{
 "template": {
  "benefits_rate": 0.24,
  "contract_premium": 1.6,
  "workforce": {
   "physicians": {
    "fte": 110,
    "comp": 380000,
    "variable": 0.5,
    "label": "Employed physicians"
   },
   "apps": {
    "fte": 70,
    "comp": 135000,
    "variable": 0.5,
    "label": "NPs / PAs"
   },
   "rn": {
    "fte": 620,
    "comp": 98000,
    "variable": 0.7,
    "label": "Registered nurses"
   },
   "clinical_support": {
    "fte": 380,
    "comp": 48000,
    "variable": 0.6,
    "label": "LPNs, aides, techs"
   },
   "allied": {
    "fte": 330,
    "comp": 85000,
    "variable": 0.6,
    "label": "Pharmacy, lab, imaging, therapy"
   },
   "revenue_cycle": {
    "fte": 150,
    "comp": 58000,
    "variable": 0.5,
    "label": "Billing, coding, payer admin"
   },
   "management": {
    "fte": 90,
    "comp": 190000,
    "variable": 0.0,
    "label": "Executives and managers"
   },
   "admin_other": {
    "fte": 210,
    "comp": 80000,
    "variable": 0.1,
    "label": "IT, HR, finance, quality"
   },
   "support": {
    "fte": 300,
    "comp": 42000,
    "variable": 0.3,
    "label": "Environmental, food, facilities"
   }
  },
  "contract_labor": {
   "amount": 15.0,
   "variable": 0.8
  },
  "nonlabor": {
   "drugs": {
    "amount": 42.0,
    "variable": 1.0,
    "label": "Drugs"
   },
   "devices": {
    "amount": 22.0,
    "variable": 1.0,
    "label": "Devices and implants"
   },
   "supplies": {
    "amount": 30.0,
    "variable": 1.0,
    "label": "Medical/surgical supplies"
   },
   "purchased_services": {
    "amount": 44.0,
    "variable": 0.3,
    "label": "Purchased services"
   },
   "bir_vendors": {
    "amount": 6.0,
    "variable": 0.8,
    "label": "Billing/insurance vendors"
   },
   "liability_insurance": {
    "amount": 9.0,
    "variable": 0.3,
    "label": "Malpractice and insurance"
   },
   "utilities_facilities": {
    "amount": 14.0,
    "variable": 0.1,
    "label": "Utilities and facilities"
   },
   "depreciation": {
    "amount": 28.0,
    "variable": 0.0,
    "label": "Depreciation"
   },
   "interest": {
    "amount": 8.0,
    "variable": 0.0,
    "label": "Interest"
   },
   "marketing": {
    "amount": 3.0,
    "variable": 0.0,
    "label": "Marketing"
   },
   "other": {
    "amount": 14.0,
    "variable": 0.2,
    "label": "Other expense"
   }
  }
 },
 "archetypes": {
  "community": {
   "name": "Community nonprofit",
   "description": "A 300-bed community hospital with a balanced payer mix",
   "scale": 1.0,
   "payer_mix": {
    "medicare": 0.44,
    "medicaid": 0.19,
    "commercial": 0.29,
    "self_pay": 0.06,
    "other_gov": 0.02
   },
   "pcr": {
    "medicare": 0.84,
    "medicaid": 0.8,
    "self_pay": 0.1,
    "other_gov": 0.9
   },
   "other_op_rev_pct": 0.02,
   "baseline_margin": 0.025,
   "days_cash": 200
  },
  "academic": {
   "name": "Academic medical center",
   "description": "A large teaching hospital with high-acuity patients and research and teaching costs",
   "scale": 4.0,
   "payer_mix": {
    "medicare": 0.38,
    "medicaid": 0.24,
    "commercial": 0.3,
    "self_pay": 0.04,
    "other_gov": 0.04
   },
   "pcr": {
    "medicare": 0.82,
    "medicaid": 0.8,
    "self_pay": 0.1,
    "other_gov": 0.95
   },
   "other_op_rev_pct": 0.06,
   "baseline_margin": 0.03,
   "days_cash": 220
  },
  "suburban": {
   "name": "High-commercial suburban",
   "description": "A hospital in an affluent service area where nearly half of care is commercially insured",
   "scale": 1.2,
   "payer_mix": {
    "medicare": 0.4,
    "medicaid": 0.08,
    "commercial": 0.46,
    "self_pay": 0.03,
    "other_gov": 0.03
   },
   "pcr": {
    "medicare": 0.84,
    "medicaid": 0.78,
    "self_pay": 0.15,
    "other_gov": 0.9
   },
