The Effects of the Single Payer Healthcare System on the Physician


The Republicans keep on threatening to repeal Obamacare but don’t really have an alternative and some of their suggestions, i.e. from Trump sound like what Bernie sanders wants, which is the Single Payer System. Bernie outright wants Medicare for all. We have looked at a single payer system and its effects on the patient, but what happens to the physician?

Joyce Frieden, the News Editor, MedPage Today , wrote that the idea of a single payer healthcare system has come back into prominence lately with the release of a single-payer healthcare/“Medicare for All”, proposal by Bernie Sanders (I-Vt.), a candidate for the Democratic presidential nomination. But what would it mean for doctors?

Proponents argue that a single-payer system — in which healthcare is financed entirely by the government through higher taxes on Americans — would have several advantages for providers. “If we look at what happened in Canada,” which went to a single-payer system in 1966, “Canadian doctors are doing quite well,” Steffie Woolhandler, MD, MPH, a co-founder of Physicians for a National Health Program, a lobbying group for single-payer, said in a phone interview. The why do we see more and more Canadian physicians trying to set up practices in the US?

“Their incomes on average are a little less than [doctors] in the U.S., but just a little less. They don’t have to pay their own healthcare costs, and the amount of time spent on [administrative tasks] is a fraction of what American doctors have to spend on administration.” And what about the long delays in treatment? What a caring system!

In addition, if the U.S. moved to single-payer, “doctors and hospitals will all be paid according to same payment rules — and I think this is a very important step because one of the problems we have now is multiple tiers of payment, and that creates incentives for doctors and hospitals to prefer one type of patient over another based on their insurance,” said Gerald Kominski, PhD, director of the Center for Health Policy Research at the University of California in Los Angeles, in a phone interview. “That’s been true for years and it has gotten worse over the last few decades.

“Now that we have the Affordable Care Act, it adds another tier. I don’t have good research evidence yet, but I can tell you anecdotally that ACA insurance is paying closer to Medicare [rates] or below, as opposed to rates more like private insurance.” Actually the ACA pays not like or slightly below Medicare, but more like Medicaid, which pays more like ten cents on the dollar.

The guaranteed payment would also relieve some worries, said Harold Pollack, PhD, Helen Ross Professor at the School of Social Service Administration at the University of Chicago, in a phone interview. “Most physicians want to know they’re getting paid and that patients can get the healthcare they need without suffering terrible financial consequences.” The physicians already have huge debt when they finish their training along with a enormous cost required for practice overhead. Think about their malpractice insurance as well as the costs for the new electric medical records required and the new quality measure, which I will review later in this post.

But it wouldn’t be all roses. “My colleagues and I think this is nothing more than a government monopoly and it would have economic consequences as any government monopoly would,” Robert Moffit, PhD, senior fellow at the Center for Health Policy Studies at the Heritage Foundation, a right-leaning think tank in Washington, said in a phone interview.

“Monopolies are bad because they are basically vast concentrations of economic power in very few hands,” he continued. “We are talking about the government controlling virtually everything because it will be the single provider of a particular set of services, and that means … every decision dealing with the system is not simply an economic decision or a medical decision, ultimately it’s a political decision.”

“You have to make political calculations, like how much you are going to spend, and when you get down to doctors and hospitals, what the reimbursement will be and will not be.”

In addition, a single-payer system probably would mostly use fee-for-service and might derail current efforts to pay for value rather than volume, according to A. Mark Fendrick, MD, director of the Center for Value-Based Insurance Design at the University of Michigan in Ann Arbor.

“There’s a very good reason for saying [patients] should have higher cost-sharing for a drug that treats toenail fungus versus one that treats cancer,” but the single-payer plan proposed by Sanders would make all covered services free of copayments or deductibles, “which is the farthest thing from value-based insurance design,” he said in a phone interview. “Single-payer says ‘You’re in or you’re out’ and that’s very problematic to me.”

Having just one entity making the rules about which services get paid for has its pluses and minuses, said Katharine London, MS, a principal at the Center for Health Law and Economics at the University of Massachusetts Medical School in Charlestown. “If there were one plan and everybody had one set of rules, the good part of that is that doctors could focus all their efforts on ensuring that those rules make sense; on the other hand, if there’s a rule they don’t like, that affects all patients and they can’t go around it.”

London was involved in developing a proposal for a single-payer plan for the state of Vermont — in the end, Vermont governor Peter Shumlin (D) ended up dropping the idea. “It was frustrating because we did come up with an option that was affordable,” she said in a phone interview. “But they had to bury it because of politics. The public financing is a heavy lift — the idea that you’re going to pay for your healthcare through your taxes.” So why hasn’t Bernie looked at history and modified his health care strategy?

The best way to get to single-payer — if the country decided that was what it wanted to do — would be a gradual approach, according to Pollack. That might mean, for example, having a “public option” that allows people to buy into the Medicare program voluntarily, and then eventually moving everyone into it. “People are saying that if you believe in single-payer, you should support the public option because it gets us from here to there and it’s cheaper than [private coverage] in a lot of ways,” he said.

The idea of a public option was floated when the ACA was passed, but it was eventually dropped from the bill because it was too controversial, Pollack noted. “Unfortunately, we ended up with these co-ops, which are a very weak substitute. I’d like to see us return to the public option idea because it has some real value.”

Like anything, when it comes to implementing a single-payer system, the devil will be in the details, London said. “It depends on the details of how it’s implemented; I don’t think how the plan is financed affects the practice of medicine necessarily. If you could change the system so doctors could practice medicine and spend time with their patients, I think that’s really what doctors want.” Well, maybe help pay the education and malpractice debt that we all have to manage.

