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Medicare For All: Much Rejoicing
There was much rejoicing.
The government seized all funding of health care and outlawed private insurance.
The first casualties were the independent practice physicians. They knew that the regulatory burden and billing complexity were far worse than any busywork imposed by the private insurers. Unable to meet the demands of the regulatory burden with Medicare reimbursement, they were forced to sell their practices to the local health system conglomerate. Independent practices had previously competed against each other, getting in the way of standardization and algorithm-based medicine. Their collapse caused much rejoicing.
The direct primary care (DPC) physicians tried to hold out with cash-pay patients. Because of the up-front, transparent pricing, the government determined DPCs were risk-taking entities, classifying them as insurance practices. Eliminated with them were the cash-pay surgical centers, also entities that assume risk in treating patients. As examples of the “free market” and “profiteering” in healthcare, their collapse caused much rejoicing.
Free from competing for independent physicians and surgical centers, the large hospital conglomerates grew into powerful, rent-seeking monopsonies. Economies of scale were the only way to navigate the Medicare regulations. These conglomerates thrived by extracting as much money as possible from the rates set by the Centers for Medicare Services (CMS). Patients whose conditions corresponded with high-value Medicare codes were cherished. Medicare also continued to reimburse for risk-adjusted quality metrics. Patients’ risk-factors were up-coded to increase payment modifiers, making the coders the most powerful entities in the hospital. Patients with risk factors that did not fit the risk-adjusting scheme were turned away. The quality metrics improved while patients were harmed. The improving metrics were widely touted by the press. There was much rejoicing.
Consulting firms boomed, helping hospitals game the system. The CMS models are so convoluted that only private consultants can decipher them. These firms thrived with the hospital conglomerates, raking in record profits, gaming the system, and working with lobbyists to write the rules to the game. The consulting firms, lobbying firms, and CMS would routinely interchange employees, driving up their value. The IPOs buoyed the stock market. There was much rejoicing.
Increasing coding and metric-gaming led to increased busywork for physicians. Medicare’s use of prior authorizations continued to grow as well, being necessary to control ever-rising costs. Physicians were held responsible for all of this and the burnout crisis worsened. The hospital conglomerates hired advanced practice providers (APPs; consisting of nurse practitioners and physician assistants) to offload some of the busywork. Once the legal restrictions on physician supervision of APP work were completely abolished, hospitals began cutting back their physician workforce. The APPs were much better at following orders, upcoding, and gaming metrics. Nurses were even allowed to perform surgery. Patients who were told they could keep their doctors were given a nurse practitioner instead. Money was saved and there was much rejoicing.
Patients that had costly conditions and comorbidities that could not be adequately captured by the Medicare codes had to be offloaded. These patients might negatively affect the bottom line. The large hospital conglomerates gamed the system to offload these patients to the local public hospitals. These hospitals, previously a haven for the un- or under-insured, were accustomed to dealing with these “difficult” patients. They were not accustomed to gaming the metrics. They operated at a loss, cutting services to the bare minimum and relied on taxpayer funds to stay afloat. Self-assured that healthcare financing was guaranteed by the government, the public no longer acknowledged the two-tiered system existed. There was much rejoicing.
The large academic hospitals were shielded from much of this. The resident workforce was used to do the documentation, coding, and metric gaming. The attrition rate in residency rose, but with many of the physician jobs filled by APPs the doctor shortage wasn’t acutely felt. Meanwhile, the physician advocates of single-payer at academic institutions beefed up their CVs by publishing on the improving metrics. Residents silently did their thankless work while the academic physicians grew their CVs. Eventually, the best and brightest college students began to turn away from medicine, towards other careers. There was much rejoicing.
The disgruntled physicians of the former DPC, cash-pay surgical centers, and independent practices also found other work. Consulting, law and politics were popular choices. However, many found that they could practice their ideal medicine just outside the reach of the US. The Cayman Islands, Bahamas, Mexico, and other nations were happy to let American trained doctors open cash-pay hospitals on their soil. These hospitals embraced free-market medicine with lower costs and superb outcomes. The wealthy American elite joined the Canadians and Brits in traveling abroad for medical care, boosting the local economies. They agreed that American doctors did provide the best medical care. They just did it on foreign soil. There was much rejoicing.