   "other_op_rev_pct": 0.02,
   "baseline_margin": 0.09,
   "days_cash": 280
  },
  "safety_net": {
   "name": "Urban safety net",
   "description": "A hospital serving a large share of Medicaid and uninsured patients, with relatively little commercial revenue",
   "scale": 1.4,
   "payer_mix": {
    "medicare": 0.36,
    "medicaid": 0.4,
    "commercial": 0.12,
    "self_pay": 0.1,
    "other_gov": 0.02
   },
   "pcr": {
    "medicare": 0.86,
    "medicaid": 0.8,
    "self_pay": 0.08,
    "other_gov": 0.9
   },
   "other_op_rev_pct": 0.09,
   "baseline_margin": -0.01,
   "days_cash": 90
  },
  "rural_cah": {
   "name": "Rural critical access",
   "description": "A 25-bed critical access hospital paid by Medicare at 101 percent of cost, less sequestration",
   "scale": 0.08,
   "payer_mix": {
    "medicare": 0.5,
    "medicaid": 0.18,
    "commercial": 0.22,
    "self_pay": 0.07,
    "other_gov": 0.03
   },
   "pcr": {
    "medicare": 0.99,
    "medicaid": 0.85,
    "self_pay": 0.1,
    "other_gov": 0.9
   },
   "other_op_rev_pct": 0.03,
   "baseline_margin": 0.0,
   "days_cash": 80,
   "medicare_cost_based": true
  }
 },
 "finance": {
  "covenant_days_cash": 60,
  "investment_yield": 0.04,
  "horizon_years": 10
 },
 "levers": [
  {
   "id": "agency_conversion",
   "group": "Workforce configuration",
   "name": "Convert agency staff to employees",
   "control": "hospital",
   "levels": {
    "low": 0.4,
    "base": 0.6,
    "high": 0.8
   },
   "actions": [
    {
     "type": "agency_conversion",
     "into": "rn"
    }
   ],
   "ramp_years": 2,
   "one_time": 0.15,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Conversion depends on the hospital's ability to recruit permanent staff, which becomes more difficult if nurse compensation is reduced at the same time.",
   "means": "Replaces agency and travel nurses with employed registered nurses. Because agency staff cost about 1.6 times as much as employed staff performing the same work, each dollar of agency spending that is converted reduces costs by roughly 37 cents."
  },
  {
   "id": "clinical_productivity",
   "group": "Workforce configuration",
   "name": "Align clinical staffing with benchmarks",
   "control": "hospital",
   "levels": {
    "low": 0.02,
    "base": 0.04,
    "high": 0.07
   },
   "actions": [
    {
     "type": "fte_cut",
     "targets": [
      "rn",
      "clinical_support",
      "allied"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.3,
   "leakage": 0.1,
   "requires_admin_simplification": false,
   "risk": "Lower staffing levels may increase burnout and adverse events, and nurse staffing laws limit reductions in some states.",
   "means": "Reduces nursing, clinical support, and allied health staffing for a given volume of care by shortening lengths of stay, improving patient flow, and aligning staffing with benchmark ratios."
  },
  {
   "id": "rn_skill_mix",
   "group": "Workforce configuration",
   "name": "Shift nursing work from RNs to LPNs and aides",
   "control": "hospital",
   "levels": {
    "low": 0.04,
    "base": 0.08,
    "high": 0.15
   },
   "actions": [
    {
     "type": "skill_mix",
     "from": "rn",
     "to": "clinical_support",
     "ratio": 1.1
    }
   ],
   "ramp_years": 3,
   "one_time": 0.2,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Research has associated a lower proportion of registered nurses in the nursing workforce with higher patient mortality and lower quality of care.",
   "means": "Shifts a portion of nursing work from registered nurses to licensed practical nurses and nursing aides. Each RN position eliminated is replaced by 1.1 support positions, reflecting the additional hours that less specialized staff require for the same tasks."
