's Connected Customer Platform, insurance customers can use their smartphones to prove that they spent time at the gym, to earn lower premiums on health insurance. Like Lemonade and Friendsurance, Amodo has also attracted the interest of some major VC companies. In 2016, Amodo received 450,000 euros of seed funding from an Austrian VC, SpeedInvest. Also like Lemonade and Friendsurance, Amodo is in the process of expanding. The company is trying to break out of the local Croatian market and spread across the world. See also: Top 10 Insurtech Trends for 2017   Insurtech Outlook In the past few years, technology finally appears to have become as useful for insurance as it has for many other industries, such as finance, social networking, and media. This is because insurance companies thrive on data, the compiling of which has become much more advanced. Lemonade, Friendsurance and Amodo are but a few examples of the excitement VCs have for insurtech. As more and more of these startups improve the insurance world for insurers and customers alike, the list of VC-funded insurtech startups will grow exponentially in the coming years.

We have reached a Cambrian moment in insurance. Just as the number of animal phyla exploded during what scientists call the Cambrian period, the number of insurtechs is accelerating at an extraordinary pace, and there are no signs of slowing.

Just look at what the carriers, alone, are doing. A KPMG survey of 200 insurance executives found that 50 reported already having corporate venture capital units. Half of those units had at least $250 million to invest, and several had more than $1 billion. Beyond those 25% who reported having a VC unit, a further 37% of the respondents said a unit was being set up. That's a boatload of cash being directed at opportunities in insurtech.

A search of news just in the hours before I wrote this found that Zurich Insurance Group, the Admiral Group, Allianz, Munich Re and Swiss Re have formed partnerships with U.K. accelerator Startupbootcamp InsurTech, as has XL Catlin. Meanwhile, Aflac announced a $100 million fund to invest in insurtech over three years. 

The fact that the industry has hit its Cambrian moment is a monumentally hopeful sign for all of us who believe that insurance needs to be disrupted, but this only puts us in what I see as the second of five stages of innovation. Based on my 30 years of following innovation as it has turned numerous industries on their heads—beginning with what personal computers did to IBM and the rest of the computer industry when I covered it for the Wall Street Journal in the 1980s and early 1990s—I believe that we're now past the denial phase but still need to go through three more phases, after this Cambrian one.

And the next stage will likely be painful. It's the winnowing phase, when we learn once again that nine out of 10 startups fail and realize that many of these huge investments will be for naught. (The final two phases are: "scaling up" the startups that succeed and then "lather, rinse, repeat"—to make sure the innovation process continues.) 

So, be careful. We're making real progress, and it's natural to be enthusiastic. That's the way the Cambrian phase always seems to work. But not every tree grows to the sky.

And let us know if we can help. We've assembled what I believe to be the best platform for evaluating insurtechs. We have nearly 950 companies in our data base, and many have already filled out detailed questionnaires that provide real insight into how they will fare. We also have developed great tools that allow for sophisticated searches by part of the value chain being addressed, by technology, by geography, etc. We even have a dating-site-like capability that will let you establish criteria for a match and be notified when an insurtech matches your criteria. You can check out our subscription-based service at the Innovator's Edge site, or contact us at info@insurancethoughtleadership.com for a demo. 

