Obverse

My support for a single-payer system of health care has been made clear. On the other hand, as I've also said, strongly, I have no illusions about the potential for running good doctors out of the business, since, so far, the only major cuts in health care costs have come via lowering reimbursement to doctors and hospitals. The dangers of continuing that process are obvious, and are taking place already. To some extent, I'm an example, as I had to work harder and harder -- to the point of irreversible burnout -- to maintain income. Beyond the financial there was both a physical and psychological toll: at no point was there recognition of the superior care I was delivering -- it simply didn't matter. Each year, reimbursement declined irrespective of my results, my costs, my efforts. (Trust me on the "superior care" claim. Or if not, believe there are docs doing a better job than others, with nothing to show for it.)

It's another in a line of emails from The American College Of Surgeons, of which I'm a Fellow, that provokes this post. It refers to the 21.2% cut (.2? That's like the offer from the car salesman, down to the penny, as if it's the best they can do, based on extremely accurate calculation) in Medicare payments to doctors, beginning Monday. The Senate, as usual, failed to act after the House did, in fact, put the cut on hold. Said the letter, written by a guy I trained with,

"...Last night, the Senate failed to pass a series of extensions that included a temporary halt to the 21.2 percent cut in Medicare physician payments. As a result, the cut will go into effect on Monday, March 1st. Earlier yesterday, the House successfully passed the extensions package by voice vote that would have maintained the current conversion factor of $36.0666 through March 28th. However, with Congress currently adjourned, the Senate will have to again attempt to pass an extensions package sometime next week. The length of the temporary extension is unclear at this point, but we do expect it to provide only short-term relief from the 21.2 percent cut and be retroactive to March 1st..."

In my former clinic it came to the point that we were losing money on Medicare patients. At the moment the only Medicare plans they accept are "Medicare Advantage," a program about to be cut, it would appear. A program that now covers me.

There's an end-point. In my area there are several doctors who do not accept Medicare at all. They'll see those patients, but only on the condition that they accept direct (and full) billing, and fight on their own for Medicare payment. In New York City, as I understand it, there are docs who don't even accept private insurance for any patient, demanding the same "deal" as I just described.

Every time I've posted on physician reimbursement, especially on Surgeonsblog which people actually read in significant numbers, I got a predictable number of nasty comments saying doctors are overpaid and that they underperform (except to the extent that they are considered able, evidently, to engage in anatomically impossible sexual acts). But, as I've also argued, in many ways doctors are quite similar to actual humans. Altruism, unrewarded, is not a good business plan, especially when we're talking livelihood. Taking 21.2% out of payment that's already inadequate isn't tenable. (What's "adequate?" Well, how about, as a minimum, covering overhead?)

There was a time when many doctors made too much money for too little work. Some still do. But generally, it's no longer true; especially if you look at Medicare and Medicaid reimbursement. I'm fine -- and I always was -- with the idea that we need to sacrifice something to care for the less well-off. But I'm not fine with the idea that it's only health care providers who sacrifice, that the only thing politicians have the balls to do -- and the only thing voters have no problem with, sacrifice-wise -- is cutting payments. And yet, there we are. [Need it be said again?: this is in large part a direct legacy of Ronald Reagan's aptly named, by his later vice-president, "voodoo economics." For generations, with a brief departure in the 90's, we've been fed the idea that we can have whatever we want and not pay for it. That belief, despite the recent unsubtle evidence to the contrary, has a half-life longer than Pu-239. (At least the Russians moved Stalin out of Red Square eventually. Republicans keep digging up Ronnie and trying to reanimate him, completely ignoring his disastrous legacy of economic falsehood. But I digress.)]

So that's the downside of single-payer: limited ability of providers to influence a rational payment structure. But, really, it isn't much better with private insurers: they've cut payments by about two-thirds since I began practice, and providers have rarely been able to resist. At least, with single payer, there'd be comparatively more money left in the system, some of which might, conceivably, make it to providers.

And there's no reason why enabling legislation couldn't include a sensible means of establishing workable reimbursement. Other than the fact that it would have to happen here.

Meanwhile, even for a guy no longer in practice, it's easy to predict that if these cuts happen, there will be hell to pay. Oh well: at least someone will get paid.

Right In Toon

Pretty much says what I've been trying to say for a long time. Building a health care delivery system around private insurers just makes no sense; at least the insurers with whom I've dealt.

And yet the left is too weak-kneed and beholden, and the right is too hide-bound and dishonest to face facts.
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Single-sayer

I rise yet again to speak of health care reform. In part, it's because I've begun to hear from Obama tiny echoes of parts of what I've been saying; and, in part, because I still believe I'm right (and I'm not sure he does): the solution will require a single-payer system.*

Among physicians, I'm part of a small minority who share this view. So let's address the objections of doctors: dressed in one kind of finery or another, they really boil down to one thing. If there's a single payer, they worry, we'll lose all control. Well, the thing is, we already have. And in having dozens of insurers, it just makes the screwing more of a cluster-f*ck.

