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April
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Government-Funded
Care Multiple
Insurers, Multiple Plans A recently approved Under the THE
DOCTOR'S OFFICE
The solution that would really put health-care dollars, and
providers, to their best use would be a single-payer system -- namely,
government-funded health coverage for all. It took me a while to conclude that a single-payer health
system was the best approach. My fear had been that government would screw up
medicine to the detriment of my patients and my practice. If done poorly, the
result might be worse than what I'm dealing with now. But increasingly I've come to believe that if done right,
health care in America could be dramatically better with true single-payer
coverage; not just another layer -- a part D on top of a part B on top of a
part A, but a simplified, single payer that would cover all Americans,
including those who could afford the best right now. Representatives and
senators in Doctors in private practice fear a loss of autonomy with a
single-payer system. After being in the private practice of family medicine
for 8 1/2 years, I see that autonomy is largely an illusion. Through Medicare
and Medicaid, the government is already writing its own rules for 45% of the
patients I see. The rest are privately insured under 301 different insurance
products (my staff and I counted). The companies set the fees and the
contracts are largely non-negotiable by individual doctors. The amount of time, staff costs and IT overhead associated
with keeping track of all those plans eats up most of the money we make above
Medicare rates. As it is now, I see patients and wait between 30 and 90 days
to get paid. My practice requires two full-time staff members for billing. My
two secretaries spend about half their time collecting insurance information.
Plus, there's $9,000 in computer expenses yearly to handle the insurance
information and billing follow up. I suspect I could go from four people in
the paper chase to one with a single-payer system. It would be simpler and better for the patient, and for me, if
the patient could choose a doctor, bring their ID card with them, swipe it in
a card reader at the time of service and have the doctor get paid on the spot
with electronic funds transfer. Instead, patients have to negotiate a maze of deductibles,
provider networks, out-of-network costs, exclusions, policy riders, ER
surcharges, etc. Wouldn't a card swipe be simpler? No preexisting conditions
to worry about. No indecipherable hospital bills. One formulary to deal with
and one set of administrative rules to learn instead of 300. With a single-payer system, there are concerns about waiting
times for procedures and not getting access to the "best doctors."
These are real issues, but not unsolvable ones. We have these disparities
now. Fact is, they are mostly a matter of geography,
insurance status and personal wealth. A single-payer system would increase access to care for the
uninsured and the underinsured, including the working poor. It would lower
total health costs, in part by replacing 50 different state Medicaid programs
and umpteen insurers with one system. This approach has the potential to
improve quality and lower costs by improving care for chronic illnesses such
as diabetes, high blood pressure and heart disease. Such a system of care would rely on evidenced-based
interventions, that is, providing the right care at the right time to the
right patients, according to generally accepted best practices, and it would
reduce the disparities in access to and quality of care among ethnic groups.
Better tracking of chronic diseases, outbreaks and identification of
bioterrorism would also be benefits. There are powerful forces that oppose a single-payer system --
the health insurance industry for one. The insurance industry got its share
of the Medicare drug benefit pie, as did the pharma
industry. It would have been better and simpler for the government to design
one plan with a standard drug fee schedule that everyone could understand, as
the government does with care that doctors provide to Medicare patients. But
that's not the way it happened. Doctors have been supportive of the idea of universal access
to care, but not necessarily a single-payer system. Some fear delays in
obtaining necessary testing and surgeries. What I suspect they fear most is a
loss of income and the fear of the unknown. A single-payer system would admittedly lower fees for
subspecialty care, such as radiology and cardiology. But if more doctors went
into family medicine or obstetrics and fewer into subspecialties like plastic
surgery, that shift might help correct the physician manpower imbalances that
exist now. That wouldn't necessarily break my heart. I suspect doctors would be more likely to support a
single-payer system if national malpractice reform was part of the package --
which it should be. I used to think a single-payer system would keep my income
down and inject bureaucracy into my medical decision-making. But with the
efficiency it could bring, it would at worst be an economic wash; more
likely, the trimmed costs would more than make up for any foregone revenue.
As for autonomy, I'm already struggling to maintain it amid the interference
of insurers. On the whole, the efficiency -- and equality -- that a
single-payer system would provide would more than compensate for its
shortcomings. Write to Dr. Benjamin Brewer at thedoctorsoffice@wsj.com4
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![[The Doctor's Office]](WSJGovernment-Funded-Care_files/image008.gif){kind=small}
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