Op-Ed - Is it time to open our minds to a single payer system?

Introduction

The healthcare debate in this country is heating up again, and as physicians, we are often asked for our opinion. While many of us have common interests, goals and standards, we also have differing political, social and economic views. The following is a brief overview of how I would envision a better payment model.

The Issue

To begin, the debate is not really about health CARE, but rather about how to pay for medical care. It is really about health insurance. Our current system is a mix of various payers, including individuals, employers and the government, both federal and state. The mix of both private and public payers adds tremendous complexity to the everyday delivery of care. In addition, the commercial medical insurance industry has a fiduciary obligation to their shareholders, not the policy holders, to maximize profit. The United States is one of the few remaining developed countries on the planet that does not ensure that all of its citizens have access to medical services. We are behind the curve. Yet, despite this, there is generalized agreement that the actual medical care that we deliver to our nation, is near the top of the world. Our physicians, nurses, paramedical professionals and medical technologists, across the spectrum, are highly educated and well trained. The problem is access, both economic and social.

For millions of Americans, the lack of medical insurance limits their ability to get both preventative care and acute care when they fall ill.  As a result, too often is the case where emergency interventions are required at a much greater cost. This further results in absent follow up and ongoing medical management which is often crucial to a more comfortable and healthy life. Many have studied the impact on social deterioration that evolves from chronic untreated disease conditions, not the least of which include substance abuse, psychological disorders, financial hardship, family disruption, crime and the decline of the most vulnerable members of our society. For others, access to the healthcare system is often beyond reach. Living in rural communities, lack of transportation, inability to continue ongoing treatments or even the absence of basic information on how to use the available resources are all contributing factors in our cultural makeup that block access. As a result, cost-shifting occurs, and everyone is a bit worse off.

So then why, if we all can see the many problems, can we not solve the “pay for” issue? To address this, let’s first understand those things that most of us can agree on, as well as, those things where we diverge. As a group, physicians have had a difficult time, historically, agreeing on many things. Let’s be honest, we all think we know better! But, we also mostly agree on several things – like getting paid for what we do. While nothing is absolute (in this paper), I will make some assumptions regarding what we can consider common ground, and those areas of disagreement. This is not meant to be all inclusive, nor will it be 100% applicable to all of us, but for the most part, I will try to keep politics out of the mix, and stick to a common-sense approach.

Agree

• Maintain physician reimbursement. We all deserve to get paid for our work. In fact, if you’ve ever spoken with friends who are in business or other professionals (like lawyers or accountants), they are always amazed that doctors settle for such poor remuneration. In a single payer system, many fear a government price fixing scheme that would hurt us all financially. I think we all agree that this would be a non-starter. We must have input into our income.
• Maintain hospital reimbursement. If the system is to work effectively, then we need facilities that can provide the services necessary to help us do our jobs. In essence, if hospitals constantly cut staff hours, fail to upgrade equipment and infrastructure, and generally try to race to the bottom (line), then no one wins. I am personally of the opinion that, like fire stations that provide emergency services to communities without seeking to make a profit, hospitals should have a similar role. But whether you support public or private medical centers, they should be adequately funded and not have to worry about the bottom line every quarter.
• Minimize paperwork. I would guess that in today’s world, there are very few offices that don’t have dedicated staff to deal with insurance claims, authorizations and payment problems. Wouldn’t it be nice if we could spend more time and money on the actual delivery of care, than the shuffling of paper (or electronic bits of data)?
• Maintain physician autonomy and patient decision making. One of the criticisms of the ACA was the fear of “death panels” that would deny services to certain people, often based on age criteria and the re-allocation of resources. We would probably all agree that patient care decisions need to be in the hands of providers, not the government. Many still believe that if a single payer system comes about, this type of rationing would be required. Simply not true, if we can all agree on standards of care. This could easily be achieved with broad parameters coupled with physician oversight.
• Lower drug costs. Does anyone disagree with this? Why should a billionaire Swiss drug company CEO own a 300ft super yacht (costing well over $200 million dollars to build and tens of millions of dollars a year to maintain) when millions of people can’t get basic care? Why must so many people have their meds sent in from Canada so they can save 60%? Why do insurance companies tell patients what drugs are not allowed, even when their physician recommends it?This needs to be fixed.
• Ensure the delivery of QUALITY care. Most of us dislike government regulations and data reporting, but if we had a simpler system and guidelines to help us, I think that we would all be in favor of consistent, quality medical care throughout the country. It is incumbent upon us, both individually and collectively, to ensure that we provide the highest level of care that our citizens deserve.
• Ensure QUALITY training of new physicians. The past 25 years has seen many changes in how we train our future physicians. However, improvements can be realized if we reinforce top quality training programs and close down those that are unable to meet acceptable standards. One of the biggest hurdles is payment for residents, and the number of program positions available. If we could reasonably fund the needed spots, we would likely get high quality residents who will be better prepared to succeed us.
• Continue to have scientific and technological progress. Certainly, we can all see that research and development has advanced the state of medical care dramatically in our lifetimes. This must continue, and I don’t know any physician who would oppose this.
• Preventative care saves lives and dollars. We can debate specific programs, like PSA testing or at what age a screening mammogram should be done, but most all of us would agree that there are some fundamental tenants that, if applied universally, would improve the health of the nation. Nutritional counseling, personal hygiene education, substance use and abuse (tobacco and alcohol) monitoring, prenatal care, diabetes and blood pressure testing, and the like, should be available to everyone. A healthier culture would result in a happier and more prosperous society. And money saved by preventing or treating conditions before they progress to a more complicated stage, can be used for some of the above expenses.
• Universal coverage. I simply cannot see any argument that access to medical care should be unavailable to anyone in the 21^st century. Put the ‘pay for’ on the back burner for a moment and ask yourself, “Should anyone not be given access to health care?”