Cheers,

Paul Carroll,
Editor-in-Chief 

Effective customer relationship management (CRM) is key to successful business, especially when it comes to smaller insurance carriers, where the focus is on the client relationship. But smaller insurance carriers are falling behind on efficiency and speed. Larger carriers are gaining market share because of innovative digital tools and techniques, ranging from new data sources, robotic process automation (RPA), advanced data analytics such as machine learning and cognitive computing, to IoT (Internet of Things). For instance, larger carriers can deliver quotes (whether personal or commercial lines) in real time and allow binding and paying online. For small and mid-sized traditional insurance carriers, to stay relevant, and increase their growth and profitability, they need to partner with insurtechs and firms providing technological infrastructure to insurance firms. Here are three reasons why this is necessary: 1. Competitive Edge Insurtechs have a natural competitive edge over traditional insurance carriers, because of their lack of legacy systems and typically narrow focus. This leads to a much quicker service delivery model. What customers have expected traditional insurance carriers to deliver in weeks, insurtechs are now delivering in minutes or hours. To reduce the gap in service delivery models, smaller insurance carriers can partner with insurtech startups to yield innovation and improve efficiency. See also: Insurtech: Unstoppable Momentum   2. Internal Efficiency Legacy insurance carriers have slow internal processes, i.e. the long cycle between brokers, carriers, underwriters and customers, and lack of digitization of customers’ requirements or customer files. If all the file work is still actually on paper and not digital or in the cloud, then searching for and acting on information does not take seconds but takes minutes or even hours. Thus, the more digitized carriers win again. The small and mid-sized insurance carriers can overcome this gap by strategically partnering with insurtechs in a very cost-effective manner. 3. Effective and Improved Service Delivery Smaller insurance carriers need to have an effective service delivery model, which reduces the dependence on long communication channels and is completely customer-oriented. To do that, traditional smaller carriers need to show a willingness to adapt and innovate. They need to start by identifying and then partnering with startups that can improve their service delivery model. Recommendation Small and medium-sized insurance companies should start to track investments and advances that are emerging within the insurtech community and consider partnering with insurtechs to move from a traditional service delivery model to an innovative customer-centric and technologically enabled model. Such partnerships will be mutually beneficial — the carrier will benefit from new techniques and digital infrastructure such as cloud-based services in a very cost-efficient manner while the insurtech will benefit from the carriers’ legacy customer base and industry knowledge. See also: Insurtech: The Approaching Storm

Small- and mid-sized businesses (SMBs) are increasingly at risk for data breach class-action lawsuits that typically have targeted large corporations. Large companies are learning to address cyber threats. Hackers are responding by setting their sights on SMBs. So it’s simply more productive and efficient to attack poorly protected companies that could take weeks or even months to notice they’ve been breached. As the risk of exposure moves downstream, the associated class-action lawsuits surely will follow. Statistics from the Identity Theft Resource Center show that the number of data breaches reported in 2016 exceeded 2015 levels by 40%, a worrying trend for those in the small business sector that likely will bear a greater percentage of those breaches going forward. The data stores held by SMBs may be smaller, but they’re no less rich in value to hackers. They contain financial data, healthcare information and other tantalizing personal details. Security falls short Unfortunately, because SMBs often lag behind larger companies in the sophistication and scope of their defensive measures, they’re much more susceptible to litigation centered on charges of negligence or a lack of due diligence. Exposures in the SMB sector also could go undetected for long periods, leaving more records vulnerable and increasing the size of the victim pool that may be interested in suing. See also: The Key to Survival in Wild West of Cyber   Smaller firms’ responses to the risk of cyber attack and litigation depend largely on their industry. Even the smallest healthcare entities are typically well-adapted to address potential data breaches and cyber risks. Long-standing mandates such as HIPAA — as well as a robust, centralized breach-reporting mechanism — have made companies in the medical space a little paranoid about their heavily regulated environment. Behind the curve Other small business sectors aren’t as prepared for the risk of a breach. Outside healthcare, the professional services industry, including legal and accounting, is much less aware of where threats exist or how to mitigate them. Many small firms don’t understand their responsibilities regarding data privacy or how data breach notification laws apply to them. Without a good awareness of data privacy concerns, obligations and solutions, these businesses are easy targets for any hacker who happens upon them. Litigation bills add up Data-breach class-action lawsuits can result in million-dollar judgments, but devastating costs may be incurred even if a settlement never materializes. A breached small business still needs to defend itself against litigation, and that takes money. Between legal counsel, forensic investigations, data recovery and any other steps the company may be required to take, the company is likely to incur significant financial penalties no matter which way the lawsuit goes. See also: Can Trump Make ‘the Cyber’ Secure?   Some SMBs are realizing they aren’t prepared for a cyber attack. The truly savvy ones are waking up to the prospect that, just as with the professional and employment liability insurance they already have, it would be wise to pursue coverage to defer defensive and recovery costs around their cyber liabilities. With the specter of more breaches — and more class-action lawsuits — coming down the pipeline, SMBs must find a way to minimize the threat of exposures while also putting protective measures in place should they find themselves facing litigation. This article was originally posted on ThirdCertainty. It was written by Eduard Goodman.

