{ "standard": "data/proposals.json is the register of every KPSGILL normative object. A proposal states what KPSGILL recommends; it never states what the law is. Passages describing current law carry their own primary citation.", "asOf": "2026-08-31T09:00:00-07:00", "labels": [ "KPSGILL POLICY PROPOSAL", "KPSGILL REFORM POSITION", "MODEL LEGISLATION", "MODEL REGULATION", "MODEL MEDICAL BOARD GUIDANCE", "MODEL CMS POLICY", "MODEL PAYER STANDARD", "MODEL CREDENTIALING STANDARD", "LITIGATION QUESTION", "LITIGATION FEASIBILITY ANALYSIS", "PUBLIC COMMENT PROPOSAL", "FUTURE-OF-MEDICINE FORECAST", "SCENARIO ANALYSIS", "EVIDENCE GAP" ], "domains": [ "Artificial intelligence & medicine", "Medical board reform", "Certification & credentialing", "Medicare", "Payer & prior authorization", "Primary care", "Physician payment", "Healthcare financing & coverage", "Physician independence & ownership", "Workforce & scope of practice", "Professional liability", "Health data & digital medicine", "Drug & device regulation", "Patient rights", "Public health", "Healthcare competition", "Litigation & courts", "Federal policy", "California policy", "Model laws", "Model regulations", "Future of medicine" ], "proposals": [ { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "ai-record-integrity-standard", "label": "MODEL LEGISLATION", "secondaryLabel": "MODEL REGULATION", "domain": "Artificial intelligence & medicine", "url": "/reform/proposals/ai-medical-record-integrity/", "title": "Model AI Medical Record Integrity Standard", "problem": "Generative systems now draft histories, assessments, discharge instructions, referral summaries and patient messages, and the record that results is attested to by a physician as though she wrote every word of it. Attestation has become fiction in exactly the place where traceability matters most: when a note is later read by another clinician, a board, or a court, nothing in it distinguishes what the physician decided from what a model generated.", "documentaryBaseline": [ "fda-cds-ai", "nhs-ambient", "tga-ai-software", "ab2575-ordered-third-reading-2026" ], "recommendation": "Require machine-readable provenance for AI-generated text in the medical record, and relocate physician responsibility from authorship to clinically material adoption.", "principles": [ "AI-generated text carries machine-readable provenance at the point of generation.", "Model and version identity are recoverable for the life of the record.", "Materially edited AI text preserves the fact and time of edit, not a diff of the physician's reasoning.", "The record distinguishes physician-authored from machine-generated content on its face.", "No clinician is required to attest to manual authorship of words she did not author.", "Physician responsibility attaches to clinically material adoption of a machine output, not to fictional authorship.", "Latent vendor or model failure remains traceable after the fact.", "A material AI safety change triggers vendor notification to deploying institutions.", "Technical audit logs are retained separately from the clinical record, under their own retention rule." ], "modelText": { "instrument": "New article, Health and Safety Code (California) — drafted as a template for any state", "jurisdiction": "California, drafted to be portable" }, "impacts": { "physician": "Attestation becomes truthful and narrower. Exposure shifts from 'you signed it' to 'you adopted it', which is the decision the physician actually made.", "patient": "A later clinician can tell which parts of the record were reasoned and which were generated.", "payer": "Coding derived from generated text becomes auditable to its source.", "competition": "Provenance is a standard, not a product; it should be a condition of certification rather than a vendor differentiator.", "equity": "Under-resourced practices are the heaviest users of automation and the least able to negotiate vendor terms; a statutory floor protects them.", "burden": "Provenance is written by software, not by clinicians. The burden falls on vendors and certification, deliberately." }, "opposition": [ "Provenance metadata will be used against physicians in discovery.", "Vendors will claim trade-secret protection over model identity.", "EHR certification is federal; a state standard invites preemption argument.", "Distinguishing 'material' from immaterial adoption is indeterminate." ], "responses": [ "The alternative is worse: without provenance the physician is the only traceable actor, so every failure lands on her.", "Model and version identity is not a trade secret in any sense the law protects; it is a serial number.", "Federal certification sets a floor, not a ceiling, and state medical-record law has always regulated record content.", "Materiality is the ordinary standard of clinical judgement and is no more indeterminate here than in informed consent." ], "metrics": [ "Proportion of notes carrying machine-readable provenance", "Time to identify all records affected by a withdrawn model version", "Board cases in which authorship, not judgement, was the contested issue" ], "sunset": "Five-year review against certification practice; the standard sunsets if federal certification adopts an equivalent or stronger provenance rule.", "openQuestions": [ "Should provenance be visible to the patient in the portal, or only recoverable on audit?", "Does the standard reach autogenerated patient messages sent without clinician review?" ], "brief": { "issue": "Generative systems draft clinical text that a physician then attests to as her own authorship, and nothing in the finished record distinguishes what she decided from what a model produced.", "whyNow": "Ambient documentation is being deployed at system scale ahead of any provenance requirement, and the first contested cases will be decided on records that cannot answer the question.", "currentLaw": "Medical-record content and retention are governed by state record requirements and by electronic-record certification criteria; neither requires that machine-generated text be identifiable as such. FDA's clinical-decision-support policy addresses device status, not authorship.", "gap": "Attestation law assumes a human author. No instrument requires provenance capture at generation, model-version recoverability, or a face-of-the-record distinction between physician and machine text.", "recommendation": "Require machine-readable provenance for AI-generated clinical text at the point of generation, and move physician responsibility from authorship to clinically material adoption.", "authority": [ "California Legislature (Health and Safety Code)", "ONC / electronic-record certification", "Medical Board of California (guidance)" ], "cost": "Analysis, not projection. Cost falls principally on record vendors as a one-time certification and engineering burden; provenance is written by software, so marginal clinician cost approaches zero. State cost is limited to rulemaking and certification oversight.", "stakeholders": [ { "group": "Patients", "effect": "favorable", "note": "Can learn how their record was produced; no new consent burden." }, { "group": "Physicians", "effect": "strongly favorable", "note": "Removes attestation to authorship they do not hold; narrows exposure to adoption decisions actually made." }, { "group": "Hospitals", "effect": "mixed", "note": "Procurement and audit obligations rise; liability allocation clarifies." }, { "group": "Technology vendors", "effect": "unfavorable", "note": "Provenance capture, version identity and retention become conditions of certification." }, { "group": "Insurers", "effect": "mixed", "note": "Cleaner evidentiary record in coverage disputes; no new duty." }, { "group": "Government", "effect": "favorable", "note": "Boards and courts get an evidentiary basis they currently lack." } ], "tradeoffs": [ { "dimension": "Patient safety", "direction": "up", "note": "Traceable text lets error be located rather than argued about." }, { "dimension": "Physician burden", "direction": "down", "note": "Attestation shifts to what was actually reviewed." }, { "dimension": "Litigation risk", "direction": "mixed", "note": "Discovery becomes more precise, which cuts both ways for the clinician." }, { "dimension": "Innovation", "direction": "uncertain", "note": "Certification cost is real; a single standard is cheaper than fifty." }, { "dimension": "Administrative complexity", "direction": "down", "note": "One provenance field replaces institution-by-institution policy." }, { "dimension": "Privacy", "direction": "up", "note": "Audit logs are separated from the clinical record under their own retention rule." } ], "options": [ { "label": "A — status quo", "text": "Authorship fiction persists; boards and courts resolve the first cases on unrecoverable records." }, { "label": "B — limited reform", "text": "Institutional policy and voluntary vendor disclosure, with no machine-readable requirement. Cheap, unenforceable, and invisible to a later reader." }, { "label": "C — structural reform", "text": "Statutory provenance duty on holders plus a certification criterion, with retention and discovery rules attached." }, { "label": "D — KPSGILL preferred", "text": "Certification criterion carries the technical duty; statute carries the attestation relief and the retention rule. The vendor builds it once; the clinician stops attesting to fiction." } ], "preferred": "D", "metrics": [ "Share of certified record systems capturing generation-time provenance", "Share of AI-drafted notes with recoverable model and version identity", "Board cases in which provenance was available to the adjudicator", "Clinician time spent on attestation language" ], "nextDecision": "The