The AURA Protocol: A Prospectus for a Decentralized Health Ecosystem<

The AURA Protocol: A Prospectus for a Decentralized Health Ecosystem

A Note on This Proposal

The framework below is a strategic thought experiment, designed to spark dialogue and inspire people to consider new approaches to solving broken systems. Please keep in mind I set aside the immediate constraints of our current regulatory frameworks and legacy systems. Any real-world implementation of this plan would, of course, require significant research, legislative evolution, and a commitment to build a more equitable and efficient future.

Executive Summary

Let's face it. Our American healthcare system is broken. It's complicated to understand, it's inefficient to operate, American's health is valued second to the profits of insurures and pharma, and it's eroding trust in the system. Utilization management (UM), particularly prior authorization (PA) administration, has become a primary source of friction. A 2021 report by McKinsey & Company, published in JAMA Viewpoint, estimates administrative expenses account for approximately a quarter of total U.S. healthcare spending. The prior authorization (PA) process alone accounted for an estimated $200 billion annually as of the publishing date.

AURA Protocol is a decentralized, physician-led clinical review network built on a transparent blockchain transforming today’s complicated and restrictive PA process into a collaborative, data-driven "care model." Above and beyonnd improving efficiency, and efficacy, it the surplus capital is deposited into the AURA Impact Fund to directly invest in proactive health initiatives, ultimately reducing the long-term cost of care for everyone in the eco-system.

The Problem

I could spend hours on the problem with the healthcare system, but for this paper I am focusing solely on the process of prior authorization. If you are not sure what that is, The PA process requires physicians and other healthcare providers to obtain advance approval from a health plan for a specific service or medication before it is provided to a patient. This is a mostly non-biased (I am proposing a significant change after all) view of the PA process, from its origin until now.

The Genesis of Prior Authorization

In the 60's, when Medicare and Medicaid was established (and as employers played an increasing role) these reviews were designed to evaluate the necessity, appropriateness, and efficiency of medical services. Initially, they focused on retrospective assessments of hospital stays to prevent over use and ensure payment. Basically, utilization reviews were a way for payers to ensure the healthcare services being provided were both medically justified and cost-effective.

How Prior Authorization Works

Prior authorization is a checkpoint. Before a patient receives certain medical treatments, procedures, or prescriptions, their healthcare provider must submit a request to the insurance company for approval. This request typically includes documentation of medical necessity, such as the patient's diagnosis, treatment history, and relevant clinical notes.

The insurer then reviews this information against its clinical guidelines and policies to determine if the requested service or medication is covered. The decision, which can be an approval, denial, or a request for more information, is then communicated back to the provider. If a request is denied, the provider and patient often have the right to an appeals process.

It's worth mentioning the PA process for prescriptions vs. medical care are slightly different.

Comparison: Pharmacy vs. Medical Prior Authorization

Feature Pharmacy Prior Authorization Medical Prior Authorization
Focus Primarily on specific medications. A broad range of services including surgeries, diagnostic imaging, and therapies.
Triggers High-cost or brand-name drugs with generic alternatives, specialty drugs, or medications with potential for misuse. Elective surgeries, advanced imaging (MRI, CT scans), durable medical equipment, and certain therapies.
Key Players Often managed by Pharmacy Benefit Managers (PBMs) on behalf of health plans. Handled directly by the health insurance company's medical management department.
Process Frequently initiated at the pharmacy when a prescription is filled and rejected by the insurer's automated system, prompting the pharmacy to notify the prescribing physician. Typically initiated by the ordering physician's office before the service is scheduled.
Criteria Formulary status (whether the drug is on the plan's preferred list), step therapy (requiring the trial of a less expensive drug first), and quantity limits. Medical necessity based on clinical practice guidelines, appropriateness of the care setting, and whether less invasive or less costly alternatives have been considered.

The administrative burden and potential for care delays associated with prior authorization have led to a significant push for legislative reform from various stakeholders.

Insurers maintain prior authorization is a necessary tool to control healthcare costs and ensure patient safety. They argue the process prevents unnecessary procedures and the use of high-cost drugs when equally effective, more affordable alternatives are available.

The pharmaceutical industry's stance is more nuanced. While they acknowledge prior authorization can be a barrier to accessing medications, their primary focus is often on the role of PBMs and insurers in steering patients towards certain drugs over others. Which is often based on rebates and formulary placement. PhRMA has expressed concerns prior authorization processes can be used to impede access to newer, innovative medicines. They generally support reforms to increase transparency and reduce administrative hurdles for both patients and providers to access prescribed medications.

Medical professional organizations are among the most vocal critics of prior authorization. They argue that the process is a significant administrative burden, diverting valuable time and resources from patient care. They also contend it can lead to dangerous delays in necessary treatment and negative patient outcomes. The AMA and other provider groups are strong advocates for legislative reforms to streamline the process, increase transparency of insurer criteria, and, in some cases, eliminate prior authorization for certain services altogether.

Patient advocacyy groups echo the concerns of providers, highlighting the detrimental impact of care delays and denials on patient health and well-being. They advocate for a more patient-centered approach with greater transparency, clearer and quicker appeals processes, and continuity of care when a patient's insurance plan changes.

A 2024 survey by the American Society for Radiation Oncology (ASTRO) noted, particularly for cancer patients, treatment delays as a result of the PA process can be life-threatening.

Key findings include:

  • Nearly a third of radiation oncologists reported that PA has caused emergency room visits, hospitalization, or permanent disability.
  • 7% said it has led to patient deaths.

In conclusion, prior authorization is a deeply entrenched component of our healthcare landscape that provides significantly more benefit to payer than it does the insured. Its implementation has created significant challenges for providers and patients. Hence, the reason for this paper about AURA.

