This document provides a sample fee schedule for a selection of common medical services under the Universal Healthcare Stabilization Act. The purpose of this schedule is to make the proposal's reimbursement model more concrete and transparent.
Methodology: These rates are based on current national average Medicare reimbursement rates. The final rates under the Act would be set by an independent commission, but this schedule serves as a realistic baseline.
Important: The rates listed here are National Base Rates. As detailed in the implementation_details.md file, all rates would be adjusted by:
- A Regional Cost Multiplier to account for geographic differences in the cost of providing care.
- A Quality of Service Multiplier to reward providers for excellent patient outcomes.
| Service / Procedure |
CPT Code(s) (Example) |
Proposed National Base Rate (Approx.) |
Description |
| Primary Care Office Visit |
99213 |
$100 |
Established patient, 20-29 minute visit. |
| Primary Care Office Visit |
99214 |
$145 |
Established patient, 30-39 minute visit for more complex issues. |
| Emergency Room Visit |
99283 |
$200 |
Mid-level severity ER visit. |
| Chest X-Ray |
71046 |
$45 |
2 views, frontal and lateral. |
| MRI of Lower Spine |
72148 |
$450 |
Without contrast material. |
| Service / Procedure |
CPT Code(s) (Example) |
Proposed National Base Rate (Approx.) |
Description |
| Electrocardiogram (ECG) |
93000 |
$20 |
Complete ECG with interpretation and report. |
| Echocardiogram |
93306 |
$250 |
Transthoracic, with Doppler and color flow. |
| Cardiovascular Stress Test |
93015 |
$150 |
Includes supervision, interpretation, and report. |
| Cardiac Catheterization |
93458 |
$400 |
Left heart catheterization with imaging. |
| Service / Procedure |
CPT Code(s) (Example) |
Proposed National Base Rate (Approx.) |
Description |
| Total Knee Replacement |
27447 |
$1,900 |
Surgeon's fee for total knee arthroplasty. |
| Total Hip Replacement |
27130 |
$1,800 |
Surgeon's fee for total hip arthroplasty. |
| Arthroscopic Rotator Cuff Repair |
29827 |
$1,200 |
Surgeon's fee for arthroscopic repair. |
| Joint Aspiration/Injection |
20610 |
$80 |
Aspiration or injection of major joint. |
| Service / Procedure |
CPT Code(s) (Example) |
Proposed National Base Rate (Approx.) |
Description |
| Screening Colonoscopy |
45378 |
$400 |
Standard diagnostic colonoscopy. |
| EGD (Esophagogastroduodenoscopy) |
43235 |
$350 |
Diagnostic, including collection of specimen(s). |
| Colonoscopy with Biopsy |
45380 |
$500 |
With biopsy, single or multiple. |
| Service / Procedure |
CPT Code(s) (Example) |
Proposed National Base Rate (Approx.) |
Description |
| Skin Biopsy |
11102 |
$100 |
Tangential biopsy of single lesion. |
| Destruction of Benign Lesion |
17110 |
$90 |
Destruction of up to 14 benign lesions. |
| Excision of Malignant Lesion |
11602 |
$200 |
Excision, malignant lesion, trunk, arms, or legs, size 1.1 to 2.0 cm. |
| Service / Procedure |
CPT Code(s) (Example) |
Proposed National Base Rate (Approx.) |
Description |
| Routine Obstetric Care |
59400 |
$2,500 |
Global fee for routine care including antepartum, vaginal delivery, and postpartum care. |
| Laparoscopic Hysterectomy |
58570 |
$820 |
Surgeon's fee for total hysterectomy. |
| Colposcopy |
57452 |
$150 |
With biopsy of cervix. |
| Service / Procedure |
CPT Code(s) (Example) |
Proposed National Base Rate (Approx.) |
Description |
| Psychiatric Diagnostic Evaluation |
90791 |
$170 |
Initial psychiatric evaluation. |
| Psychotherapy (45 mins) |
90834 |
$105 |
Individual psychotherapy session. |
| Psychotherapy (60 mins) |
90837 |
$155 |
Individual psychotherapy session. |
| Group Psychotherapy |
90853 |
$30 |
Per person, per session. |
The healthcare landscape is constantly evolving with new technologies, procedures, and treatments. The Universal Healthcare Stabilization Act is designed to be adaptable and responsive to innovation. The process for proposing and integrating new items into the fee schedule is as follows:
- Submission by Stakeholders: Healthcare providers, medical associations, research institutions, and patient advocacy groups can submit proposals to the independent national commission responsible for maintaining the fee schedule.