Remember that this next election in the fall, in Colorado will feature the single-payer model proposed by the group ColoradoCareYes on the ballot. The vote may primarily come down to the issue of the massive tax hike a single-payer system would necessitate, and the potential that would have to dissuade businesses and young people from the state, detractors say.

The system would be funded by an employer payroll tax of almost 7%, an employee tax of 3% or more of gross pay, and a self-employed tax 10% of annual net income, which would raise about $25 billion. The plan’s likely to be a hard sell in Colorado, where voters haven’t approved a statewide tax increase for more than 20 years on anything besides marijuana or tobacco.

Opponents also argue the measure would give too much power and taxing authority to the plan’s governing board without sufficient oversight to ensure transparency.

Part of that transparency involves Quality Measures, which is part of the ACA. We will now look at the cost of the Quality Measures to the physicians and their practices.

Physician practices in the U.S. spend more than $15.4 billion annually on reporting quality measures, according to survey results analyzed in the March issue of Health Affairs.

Shannon Firth wrote that the average physician spends roughly 2.6 hours each week on quality measures, the equivalent of about 9 patient visits, said Lawrence Casalino, MD, of Weill Cornell Medical College in New York City and lead author of the study. If you don’t believe those numbers come by my office at 7:30 PM and you will see the lights in the office still on as I finish up all the paper and computer work necessary to care for my patients.

Whole practices spent an average of 15.1 hours per physician per week managing quality measures and $40,069 per physician per year on tasks, such as entering data or creating systems to collect data. Extrapolated to the entire population, this translates to $15.4 billion across general internists, family physicians, cardiologists, and orthopedists each year.

Primary care practices appeared to bear the biggest burden from the quality reporting requirements. They spent an average of 3.9 hours per week focused on quality measures, while cardiologists spent 1.7 hours and orthopedists about 1.1 hours per week, Casalino and colleagues found.

Among five components of the reporting process, Casalino said the first — data entry — was reported to be the most time-consuming for practices.

The researchers worked with the Medical Group Management Association (MGMA) in Denver, using its database to send surveys to 1,000 randomly chosen practices. In all 394 practices responded, for an adjusted response rate of 54.3% after accounting for problems in reaching practices by email or phone.

The survey, which was intended to be answered by a leader at each practice, asked about the amount of time physicians and support staff spent reporting and examining quality data, as well as leaders’ views about the usefulness of tracking and sharing such measures.

The researcher established “per physician, per week estimates” of how much time was spent in the following activity categories: Entering information, reviewing quality reports from sources outside the practice, tracking quality metrics, developing processes for data collections and executing them, collecting and transmitting data.

Regarding the usefulness of these activities, only 27% said that current measures are “moderately or very representative” of the quality of care patients receive. And just 28% said they used quality scores as the basis for quality improvement activities.

One problem is that the required metrics vary depending on whom they’re being reported to. A previous study cited in the Health Affairs paper found that 23 insurers were using a total of 546 measures, “few of which matched across insurers.”

The study authors noted that “practices having stronger negative feelings about quality measures may have been more likely to respond to the survey” which could lead to overestimates of time spent managing quality measures.

They also noted that responses stem from only one source in each practice, which is another limitation. To compensate for this problem, researchers “trimmed outlier values.”

Casalino noted a stream of “passionate comments” in the free response portion of the survey, most of which were complaints about the inconsistency in standards and the cost of new add-on components to already flawed electronic health record (EHR) systems.

“It wouldn’t be too strong to say we’re sacrificing a generation of physicians and staff to the problems with EHRs,” he said, targeting such systems as “the main source of physician dissatisfaction.”

Casalino also said that dealing with these systems and metrics has been one more factor contributing to the surge of physicians selling their practices to hospitals and other large entities.

But there is hope: a commitment to a common set of standards announced in February by the Core Quality Measures Collaborative, which includes the Centers for Medicare & Medicaid Services, America’s Health Insurance Plans, and the National Quality Forum.

Casalino called the announcement “a very encouraging step” that is long overdue. Additionally, 81 percent of practices reported their effort in reporting on quality measures is increasing compared to three years ago, and 46 percent called it a significant burden to deal with similar, but different, quality measures. For instance, the study authors noted the Medicare Shared Savings Program metric for poor diabetes control is a hemoglobin A1c at or below 8 percent, while the Healthcare Effectiveness Data and Information Set puts the level at or below 9 percent.

Even though physician practices are putting a lot of time and effort into reporting on quality metrics, most of them aren’t using the information to improve quality. The survey found that just 28 percent of surveyed practices used the quality scores to focus quality improvement activities, and just 27 percent said current measures were moderately or strongly representative of the quality of care.

“There is much to gain from quality measurement, but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures,” the authors wrote. They noted that rapid improvements to the system will be difficult to make, but urged focus on the area. “Our data suggest that U.S. healthcare leaders should make these efforts a priority.”

Halee Fischer-Wright, MD, president and CEO of MGMA, said in a statement, “This study proves that the current top-down approach has failed. It serves no purpose to have over 3,000 competing measures of quality across government and private initiatives. Although standardization is critical, if measures don’t improve patient care, it’s an exercise in futility. As the largest contributor to the problem, the federal government needs to get out of the business of dictating patient care through wasteful mandates and create simplified systems to support medical practices in improving quality across the country.”

However, with a single payer/Medicare for All health care system or the progressive ACA you can be assured that the government will control and direct all. This is a surer bet than picking the Final Four in the NCAA tournament.


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