Every time a new president entered office, half of America was horrified that the person was a tyrant. Occasionally they were correct. Given that all healthcare was funded through the federal government, the new president had control over the entire entity via executive action. The new president, through the HHS secretary, manipulated the Medicare reimbursement to specifically harm target populations. The power that comes with central control of the largest industry in the nation is outstanding. Subtle changes in funding were used to influence life and death. Levers were pulled, cronies made money and enemies had healthcare funding choked off. The would-be tyrant realized that controlling healthcare meant controlling America. There was no more rejoicing.
Published in Healthcare
The last time the Dems wanted to takeover healthcare, the AMA and insurance companies wrote the legislation. Prices went up, taxes when up, and we got a mandate to buy private insurance. The AMA is undefeated, when it comes to lobbying.
The AMA loses to insurance companies and the hospital association. The AMA also doesn’t speak for most physicians any more. They wrote the ACA and betrayed physicians. The burnout rate among physicians is now sky high.
one other thing. The Democrats have been very public about hunting down Trump supporters after Trump loses the election. One method to eliminate their enemies is to centralize healthcare ad restrict it application to those on the Right.
Either side could do it if it were centralized. But just look at what’s happening to rural healthcare now to see the effect of the ACA and consolidation.
You forgot Costa Rica. Have relatives who are making plans there.
Interesting post, but insufficiently cynical.
The saddest people of all when this goes through are going to be our Canadian friends. They use the US as a safety valve for their Medicare for all system, while tut tuting about how bad ours is. When we go the same route they will be trapped. No more running to Buffalo for that MRI. No more flying the pregnant high risk patient to the US for a NICU. No more running to Seattle for a total hip.
I am so glad I am in the last year or two of my medical career. Over the decades it’s just gotten worse and worse.
Anecdote.
I was a medical student on my Surgery rotation at Evanston Hospital during Nov 1980. The morning after the election, I was in the surgical lounge waiting for our first case when all the surgeons and anesthesiologists came in. They were high fiving each other ” no socialized medicine in our lifetimes”. They were right, and it lasted just long enough for me to squeeze out a career.
I’m reminded of the Pharmacy Benefit Managers in the current system. They continually ‘save’ us gajillions of dollars yet somehow costs continue to rise.
You’re lucky. I’m only a few years into my career. The money is fine. It’s just the crap that goes with the everyday job. It’s having to make 47 clicks to order an MRI (not hyperbole, I counted). It’s being talked down to by nursing, administrators and coders for not checking the correct boxes in the chart. It’s the massive inefficiency making it so I can only get one or two cases a day done when I should realistically get four or five done. It’s spending 5 minutes with a patient in clinic and another 20 clicking and typing (and I’m good with computers!).
Sorry, just my morning rant.
And the Democrats want to do to our medical care what they did to the housing market. Community Reinvestment Act anyone?
Does the complete inability of Progressives to learn from their mistakes blow anyone else’s mind (besides mine)?
YES!!! It takes 5 minutes to draw up and give a vaccination, but 40 minutes to document it.
From the patient perspective …
Just had an outpatient procedure done. Both the nursing staff and the physicians spent much more time with the computer system than with me. It was disconcerting. Almost as if their job was to minister to the needs of the machines. I was just there to provide the machines with real-time data. This is not meant to be a critique of the professional staff. They did a fine job and were attentive during their brief interactions with me. But one of the first things I said to my lovely bride was when we got home was “Whoever designed the computer system has NEVER done the job of patient care.”
This is probably truer than you or I will admit.
Sorry I am unable to like comments #12 and #13 20,000 times each
This is just so true. I feel for you as a patient. My only options in clinic are to either try to get the computer work done while talking with you OR to do it in between patients, increasing wait times. I could just take it all home with me and be on the computer until 10pm but then the quality of documentation decreases substantially as the encounter isn’t fresh in my mind. Plus, orders need to be placed at the time of the visit so medications & labs can be ready.