The Solution: The AURA Protocol

The systemic friction driven by the PA process prevents the healthcare industry from focusing on its true mission: keeping people healthy. AURA replaces removes friction with a decentralized, transparent, and automated protocol.

At its core, AURA facilitates an anonymous, peer-to-peer clinical review for prior authorization cases. For example, When a patient requires a PA for an imaging claim their physician would submit their anonymized case for review, The AURA protocol would then dynamically determine the number of physician reviewers for the case (based on the total pool of available board certified specialists in the submiters feild ), and selects a statistically significant sample size, ensuring each decision is both rapid and clinically valid. Their consensus vote, recorded in a way that cannot be changed on the blockchain, represents the true standard of care. This process is faster, more objective, and restores trust and professional autonomy to the system.

The side benefit of this peer-to-peer process is two fold. One it ensures the reviewer is a practicing physician in the same field and role as the physician submiting notes. And two, by learning which PAs get frequent approval AURA can make recommendations for removing them from the PA requirement, reducing the admin burden and any friction experienced by the patient.

3. The Ecosystem: A Three-Sided Network

AURA is not just a technology; it's an ecosystem that creates a virtuous cycle for its three key partners.

  • For Health Insurers (The Partners): AURA drastically reduces administrative costs and member friction. More importantly, it would provide access to a Donnor-advised fund (DAF), which acts as a powerful R&D engine, providing grants to fund the innovative wellness programs, digital health tools, and proactive care initiatives. It allows insurance comapnies to pivot from a defensive risk-mitigation business to an offensive health-creation business.
  • For Physicians (The Experts): AURA participation is free, frictionless, and restores professional autonomy. For their expertise in performing reviews, they are fairly and instantly compensated with the network's native token. It allows doctors to be doctors, not administrators, and reduces their patient's "down-time" between claim and recommended procedure.
  • For Patients (The Members): AURA provides a secure, portable Personal Health Record (PHR) that eliminates repetitive paperwork. It provides a "Data Dividend," rewarding patients with tokens for contributing their anonymized data to research. And through the Wellness Marketplace, it offers free or discounted access to premium health services like Peloton and Sprited Food Health Coaching.

    • 4. The Economic Flywheel: A Self-Sustaining Model

    AURA is powered by a sophisticated economic model designed for sustainable operation and scalable impact.

    • Initial Capital: A finite number of Software Licenses are sold to investors ("Miners" or "Stakers"). This provides the non-dilutive seed capital to build the network.
    • The Work: Physicians perform clinical reviews. This creates a valuable, anonymized Data Asset.
    • The Reward (The 3-Way Split): For each review, the protocol automatically mints and distributes its native token, $AURA. The split is hard-coded:
      • 50% to the Physician who performed the review.
      • 30% to the Miner/Staker whose license was used.
      • 20% to the Aura Impact Fund.
      • Revenue Streams: AURA, the Decentralized Autonomous Organization (DAO), generates real-world revenue (USD) from three sources: the initial license sales, the sale of research access to the Data Asset, and partnership fees from the Wellness Marketplace.
      • Capital Allocation: This revenue is managed by a dual-treasury system. The Operating Treasury covers all business costs first. All surplus revenue (profit) then flows directly into the Aura Impact Fund, creating a perpetual engine for its mission.

      A note on "the business". No AURA employee, including the company exectutive team, will be paid more than $2 million in annual salary. There may be opportunities to own $AURA, but a ceiling will be defined to ensure the company mission of a proactive health network comes first.

      5. Advanced Applications & Future Vision

      A foundational platform for next-generation healthcare solutions.

      • A New Liability Framework: AURA solves the complex issue of fault, by way of "Non-Fault Consensus" (e.g., an 80%/20% vote), which establishes alignment on an industry standard of care. "Split Decisions" (e.g., a 60%-40% vote) may empower the patient with transparent information to make the final choice, relinquishing their right to sue for a poor outcome.
      • Public Health Surveillance: The real-time data stream can serve as an early warning system for pandemics, detecting anomalous clinical patterns weeks or months before traditional methods.
      • The Patient as a Partner: The integrated PHR and the "Data Dividend" model transform patients from passive subjects into active, empowered, and compensated owners of their health journey.

      6. Go-to-Market Strategy

      Our rollout is pragmatic and designed to build momentum.

      • Phase 1: Launch a pilot program in a single, favorable state, focusing exclusively on the high-cost, high-friction appeals process for a single insurance partner. Our "no-risk, shared savings" model eliminates the sales barrier.
      • Phase 2: Based on the pilot's success, expand to cover more types of reviews and onboard more insurer and physician partners.
      • Phase 3: Launch the patient-facing PHR and the Wellness Marketplace to drive mass adoption and activate the full, three-sided network effect.

      7. The Final Investment Thesis

      By building a public good utility which creates a virtuous cycle for every stakeholder in healthcare, is funded by a passive, decentralized investor class, and powered by an incentivized network of clinical experts, you achieve both sustainable operation and scalable social impact.

      • The Miners (Investors) get a simple, passive return for providing the initial capital, participating in a transparent and ethical ecosystem.
      • The Physicians (Experts) get a fair, transparent reward for their clinical expertise, restoring professional autonomy and eliminating administrative waste.
      • The Insurers (The Partners) transform their business. They dramatically reduce operational costs and member friction, and unlock new revenue streams in the wellness economy through access to innovation grants from the network's AURA Impact Fund.
      • The AURA Impact Fund (The Mission) is perpetually capitalized by the network's surplus revenue, ensuring that as the ecosystem becomes more profitable, its social impact mission scales directly alongside its success.

        This is an opportunity to invest in the foundational infrastructure for a more efficient, transparent, and healthier future.