next electronic-record certification rulemaking cycle, and any state record-content bill introduced in the 2027 session.", "quotable": "A physician should be accountable for what she adopted, not for pretending she typed it.", "smallPractice": "A five-physician practice buys a certified product and inherits compliance. The duty is deliberately placed where the software is built, not where it is used.", "briefUrl": "/reform/briefs/ai-medical-record-integrity/" } }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "parallel-certification-recognition", "label": "MODEL LEGISLATION", "secondaryLabel": "LITIGATION QUESTION", "domain": "Certification & credentialing", "url": "/reform/proposals/parallel-certification-recognition/", "title": "Parallel Certification Recognition Act, and the competition question underneath it", "problem": "Hospital privileges, payer networks and employment increasingly turn on continuing certification by a single family of boards, while the underlying claim — that continuing certification predicts patient outcomes — has never been established at the strength the requirement implies. The result is a private credential functioning as a licence, with no public accountability and no alternative route.", "documentaryBaseline": [ "mbc-discipline" ], "recommendation": "Bar hospitals, payers and employers from conditioning privileges, network participation or employment on any single certifying body's continuing-certification product, and require recognition of any certification programme meeting published, outcome-relevant criteria.", "modelText": { "instrument": "Business and Professions Code (California), new article; parallel provision for payer contracts in the Insurance Code", "jurisdiction": "California, drafted to be portable" }, "impacts": { "physician": "Removes a recurring private tax on practice and restores an exit option.", "patient": "Nothing in the proposal weakens initial certification or licensure — the two things with an evidentiary basis.", "payer": "Network criteria must be stated in terms of what they are trying to predict.", "competition": "Creates the conditions for a second entrant to be viable rather than nominal.", "equity": "The cost of continuing certification is regressive across practice settings and hits solo and rural practice hardest.", "burden": "Falls on institutions to state criteria, which they should be able to state anyway." }, "opposition": [ "Multiple certifying bodies confuse patients and hospitals.", "A recognition standard invites a race to the least rigorous credential.", "Certification is voluntary; nobody is compelled.", "Hospitals need a single bright line for privileging." ], "responses": [ "Confusion is answered by disclosure, not by monopoly.", "That is why recognition must run to published, outcome-relevant criteria rather than to any body that applies.", "A credential that determines whether a physician may work is not voluntary in any meaningful sense.", "A bright line drawn around one private product is a delegation of public authority to a private party." ], "litigationQuestion": "Whether conditioning privileges or network participation on a single body's continuing-certification product, absent evidence that it predicts patient outcomes, is an unreasonable restraint of trade or an unlawful delegation.", "metrics": [ "Number of institutions publishing outcome-relevant privileging criteria", "Physician time and cost per certification cycle", "Whether a second programme achieves durable recognition" ], "sunset": "Seven-year review; the recognition mechanism sunsets if a competitive market for continuing certification is demonstrably functioning.", "openQuestions": [ "Who evaluates whether criteria are outcome-relevant, and on what record?", "Should the recognition duty reach federal programme participation, or stop at state-regulated payers?" ], "brief": { "issue": "Hospital privileges, payer networks and employment are commonly conditioned on one certifying body's continuing-certification product, which converts a private credential into a licence to practise.", "whyNow": "Continuing-certification requirements keep expanding while workforce scarcity makes the exclusion costly; several systems have already dropped the condition informally for recruitment.", "currentLaw": "State law sets licensure; certification is private. A minority of states restrict maintenance-of-certification conditions in licensure or hospital-privileging contexts. California imposes no such restriction.", "gap": "Nothing requires an institution to state the criteria a credential must meet, so a body that meets every stated criterion can be refused without reason.", "recommendation": "Bar conditioning privileges, network participation or employment on any single body's continuing-certification product, and require published, criterion-based recognition open to any body that meets it.", "authority": [ "California Legislature (Business and Professions Code; Insurance Code)", "Medical Board of California", "Hospital governing boards", "Health plans" ], "cost": "Analysis, not projection. Administrative: institutions must publish criteria and evaluate applications. No state expenditure beyond ordinary enforcement. Any patient-safety cost depends on whether certification differences track outcomes, which the evidence does not currently establish in either direction.", "stakeholders": [ { "group": "Physicians", "effect": "strongly favorable", "note": "Removes a career condition unrelated to licensure or demonstrated competence." }, { "group": "Patients", "effect": "mixed", "note": "More available clinicians; a genuine, unresolved question about credential comparability." }, { "group": "Hospitals", "effect": "unfavorable", "note": "Must state and defend criteria rather than adopt one body's product." }, { "group": "Insurers", "effect": "unfavorable", "note": "Same, for network rules." }, { "group": "Professional organizations", "effect": "strongly unfavorable", "note": "Directly reduces the market power of the incumbent product." }, { "group": "Government", "effect": "favorable", "note": "Competition without a new programme." } ], "tradeoffs": [ { "dimension": "Competition", "direction": "up", "note": "The whole point: recognition on criteria, not identity." }, { "dimension": "Access", "direction": "up", "note": "Especially in shortage specialties and underserved regions." }, { "dimension": "Patient safety", "direction": "uncertain", "note": "Depends on criterion quality; the standard must be written to hold the floor." }, { "dimension": "Administrative complexity", "direction": "up", "note": "Institutions take on an evaluation duty they do not have today." }, { "dimension": "Physician burden", "direction": "down", "note": "One recognised pathway replaces a compulsory product." }, { "dimension": "Litigation risk", "direction": "mixed", "note": "Refusals become reviewable, which invites suits and disciplines decisions." } ], "options": [ { "label": "A — status quo", "text": "Single-board condition persists; unbundling happens ad hoc through recruitment pressure." }, { "label": "B — limited reform", "text": "Prohibit the condition in licensure only. Symbolic: licensure is not where the condition bites." }, { "label": "C — structural reform", "text": "Prohibit the condition across privileges, networks and employment, with a criterion-based recognition duty and an appeal." }, { "label": "D — KPSGILL preferred", "text": "C, with the criteria published and a floor written into the statute, so recognition cannot become a race to the weakest credential." } ], "preferred": "D", "metrics": [ "Institutions publishing recognition criteria", "Applications by non-incumbent bodies, and disposition", "Privileging denials attributable to certification status", "Time-to-credential in shortage specialties" ], "nextDecision": "Introduction in the 2027 California session; in the interim, any health-system governing-board policy revision.", "quotable": "A private credential should be recognised on stated criteria, not on the identity of the body that issued it.", "smallPractice": "Independent physicians carry the certification cost personally and have no institutional subsidy for it; they are the group the single-board condition most often excludes.", "briefUrl": "/reform/briefs/parallel-certification-recognition/" } }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "ai-liability-follows-control", "label": "KPSGILL REFORM POSITION", "domain": "Professional liability", "url": "/reform/ai-and-the-practice-of-medicine/#liability", "title": "Liability should follow control: allocating responsibility for AI-assisted clinical decisions", "problem": "The default allocation puts the entire loss on the physician, who controls the least of the system: she did not design the model, choose the training data, write the warnings, negotiate the contract, or configure the workflow. Everyone with more control has less exposure.", "documentaryBaseline": [ "fda-cds-ai", "health-canada-ml", "moh-aihgle-2", "eu-ai-act-50" ], "recommendation": "Allocate responsibility to the party controlling the failure: developer for architecture, training data and known limitations; vendor for claims, warnings, monitoring and support; health system for procurement, integration, workflow and governance; physician for the clinical decision actually adopted within realistic conditions of practice.", "opposition": [ "Apportionment invites endless third-party litigation.", "Physicians will over-rely on tools if their exposure narrows.", "Vendors will exit the market or price the risk into contracts." ], "responses": [ "Apportionment already happens in product