Disagree

• Government funding. As alluded to above, we may not all trust the government having financial control over our livelihood. We have seen that Medicare (CMS) determines our reimbursement and we have only the choice to participate of opt out. For many of us, it comes down to a financial decision often based on our practice demographics. I would postulate, however, that in a well-designed single payer system, we negotiate our fees. More on this later.
• Increased taxes. Lots of disagreement here. Some see any increase in taxes as a non-starter, while others are willing to pay more for the good of the many. Nothing is for free, and if we want to get the benefits (outlined above in the agree section), we have a price to pay. But what if that price was spread out such that many of those who are already paying will pay less, but those who have not contributed, start to put in their share?
• Individual mandate. Another hot topic. This is tied into the above tax issue. The “mandate” may be in the form of a tax. But instead of paying for your own individual coverage, we spread out the burden. This becomes a philosophical discussion, and certainly there is disagreement, which is why it needs to be on the table for debate.
• Growth of government entitlement programs. Small government vs big government.Old debate. That said, I again postulate, “What if it is designed to both save money and preserve the integrity of the medical system we all want?” Perhaps we, as physicians, can open our minds to viewing health care like national defense. We all pay into the system to keep all of us safe and healthy. This is not a program for the few or the needy – it is for everyone in our society to use and benefit from.
• Best practice protocols. When I was a resident, this was referred to as “cookie cutter medicine”.Welcome to the age of information. The current and future generations of young doctors understand that data is a part of everything we do. Anecdotal tales of occasional success stories should not replace factual evidence. That said, there is certainly an “art” to the practice of medicine. It is this “art” that may eventually separate the good from the great providers, but it still remains that data driven patient care is consistently more reliable. All other major industries know this, and as the business of medicine continues to erode the roles of individual practices, conformation to standard best practice protocols should be the measuring stick we use to determine which providers stay or go. (Just as we would all agree that a consistently bad airline pilot should not be in the cockpit on our next flight, a universal healthcare system cannot accept poor quality doctors.) All this being said, some will resist the feeling of being told how to practice and we need to be sensitive to this.
• Should the VA system stay or go? Although I was never in the armed services, I certainly understand that there is this group of men and women in uniform who seek others like them and feel more comfortable in the VA environment. I also understand that the system allows for the very large department of veterans affairs to have more control over our retired troops. But when we look at the costs, the duplication of services, the inefficiencies in the veterans healthcare system, it really begs the question of why does it still exist? I feel very strongly that those men and women who put their lives on the line to protect our freedom deserve 100% of our support. What I don’t understand is why nearly every VA hospital is in close proximity to other medical centers, yet are entirely separate, and why our veterans can’t easily access private sector services.
• The use of midlevel providers and physician extenders. While many see this as a threat or an affront to our professional competence, others welcome physician assistants and nurse practitioners into their practices. In fact, many medical futurists believe that midlevel providers, in conjunction with artificial intelligence systems (think IBM’s WATSON), will be the backbone of primary care delivery in the near future. What is clear is that for basic routine medical work, this is a less expensive approach in the use of personnel, and cost containment will continue to drive this forward.

