As the nation still struggles with high healthcare costs that consume larger and larger portions of patient budgets as well as government coffers, the search for ways to get costs under control continues. Total healthcare spending in the U.S. now represents almost 18 percent of our entire economy. One promising cost-savings approach is called “reference pricing,” where the insurer establishes a price ceiling on selected services (joint replacement, colonoscopy, lab tests, etc.). Often, this price cap is based on the average of the negotiated prices for providers in its network, and anything above the reference price has to be covered by the insured consumer.

A study published in JAMA Internal Medicine by James Robinson and colleagues analyzed grocery store Safeway’s experience with reference pricing for laboratory services such as such as a lipid panel, comprehensive metabolic panel or prostate-specific antigen test. Safeway’s non-union employees were given information on prices at all laboratories through a mobile digital platform and told what Safeway would cover. Patients who chose a lab charging above the payment limit were required to pay the full difference themselves.

Employers see this type of program as a way to incentivize employees to think through the price of services when making healthcare decisions. Employees enjoy savings when they switch to a provider whose negotiated price is below the reference price, whereas if they choose services above it, they are responsible for the additional cost.

Robinson’s results show substantial savings to both Safeway and to its covered employees from reference pricing. Compared to trends in prices paid by insurance enrollees not subject to the caps of reference pricing, costs paid per test went down almost 32 percent, with a total savings over three years of $2.57 million – patients saved $1.05 million in out-of-pocket costs and Safeway saved $1.7 million.

I wrote an accompanying editorial in JAMA Internal Medicine focusing on different types of consumer-driven approaches to obtain lower prices; I argue that approaches that make the job simpler for consumers are likely to be even more successful. There is some work involved for patients to make reference pricing work, and many may have little awareness of price differences across laboratories, especially differences between those in some physicians’ offices, which tend to be more expensive but also more convenient, and in large commercial laboratories. Safeway helped steer their employees with accessible information: they provided employees with a smartphone app to compare lab prices.

But high-deductible plans like Safeway’s that provide extensive price information to consumers often have only limited impact because of the complexity of shopping for each service involved in a course of treatment -- something close to impossible for inpatient care. In addition, high deductibles are typically met for most hospitalizations (which tend to be the very expensive), so those consumers are less incentivized to comparison shop.

Plans that have limited provider networks relieve the consumer of much complexity and steer them towards providers with lower costs. Rather than review extensive price information, the consumer can focus on whether the provider is in the network. Reference pricing is another approach that simplifies—is the price less than the reference price? What was striking about Robinson’s results is that reference pricing for laboratories was employed in a high-deductible plan, showing that the savings achieved—in excess of 30 percent compared to a control—were beyond what the high deductible had accomplished.

While promising, reference pricing cannot be applied to all medical services: it works best for standardized services and where variation in quality is less of a concern. It also can be applied only to services that are “shoppable,” which is only about one-third of privately-insured spending. Even if reference pricing expanded to a number of other medical services, other cost containment approaches, including other network strategies, are needed to successfully contain health spending and lower costs for non-shoppable medical services.

---

Editor's note: This piece originally appeared in JAMA.

       

       

Publish What You Fund’s 2016 Aid Transparency Index is out. And as a result, today we can assess whether major donors met the commitments they made five years ago at Busan to make aid transparent by the end of 2015. The index is also a window into the state of foreign aid transparency and how the U.S.—the world’s largest bilateral donor—stacks up.

The global picture

On the positive side, the index found that ten donors of varied types and sizes, accounting for 25 percent of total aid, have met the commitment to aid transparency. And more than half of the 46 organizations included in the 2016 index now publish data to the International Aid Transparency Initiative (IATI) registry at least quarterly.

At the same time, the index’s assessments show more than half of the organizations still fall into the lowest three categories, scoring below 60 percent in terms of the transparency of their information.