liability; medicine is the outlier in refusing it.", "Exposure that cannot be avoided by any available action does not deter anything — it only allocates loss.", "A vendor unwilling to stand behind its own performance claims is telling the buyer something useful." ], "metrics": [ "Share of AI-related claims naming a non-physician defendant", "Contractual indemnity terms available to small practices" ], "openQuestions": [ "What counts as realistic conditions of practice, and who establishes them?" ] }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "fsmb-model-ai-board-guidance", "label": "MODEL MEDICAL BOARD GUIDANCE", "domain": "Medical board reform", "url": "/reform/ai-and-the-practice-of-medicine/#board-guidance", "title": "Model board guidance: when AI use becomes a disciplinary question", "problem": "State boards are being asked to police AI use with a disciplinary vocabulary built for human conduct. Without guidance issued in advance, the first cases will set the standard by accident.", "documentaryBaseline": [ "ab1979-senate-dopass-2026", "ab2575-ordered-third-reading-2026" ], "recommendation": "Boards should publish, before enforcement, a risk-tiered statement of what physician review of an AI output must involve, what is nondelegable, and what documentation discharges the duty.", "opposition": [ "Guidance issued early will be obsolete within a year.", "Boards should not endorse or discourage particular technologies." ], "responses": [ "Guidance that names the duty rather than the technology survives the technology.", "Declining to state a standard is itself a policy, and the least fair one." ], "metrics": [ "Boards publishing risk-tiered guidance before their first AI case" ], "openQuestions": [ "Should failure to use an available AI tool ever be a disciplinary question?" ] }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "primary-care-prospective-payment", "label": "MODEL CMS POLICY", "secondaryLabel": "PUBLIC COMMENT PROPOSAL", "domain": "Primary care", "url": "/reform/policy-lab/#primary-care", "title": "A prospective primary-care payment design worth commenting on", "problem": "Primary care is paid for encounters and is expected to deliver continuity. Every high-value activity in the discipline — the phone call that prevents an admission, the medication reconciliation, the message answered at nine at night — is either unbilled or billed at a fraction of a visit.", "documentaryBaseline": [ "cms-1848-p" ], "recommendation": "A prospective, risk-adjusted primary-care payment with a floor tied to panel complexity, an explicit continuity measure, and a technology term that pays for asynchronous work instead of adding documentation to it.", "opposition": [ "Prospective payment invites under-service.", "Risk adjustment will be gamed.", "Small practices lack the infrastructure to take prospective payment." ], "responses": [ "Under-service is measurable and can be paid against; unbilled work is not measurable at all.", "Gaming is a coding-integrity problem with existing enforcement tools.", "Which is why the floor must be tied to complexity rather than to negotiated capacity." ], "metrics": [ "Share of primary-care revenue not tied to a visit", "Continuity index at practice level", "Asynchronous work volume paid rather than absorbed" ], "openQuestions": [ "Should the technology term be conditioned on provenance standards for AI-drafted patient messages?" ] }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "forecast-ai-board-discipline-2027", "label": "FUTURE-OF-MEDICINE FORECAST", "domain": "Future of medicine", "url": "/reform/policy-lab/#forecasts", "title": "Forecast: the first AI-adjacent board discipline cases arrive before the guidance does", "horizon": "12 months", "confidence": "Moderate", "assumptions": [ "Ambient documentation continues to spread faster than board guidance is issued.", "Boards receive complaints framed as documentation failures rather than as AI failures." ], "forecast": "Within twelve months, state boards will be deciding cases in which a generated note is the central evidence, under standards written for human authorship — and the earliest published guidance will be reactive to those cases rather than prior to them.", "competingScenario": "A model framework issued to state boards during 2026 is adopted quickly enough that the first contested cases are decided under a published standard. This would require boards to move faster on guidance than they have on any comparable technology.", "whatWouldFalsify": "Publication of adopted, risk-tiered AI guidance by a majority of large-state boards before the first contested case is decided.", "documentaryBaseline": [ "nhs-ambient", "fda-cds-ai" ], "forecastStatus": "ACTIVE", "issued": "2026-08-30" }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "prior-auth-duration-algorithmic-denial", "label": "MODEL PAYER STANDARD", "secondaryLabel": "PUBLIC COMMENT PROPOSAL", "domain": "Payer & prior authorization", "url": "/reform/proposals/prior-authorization-duration-and-algorithmic-denial/", "title": "Prior authorization: a duration floor and a named decision-maker", "problem": "Two failures usually discussed as one: approvals that expire on a calendar rather than on a clinical change, and adverse determinations whose real decision-maker is not the clinician named on the letter.", "documentaryBaseline": [ "cms-0057-f", "oig-kansas-parity-pa-2026", "oig-louisiana-parity-pa-2026", "ab539-suspense-cleared-2026" ], "recommendation": "Duration valid for the course of treatment or twelve months; ninety-day continuity on coverage transition; a named accountable clinician on every adverse determination; disclosure of algorithmic participation; no automated final denial of medical necessity; published metrics including automation and overturn rates.", "opposition": [ "A twelve-month floor removes the payer's ability to act on new evidence.", "Barring automated final denials outlaws review that is faster and more consistent.", "Naming reviewers exposes them to harassment.", "Metrics will be gamed by reclassifying denials as pends.", "Premiums rise." ], "responses": [ "Plan-year coverage changes and material clinical change are both preserved; what is removed is reauthorisation for its own sake.", "Screening and recommendation remain permitted; only the final adverse determination is reserved to a clinician.", "Licence numbers are already public for the treating physician who signs the order.", "A serious metrics provision counts pends and administrative closures as categories.", "Some. Interrupted therapy also has a price, and only one of the two currently appears on a ledger." ], "metrics": [ "Reauthorisations avoided per 1,000 members", "Median days of therapy interruption at coverage transition", "Overturn rate where an automated system participated versus where none did", "Share of adverse determinations naming a same-specialty clinician" ], "sunset": "Five-year review; the automation provisions sunset if published metrics show automated determinations overturned no more often than clinician determinations.", "openQuestions": [ "Should the duration floor differ for high-cost therapies with genuinely evolving evidence?", "Does the no-automated-denial rule reach a delegated utilisation-management vendor?" ], "brief": { "issue": "An approved authorisation for chronic treatment expires on a schedule set by the payer, and adverse determinations can be produced by automated systems without a named clinician accountable for the decision.", "whyNow": "Automated utilisation review is now in production at scale, and coverage transitions routinely interrupt stable treatment at the moment of greatest risk.", "currentLaw": "California law sets response timeframes and requires that denials on medical necessity be made by a licensed reviewer with appropriate expertise; federal interoperability rules set decision timelines for certain plans. Neither fixes authorisation duration nor bars automated final denial.", "gap": "Duration, continuity across plan transition, and accountability for an automated determination are all unaddressed.", "recommendation": "Authorisation valid for the course of treatment or twelve months; ninety-day continuity on coverage transition; a named accountable clinician on every adverse determination; disclosure of automated involvement.", "authority": [ "California Legislature (Health and Safety Code; Insurance Code)", "DMHC", "CDI", "CMS (Medicare Advantage and marketplace plans)" ], "cost": "Analysis, not projection. Payers bear review-cycle and system-change cost; the offsetting saving is fewer repeat reviews of approved chronic therapy. Net direction is genuinely uncertain and should be measured, not asserted.", "stakeholders": [ { "group": "Patients", "effect": "strongly favorable", "note": "Stable therapy survives a plan change." }, { "group": "Physicians", "effect": "strongly favorable", "note": "Removes the largest single source of repeat administrative work." }, { "group": "Insurers", "effect": "strongly unfavorable", "note": "Constrains duration, timing and automation simultaneously." }, { "group": "Employers", "effect": "mixed", "note": "Premium effect uncertain; absence and disruption effects favorable." }, { "group": "Government", "effect": "favorable", "note": "Enforceable standard replaces case-by-case complaint handling." }, { "group": "Technology vendors", "effect": "unfavorable", "note": "Automated final denial becomes unavailable as a product feature." } ], "tradeoffs": [ { "dimension": "Access", "direction": "up", "note": "Continuity is the mechanism." }, { "dimension": "Physician burden", "direction": "down", "note": "Fewer authorisation cycles per