  },
  {
   "id": "physician_app_mix",
   "group": "Workforce configuration",
   "name": "Substitute NPs and PAs for physicians",
   "control": "hospital",
   "levels": {
    "low": 0.05,
    "base": 0.1,
    "high": 0.2
   },
   "actions": [
    {
     "type": "skill_mix",
     "from": "physicians",
     "to": "apps",
     "ratio": 1.25
    }
   ],
   "ramp_years": 3,
   "one_time": 0.2,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "State scope-of-practice laws limit substitution in some states, and substitution is not appropriate for many procedural specialties.",
   "means": "Substitutes nurse practitioners and physician assistants for a portion of the work of employed physicians. Each physician position eliminated is replaced by 1.25 NP or PA positions."
  },
  {
   "id": "mgmt_delayering",
   "group": "Workforce configuration",
   "name": "Reduce management layers",
   "control": "hospital",
   "levels": {
    "low": 0.08,
    "base": 0.15,
    "high": 0.25
   },
   "actions": [
    {
     "type": "fte_cut",
     "targets": [
      "management"
     ]
    }
   ],
   "ramp_years": 1,
   "one_time": 0.5,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Reducing management capacity may impair the hospital's ability to carry out the restructuring itself.",
   "means": "Reduces the number of executive, director, and manager positions by eliminating management layers and widening spans of control."
  },
  {
   "id": "back_office",
   "group": "Workforce configuration",
   "name": "Automate and consolidate administrative functions",
   "control": "hospital",
   "levels": {
    "low": 0.05,
    "base": 0.12,
    "high": 0.2
   },
   "actions": [
    {
     "type": "fte_cut",
     "targets": [
      "admin_other"
     ]
    },
    {
     "type": "fte_cut",
     "targets": [
      "support"
     ],
     "scale": 0.4
    }
   ],
   "ramp_years": 3,
   "one_time": 0.6,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Automation requires upfront investment in technology, and savings often materialize later than planned.",
   "means": "Reduces administrative staffing in information technology, human resources, finance, and quality through automation and consolidation, and reduces environmental services, food service, and facilities staffing at 40 percent of that rate."
  },
  {
   "id": "bir_staff",
   "group": "Insurance overhead",
   "name": "Reduce billing and payer administration staff",
   "control": "policy",
   "levels": {
    "low": 0.25,
    "base": 0.45,
    "high": 0.65
   },
   "actions": [
    {
     "type": "fte_cut",
     "targets": [
      "revenue_cycle"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.4,
   "leakage": 0.0,
   "requires_admin_simplification": true,
   "risk": "Savings depend on payers adopting a common fee schedule and rule set. Coding and compliance functions would remain under any payment system.",
   "means": "Reduces billing, coding, and payer administration staff whose work arises from differences in prices, rules, forms, and appeals processes across insurers. Savings are limited to the share of administrative complexity that the policy scenario eliminates."
  },
  {
   "id": "bir_vendors",
   "group": "Insurance overhead",
   "name": "Reduce billing and collection vendor spending",
   "control": "policy",
   "levels": {
    "low": 0.3,
    "base": 0.5,
    "high": 0.7
   },
   "actions": [
    {
     "type": "nonlabor_cut",
     "targets": [
      "bir_vendors"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.1,
   "leakage": 0.0,
   "requires_admin_simplification": true,
   "risk": "Existing vendor contracts may include termination penalties or minimum terms.",
   "means": "Reduces spending on outsourced billing services, claims clearinghouses, and collection agencies as claims processing becomes simpler."
  },
  {
   "id": "clinician_admin_time",
   "group": "Insurance overhead",
   "name": "Reduce clinician time on payer requirements",
   "control": "policy",
   "levels": {
    "low": 0.01,
    "base": 0.02,
    "high": 0.04
   },
   "actions": [
    {
     "type": "fte_cut",
     "targets": [
      "physicians",
      "apps",
      "rn"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.1,
   "leakage": 0.0,
   "requires_admin_simplification": true,
   "risk": "Time freed from administrative tasks produces savings only if it results in fewer positions or additional billable services.",
   "means": "Converts time that physicians, nurse practitioners, physician assistants, and nurses currently spend on prior authorization and other payer requirements into a reduction in clinical positions."