The U.S. picture

Continuing its leadership on transparency, the Millennium Challenge Corporation comes in second overall in the index, meeting its Busan commitment and once again demonstrating that the institutional commitment to publishing and using its data continues.

Otherwise, at first glance, U.S. progress seems disappointing. The five other U.S. donors included in the 2016 index are all in the “fair” category. Seen through a five-year lens, however, these same five U.S. donors were either in the “poor” or “very poor” categories in the 2011 index. So, all agencies have moved up, and three of them—U.S. Agency for International Development (USAID), Department of the Treasury, and the U.S. President's Emergency Plan for AIDS Relief—are on the cusp of “good.”

In the two biggest U.S. agencies that administer foreign assistance, USAID and the State Department, the commitment is being institutionalized and implemented through more systematic efforts to revamp their outdated information systems. Both have reviewed the gaps in their data reporting systems and developed a path forward. USAID’s Cost Management Plan identifies specific steps to be taken and is well under way. The State Department Foreign Assistance Data Review (FADR) involves further reviews that need to be executed promptly in order to lead to action. Both are signs of a heightened commitment to data transparency and both require continued agency leadership and staff implementation.

The Department of Defense, which slid backwards in the last three assessments (and began at the "very poor" category in 2011), has for the first time moved into the "fair" category.  It is still the lowest performing U.S. agency in the index, but it is now publishing 12 new IATI fields. It is moving in the right direction, but significant work remains to be done.

The third U.S. National Action Plan (NAP) announced last fall—the strongest issued by the U.S. to date—calls for improvements to quality and comprehensiveness of U.S. data and commits the U.S. to doing more to raise awareness, accessibility, and demand for foreign assistance data. This gives all U.S. agencies the imperative to do much more to make their aid information transparent and usable.  

Going forward—what should the U.S. being focusing on?

The overall challenge has been laid out in the third NAP:

• Almost all of the U.S. agencies need to improve the breadth and depth of the information they are publishing to meet IATI standards. Far too often, basic information—such as titles—are either not published or are not useful.
• The Millennium Challenge Corporation should continue its leadership role, especially on data use. All agencies should be promoting the use of data among their own staff and by external stakeholders, especially at country level. Feedback will go a long way toward helping them improve the quality of the data they are publishing and thereby help them meet the IATI standards.
• USAID must finish the work on its Cost Management Plan, including putting IATI in the planned Development Information Solution. Additionally, more progress needs to be made on the follow-up to the Aid Transparency Country Pilot Assessment to meet the needs of partners.   
• The State Department needs to follow through on including IATI in the new integrated solution mapped out in its data review.

The leadership of all foreign affairs agencies needs to work harder to make the business case for compiling, publishing, and using data on foreign aid programs. Open data, particularly when it is comparable, timely, accessible, and comprehensive, is an extremely valuable management asset.  Agency leadership should be its champion. So far, we have not seen enough.

U.S. progress on aid transparency was slow to start. It is still not where it needs to be. But with a modest but concerted push, three additional agencies will be in the “good” category and that is a story we can start to be proud of.   

We look forward to continued progress and to the day when all U.S. foreign aid meets transparency standards—a day I believe will be an important one for the cause of greater development, better governance, democratic participation, and reduced poverty worldwide.

       

Spring has sprung and once again Publish What You Fund has issued its Aid Transparency Index (ATI). Once again most of the multilateral development banks (MDBs) receive high grades rated as very good. And once again I ask whether those grades are well deserved? At the heart of my question is whether aid agencies are disclosing sufficient information during the critical implementation stage of a project.

Last year we reviewed the practices of 8 aid agencies, 7 of which consistently receive the highest accolades in the ATI. What was evident from our review was the serious asymmetry of the type of aid data released to the public. A major target at Busan in 2011 when donors made commitments to aid transparency and in the establishment of the ATI has been the reporting of aid flows and the projects approved by each agency. There has been growing emphasis since then on reporting information on the results of those projects. But there has been very limited progress in the release of information during project implementation.