patient-year." }, { "dimension": "Government cost", "direction": "uncertain", "note": "Medi-Cal managed-care rates could move in either direction." }, { "dimension": "Innovation", "direction": "mixed", "note": "Automation remains available for approval, not for final denial." }, { "dimension": "Administrative complexity", "direction": "down", "note": "One duration rule replaces plan-by-plan schedules." }, { "dimension": "Litigation risk", "direction": "mixed", "note": "A named accountable clinician creates a defendant and a deterrent." } ], "options": [ { "label": "A — status quo", "text": "Duration set by payer; automated denial continues undisclosed." }, { "label": "B — limited reform", "text": "Extend timelines and require disclosure only. Leaves the interruption problem intact." }, { "label": "C — structural reform", "text": "Statutory duration floor, transition continuity, named clinician, automation disclosure, published overturn data." }, { "label": "D — KPSGILL preferred", "text": "C, sequenced: publish plan-level overturn rates first, because the published data is what makes the rest enforceable." } ], "preferred": "D", "metrics": [ "Adverse determinations per thousand covered lives", "Overturn rate on internal appeal, by plan", "Therapy interruptions at coverage transition", "Median days from request to determination", "Share of determinations with a named accountable clinician" ], "nextDecision": "DMHC rulemaking and the 2027 session; federal interoperability compliance dates for affected plans.", "quotable": "Automation may recommend a denial; a named clinician should have to own it.", "smallPractice": "A five-physician practice has no authorisation staff. Duration is the variable that determines whether the work is survivable, which is why the floor matters more than the timeline.", "briefUrl": "/reform/briefs/prior-authorization-duration-and-algorithmic-denial/" } }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "corporate-control-levers", "label": "MODEL REGULATION", "domain": "Physician independence & ownership", "url": "/reform/proposals/corporate-control-of-clinical-judgement/", "title": "Corporate control of clinical judgement: naming the levers", "problem": "An operative statute prohibits interference with professional judgement at the level of principle, while the conduct it prohibits happens through administrative mechanisms nobody has enumerated — the productivity target, the schedule template, the compensation formula, the code configuration, the staffing decision, control of the record.", "documentaryBaseline": [ "sb-351", "cpom-fca", "ab-1415" ], "recommendation": "Implement the statute as a regulation that enumerates the levers, permits ordinary administrative services expressly, requires disclosure of the agreement to each licensee practising under it, requires a retained record of who set any productivity target, and protects a documented clinical override.", "opposition": [ "The lever list is so broad that ordinary practice management becomes unlawful.", "The override provision lets a physician ignore any productivity expectation.", "Disclosure exposes commercially sensitive terms.", "Capital will leave underserved markets.", "Enumeration invites avoidance through unlisted mechanisms." ], "responses": [ "A permitted-functions section is drafted alongside it; the line is whether a function determines a clinical variable.", "The protection attaches to a documented determination in a specific case, not to a general refusal.", "Disclosure runs only to the licensees practising under the agreement, and only as to the enumerated functions.", "An empirical question the retained-record duty would let a regulator actually answer.", "The list is inclusive, not exhaustive, and the statutory prohibition remains the operative rule." ], "metrics": [ "Share of management agreements disclosed", "Adverse actions in which the override provision was invoked, and their outcomes", "Median scheduled encounter length by ownership type", "Enforcement actions in which the retained record was the evidence" ], "sunset": "No sunset on the provisions implementing the statute; the disclosure and record duties carry a five-year review.", "openQuestions": [ "Should payer-contracting decisions be a listed lever at all?", "Should hospital employment be treated identically to management-company control?" ], "brief": { "issue": "California's bar on corporate practice of medicine prohibits lay control of clinical judgement, but the levers through which control is actually exercised — productivity targets, panel size, referral steering, template design, coding pressure, staffing ratios, schedule control, termination-without-cause — are nowhere enumerated.", "whyNow": "Practice acquisition continues, management-services agreements are now the standard structure, and enforcement has no operative definition of the conduct it prohibits.", "currentLaw": "The corporate-practice doctrine and the professional-corporation provisions prohibit lay interference with professional judgement; the Attorney General reviews certain health-facility transactions. No regulation enumerates prohibited levers.", "gap": "A prohibition without an enumerated conduct list is unenforceable in the cases that matter, and it also fails to protect ordinary administrative services from over-reading.", "recommendation": "Implement the statute by regulation: enumerate the eight levers, expressly permit ordinary administrative services, require disclosure of the management agreement to each licensee practising under it, and make the target-setter traceable.", "authority": [ "Medical Board of California (rulemaking)", "California Attorney General", "California Legislature (if statutory authority must be widened)" ], "cost": "Analysis, not projection. Compliance cost is disclosure and record-keeping at the management entity. Enforcement cost is one rulemaking plus complaint handling. No new programme.", "stakeholders": [ { "group": "Physicians", "effect": "strongly favorable", "note": "A named lever list is what makes a complaint provable." }, { "group": "Patients", "effect": "favorable", "note": "Referral steering and panel pressure become reviewable." }, { "group": "Hospitals", "effect": "mixed", "note": "Employment models survive; explicit clinical-override terms are required." }, { "group": "Technology vendors", "effect": "mixed", "note": "Template and coding-prompt design enters the enumerated list." }, { "group": "Government", "effect": "favorable", "note": "Enforceable definition replaces a doctrine that cannot be applied." }, { "group": "Employers", "effect": "unfavorable", "note": "Management agreements become disclosable to the clinicians bound by them." } ], "tradeoffs": [ { "dimension": "Physician autonomy", "direction": "up", "note": "The purpose of the doctrine, made operative." }, { "dimension": "Administrative complexity", "direction": "up", "note": "Disclosure and traceability are new duties." }, { "dimension": "Competition", "direction": "mixed", "note": "Raises the cost of the acquisition model without prohibiting it." }, { "dimension": "Innovation", "direction": "uncertain", "note": "Care-model experimentation must document who set the target." }, { "dimension": "Access", "direction": "uncertain", "note": "If capital exits underserved markets, access falls; that risk must be monitored." }, { "dimension": "Litigation risk", "direction": "up", "note": "Enumerated conduct invites private claims. That is a feature and a cost." } ], "options": [ { "label": "A — status quo", "text": "Doctrine remains declaratory; enforcement remains rare and structural cases fail." }, { "label": "B — limited reform", "text": "Guidance letter listing concerns, with no rule. Non-binding and easily distinguished." }, { "label": "C — structural reform", "text": "Regulation enumerating levers, plus disclosure and traceability duties, plus a private right." }, { "label": "D — KPSGILL preferred", "text": "C without the private right in the first instrument: enumerate, disclose, trace, then measure enforcement before adding a cause of action." } ], "preferred": "D", "metrics": [ "Complaints alleging enumerated levers, and disposition", "Management agreements disclosed to practising licensees", "Documented clinical overrides and any adverse action following one", "Share of acquired practices retaining physician control of panel size" ], "nextDecision": "Medical Board rulemaking calendar; any Attorney General transaction condition that could carry the enumeration first.", "quotable": "A prohibition on lay control of clinical judgement means nothing until the levers of control are named.", "smallPractice": "Independent practices are the intended beneficiary: enumeration is what lets a physician negotiate against a management agreement instead of signing it.", "briefUrl": "/reform/briefs/corporate-control-of-clinical-judgement/" } }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "lab-quality-payment-integrity", "label": "MODEL CMS POLICY", "domain": "Drug & device regulation", "url": "/reform/proposals/laboratory-quality-as-payment-integrity/", "title": "Laboratory quality as payment integrity", "problem": "Laboratory quality and laboratory payment are regulated as separate subjects, so clinical reliability — whether a result can support the decision it is ordered for — is addressed only retrospectively, through false-claims litigation years later.", "documentaryBaseline": [ "cms-lab-program-integrity-2026", "dermtech-fca-bankruptcy-2026", "villages-health-fca-2026" ], "recommendation": "Make performance characteristics for the billed clinical use a condition of payment; require an annual quality-control