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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