The importance of such information should be obvious. It is during project implementation that the various stakeholders need to monitor project progress, report on issues requiring attention, and make changes to ensure achievement of the desired results. It is insufficient to only disclose who wins a contract; consideration should be given to publishing the contracts, reporting on its execution, and disclosing amendments to the contracts. And it is not enough to simply publish the resettlement action plan for a project; how that plan is being implemented must be reported. Real time reporting is the key to being able to adapt and make changes as projects evolve.

Adapting the ATI

It is very evident that the International Aid Transparency Initiative (IATI) and the ATI have had a major positive impact on raising the level of transparency of aid agencies. Discussions with various agencies illustrate how they are keen to getting higher scores each year, carefully analyzing the indicators to guide their actions. However, with only a limited focus and weighting of reporting on project implementation in the ATI, there is no incentive to fill this important gap. 

In its 2016 report, Publish What You Fund has indicated that it will be reviewing its indicators later this year and intends to raise the bar. It would be timely to include information on project implementation in those revisions. One challenge is how to develop indicators that are similarly relevant across a wide variety of aid agencies. Implementation information is most critical for agencies that finance longer-term projects, especially infrastructure, such as the MDBs.  One option is to consider a set of indicators to better “incentivize” the relevant agencies and refer to these as ATI+.

Reviewing the use and abuse of protecting deliberative information

The MDB’s, in their major disclosure reforms since 2010, adopted a principle that “deliberative” information would not be disclosed in order to foster candid and open dialogue within the organization and between the organization and the client country. As per the World Bank’s policy, “The Bank, like any institution or group, needs space to consider and debate, away from public scrutiny.” This excludes emails, notes, and other exchanges either internally or with member countries.

As a result, the project supervision reports, which managements use to monitor projects under execution and are generally published twice a year, were divided between disclosed versus undisclosed sections. The undisclosed sections would offer space for reporting on confidential project concerns including potential corruption. Our review of the disclosed reports suggests that most aid agencies’ task managers tend to take a cautious approach, placing most information in the undisclosed sections. Stakeholders outside the MDB, such as local civil society groups, then, often only see truncated information.

While the adoption of the “deliberative” principle is understandable, its application places a serious responsibility on management to ensure that this is applied with considerable restraint. The MDBs should review the application of this principle and assess the type of information released during implementation.

It is indeed time to raise the bar on transparency and to focus on the most critical information required to ensure results. This is not the moment for complacency with high grades.

       

Scholars from the Brookings Institution and the American Enterprise Institute are collaborating to promote transparency in redistricting. In January 2010, an advisory board of experts and representatives of good government groups was convened in order to articulate principles for transparent redistricting and to identify barriers to the public and communities who wish to create redistricting plans. This document summarizes the principles for transparency in redistricting that were identified during that meeting.

Benefits of a Transparent, Participative Redistricting Process

The drawing of electoral districts is among the most easily manipulated and least transparent systems in democratic governance. All too often, redistricting authorities maintain their monopoly by imposing high barriers to transparency and public participation. Increasing transparency and public participation can be a powerful counterbalance by providing the public with information similar to that which is typically only available to official decision makers, which can lead to different outcomes and better representation.

Increasing transparency can empower the public to shape the representation for their communities, promote public commentary and discussion about redistricting, inform legislators and redistricting authorities which district configurations their constituents and the public support, and educate the public about the electoral process.  

Fostering public participation can enable the public to identify their neighborhoods and communities, promote the creation of alternative maps, and facilitate an exploration of a wide range of representational possibilities. The existence of publicly-drawn maps can provide a measuring stick against which an official plan can be compared, and promote the creation of a “market” for plans that support political fairness and community representational goals.