Q: Congratulations on becoming the new Iowa insurance commissioner. You’re a Missouri native with 30 years of experience in the industry. What brought you to Iowa? A: Thank you very much. About four years ago, I met Nick Gerhart, who was beginning his tenure as Iowa’s insurance commissioner. We had really good discussions at NAIC meetings, and he needed another member for his senior leadership team. Things really just fell into place. I’ve spent my entire career in consumer protection, and I shared Nick’s values of making government work for the people we serve — in our case, the consumers of insurance products. Another draw for me was that Iowa is a huge insurance hub. From the outside looking in, I knew that Iowa’s regulatory culture was open communication with the regulated industry. We protect consumers and have high standards for the industry we regulate, but we communicate openly. We may not always agree with insurers, but we are willing to talk about it. I feel many states don’t have that mindset. It makes a big difference to have a focus on consumers while also working with industry in a fair, flexible and positive way. Industry ultimately wants stability and to be treated fairly, and I think that is why Iowa is home to so many insurance companies. See also: A Commissioner’s View of Innovation   Q: How does it feel to have the title of insurance commissioner once again? Not many can say that. A: I am confident that those insurance commissioner statistics are not kept, but in the 150 years of state insurance regulation, I may be the sixth or seventh to serve as insurance commissioner in two separate states. Perhaps I’ll be the answer to a Jeopardy question someday. I’m very pleased to have been appointed by Gov. Branstad and Lt. Gov. Reynolds so that I can continue working to help protect consumers. We have a really, really good staff here at the Iowa Insurance Division, and I consider it an honor to lead them. Q: What’s your vision for the Iowa Insurance Division moving forward? A: Consumer protection will be the main focus. Our multi-faceted team is in place to make sure that Iowans are protected. We have a market regulation team that works with consumers on complaints, enforcement attorneys that ensure companies and producers who are doing what they are supposed to be doing, a fraud bureau that consists of law enforcement officers that investigate insurance fraud and a Senior Health Insurance Information Program (SHIIP) that helps Iowans on Medicare get the information they need to make informed decisions. Another huge part of consumer protection is ensuring that the insurance companies are solvent to be able to pay claims when needed. Our financial team works hard every day so consumers are protected that way. We also just recently launched a new website, which really puts consumers first so they can quickly and easily get the information they need. Q: There’s always talk during a new president’s term about the first 100 days and discussions about the cabinet picks. Is it the same for a new commissioner taking over? A: Well, in my case, I’ve been appointed by the same administration that my predecessor was. On one level, much stays the same. Early on in Commissioner Gerhart’s tenure, he knew there was a crisis coming as much of our staff was retirement-eligible in the coming years. We put in a lot of work in terms of strategic hires, putting our younger staff in positions to both learn and lead and reorganizing as necessary. We’ve been able to add necessary staff to those regulating company solvency to keep up with the growing and increasingly complex nature of our domestic industry. Still, we may look to continue adding to our senior leadership, whether that be from inside Iowa or outside given the strategic plans put in place under Commissioner Gerhart. I will work with industry, our universities, Lt. Gov. Reynolds and Gov. Branstad to help make Iowa an attractive place to do business and a home for talented insurance professionals. As for the first 100 days, I think a lot depends on what happens at the federal level in a few areas. What happens with the ACA is yet to be seen but will have a huge impact on what we do here in Iowa. The DOL fiduciary rule is also out there as something we are waiting to see how the new administration deals with. There’s also FIO, and I suppose the list could go on. We’ll continue to be active at the NAIC level to bring ideas forward and work for the best interest of Iowans. See also: What Is the Right Innovation Process?   Q: Iowa has generally been very forward-thinking in terms of innovation in the industry. ITL has even joined as a partner to the Global Insurance Symposium that the Iowa Insurance Division helped create. What should we expect at this year’s event? A: The Iowa Insurance Division has been a founding partner of the Global Insurance Symposium, which is held each spring in Des Moines. This year will be the fourth year, and I think it will be the best one yet. There really is something for everyone. Many of the topics such as artificial intelligence, blockchain, corporate strategy, risk mitigation and innovation in the industry truly transcend all types of insurance. This event brings together top thought leaders in industry from around the world, industry executives, regulators and insurtech startups. I think this event is in a caliber of its own, and I’m really proud to be in a position to help the event grow and showcase all we are doing in Iowa to the rest of the insurance world. This will be an event that folks won’t want to miss.