attestation above a volume threshold; make claims for results produced during a known quality-control failure unpayable; require clinician notification within thirty days; and fix a published escalation ladder from education to referral.", "opposition": [ "Clinical validity is contested; conditioning payment on it permits denial by definitional fiat.", "The known-failure rule turns an ordinary quality lapse into a payment violation.", "This duplicates the existing laboratory quality regime.", "The escalation ladder ties the programme's hands where fraud is obvious.", "Prospective review slows access to new diagnostics." ], "responses": [ "The duty is to produce what is known, not to meet a threshold set after the fact.", "The rule is narrow: the laboratory's own criteria, known not to be met, and it disclaims any finding of intent.", "It connects that regime to payment, which is a connection currently made only by litigation.", "The ladder governs failures under this policy; existing fraud authority is untouched.", "A real cost, against the alternative of paying for years and litigating afterwards." ], "metrics": [ "Share of high-volume tests with performance characteristics on file for the billed use", "Median days from quality-control failure to clinician notification", "Distribution of actions across the escalation ladder", "Settlement recoveries as a share of total programme action" ], "sunset": "Five-year review; the prospective conditions sunset if the laboratory quality regime adopts equivalents.", "openQuestions": [ "What volume threshold makes the attestation proportionate for a small laboratory?", "Should notification run to patients as well as ordering clinicians?", "Is a self-disclosure safe harbour needed?" ], "brief": { "issue": "Payment for a laboratory test does not depend on whether the test performs as claimed for the clinical use billed, so a known analytic failure can continue to generate clean claims.", "whyNow": "High-volume testing under laboratory-developed-test pathways has outrun the oversight designed for it, and the enforcement record shows failures persisting through billing cycles.", "currentLaw": "CLIA governs laboratory operations and quality control; FDA asserts device authority over certain tests; Medicare pays on coding and coverage rules that do not incorporate performance characteristics for the billed use.", "gap": "Quality oversight and payment integrity are separate systems, so a quality failure has no payment consequence until it becomes a fraud case.", "recommendation": "Make performance characteristics for the billed clinical use a condition of payment, require an annual quality-control attestation above a volume threshold, and treat claims for results from a known failed process as improper payments with a thirty-day clinician notice duty.", "authority": [ "CMS (payment rules)", "CLIA programme / CDC", "FDA", "California Department of Public Health (state licensure)" ], "cost": "Analysis, not projection. Attestation cost falls on laboratories above the volume threshold. Programme savings come from recoveries and deterrence, magnitude unknown. Small-laboratory exposure is the principal cost risk and is why the threshold exists.", "stakeholders": [ { "group": "Patients", "effect": "strongly favorable", "note": "Notice when a result they were treated on came from a failed process." }, { "group": "Physicians", "effect": "favorable", "note": "Learn of a failure while the patient is still treatable." }, { "group": "Government", "effect": "favorable", "note": "Payment lever available before a fraud theory is required." }, { "group": "Hospitals", "effect": "mixed", "note": "Outreach laboratories take on attestation duty." }, { "group": "Device manufacturers", "effect": "unfavorable", "note": "Performance claims become payment-relevant." }, { "group": "Insurers", "effect": "favorable", "note": "Same lever available in private coverage terms." } ], "tradeoffs": [ { "dimension": "Patient safety", "direction": "up", "note": "Notice is the mechanism, not the payment penalty." }, { "dimension": "Government cost", "direction": "down", "note": "Recovery and deterrence, offset by administration." }, { "dimension": "Administrative complexity", "direction": "up", "note": "One attestation cycle plus a notice duty." }, { "dimension": "Innovation", "direction": "mixed", "note": "Raises the cost of bringing a test to market on thin validation. Intended." }, { "dimension": "Access", "direction": "uncertain", "note": "If small laboratories exit, rural access falls; the threshold and a phase-in must be sized against that." }, { "dimension": "Competition", "direction": "mixed", "note": "Favours laboratories that already validate; consolidates at the margin." } ], "options": [ { "label": "A — status quo", "text": "Quality and payment stay separate; failures are addressed as fraud, years later." }, { "label": "B — limited reform", "text": "Strengthen CLIA proficiency requirements without touching payment. Leaves the incentive untouched." }, { "label": "C — structural reform", "text": "Performance characteristics as a condition of payment, with attestation, known-failure rule and clinician notice." }, { "label": "D — KPSGILL preferred", "text": "C with a volume threshold, a phase-in, and the clinician-notice duty effective first — the notice is the patient-safety instrument and should not wait for the payment rule." } ], "preferred": "D", "metrics": [ "Laboratories attesting, by volume band", "Known-failure notices issued, and time from detection to notice", "Improper-payment recoveries attributable to the rule", "Rural laboratory participation before and after phase-in" ], "nextDecision": "The next Medicare clinical-laboratory payment rulemaking; any CLIA proficiency-testing revision.", "quotable": "A test that is known not to work should stop generating clean claims before it becomes a fraud case.", "smallPractice": "Ordering clinicians gain a notice right and take on no attestation duty; the volume threshold keeps the burden off small independent laboratories.", "briefUrl": "/reform/briefs/laboratory-quality-as-payment-integrity/" } }, { "status": "NO POSITION TAKEN", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "coverage-architecture-gap", "label": "EVIDENCE GAP", "domain": "Healthcare financing & coverage", "url": "/reform/coverage-architecture-evidence-gap/", "title": "Coverage architecture: an evidence gap, not a position", "problem": "Coverage architecture is the most argued subject in health policy and the thinnest part of this record. A recommendation here would be a preference dressed as an analysis.", "documentaryBaseline": [ "medi-cal-eligibility-timeline-2026-2027", "cms-1848-p" ], "recommendation": "No position. Five primary-source acquisitions are required first: transition cost from actuarial primary sources at comparable scale; physician supply response from workforce data; what happened to authorisation, denial and appeal mechanisms in systems that changed architecture; access outcomes in a comparable geography; and the official assessments of jurisdictions that attempted a transition and abandoned it.", "opposition": [ "Declining to take a position on the central question of health policy is an evasion.", "The evidence will never be complete, so the standard is unmeetable.", "Others take positions on less." ], "responses": [ "Taking one on this record would forfeit the reason anyone should credit the positions we do take.", "The five acquisitions are specific and finite, which is the difference between a standard and an excuse.", "That is an argument about them, not about what belongs on this site." ], "metrics": [ "Number of the five acquisitions completed and in the record layer" ], "openQuestions": [ "Should this open as several competing positions rather than one, once the record supports it?" ] }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "physician-payment-update-redistribution", "label": "MODEL LEGISLATION", "secondaryLabel": "MODEL CMS POLICY", "domain": "Physician payment", "url": "/reform/proposals/physician-payment-conversion-factors/", "title": "Physician payment: fix the update, then fix the redistribution", "problem": "Two failures ride in one annual rule: a statutory update that does not track practice cost, and redistribution inside the fee schedule decided without anyone publishing who loses.", "documentaryBaseline": [ "cms-1848-p", "cms-0057-f" ], "recommendation": "Inflation-linked update without offsetting budget neutrality; a cap on annual specialty redistribution; published impact by specialty and practice size at proposal; evidence required for any efficiency adjustment; a small-practice phase-in.", "opposition": [ "An inflation-linked update removes the discipline of annual negotiation.", "A redistribution cap freezes misvalued services.", "Impact publication invites lobbying over patient need.", "The small-practice floor entrenches inefficiency." ], "responses": [ "Discipline arriving as an expiring one-year patch is not discipline.", "Correction on evidence is preserved; the cap phases rather than prohibits.", "The lobbying happens now, later and on worse information.", "It phases a reduction rather than preventing one." ], "metrics": [ "Net payment change versus practice-cost index by specialty and practice size", "Share of adjustments with service-level efficiency evidence", "Primary-care panel closures following a redistribution" ], "sunset": "Ten-year review of the redistribution cap and small-practice floor.", "openQuestions": [ "What index, and who maintains it?", "Should the cap be set against total spending or single-specialty revenue?" ], "brief": { "issue": "The Medicare