Transparency Principles

All redistricting plans should include sufficient information so the public can verify, reproduce, and evaluate a plan. Transparency thus requires that:

• Redistricting plans must be available in non-proprietary formats.
• Redistricting plans must be available in a format allowing them to be easily read and analyzed with commonly-used geographic information software.
• The criteria used as a basis for creating plans and individual districts must be clearly documented.

Creating and evaluating redistricting plans and community boundaries requires access to demographic, geographic, community, and electoral data. Transparency thus requires that:

• All data necessary to create legal redistricting plans and define community boundaries must be publicly available, under a license allowing reuse of these data for non-commercial purposes.
• All data must be accompanied by clear documentation stating the original source, the chain of ownership (provenance), and all modifications made to it.

Software systems used to generate or analyze redistricting plans can be complex, impossible to reproduce, or impossible to correctly understand without documentation. Transparency thus requires that:

• Software used to automatically create or improve redistricting plans must be either open-source or provide documentation sufficient for the public to replicate the results using independent software.
• Software used to generate reports that analyze redistricting plans must be accompanied by documentation of data, methods, and procedures sufficient for the reports to be verified by the public.

Services offered to the public to create or evaluate redistricting plans and community boundaries are often opaque and subject to misinterpretation unless adequately documented. Transparency thus requires that:

• Software necessary to replicate the creation or analysis of redistricting plans and community boundaries produced by the service must be publicly available.
• The service must provide the public with the ability to make available all published redistricting plans and community boundaries in non-proprietary formats that are easily read and analyzed with commonly-used geographic information software.
• Services must provide documentation of any organizations providing significant contributions to their operation.

Promoting Public Participation

New technologies provide opportunities to broaden public participation in the redistricting process. These technologies should aim to realize the potential benefits described and be consistent with the articulated transparency principles.

Redistricting is a legally and technically complex process. District creation and analysis software can encourage broad participation by: being widely accessible and easy to use; providing mapping and evaluating tools that help the public to create legal redistricting plans, as well as maps identifying local communities; be accompanied by training materials to assist the public to successfully create and evaluate legal redistricting plans and define community boundaries; have publication capabilities that allow the public to examine maps in situations where there is no access to the software; and promoting social networking and allow the public to compare, exchange and comment on both official and community-produced maps.

---

Official Endorsement from Organizations – Americans for Redistricting Reform, Brennan Center for Justice at New York University, Campaign Legal Center, Center for Governmental Studies, Center for Voting and Democracy, Common Cause, Demos, and the League of Women Voters of the United States.

Attending board members – Nancy Bekavac, Director, Scientists and Engineers for America; Derek Cressman, Western Regional Director of State Operations, Common Cause; Anthony Fairfax, President, Census Channel; Representative Mike Fortner (R), Illinois General Assembly; Karin Mac Donald, Director, Statewide Database, Berkeley Law, University of California, Berkeley; Leah Rush, Executive Director, Midwest Democracy Network; Mary Wilson, President, League of Women Voters.

Editors – Micah Altman, Harvard University and the Brookings Institution; Thomas E. Mann, Brookings Institution; Michael P. McDonald, George Mason University and the Brookings Institution; Norman J. Ornstein, American Enterprise Institute.

This project is funded by a grant from the Sloan Foundation to the Brookings Institution and the American Enterprise Institute.

      

       

Editor's Note: As part of the 2014 Midterm Elections Series, Brookings scholars and outside experts will weigh in on issues that are central to this year's campaigns, how the candidates are engaging those topics, and what will shape policy for the next two years.

Since the Citizens United decision, political spending by outside groups has been shaping voters’ opinions before Election Day and public policy afterwards.  Spending patterns that began after the 2010 decision will continue during the upcoming midterms: nonparty, outside spending will flow through two distinct pipelines—super PACs and politically active nonprofits. This time around there seems to be a partisan split to the spending, with Democrats leaning towards super PACs and Republicans relying more on dark money nonprofits. But whichever tool is used to funnel money into competitive races, imperfect or non-existent disclosure rules leave voters unable to determine whether access and influence is being sold to highest bidder.