  },
  {
   "id": "payer_contracting",
   "group": "Insurance overhead",
   "name": "Eliminate payer contracting and related marketing",
   "control": "policy",
   "levels": {
    "low": 0.02,
    "base": 0.04,
    "high": 0.06
   },
   "actions": [
    {
     "type": "fte_cut",
     "targets": [
      "admin_other"
     ]
    },
    {
     "type": "nonlabor_cut",
     "targets": [
      "marketing"
     ],
     "scale": 10.0
    }
   ],
   "ramp_years": 2,
   "one_time": 0.3,
   "leakage": 0.0,
   "requires_admin_simplification": true,
   "risk": "The reduction in marketing assumes that hospitals no longer compete for commercially insured patients.",
   "means": "Eliminates managed care contracting and payer-specific finance and information technology functions, and reduces marketing directed at commercially insured patients. Marketing is reduced at ten times the lever's rate, so the base level eliminates 40 percent of marketing spending."
  },
  {
   "id": "denials_recovery",
   "group": "Insurance overhead",
   "name": "Reduce claim denials and underpayments",
   "control": "policy",
   "levels": {
    "low": 0.003,
    "base": 0.007,
    "high": 0.012
   },
   "actions": [
    {
     "type": "revenue_uplift"
    }
   ],
   "ramp_years": 2,
   "one_time": 0.0,
   "leakage": 0.0,
   "requires_admin_simplification": true,
   "risk": "Medicare also audits and denies claims, so the gain reflects only the difference from current commercial practice.",
   "means": "Increases collections by reducing claim denials, underpayments, and write-offs when all payers follow a common set of rules. The model represents this as a small increase in patient revenue."
  },
  {
   "id": "drugs",
   "group": "Purchasing",
   "name": "Lower drug acquisition costs",
   "control": "policy",
   "levels": {
    "low": 0.05,
    "base": 0.12,
    "high": 0.3
   },
   "actions": [
    {
     "type": "nonlabor_cut",
     "targets": [
      "drugs"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.05,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "The high level assumes international reference pricing. Lower acquisition prices would also reduce 340B program savings for eligible hospitals, an effect the model does not capture.",
   "means": "Lowers drug acquisition costs through group purchasing, formulary management, and biosimilar substitution and, at the high level, through national drug price regulation."
  },
  {
   "id": "devices",
   "group": "Purchasing",
   "name": "Lower device and implant costs",
   "control": "hospital",
   "levels": {
    "low": 0.05,
    "base": 0.12,
    "high": 0.3
   },
   "actions": [
    {
     "type": "nonlabor_cut",
     "targets": [
      "devices"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.1,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Savings require physicians to agree to standardized products, and the high level assumes price transparency or reference pricing requirements.",
   "means": "Lowers implant and device costs by standardizing physician preference items and, at the high level, through price transparency or reference pricing."
  },
  {
   "id": "supplies",
   "group": "Purchasing",
   "name": "Lower medical and surgical supply costs",
   "control": "hospital",
   "levels": {
    "low": 0.03,
    "base": 0.08,
    "high": 0.15
   },
   "actions": [
    {
     "type": "nonlabor_cut",
     "targets": [
      "supplies"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.1,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Most hospitals already purchase through group purchasing organizations, so many of the most readily available savings have been realized.",
   "means": "Lowers medical and surgical supply costs through product standardization, group purchasing, and waste reduction."
  },
  {
   "id": "purchased_services",
   "group": "Purchasing",
   "name": "Renegotiate or insource purchased services",
   "control": "hospital",
   "levels": {
    "low": 0.05,
    "base": 0.1,
    "high": 0.18
   },
   "actions": [
    {
     "type": "nonlabor_cut",
     "targets": [
      "purchased_services"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.1,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Vendors face the same labor cost pressures as hospitals, and multiyear contracts delay savings.",
   "means": "Lowers the cost of contracted services, such as staffing, information technology, laundry, food service, and consulting, through renegotiation or insourcing."
  },
  {
   "id": "liability",
   "group": "Purchasing",
   "name": "Lower malpractice and insurance costs",
   "control": "policy",
   "levels": {
    "low": 0.0,
    "base": 0.05,
    "high": 0.2
   },
   "actions": [
    {
     "type": "nonlabor_cut",
     "targets": [
      "liability_insurance"
     ]
    }
   ],
   "ramp_years": 3,
   "one_time": 0.0,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "The high level depends on enactment of tort reform.",
   "means": "Lowers malpractice and other insurance premiums. The high level assumes enactment of tort reform."