physician payment update is not linked to practice-cost inflation, and budget neutrality redistributes between specialties without published impact analysis at the proposal stage.", "whyNow": "Successive years of updates below input-cost growth compound, and the redistribution effects land hardest on practices with the least capacity to absorb them.", "currentLaw": "Statute sets the conversion-factor update and requires budget-neutrality adjustments for changes in relative values; the Medicare Economic Index measures practice-cost inflation but does not drive the update.", "gap": "Two separate defects: an update disconnected from measured input cost, and redistribution decided without published specialty and practice-size impact.", "recommendation": "Inflation-linked update without offsetting budget neutrality; a cap on annual specialty redistribution; published impact by specialty and practice size at the proposal stage; an evidence requirement for relative-value changes.", "authority": [ "Congress", "CMS (rulemaking and impact disclosure)", "MedPAC (recommendation)" ], "cost": "Analysis, not projection. An inflation-linked update raises federal spending; the magnitude depends entirely on the index chosen and the base year. This is the proposal's principal vulnerability and should be stated as such rather than minimised.", "stakeholders": [ { "group": "Physicians", "effect": "strongly favorable", "note": "Directly addresses the compounding gap." }, { "group": "Patients", "effect": "favorable", "note": "Participation is the access mechanism; effect is indirect." }, { "group": "Government", "effect": "strongly unfavorable", "note": "Removes the fiscal control the current formula provides." }, { "group": "Hospitals", "effect": "mixed", "note": "Employed-physician economics improve; site-of-service differentials shift." }, { "group": "Taxpayers", "effect": "unfavorable", "note": "Higher outlay, honestly stated." }, { "group": "Professional organizations", "effect": "favorable", "note": "Impact disclosure changes the redistribution fight." } ], "tradeoffs": [ { "dimension": "Access", "direction": "up", "note": "Participation and panel capacity are the channel." }, { "dimension": "Government cost", "direction": "up", "note": "Unambiguously. The trade is explicit." }, { "dimension": "Physician burden", "direction": "down", "note": "Redistribution shocks are what force practice-model change." }, { "dimension": "Competition", "direction": "up", "note": "Cap limits the advantage of well-represented specialties." }, { "dimension": "Administrative complexity", "direction": "down", "note": "Fewer mid-year corrections." }, { "dimension": "Evidence quality", "direction": "up", "note": "Relative-value changes must carry evidence." } ], "options": [ { "label": "A — status quo", "text": "Annual patch cycle continues; the gap compounds." }, { "label": "B — limited reform", "text": "Impact disclosure and a redistribution cap only. Cheap, and it fixes the fairness problem without the level problem." }, { "label": "C — structural reform", "text": "Inflation-linked update, no offsetting neutrality, cap, disclosure, evidence requirement." }, { "label": "D — KPSGILL preferred", "text": "B first, C second — disclosure and the cap can be enacted without new money, and the published impact data is what makes the case for the update." } ], "preferred": "D", "metrics": [ "Update relative to the Medicare Economic Index, by year", "Annual redistribution magnitude by specialty", "Physician Medicare participation, by practice size", "Panel capacity in primary care and shortage specialties" ], "nextDecision": "The annual physician fee schedule proposed rule, and any year-end congressional payment package.", "quotable": "Fix the update and the redistribution separately: one is a level problem, the other is a fairness problem, and conflating them has stalled both.", "smallPractice": "A five-physician practice cannot cross-subsidise a redistribution year. The cap, not the update, is what keeps it open.", "briefUrl": "/reform/briefs/physician-payment-conversion-factors/" } }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "board-process-due-process", "label": "MODEL LEGISLATION", "domain": "Medical board reform", "url": "/reform/proposals/medical-board-due-process/", "title": "Medical board process: the decisive moments happen before the accusation", "problem": "Formal protections attach at the accusation, while outcomes are determined earlier, where the licensee has the least information she will ever have.", "documentaryBaseline": [ "mbc-discipline" ], "recommendation": "Specific notice; advice of rights including counsel at interview; a closing-or-charging clock extendable once on findings; recorded interviews released within ten days; disclosure and a hearing before a compelled examination; separation of investigative and adjudicative functions; emergency authority preserved.", "opposition": [ "An investigation clock forces premature charging or closure.", "Recorded interviews reduce candour.", "Serving evidence before a compelled examination lets a licensee tailor it.", "This is physician protection sold as due process.", "Separation of functions duplicates the hearing." ], "responses": [ "One extension on findings is permitted; an indefinite investigation is a sanction without a hearing.", "A recording protects both sides against later disagreement.", "If disclosure defeats the examination, the basis was not evidence.", "Both are true, which is why emergency authority is preserved in full.", "The hearing reviews the record; it does not cure advice given before the record was made." ], "metrics": [ "Median days from complaint to closure or accusation", "Share of first letters meeting the specificity standard", "Share of interviews recorded", "Compelled examinations contested and their outcomes" ], "sunset": "Five-year review of the clock length against board capacity.", "openQuestions": [ "What clock length is defensible for a complex quality-of-care matter?", "Should pre-examination review sit inside the board or with an administrative law judge?" ], "brief": { "issue": "Licensing-board protections attach at the accusation, but the record is built earlier — in a complaint letter answered without counsel and an interview the physician did not know was decisive.", "whyNow": "Investigation timelines have lengthened while the pre-accusation phase remains ungoverned, and an unresolved investigation is itself a reportable and career-limiting condition.", "currentLaw": "The Administrative Procedure Act governs hearings; licensing statutes authorise investigation, compelled examination and interim suspension. Clear and convincing proof applies at hearing. The investigative phase carries no notice, disclosure or timing requirement.", "gap": "No specific notice of the allegation, no advice of the right to counsel at interview, no closing-or-charging clock, no disclosure before a compelled examination, and investigative and adjudicative functions are not separated.", "recommendation": "Specific notice; advice of rights including counsel at interview; a closing-or-charging clock extendable once on stated findings; recorded interviews released within ten days; disclosure of the basis before a compelled examination; separation of investigative and adjudicative functions.", "authority": [ "California Legislature (Business and Professions Code; Government Code)", "Medical Board of California", "Office of Administrative Hearings" ], "cost": "Analysis, not projection. Recording and disclosure are modest operating costs. The clock is the expensive provision: it may require investigator capacity, and that cost should be funded rather than met by premature closure.", "stakeholders": [ { "group": "Physicians", "effect": "strongly favorable", "note": "Protections arrive when they change the outcome." }, { "group": "Patients", "effect": "mixed", "note": "Faster disposition helps; complainants may perceive procedure as protection of the licensee." }, { "group": "Government", "effect": "unfavorable", "note": "Board operations bear the clock and the separation requirement." }, { "group": "Hospitals", "effect": "favorable", "note": "Fewer indefinite pending-investigation credentialing holds." }, { "group": "Insurers", "effect": "favorable", "note": "Same, for network decisions." }, { "group": "Consumer advocates", "effect": "mixed", "note": "Legitimately concerned that a clock could close hard cases." } ], "tradeoffs": [ { "dimension": "Due process", "direction": "up", "note": "The object of the proposal." }, { "dimension": "Patient safety", "direction": "uncertain", "note": "Interim suspension is preserved precisely so it is not reduced." }, { "dimension": "Government cost", "direction": "up", "note": "Investigator capacity and recording infrastructure." }, { "dimension": "Administrative complexity", "direction": "mixed", "note": "Separation of functions is structurally cleaner but organisationally harder." }, { "dimension": "Litigation risk", "direction": "down", "note": "Fewer collateral challenges to investigative conduct." }, { "dimension": "Evidence quality", "direction": "up", "note": "Recorded interviews are better evidence than an investigator's summary." } ], "options": [ { "label": "A — status quo", "text": "Outcomes continue to be determined in an ungoverned phase." }, { "label": "B — limited reform", "text": "Notice and advice of rights only. Real gain, low cost, leaves the timing problem." }, { "label": "C — structural reform", "text": "Full package: notice, counsel, clock, recording, disclosure, separation of functions." }, { "label": "D — KPSGILL preferred", "text": "B and recording