Show Me the Money

Recently, it was noted that annual Medicare spending was approximately $696 billion and Medicaid was $533 billion. With the current Republican healthcare replacement bill in the news, we know that this represents approximately 20% of the government’s annual spending. We also know that the US Treasury takes in approximately $3.2 trillion per year in taxes, and that there are approximately 250 million adults in the US, with an average annual median household income of around $52,000.

From our paychecks, 1.6% is taken for Medicare. Some think of this as a Ponzi scheme. Younger working people pay in so that older (sicker?) people can get care. As we pay this forward, many people have predicted the demise of the system, even though the baby boom generation will be eclipsed by the millennials in sheer numbers by 10%. So theoretically, as they enter the workforce, their tax contributions should cover more than just the next 20 years. In addition, employers also contribute to Medicare with taxes on our behalf. And for the very wealthy, those earning over $200,000 per year, there is an additional 0.9% tax that was part of the original Affordable Care Act.

As for the price of health insurance, it has been estimated to cost, on average, between 10-20% of a family’s gross income. So for the average family earning the $52k noted above, 10% equates to $5,200 per year for their health insurance policy, in addition to the 1.6% Medicare tax, or an additional $832.

How about if we eliminate the Medicare tax and if no one pays for any private health insurance? For the above median income family, that would save them $6,032 per year. Instead, let’s hypothetically say that they need to pay 4% of their income and would get all of their medical coverage with a universal single payer program. That’s an annual cost of $2,080, or a net savings of $3,952! In addition, let’s estimate that business would be required to pick up 6% of employees’ salaries to makeup the deficit; but, that too, would be offset by the elimination of the business Medicare tax. High income earners would likely pay more, as illustrated in an example of an individual earning $500,000 and having a single private insurance policy for $900 per month (a family plan may be much higher). Instead of $10,800 per year, that person would be paying 4%, or $20,000.

The above examples are just that, hypothetical examples. But, I would argue that these numbers are not far off from reality. What makes this work is everyone participates and reaps the benefits. Additional savings are easily met with the elimination of for-profit insurance companies that drain billions from the system, elimination of staff employees who deal just with these companies, a healthier population requiring less emergency care, and other areas where costs are decreased or eliminated.

On the flip side, it is my opinion that physician fees should be tied to the cost of living or inflation. Let’s pick a year and say that this is the baseline. Then, each year the reimbursement will rise with the cost of living number, maybe 2% per year. I’m sure we’d all agree that this is better than a 2% cut per year! You can still get paid on a fee for service basis or through a group/employment model, but there is the security in knowing that you earn what you generate. Likewise, you will need to follow agreed upon guidelines for high quality and cost effective care. For example, not every patient who walks in with knee pain needs to go straight to the MRI center, nor does every patient with a stomachache need a GI consult. If you are compliant with guidelines, then medical legal jeopardy should be minimized. Tort reform, to include a review panel of specialists with specific term limits, should also be included. Pre-agreed upon issues of medical necessity would be developed, and like the current system, cosmetic procedures would not be covered. It would be up to the individual patient and physician to determine appropriate care on a case by case basis, but guidelines would be available. For example, advanced age would not prevent someone from going onto hemodialysis; however, if the person is determined to be irreversibly non-responsive or in some type of pre-vegetative state, dialysis may not be advised.

Conclusion

While it is certainly beyond the scope of this short paper to re-write the healthcare system in the country, it is my goal to get us thinking of reasonable and appropriate changes that we can all agree on.

If we, as physicians, are not participating in the discussion, do not take a seat at the table, and do not take the time to open our minds to alternative ideas, then the future of our profession will be in the hands of others. I’m sure that there are hundreds of sub-topics that readers have thought of while reading this, and, again, this short paper is not about writing a new law. Hopefully though, it will prompt you to get involved.

Think about how you would optimize the system.  What would you do if you were in charge?

Richard D. Kimmel, D.O., FCCP, FACOS

Past President, American College of Osteopathic Surgeons

[email protected]

The views and opinions expressed in this article are those of the author(s) and do not imply endorsement or represent a position of the American College of Osteopathic Surgeons

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