Shining a brighter light on super PAC and nonprofit campaign spending would not cleanse the system of all of its corrupting influences, but it would help to restore citizens’ trust in government by eliminating the secrecy that makes voters believe their elected officials have something to hide. More disclosure would also result in the equally important outcome of demonstrating that government trusts us, its citizens, with information about how the influence industry works.   

When Thomas Jefferson wrote, “Whenever the people are well-informed, they can be trusted with their own government...whenever things get so far wrong as to attract their notice, they may be relied on to set them to rights,” he certainly could not have conceived of secret money’s impact on elections and policy-making. But every year that goes by with Congress failing to address secret campaign spending challenges the founding father’s time-tested wisdom.

When the Supreme Court decided Citizens United, it was either willfully blind or sorely naïve about the state of political finance disclosure. Justice Kennedy swept aside concerns about the corrupting influence of unlimited political spending by claiming that, “With the advent of the Internet, prompt disclosure of expenditures can provide shareholders and citizens with the information needed to hold corporations and elected officials accountable for their positions. . . This transparency enables the electorate to make informed decisions and give proper weight to different speakers and messages.”

Unfortunately, no such prompt disclosure existed at the time, nor has Congress been able to pass any improvements to the transparency regime since then. In the case of super PACs, while information about donors must eventually be disclosed to the Federal Election Commission (FEC), disclosures can be delayed by up to three months.  This is not an inconsequential delay, especially when contributions come are in the multi-million dollar range.

There is even less disclosure by politically active nonprofits.  Their overall expenditures are only disclosed after the election in annual reports filed with the Internal Revenue Service (IRS). The donors to dark money groups may never be known, as the law does not require the names of donors to such groups to be disclosed. Yet more than 55 percent of advertising has been paid for by dark money groups, and 80 percent advertising benefitting Republican candidates has been paid for with undisclosed funds according to the New York Times. 

Congress and the executive branch have no shortage of methods to make money in politics more transparent, but have so far failed to demonstrate they respect voters enough to entrust us with that information.  The Real Time Transparency Act (S. 2207, H.R. 4442) would ensure that contributions of $1000 or more to candidates, parties and PACs, including super PACs, are disclosed within 48 hours. It would also require electronic filing of campaign finance reports.  The DISCLOSE Act, S. 2516, would disclose contributors to political nonprofits entrusting voters with information that currently is only known to the candidates who may benefit from dark money contributions. 

Affirmative congressional action would be the strongest signal that government trusts its citizens, but executive branch agencies can also take important steps to make political finance information more transparent. The IRS is in the process of reforming rules to better clarify when a nonprofit is a political organization and thus must disclose its donors.  The Securities and Exchange Commission can likewise modify its rules to require publicly traded companies to disclose their political activities.

Many large donors have gone to great lengths to take their political activities underground, claiming they fear attacks in the form of criticism or boycotts of their companies.  But just as participating in the political process through contributing to election efforts is an expression of free speech, so is criticizing such efforts.  Yet until campaign finance information is fully and quickly made public, the first amendment rights of voters and their ability to participate fully in our democracy are drastically shortchanged.

      

       

       

Scholars from the Brookings Institution and the American Enterprise Institute are collaborating to promote transparency in redistricting. In January 2010, an advisory board of experts and representatives of good government groups was convened in order to articulate principles for transparent redistricting and to identify barriers to the public and communities who wish to create redistricting plans. This document summarizes the principles for transparency in redistricting that were identified during that meeting.

Benefits of a Transparent, Participative Redistricting Process

The drawing of electoral districts is among the most easily manipulated and least transparent systems in democratic governance. All too often, redistricting authorities maintain their monopoly by imposing high barriers to transparency and public participation. Increasing transparency and public participation can be a powerful counterbalance by providing the public with information similar to that which is typically only available to official decision makers, which can lead to different outcomes and better representation.