immediately; the clock phased in with funded investigator capacity, because an unfunded clock closes hard cases rather than deciding them." } ], "preferred": "D", "metrics": [ "Median days from complaint to closure or accusation", "Share of interviews recorded and released within ten days", "Physicians represented at first interview", "Interim suspensions sought, as a check on displaced urgency", "Cases dismissed after accusation" ], "nextDecision": "Medical Board sunset review and the 2027 session; any board policy change on interview recording, which requires no statute.", "quotable": "The protections a physician has arrive after the phase in which the case was decided.", "smallPractice": "A solo or small-group physician has no institutional counsel and answers the letter alone. Notice and advice of rights are worth more to her than any hearing right.", "briefUrl": "/reform/briefs/medical-board-due-process/" } }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "litigation-feasibility-algorithmic-denial", "label": "LITIGATION FEASIBILITY ANALYSIS", "domain": "Litigation & courts", "url": "/reform/litigation-questions/algorithmic-denial/", "title": "Litigation feasibility: challenging an algorithmic coverage denial", "problem": "Whether an adverse medical-necessity determination shaped by an automated system and issued without an identified clinician is unlawful, and what a plaintiff would actually have to prove.", "documentaryBaseline": [ "cms-0057-f", "oig-louisiana-parity-pa-2026", "nica-v-kennedy-5th-cir-2026" ], "recommendation": "On the current record a case fails on two elements: no document establishes automated determination, and forum questions dispose of the claim before the evidence is reached. Legislate disclosure and metrics first; compliance creates the evidence.", "opposition": [ "Saying a case would fail discourages people with real injuries.", "This is effectively legal advice.", "Naming weak elements hands defendants a roadmap." ], "responses": [ "A plaintiff is better served knowing which document to preserve than by a dismissal on unwarned grounds.", "No actual matter, no client, no advice.", "Defendants already know their own preemption and arbitration positions." ], "metrics": [ "Whether payer metrics showing automated participation become obtainable", "Regulator findings on utilisation-review practice" ], "openQuestions": [ "Does a plan document promising clinician review change the analysis on its own?" ] }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "health-data-outside-hipaa", "label": "MODEL LEGISLATION", "domain": "Health data & digital medicine", "url": "/reform/proposals/health-data-outside-hipaa/", "title": "Health data outside HIPAA: a duty attached to the data, not the holder", "problem": "Obligations attach to covered entities; health information does not stay inside them. A clinic that delays records access is penalised; an app holding the same data, or an inference drawn from purchase history, owes almost nothing.", "documentaryBaseline": [ "azul-vision-hipaa-roa-2026", "eu-ai-act-50" ], "recommendation": "Duties that follow health-related data and inferences into any holder: thirty-day portable access; deletion with recipient notification and an honest model boundary; express separate consent for sale or advertising use; disclosure duties for AI services answering health questions; AG and private enforcement.", "opposition": [ "A state statute cannot regulate a national data market.", "Treating inferences as data makes ordinary analytics unlawful.", "Deletion duties are unworkable once data has moved.", "Compliance cost entrenches large firms.", "Thirty days is unrealistic for a small developer." ], "responses": [ "State law has always regulated conduct toward residents.", "Analysis remains lawful; sale and advertising use do not.", "The provision states the model boundary rather than promising erasure it cannot deliver.", "Proportionate obligations, not exemptions from the cheapest duty.", "A two-person clinic meets that clock today." ], "metrics": [ "Median days to fulfil an access request by holder type", "Share of AI services disclosing retention and training", "Enforcement actions involving inferred data" ], "sunset": "Five-year review; sunsets if a federal framework reaches non-covered holders with equivalent duties.", "openQuestions": [ "Should recipient notification run beyond twelve months?", "Does the AI disclosure duty need a device carve-out?" ], "brief": { "issue": "Health-related data and inferences held by entities outside HIPAA — apps, wearables, brokers, advertising platforms — carry no access, deletion or use duties comparable to those attaching to the same facts inside a medical record.", "whyNow": "Inference now does the work formerly done by disclosure: a condition can be derived from behaviour without any protected record being touched.", "currentLaw": "HIPAA binds covered entities and business associates. California consumer-privacy law grants access and deletion rights to residents against businesses meeting thresholds, with exemptions; state confidentiality law binds providers and plans. Inferences are treated as personal information in California but not as health data with heightened duties.", "gap": "Duties follow the holder, not the data. The same fact is protected in one hand and unregulated in another.", "recommendation": "Attach duties to health-related data and inferences in any holder: thirty-day portable access, deletion with recipient notification and an honest statement of model boundaries, and express separation of clinical from commercial use.", "authority": [ "California Legislature (Civil Code)", "California Privacy Protection Agency", "Attorney General", "Congress / FTC (for the national market)" ], "cost": "Analysis, not projection. Compliance falls on data holders and is meaningful for those without existing privacy infrastructure. Recipient notification is the costly element. State cost is enforcement capacity.", "stakeholders": [ { "group": "Patients", "effect": "strongly favorable", "note": "Access and deletion reach the data that actually describes them." }, { "group": "Physicians", "effect": "favorable", "note": "Fewer commercial inferences re-entering clinical decisions unexamined." }, { "group": "Technology vendors", "effect": "strongly unfavorable", "note": "Inference-as-data is the provision they will contest." }, { "group": "Insurers", "effect": "unfavorable", "note": "Commercial-use separation constrains data acquisition." }, { "group": "Government", "effect": "mixed", "note": "Enforcement burden; interstate reach is genuinely contested." }, { "group": "Researchers", "effect": "mixed", "note": "Secondary-use pathways must be stated expressly." } ], "tradeoffs": [ { "dimension": "Privacy", "direction": "up", "note": "The object of the proposal." }, { "dimension": "Innovation", "direction": "down", "note": "Some inference-based products become non-viable. Stated, not hidden." }, { "dimension": "Administrative complexity", "direction": "up", "note": "Recipient notification requires downstream mapping." }, { "dimension": "Competition", "direction": "mixed", "note": "Compliance cost favours large holders; the threshold must be set with that in view." }, { "dimension": "Litigation risk", "direction": "up", "note": "Extraterritorial reach will be challenged." }, { "dimension": "Patient safety", "direction": "up", "note": "Clinical decisions stop absorbing unvalidated commercial inference." } ], "options": [ { "label": "A — status quo", "text": "Protection depends on which hand holds the fact." }, { "label": "B — limited reform", "text": "Extend existing consumer rights to enumerated health data without touching inference. Administrable, and it misses the mechanism." }, { "label": "C — structural reform", "text": "Data-following duties including inference, with notification and use separation." }, { "label": "D — KPSGILL preferred", "text": "C, with inference defined by clinical sensitivity rather than by technique, and a threshold that does not make compliance a barrier to entry." } ], "preferred": "D", "metrics": [ "Access requests fulfilled within thirty days, by holder class", "Deletion requests with recipient notification completed", "Enforcement actions and their subject matter", "Documented commercial inferences entering clinical or coverage decisions" ], "nextDecision": "California Privacy Protection Agency rulemaking; introduction in the 2027 session; any FTC health-data enforcement that sets the national baseline.", "quotable": "If a fact about a patient's body is protected in one hand and unregulated in another, the duty is attached to the wrong thing.", "smallPractice": "A small practice is not the target; the point of the threshold is that the duty lands on data-holding businesses rather than on clinicians.", "briefUrl": "/reform/briefs/health-data-outside-hipaa/" } }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "public-health-emergency-powers", "label": "MODEL LEGISLATION", "domain": "Public health", "url": "/reform/proposals/public-health-emergency-powers/", "title": "Emergency powers that expire, and a state determination that is not a foreign one", "problem": "Statutes treat international determinations as domestic triggers, and declarations have no forcing function to end. The outbreak record shows one pathogen in two opposite national states, and a border measure whose own guidance page displayed a superseded expiry.", "documentaryBaseline": [ "bundibugyo-two-state-2026", "medi-cal-eligibility-timeline-2026-2027" ], "recommendation": "Declarations stating condition, geography, evidence, authorities and expiry; no adoption of a foreign