  },
  {
   "id": "facilities",
   "group": "Purchasing",
   "name": "Lower utility, lease, and facilities costs",
   "control": "hospital",
   "levels": {
    "low": 0.02,
    "base": 0.05,
    "high": 0.1
   },
   "actions": [
    {
     "type": "nonlabor_cut",
     "targets": [
      "utilities_facilities"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.2,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "This category accounts for a small share of hospital spending, which limits potential savings.",
   "means": "Lowers utility, lease, and facilities costs through energy contracting, space consolidation, and lease terminations."
  },
  {
   "id": "other_expense",
   "group": "Purchasing",
   "name": "Reduce discretionary spending",
   "control": "hospital",
   "levels": {
    "low": 0.05,
    "base": 0.1,
    "high": 0.15
   },
   "actions": [
    {
     "type": "nonlabor_cut",
     "targets": [
      "other"
     ]
    }
   ],
   "ramp_years": 1,
   "one_time": 0.0,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Reductions in training and community programs may affect workforce development and community benefit activities.",
   "means": "Reduces discretionary spending, including travel, training, professional dues, community programs, and miscellaneous expenses."
  },
  {
   "id": "capex",
   "group": "Capital and footprint",
   "name": "Defer capital spending",
   "control": "hospital",
   "levels": {
    "low": 0.05,
    "base": 0.12,
    "high": 0.2
   },
   "actions": [
    {
     "type": "nonlabor_cut",
     "targets": [
      "depreciation"
     ]
    },
    {
     "type": "capex_cut",
     "scale": 2.5
    }
   ],
   "ramp_years": 5,
   "one_time": 0.0,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Deferral improves cash flow quickly but affects operating income only gradually, and deferred investment in facilities and equipment creates future obligations.",
   "means": "Reduces capital spending on buildings and equipment. Cash savings begin immediately, with capital spending falling by 2.5 times the lever's rate, while depreciation expense, and therefore operating income, adjusts gradually."
  },
  {
   "id": "service_exit",
   "group": "Capital and footprint",
   "name": "Close service lines with the largest losses",
   "control": "hospital",
   "levels": {
    "low": 0.02,
    "base": 0.04,
    "high": 0.08
   },
   "actions": [
    {
     "type": "service_exit",
     "exit_pcr_rel": 0.75,
     "avoidable": 0.8
    }
   ],
   "ramp_years": 2,
   "one_time": 0.5,
   "leakage": 0.0,
   "requires_admin_simplification": false,
   "risk": "Closures reduce community access to affected services, and shared overhead costs remain after a service closes.",
   "means": "Closes the service lines with the largest operating losses, which typically include obstetrics, behavioral health, pediatrics, and trauma care. The hospital forgoes the revenue from these services and eliminates most, but not all, of their costs."
  },
  {
   "id": "exec_comp",
   "group": "Compensation",
   "name": "Reduce executive and management compensation",
   "control": "hospital",
   "levels": {
    "low": 0.1,
    "base": 0.2,
    "high": 0.35
   },
   "actions": [
    {
     "type": "comp_cut",
     "targets": [
      "management"
     ]
    }
   ],
   "ramp_years": 1,
   "one_time": 0.0,
   "leakage": 0.05,
   "requires_admin_simplification": false,
   "risk": "Executive compensation reductions are often a precondition for broader concessions from staff, but they produce relatively small savings.",
   "means": "Reduces compensation for executives and managers who remain after management positions have been reduced."
  },
  {
   "id": "physician_comp",
   "group": "Compensation",
   "name": "Reduce employed physician compensation",
   "control": "market",
   "levels": {
    "low": 0.05,
    "base": 0.15,
    "high": 0.3
   },
   "actions": [
    {
     "type": "comp_cut",
     "targets": [
      "physicians"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.05,
   "leakage": 0.15,
   "requires_admin_simplification": false,
   "risk": "Physicians generate referrals and admissions. The high level would bring compensation closer to levels in other high-income countries and assumes that all employers in the market make similar reductions.",
   "means": "Reduces compensation for employed physicians."