- Evidence-Based Review: The commission will conduct a rigorous, evidence-based review of the proposed item. This review will assess:
- Clinical Efficacy: Does the new procedure or treatment improve patient outcomes compared to existing options?
- Safety: Has the procedure been proven safe through clinical trials and peer-reviewed studies?
- Cost-Effectiveness: Does the new item provide value to the healthcare system?
- Public Comment Period: Before a final decision is made, the commission's initial recommendation will be released for a public comment period, allowing for feedback from all stakeholders.
- Integration into the Schedule: If the commission approves the new item, it will be assigned a CPT code and a national base rate, and integrated into the fee schedule. This process ensures that the healthcare system remains current and that patients have access to the best available care.
¶ Hospital and Facility Fees
The rates above primarily represent the fees paid to physicians and clinics for their services. A separate payment system, known as a Global Budget or a Diagnosis-Related Group (DRG) system, would be used for hospitals.
- DRG System: For inpatient procedures like a knee replacement, the hospital would receive a single bundled payment (e.g., ~$15,000 - $20,000) that covers the entire patient stay, from the surgery itself to nursing care, room, and board. This incentivizes efficiency and coordinated care.
- Global Budgets: Alternatively, hospitals could receive an annual lump sum (a global budget) to cover all operating costs. This budget would be negotiated annually and determined by factors such as the hospital's capacity (e.g., available equipment and number of active physicians) and historical service levels, ensuring funding aligns with the hospital's ability to deliver care. This model allows hospitals to provide necessary services to their community without the need to bill on a per-procedure basis.
¶ Determining and Justifying a Global Budget
A global budget is a fixed, pre-negotiated amount of funding given to a hospital to cover its operating expenses for a set period (typically one year). This model shifts the focus from the volume of services provided to the overall health needs of the community. The budget would be determined and justified based on a transparent set of metrics, including:
- 1. Historical Operating Costs: The budget from the previous year serves as a baseline, which is then adjusted based on the following factors.
- 2. Hospital Capacity: The physical and human resources the hospital has available.
- Number of licensed beds.
- Availability of specialized equipment (e.g., MRI machines, cancer treatment facilities).
- Number and types of clinical staff (doctors, nurses, technicians).
- 3. Community Health Needs: The characteristics of the population the hospital serves.
- Service Area Population: The number of people in the hospital's geographic service area.
- Patient Demographics & Acuity: The age, income level, and prevalence of chronic diseases in the community. A hospital serving an older, sicker population would require a larger budget.
- Historical Patient Volume: The number of admissions, emergency visits, and outpatient procedures performed in previous years.
- 4. Scope of Services Offered: The range and complexity of care the hospital provides.
- Specialized Services: Funding for high-cost, essential services like trauma centers, neonatal intensive care units (NICUs), burn units, or transplant programs.
- Teaching and Research: Additional funding if the hospital is a teaching facility that trains new doctors and conducts medical research.
- 5. Quality and Outcomes: A portion of the budget would be tied to performance on key quality metrics, creating a financial incentive for high-quality care. This could include:
- Reduced hospital readmission rates.
- Patient satisfaction scores.
- Rates of hospital-acquired infections.
- 6. Capital Investment: A separate, pre-approved allocation for major capital projects, such as building a new wing or purchasing new diagnostic equipment.
- 7. Annual Inflation Adjustment: An automatic annual adjustment to account for medical inflation.