Wednesday, September 09, 2009

Forget Public Option, Doctors Prefer Single Payer

Recent polls signal a significant dissatisfaction with the status quo among American physicians. Up to 81% of primary care providers would prefer a single payer system, not just a public option.

The Annals of Internal Medicine last year reported that 59% of physicians wanted a single payer to alleviate the paperwork and authorization hassles. As the American Prospect article points out:

The ever-accelerating corporatization of health care is producing a seismic shift in the way that doctors look at universal health care. Doctors are experiencing an extreme and relatively sudden loss of control at the hands of insurers and hospital networks, while being snowed under by paperwork and bureaucratic battles with insurance companies over authorizations and payments.

Another survey shows that 64% of physicians prefer a single payer. From that same survey of Minnesotan doctors:

Physicians also were asked who should be responsible for providing access to health care. Nearly all (86%) believed it is the responsibility of society through government to ensure access to good medical care for all, regardless of ability to pay. Only 41% held that the private insurance industry should continue to play a major role in medical care financing and delivery.

Perhaps this may seem counter-intuitive, but not to me. On a day to day basis, the hassle in medicine comes from the plethora of arbitrary requirements and authorizations from the various payers. One insurance company will require one treatment first, and another will use only one visiting nurse company, while yet a third will change their pharmacy formulary every quarter.

A few years ago I decided to leave my long term hospital employer to scale back my practice from a patient mill to something more consistent with humanity. I consulted with various people and colleagues about the process. Unbelievable. Over 20 different payers with 20-30 page contracts and complicated reimbursement schedules, different billing forms, separate credentially processes, etc. Just to get started would have taken 3 months and a staff of five people and legal counsel. And as a solo practitioner, I had no bargaining power with any of the payers.

Needless to say, forget that bullshit. I went to work for another hospital which had the clerical and support staff to do all this crap. Eventually it got bought out by my original employer and I'm right back where I started. No complaints, they are an excellent employer, but the point is that the market place is stacked against the small guy and the pressure to be employed by a corporation is overwhelming. This plays into the corporatization scheme and leads to frustrations among some physicians and patients who might prefer a smaller setting.

Again, this might seem counter-intuitive, but if we had single payer we might actually see a resurgence of smaller, patient-centered practices. The hassle of dealing with different payers would be eliminated and the doctors would not feel that they need a huge hospital or medical group to do all the billing and negotiating of payments. One set of standards, one set of paperwork, one set of reimbursement rates.

Physicians will make a good salary regardless, and that salary will be based on market economics of supply and demand. If you're in demand, you'll be busy and make a good living.... but you will never be able to charge more than insurance pays for basic services.

Another fundament of physician labor economics is that if you provide a service that is necessary, then someone will find the money to pay you for your services. Hospitals want Trauma designation for various reasons: it brings in motor vehicle accidents that are all insured patients and it gives the hospital some cache within the community (and there are probably other reasons that I don't know.) But to keep this designation, the hospital must pay for 24 hour orthopedic, radiology, anesthesia and surgery coverage... not cheap, but that's the market.

Bottom-line... physicians care little about who pays the bill, the amount paid will be determined by the market anyway and the more pressing issues surround patient care: access, formularies, authorizations and paperwork.

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