  },
  {
   "id": "app_comp",
   "group": "Compensation",
   "name": "Reduce NP and PA compensation",
   "control": "market",
   "levels": {
    "low": 0.0,
    "base": 0.05,
    "high": 0.1
   },
   "actions": [
    {
     "type": "comp_cut",
     "targets": [
      "apps"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.05,
   "leakage": 0.2,
   "requires_admin_simplification": false,
   "risk": "Reductions may conflict with a strategy of relying more heavily on nurse practitioners and physician assistants.",
   "means": "Reduces compensation for nurse practitioners and physician assistants."
  },
  {
   "id": "nurse_comp",
   "group": "Compensation",
   "name": "Reduce registered nurse compensation",
   "control": "market",
   "levels": {
    "low": 0.0,
    "base": 0.05,
    "high": 0.15
   },
   "actions": [
    {
     "type": "comp_cut",
     "targets": [
      "rn"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.05,
   "leakage": 0.25,
   "requires_admin_simplification": false,
   "risk": "Nurses may leave bedside practice or the profession, collective bargaining agreements may limit reductions, and higher vacancy rates may increase reliance on agency staff.",
   "means": "Reduces compensation for registered nurses."
  },
  {
   "id": "other_clinical_comp",
   "group": "Compensation",
   "name": "Reduce allied health and clinical support compensation",
   "control": "market",
   "levels": {
    "low": 0.0,
    "base": 0.03,
    "high": 0.08
   },
   "actions": [
    {
     "type": "comp_cut",
     "targets": [
      "allied",
      "clinical_support"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.05,
   "leakage": 0.25,
   "requires_admin_simplification": false,
   "risk": "Wages for aides and technicians are already close to those in retail and warehouse employment, which gives these workers ready alternatives.",
   "means": "Reduces compensation for allied health professionals (pharmacy, laboratory, imaging, and therapy) and clinical support staff (licensed practical nurses, aides, and technicians)."
  },
  {
   "id": "nonclinical_comp",
   "group": "Compensation",
   "name": "Reduce administrative and support staff compensation",
   "control": "market",
   "levels": {
    "low": 0.0,
    "base": 0.03,
    "high": 0.08
   },
   "actions": [
    {
     "type": "comp_cut",
     "targets": [
      "revenue_cycle",
      "admin_other",
      "support"
     ]
    }
   ],
   "ramp_years": 2,
   "one_time": 0.05,
   "leakage": 0.2,
   "requires_admin_simplification": false,
   "risk": "Administrative and support skills transfer readily to other industries, which increases the risk of turnover.",
   "means": "Reduces compensation for billing, administrative, information technology, human resources, and support staff."
  },
  {
   "id": "benefits",
   "group": "Compensation",
   "name": "Reduce employee benefits",
   "control": "market",
   "levels": {
    "low": 0.05,
    "base": 0.1,
    "high": 0.2
   },
   "actions": [
    {
     "type": "benefits_cut"
    }
   ],
   "ramp_years": 1,
   "one_time": 0.0,
   "leakage": 0.1,
   "requires_admin_simplification": false,
   "risk": "Benefit reductions affect all employees at once and may increase turnover across the workforce.",
   "means": "Reduces employee benefits, including retirement contributions, the employer share of health insurance premiums, and paid time off. The model applies this as a reduction in the benefits rate for all employees."