Here's my point: Medicare is the US version of a single-payer system, and overall it works pretty well. Its administrative costs are low, it handles millions of patients fairly efficiently. And, if it needs pointing out again, it's NOT the same as the Canadian or English system: single-payer does NOT imply a nationalized system, with only public hospitals and public employees. But here is my point: in the US we have, in addition to Medicare, countless private insurers; yet Medicare is still the ruling force. When it changes fee schedules, so do private insurers. When it establishes certain performance criteria, so do the others. As an interesting example, when the outpatient surgery center at which I worked was seeking certification that would allow it to receive payment from private insurers, it had to get Medicare certification first, even though it did not, nor intended to, have Medicare patients. No private insurer would accept it until it had Medicare approval. We already have, in other words, a single entity that calls the shots. Except it's worse than that, because there's all these other sub-entities with more rules and layers adding cost and hassle to the operation (while expropriating money out of it). Loss of control to a single payer? We're already there. So why not simplify the system?

I have no idea how many billions of health care dollars are sucked away from the bedside by the morass of private insurers, but it has to be a ton. A ton of billions (!?) From the salaries and bonuses of insurance executives, many/most of whom make WAY more than doctors, to the profits of investors (how does it make ANY sense that people can invest in health insurers and make money from it, pocketing patients' dollars that were spent with the understanding they'd be spend on their health care?), to the tens of thousands of workers in cubicles of hospitals and businesses and carriers all across the country, doing nothing but data-entry and/or permission-getting and receiving in the convolutions of countless plans and regulations; while money intended for the provision of care is going to anything but. In elimination of redundancies, in ending the siphoning off of profits to people who have nothing to do with providing health care, with a single set of rules a single-payer system will save billions.

Properly constituted, the control issue can be addressed, and it must be. As I've written elsewhere, my concept includes a sort of board of directors composed of "providers" (great bureaucratic word, that) as well as consumers. Ideally, there'd be meaningful regulations allowing effective input on reimbursement and rules, and avenues for reevaluation and recourse. But here's the thing: I'm feeling a little less sympathetic to docs and their money worries than I once was, and it's not just because I'm retired. They have it pretty damn good now, way more than I ever did, and the trends are that it'll get even better. I refer to lifestyle. Hours worked. Stresses. If I'd had it then like they have it now, I'd never have burned out. I'd still be working.

Okay, I realize it's not yet universal, and that many docs still work like I did, and that they're burning out in the same ways, flaming in sputters as they spin into despair. But the ground is shifting. As I've described, in more and more hospitals there are round-the-clock hospital teams caring for all inpatients and covering emergency room consultations. Working predictable hours, well-paid for their efforts, they have a damn fine lifestyle: no calls at home, an orderly and planned life. And for the office-based docs in those communities, it's the same. Since someone else is admitting their patients and making the hospital rounds, seeing all comers in the ER, their lives, too, are orderly and predictable. No more going to the emergency room in the middle of the night. No more hospital care at all. Pretty sweet. Practically bankers' hours. (Of course primary care docs, given their much greater numbers compared to specialists, never had to do that very often anyway, assuming they were in a call-sharing situation.)

My former surgical partners, in addition to making more money than I ever did, no longer have to worry about interrupting their office schedule with a run to the emergency room, nor to break out of their operating list to take stairs two at a time (I could do a whole set of stairs in one motion, leaning onto the rails way down and swinging to the bottom in what was, for a lummox like me, a pretty acrobatic move. I have long arms and legs) in a rush to the ER to find god-knows-what. Not even, if they so choose, to worry about an emergency take-back on one of their own operative cases. It ain't a bad life. Ain't a bad life at all. If a single-payer system would be in some ways onerous to them, well, it's not as if they're suffering that much any more, in the ways that matter.

I've heard it said that Barack Obama, politics aside, prefers a single-payer system but feels it's not politically doable. Don't know if that's the case or no, and it'd take a hell of an effort and lots of political capital, as they say. But the idea to which I referred at the beginning of this post, and to which I heard him allude recently, is the other reform requirement I've also advocated: the need to identify those docs who provide the best care, to figure out why it is, and to spread the word. Not as a way to reward them and not the others (although that, I think ought to be part of it), but simply as a way to find out what's working and what isn't and to educate those who need it. For that, I'd be happy to sign up. Because, naturally, what I did was coster effective and resulter producing than most of my colleagues. So I aver.
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*On cue, the House Republicans -- in addition to skewing the tax burden even further away from the wealthy than Bush did -- propose in their latest late budget to privatize Medicare! So they'd take the one deliverer of medical care that does so efficiently and lard it with private insurance, which, most clearly, would increase the costs!! It's as if they want to be seen as irrelevant and incapable.


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