If you wanted to buy health insurance, how would you do it? I’d probably Google “health insurance,” click on the first link (maybe skip the ads out of an irrational disdain) and reach a website that looks something like this: Once I am here, I find that I am woefully unprepared to carry on. What is basic sum insured? Pre-hospitalization? Post-hospitalization? Convalescence benefit? Ideally, I would have known what all these terms meant before I started searching for insurance, but I didn't. Insurance providers such as HDFC Ergo know that many people don't understand these terms and provide more information. In the picture above, clicking on the little circled “i’s” next to each plan feature reveals further information. This is helpful — but only to a point. If I expand too many boxes, the screen starts to look like a jumble of words. At this point, I would do what all people do best: procrastinate. I would return to Facebook, YouTube, Snapchat or Instagram and indulge myself in the endless stream of instant gratification I can get by simply picking up my phone or opening a new tab. Suffice it to say that websites can only take you so far. Too much text clutters the user interface (UI) and makes the experience unpleasant. Too little text, and the user is too uninformed to make a decision. See also: How Chatbots Change Open Enrollment   Consequently, insurance providers add the option for real human interaction in the form of instant call-backs and live chats. Through these media, an insurance broker could answer all the questions a potential customer has and tell him exactly what he should or shouldn’t buy. The customer doesn’t need to do any digging or reading on his own. However, this, too, is not a perfect solution. Hiring real people is not scalable. They need to be clothed, fed and given days off. If you are a multinational insurance company, you can throw money at these problems and minimize the inconvenience. If you are a smaller company, though, this is not an option. You might as well say goodbye to on-the-fence customers and focus on the informed ones. But what if there was a solution? What if you could have human interaction without the cost? Or could inform users without human interaction? This is the promise of chatbots. Chatbots make conveying information easier than in traditional media. They take a daunting and impersonal process like reading up on insurance plans and turn it into a simple conversation. Imagine if all those uninformed leads could be funneled into a familiar WhatsApp-like interface, where a piece of software living on Amazon’s servers personally answered all queries as if it were a human. Chatbots interact with potential clients as a real human would to collect basic information about a person's level of knowledge and stage in the buying process. Thus, when a human does eventually get in touch with each potential client, that human doesn't need to waste time figuring out what the client knows and can begin helping immediately. See also: 4 Hot Spots for Innovation in Insurance   Here is an example of how Securenow, an insurance brokerage company, uses chatbots to help customers. And this is how you can even showcase the best-suited insurance plans over a chatbot. Chatbots are still in their early stages, but it is hard not to see their game-changing potential in the insurance space. In an industry where information is important — if not necessary — in making purchasing decisions, chatbots have the potential to make the buying process easier for all parties involved.