  }
 ],
 "policies": {
  "rates_only": {
   "name": "Commercial capped at Medicare",
   "description": "Commercial insurers pay Medicare rates but retain their own coverage rules and administrative processes. Medicaid and uninsured patients are unaffected.",
   "commercial_to_medicare": true,
   "medicaid_to_medicare": false,
   "self_pay_to_medicare": false,
   "admin_simplification": 0.15,
   "volume_change": 0.0,
   "phase_in_years": 1,
   "rate_multiple": 1.0
  },
  "all_payer": {
   "name": "All payers at Medicare",
   "description": "Commercial insurers and Medicaid pay Medicare rates under a common fee schedule. Uninsured patients are unaffected.",
   "commercial_to_medicare": true,
   "medicaid_to_medicare": true,
   "self_pay_to_medicare": false,
   "admin_simplification": 0.5,
   "volume_change": 0.0,
   "phase_in_years": 1,
   "rate_multiple": 1.0
  },
  "all_payer_phased": {
   "name": "All payers, 5-year phase-in",
   "description": "Identical to the all-payer scenario, except that payment rates decline to Medicare levels in equal steps over five years.",
   "commercial_to_medicare": true,
   "medicaid_to_medicare": true,
   "self_pay_to_medicare": false,
   "admin_simplification": 0.5,
   "volume_change": 0.0,
   "phase_in_years": 5,
   "rate_multiple": 1.0
  },
  "single_payer": {
   "name": "Single payer at Medicare",
   "description": "All residents are covered, and care is paid for at Medicare rates under a single set of rules. Patient volume increases by 3 percent.",
   "commercial_to_medicare": true,
   "medicaid_to_medicare": true,
   "self_pay_to_medicare": true,
   "admin_simplification": 1.0,
   "volume_change": 0.03,
   "phase_in_years": 1,
   "rate_multiple": 1.0
  }
 },
 "responses": {
  "none": {
   "name": "No response",
   "description": "The hospital makes no changes.",
   "default": "none"
  },
  "conventional": {
   "name": "Conventional turnaround",
   "description": "Measures a hospital board would typically approve first, including operational improvements, purchasing savings, and capital discipline, without pay reductions for frontline staff.",
   "default": "none",
   "levers": {
    "agency_conversion": "base",
    "clinical_productivity": "low",
    "mgmt_delayering": "low",
    "back_office": "low",
    "bir_staff": "low",
    "bir_vendors": "low",
    "clinician_admin_time": "low",
    "payer_contracting": "low",
    "denials_recovery": "low",
    "drugs": "low",
    "devices": "low",
    "supplies": "base",
    "purchased_services": "low",
    "facilities": "low",
    "other_expense": "low",
    "capex": "low",
    "service_exit": "low",
    "exec_comp": "low",
    "benefits": "low"
   }
  },
  "aggressive": {
   "name": "Aggressive restructuring",
   "description": "All levers at their base levels, including compensation reductions for all staff, changes in skill mix, and service line closures.",
   "default": "base"
  },
  "redesign": {
   "name": "System redesign",
   "description": "All levers at their high levels. Compensation moves toward levels in other high-income countries, drug and device prices are regulated, and payer administrative complexity is eliminated. These changes are beyond the control of any single hospital.",
   "default": "high"
  }
 },
 "default_policy": "all_payer",
 "payers": [
  "medicare",
  "medicaid",
  "commercial",
  "self_pay",
  "other_gov"
 ],
 "payer_labels": {
  "medicare": "Medicare",
  "medicaid": "Medicaid",
  "commercial": "Commercial",
  "self_pay": "Uninsured (self-pay)",
  "other_gov": "Other government"
 },
 "role_labels": {
  "physicians": "Employed physicians",
  "apps": "NPs / PAs",
  "rn": "Registered nurses",
  "clinical_support": "LPNs, aides, techs",
  "allied": "Pharmacy, lab, imaging, therapy",
  "revenue_cycle": "Billing, coding, payer admin",
  "management": "Executives and managers",
  "admin_other": "IT, HR, finance, quality",
  "support": "Environmental, food, facilities"
 },
 "line_labels": {
  "physicians": "Employed physicians",
  "apps": "NPs / PAs",
  "rn": "Registered nurses",
  "clinical_support": "LPNs, aides, techs",
  "allied": "Pharmacy, lab, imaging, therapy",
  "revenue_cycle": "Billing, coding, payer admin",
  "management": "Executives and managers",
  "admin_other": "IT, HR, finance, quality",
  "support": "Environmental, food, facilities",
  "drugs": "Drugs",
  "devices": "Devices and implants",
  "supplies": "Medical/surgical supplies",
  "purchased_services": "Purchased services",
  "bir_vendors": "Billing/insurance vendors",
  "liability_insurance": "Malpractice and insurance",
  "utilities_facilities": "Utilities and facilities",
  "depreciation": "Depreciation",
  "interest": "Interest",
  "marketing": "Marketing",
  "other": "Other expense",
  "contract": "Agency / contract labor"
 },
 "cost_report_mapping": {
  "medicare_pcr_pps": 0.84,
  "medicare_pcr_cah": 0.99,
  "ma_to_ffs": 0.8,
  "ma_to_ffs_cah": 0.4,
  "default_benefits_rate": 0.24,
  "default_medicaid_pcr": 0.8,
  "self_pay_pcr": 0.0,
  "min_opex": 5000000,
  "min_commercial_share": 0.03,
  "commercial_rel_range": [
   0.7,
   6.0
  ]
 }
}