determination by reference; geography-specific findings; sixty-day sunset with legislative extension; written individual orders reviewable within seventy-two hours; least-restrictive-means statement; guidance dated to its instrument; a duty to terminate with published basis.", "opposition": [ "Sixty-day sunsets invite lapse while a threat continues.", "Seventy-two-hour review is unworkable at scale.", "Barring borrowed triggers discards international expertise.", "Geographic specificity slows response.", "Termination duties invite premature political pressure." ], "responses": [ "Unlimited successive extensions are permitted; only an unexamined declaration lapses.", "The order remains in effect pending review.", "Such determinations remain evidence; only adoption by reference is barred.", "Separate findings can issue simultaneously.", "The published basis for termination cuts both ways." ], "metrics": [ "Median declaration duration and extensions", "Share of individual orders reviewed within seventy-two hours", "Instances of guidance inconsistent with a current instrument" ], "sunset": "None needed; every declaration is self-limiting.", "openQuestions": [ "Is sixty days right for a slow-moving threat?", "Should review extend to group orders?" ], "brief": { "issue": "Emergency public-health authority is triggered by broad standards, sustained without expiry, and exercised through individual orders that carry no prompt independent review.", "whyNow": "The powers exercised since 2020 remain on the books largely unamended, and the next declaration will run on the same architecture.", "currentLaw": "State health and emergency statutes authorise declarations, isolation and quarantine, and local officer orders. Some declarations incorporate federal or foreign determinations by reference. Judicial review exists but is not time-bound.", "gap": "No requirement that a declaration state condition, geography, evidence and expiry; no bar on borrowed triggers; no sunset; no prompt review of an individual order.", "recommendation": "Declarations stating condition, geography, evidence, authorities relied on and expiry; no adoption of a foreign or federal determination by reference; geography-specific findings; a sixty-day sunset with renewal on stated findings; and review of an individual order within seventy-two hours.", "authority": [ "California Legislature (Health and Safety Code; Government Code)", "Governor", "CDPH", "Local health officers", "Superior Courts (review mechanism)" ], "cost": "Analysis, not projection. Renewal findings and geography-specific analysis are staff cost at the agency. Seventy-two-hour review is court cost and is the provision most likely to be called unworkable at surge scale; a duty magistrate model is the answer that should be costed.", "stakeholders": [ { "group": "Patients", "effect": "favorable", "note": "Individual orders become reviewable." }, { "group": "Physicians", "effect": "favorable", "note": "Clinical obligations under an order become legible and time-bound." }, { "group": "Government", "effect": "unfavorable", "note": "Renewal discipline and review duty are real constraints." }, { "group": "Local health officers", "effect": "strongly unfavorable", "note": "Geography-specific findings remove the convenience of a borrowed trigger." }, { "group": "Hospitals", "effect": "mixed", "note": "Clearer authority; more frequent re-authorisation cycles." }, { "group": "Courts", "effect": "unfavorable", "note": "A new time-bound docket." } ], "tradeoffs": [ { "dimension": "Due process", "direction": "up", "note": "Prompt review of an individual order is the core." }, { "dimension": "Public health capacity", "direction": "mixed", "note": "Discipline improves legitimacy and slows the initial response." }, { "dimension": "Government cost", "direction": "up", "note": "Agency findings and judicial capacity." }, { "dimension": "Administrative complexity", "direction": "up", "note": "Renewal cycles and per-geography findings." }, { "dimension": "Litigation risk", "direction": "down", "note": "Stated findings survive challenge better than borrowed ones." }, { "dimension": "Transparency", "direction": "up", "note": "Evidence and authorities are on the face of the declaration." } ], "options": [ { "label": "A — status quo", "text": "Broad triggers, indefinite duration, borrowed determinations." }, { "label": "B — limited reform", "text": "Require findings and publication, without sunset or individual review. Improves the record only." }, { "label": "C — structural reform", "text": "Findings, no borrowed triggers, sunset with renewal, seventy-two-hour individual review." }, { "label": "D — KPSGILL preferred", "text": "C, with the review duty implemented through a duty-magistrate mechanism so that the seventy-two-hour clock survives surge conditions instead of being suspended in them." } ], "preferred": "D", "metrics": [ "Declarations stating condition, geography, evidence and expiry", "Renewals with stated findings, and duration distribution", "Individual orders reviewed within seventy-two hours", "Orders modified or vacated on review", "Declarations relying on a borrowed determination" ], "nextDecision": "The 2027 session; any CDPH guidance revision on local officer order practice.", "quotable": "Emergency power should be renewed on stated findings rather than sustained by inertia.", "smallPractice": "A small practice complies with orders it did not receive notice of and cannot challenge. Geography-specific findings and published authorities are what make compliance possible.", "briefUrl": "/reform/briefs/public-health-emergency-powers/" } }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "forecast-automation-disclosure", "label": "FUTURE-OF-MEDICINE FORECAST", "domain": "Future of medicine", "url": "/reform/policy-lab/#forecasts", "title": "Automation disclosure arrives through metrics, not through a prohibition", "horizon": "18 months", "confidence": "Moderate to high", "forecast": "The first enforceable constraint on algorithmic coverage denial will be a reporting requirement whose published overturn rates make automated denial commercially unattractive before any statute prohibits it.", "assumptions": [ "Authorisation metrics are published at plan level and are comparable.", "Overturn rates for automated determinations exceed those for clinician determinations." ], "competingScenario": "A state enacts an outright bar on automated medical-necessity denial first, and metrics follow rather than cause it.", "whatWouldFalsify": "Published metrics showing no overturn-rate difference between automated and clinician determinations.", "documentaryBaseline": [ "cms-0057-f" ], "forecastStatus": "ACTIVE", "issued": "2026-08-30" }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "forecast-certification-unbundling", "label": "FUTURE-OF-MEDICINE FORECAST", "domain": "Future of medicine", "url": "/reform/policy-lab/#forecasts", "title": "Continuing certification is unbundled by purchasers, not by regulators", "horizon": "3 years", "confidence": "Low to moderate", "forecast": "The single-board condition breaks first when a large employer or health system drops it for recruitment reasons, and only afterwards through statute or litigation.", "assumptions": [ "Workforce scarcity in shortage specialties continues.", "Recruitment pressure outweighs the convenience of a single privileging line." ], "competingScenario": "The requirement survives because purchasers treat it as liability protection, and change comes only through competition enforcement.", "whatWouldFalsify": "Large systems publishing privileging criteria that retain the single-body condition while carrying unfilled positions.", "documentaryBaseline": [ "mbc-discipline" ], "forecastStatus": "ACTIVE", "issued": "2026-08-30" }, { "status": "OPEN FOR CRITIQUE", "sourceVerification": "BASELINE VERIFIED", "reviewState": "PENDING_PHYSICIAN_REVIEW", "lastVerifiedAt": "2026-08-30", "id": "forecast-provenance-certification", "label": "FUTURE-OF-MEDICINE FORECAST", "domain": "Future of medicine", "url": "/reform/policy-lab/#forecasts", "title": "Provenance becomes a certification requirement, and the attestation problem is solved sideways", "horizon": "5 years", "confidence": "Moderate", "forecast": "Machine-readable provenance for generated clinical text arrives as an electronic-record certification criterion rather than as medical-record legislation, and the false-authorship attestation disappears with it.", "assumptions": [ "Certification bodies act because vendors want one uniform standard.", "No major litigation forces the question earlier." ], "competingScenario": "A malpractice verdict turning on an unattributable generated note forces the question into state medical-record law first.", "whatWouldFalsify": "A certification cycle passing with no provenance criterion while ambient documentation share continues to rise.", "documentaryBaseline": [ "fda-cds-ai", "nhs-ambient" ], "forecastStatus": "ACTIVE", "issued": "2026-08-30" } ], "generated": "2026-08-30", "briefStandard": "A Legislator Brief is a compressed, print-clean restatement of a proposal already published in full. It adds no facts and no recommendations of its own. Trade-off directions, stakeholder effects and cost lines are KPSGILL impact analysis, not projections, and not claimed positions of the groups named.", "forecastStatuses": [ "ACTIVE", "CONFIRMED", "PARTIALLY CONFIRMED", "MISSED", "INVALIDATED", "SUPERSEDED" ], "forecastRule": "A forecast is never deleted and never silently edited. When it resolves, its status changes and a dated resolution note is appended; a wrong forecast stays on the ledger with MISSED or INVALIDATED against it." }