The PATIENTS Framework
Publicly Accountable Transparent Interoperable Efficient Nonproprietary Transaction Standard (PATIENTS)
The United States healthcare system has broken under the weight of its own complexity. We spend about $5 trillion dollars on healthcare, or 17.6% of GDP, an outlier among all nations, with minimal compelling healthcare outcomes to show for it. Patients are lost, frustrated and forced into passive participation in their own healthcare journey. It's not a poorly designed system, it’s a system that was never designed.
The numbers tell a stark story: U.S. healthcare administrative costs are about ten times higher than other developed nations, with two-thirds going to billing and insurance paperwork. Picture this: for every $100 a primary care doctor bills, they spend $20 just to collect that payment (Tseng et al., 2018). By streamlining these administrative tasks, we could save $265.6 billion every year in the U.S (Sahni et al., 2021).
- Providers and group purchasers (employers and health plans) to contract at simple prospective rates at a percent of base.
- Patients and providers to understand standard clinical coverage upfront.
- Providers to get paid predictably and immediately.
- Patients and group purchasers to receive guaranteed upfront prices, enabling cost comparison.
A blueprint for healthcare administrative reform
How did we get here? It was compounded piece by piece: the creation of employer-sponsored healthcare during World War II, the creation of Medicare and Medicaid, new billing codes, HIPAA rules, Meaningful Use requirements, and the Affordable Care Act. All well-meaning, but designed without consideration for the entire ecosystem. As a result, we have Medicare, Medicaid, Tricare, and private insurance all running on different systems, with different rules for billing, approvals, and benefits—a chain of unnecessarily complex steps to accomplish straightforward tasks at exponentially rising costs.
But there's hope. We’ve solved similarly complex, far-reaching problems before. Banks share common transaction standards through federal clearinghouses. Mortgage lenders simplified their agreements through Fannie Mae and Freddie Mac. Even other countries with private healthcare, like Germany, have successfully standardized health plan designs and clinical policies across their entire system.
Enter the PATIENTS framework – a simpler way to handle healthcare administration that puts patient care back in focus. Here's what changes:
Before | After |
|---|---|
| Complexity | Simplicity |
| Fragmentation | Standardization |
| Business-centered | Patient-centered |
| Opaque | Transparent |
| Proprietary Transaction Standard | Open License Transaction Standard |
By adopting the PATIENTS framework, your organization will be able to:
- Put patients first
- Make payer-provider interactions seamless
- Keep compatibility with existing payment systems
- Create open standards everyone can use
- Write everything in clear, simple language
We started by asking a fundamental question: In today's world, what's the simplest way to handle healthcare payments while ensuring excellent patient care?
When we get this right, healthcare will work better for everyone:
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Patients know exactly what their care will cost—and what quality to expect
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Doctors and insurance companies work from the same, transparent playbook
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Insurance plans use standardized benefit and network designs
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Providers adopt standard processes for billing and patient payments
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Everyone understands each step and can precisely predict their financial responsibility
The framework includes these essential pieces:
- Standard Modular Provider <> Group Purchaser Contract
- Open Payment, Grouping and Pricing System
- Universal Clinical Coverage Library
- Standard Plan Design and Benefits Mapping
- Open and Patient-Facing Transaction Rails
is to view each module through the lens of a medical claim. We seek to decouple clinical complexity from financial complexity through the Open Payment, Grouping & Pricing system. The PATIENTS framework uncovers the minimum necessary data for determining precise adjudication details prior to the encounter. Use the interactive diagram below to model this experience from the patient, provider and payer perspectives.
Pre Claim
Claim (Encounter)
Post Claim
The patient journey begins here.
Advance slider to initiate the patient financial experience.
With new technology and a shared desire for change, we can move past the old ways of doing things that came before smartphones, AI, and the internet. We're inviting forward-thinking leaders to join us in rebuilding healthcare administration into something that truly serves patient care. We hope you’ll join us.