Increasing transparency can empower the public to shape the representation for their communities, promote public commentary and discussion about redistricting, inform legislators and redistricting authorities which district configurations their constituents and the public support, and educate the public about the electoral process.  

Fostering public participation can enable the public to identify their neighborhoods and communities, promote the creation of alternative maps, and facilitate an exploration of a wide range of representational possibilities. The existence of publicly-drawn maps can provide a measuring stick against which an official plan can be compared, and promote the creation of a “market” for plans that support political fairness and community representational goals.

Transparency Principles

All redistricting plans should include sufficient information so the public can verify, reproduce, and evaluate a plan. Transparency thus requires that:

• Redistricting plans must be available in non-proprietary formats.
• Redistricting plans must be available in a format allowing them to be easily read and analyzed with commonly-used geographic information software.
• The criteria used as a basis for creating plans and individual districts must be clearly documented.

Creating and evaluating redistricting plans and community boundaries requires access to demographic, geographic, community, and electoral data. Transparency thus requires that:

• All data necessary to create legal redistricting plans and define community boundaries must be publicly available, under a license allowing reuse of these data for non-commercial purposes.
• All data must be accompanied by clear documentation stating the original source, the chain of ownership (provenance), and all modifications made to it.

Software systems used to generate or analyze redistricting plans can be complex, impossible to reproduce, or impossible to correctly understand without documentation. Transparency thus requires that:

• Software used to automatically create or improve redistricting plans must be either open-source or provide documentation sufficient for the public to replicate the results using independent software.
• Software used to generate reports that analyze redistricting plans must be accompanied by documentation of data, methods, and procedures sufficient for the reports to be verified by the public.

Services offered to the public to create or evaluate redistricting plans and community boundaries are often opaque and subject to misinterpretation unless adequately documented. Transparency thus requires that:

• Software necessary to replicate the creation or analysis of redistricting plans and community boundaries produced by the service must be publicly available.
• The service must provide the public with the ability to make available all published redistricting plans and community boundaries in non-proprietary formats that are easily read and analyzed with commonly-used geographic information software.
• Services must provide documentation of any organizations providing significant contributions to their operation.

Promoting Public Participation

New technologies provide opportunities to broaden public participation in the redistricting process. These technologies should aim to realize the potential benefits described and be consistent with the articulated transparency principles.

Redistricting is a legally and technically complex process. District creation and analysis software can encourage broad participation by: being widely accessible and easy to use; providing mapping and evaluating tools that help the public to create legal redistricting plans, as well as maps identifying local communities; be accompanied by training materials to assist the public to successfully create and evaluate legal redistricting plans and define community boundaries; have publication capabilities that allow the public to examine maps in situations where there is no access to the software; and promoting social networking and allow the public to compare, exchange and comment on both official and community-produced maps.

---

Official Endorsement from Organizations – Americans for Redistricting Reform, Brennan Center for Justice at New York University, Campaign Legal Center, Center for Governmental Studies, Center for Voting and Democracy, Common Cause, Demos, and the League of Women Voters of the United States.

Attending board members – Nancy Bekavac, Director, Scientists and Engineers for America; Derek Cressman, Western Regional Director of State Operations, Common Cause; Anthony Fairfax, President, Census Channel; Representative Mike Fortner (R), Illinois General Assembly; Karin Mac Donald, Director, Statewide Database, Berkeley Law, University of California, Berkeley; Leah Rush, Executive Director, Midwest Democracy Network; Mary Wilson, President, League of Women Voters.

Editors – Micah Altman, Harvard University and the Brookings Institution; Thomas E. Mann, Brookings Institution; Michael P. McDonald, George Mason University and the Brookings Institution; Norman J. Ornstein, American Enterprise Institute.

This project is funded by a grant from the Sloan Foundation to the Brookings Institution and the American Enterprise Institute.