This is well established. Multiple studies have examined how much time physicians spend on the computer rather than face-to-face with patients. The average consensus is that the computer to patient ratio is greater than 2:1. Personally, I think it’s more like 4:1.
The problem is making the case to the average voter. The left is much better at appealing to emotion and wins over lots of people with “guarantees” that no one will go without, or go into debt to pay for surgery.
It is difficult to counter that argument with a logical reasoned argument about adverse effects on innovation, rationing, and hidden costs. We on the right need to work on improving our storytelling.
I hear you. When aspiring medical students ask me my opinion I tell them, “do it if you really really love it, but pick something else otherwise.” I tell those in med school the happiest physicians I know are all in specialties that can avoid the hospital and insurance companies as much as possible. Plastic surgery, dermatology, ophthalmology, radiology etc. Anything where you can set up independent of a hospital, can run your own show, office or surgicenter, and can avoid having to deal with insurance.
My mom’s PCP, and specialists I’ve seen, are now using medical scribes (either an actual person in the room or the medical version of Alexa. In the latter case, some transcription services farm the work out to medically trained people in English speaking countries abroad; India and I think the Philippines are common. The practitioner still has to review and approve the notes.)
The money is fine for now.
FIFY.
The EMR’s are coding/billing platforms disguised as clinical systems. Their real purpose is to maximize billing. Pretty much every clinician hates them with a passion.
Now we know what we can do with those underutilized hospital ships. In the Prohibition era, there were casinos and night clubs on ships in international waters.
Exactly. When the Left brays their spiel about “You have the right to affordable (meaning free) health care”, all logic goes out the window.
As with a lot of other things, it’s tough to top free.
Absolutely outstanding post. Outstanding.
Most of these things are already happening.
I’ll try to respond more after work.
I don’t have time right now. I’ve got boxes to click. Which takes longer than it should, because these sick people keep interrupting me…
In case there was any question who’s in charge in the practice of medicine these days.
I hate the EMR and I’m good with computers. I’m young enough that I’ve never NOT had a computer in my life. My dad and I were custom building our home PC when I was in grade-school. I’m not good at coding, but I can actually do some of it. That’s why EMR frustrates me so much. It’s just such an awful product it would never survive in a competitive market.
Pirate Radio Caroline!!!!
In another life I had a consulting firm. We did back office and middle office stuff for banks, brokers … any large institutional investor. 30 years. I’m intimately familiar with how people interact with a poorly designed system. What I watched at the hospital was one of the worst things I’d seen in my career.
By the way, doc, that’s one heck of a first post. Brilliant. Great to have you here!
Thank you very much! Long time listener to the podcast. On my list of presents to buy myself with my new attending salary was a membership here. Glad I could contribute.
I recall reading that the NHS (UK) tried to threaten doctors who also did private care on the side that they would be kicked out of NHS unless they stopped doing that. It backfired as a number of top-flight MDs in various specialities said they would be happy to go all-private if that were the rule. Shortages (unreasonable wait times, for example) create markets.
It also irks me that monopsony buying by Canada and other socialized medicine countries is an abuse of trade law that effectively makes US buyers pay for all the sunk costs (and most of the profits) from new drugs. A refusal to sell at the price set by the government buyer triggers an exemption in international trade law governing patents such that a national government can allow another drug company to manufacture that drug for sale in that country with impunity–no intellectual property violation. So if the patent-holding drug company refuses to sell at the dictated price (usually only production costs plus a small profit but zero for sunk costs like research and testing) then a rival can tool up and invade that market before patent expires with inevitable leakage into other markets. Then they will crow about how they are more efficient and reasonable than the US and the American suckers paying higher drug prices.
I work for a medical device manufacturer, writing instruction manuals for the software that enables various bedside devices to talk to each other. Integrating it with EMR has been an exhausting exercise, with plenty of examples of “I can’t believe they’re doing it like this” along the way. We’ve had engineers quit in frustration, and there’s not a thing we can do about it, because the stuff we make has to conform to their absurd system.