Congress is debating the American Health Care Act, the first of three steps in Republicans’ march toward repealing and replacing the Affordable Care Act. Things are not going smoothly. GOP conservatives, which have considerable clout in the House of Representatives, want the bill to repeal more and replace less. More moderate Republican Senators, of which there are enough to block any legislation, argue the legislation goes too far in some respects. Attempts to mollify one side hardens opposition on the other. And so far, no real effort has been made to entice Democrats to do more than watch Republicans fight one another. It’s possible President Trump, Speaker Paul Ryan and Senate Majority Leader Mitch McConnell can corral enough votes in each chamber to push the AHCA through Congress. It’s possible, but I’m skeptical. And what if they can’t? See also: What Trump Wants to Do on ACA   Well, they could do nothing, leaving enough uncertainty lying about that the individual market, at least, collapses. That could make 2018 a tough election year for Republicans. Or they could offer AHCA version 2.0 and hope for better results. Wishful thinking is a great pastime but hardly a vehicle for making public policy. All of which argues for doing something outside the proverbial box. Maybe Congress could even address the core problem facing America’s healthcare system: the cost of medical care. What might that look like? One option would be to look at an idea that’s been around since the 1990s, if not longer: an all payer system. It would certainly be an interesting debate. To oversimplify, under an all payer system, providers and payers (usually the government) establish a price for each medical treatment and service. Every provider accepts this rate as payment in full, and every payer (government, private insurance, self-funded plans and individuals) pays this rate. As noted by The Hill, several states experimented with one version or another of all payer systems in the 1990s, although today only Maryland’s remains. As recently as 2014, academics at Dartmouth proposed using 125% of Medicare reimbursement rates for a national all payer program. Pricing transparency advocates like all payer systems because everyone knows the cost of care – the ultimate transparency. And this system eliminates the wide variance in pricing for identical treatment so prominent today. A pure all payer system would be difficult to pass, however. Free market Republicans will not accept the government setting the price for all medical care payments. And pharmaceutical companies, doctors, hospitals and other providers are not going to take kindly to having anyone set a one-size-fits-all cost structure. But there are variations on the all payer theme that might make such a system more palatable — and allow for a healthy (and entertaining) debate.. For example, consider an all-payer system in which Medicare reimbursement rates are simply a starting point -- the benchmark used by all providers in setting their costs and all payers in determining their reimbursement levels. No more Alice in Wonderland pricing by hospitals and other providers. Each service provider would describe its fees as a multiple of Medicare. Insurers would offer plans that cap reimbursements at different multiples of Medicare. If the doctor’s charges are at a lower or the same multiple as an insurance policy’s, that provider would be fully reimbursed by the carrier, and no charges beyond co-payments, deductibles and co-insurance (if any) would be required of the patient. If the practice has set a higher Medicare multiple than a patient’s policy covers then the patient is liable for the additional cost. The key, however, is that the consumer would know this before incurring the charge. (Which is why emergency care would be treated somewhat differently). See also: Letter to Congress on Replacing ACA   An all payer system requires higher cost providers to justify the extra expense. It eliminates the helter skelter of ever-changing networks. Health insurance premiums would reflect reimbursement rates and would correlate with the number of providers whose services would be covered in full. Conservatives can’t claim all payer systems is a government takeover of healthcare. On the contrary, the only role Medicare plays is providing the baseline for reimbursement … a common language all providers and payers speak. What they do with that baseline is up to them. Liberals won’t like that insurance companies remain in the healthcare system and will object to limiting, as a practical matter, poorer Americans to low reimbursement policies. Right now, all attention is on the American Health Care Act. That’s as it should be. After all, it’s not dead yet. But, given that there’s a good chance the legislation will crash and burn, there’s no harm in thinking about what could come next. I’m rooting for something that isn’t just a rehash of the 2009 debate, but rather something bolder. An all payer proposal is just one idea, and there are no doubt many better ones. What’s your favorite? This article first appeared at the Alan Katz Blog.