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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
Are they completely standardized?
This was one of the many goals of HIPAA from Al Gore. And government mandated efficiency has worked out just about as well as you would expect it to. Most EMR’s can’t even communicate with themselves. You just can’t imagine…
LOL. I started on main frame computers in high school, an IBM 360 that was downtown at the main office. Coding fortran on IBM punch cards. Graduated to PC’s in college , first an Atari, then a Commodore Amiga, then a Mac, then windows PC, back to Macs. Took Basic coding in college. Was using the internet with one of the first web browsers on a dial up modem right at the birth of the WWW. Did a bunch with HTML. So I have a long history of using and being familiar with computers. One of the reasons I get so pissed off at the EMR. When it demands something stupid I know that it’s because the people writing the code either are lazy or just don’t care.
I believe it’s a combination of bad federal policy and lack of competition in the market (which is also due to bad policy). I’m writing up an entire piece on this as well.
I thought Obamacare was going to create uniform reporting standards for the uniform collection of medical records into a common system. It was the only aspect of the legislation I thought would be a boon.
The EMR companies got monopoly power and then fought the interoperability rules until they were adjusted for their rent-seeking needs: https://www.fiercehealthcare.com/tech/after-fierce-opposition-ehr-giant-epic-now-supports-onc-cms-interoperability-rules
First the government introduced or made mandatory for medicare EMRs. Then under 0bamacare they made all medical services mandatory to have EMRs. At the same time, medical records began to include asking a variety of of socially intrusive questions, including but not limited to Do you own a gun?, and Do you often fly? It seems to me that the government has not only taken over data collection and collation, but has taken over the purpose and thrust of data collection. What is more, health insurance companies can data mine this information for in-house purposes, but also I’m sure sell it to third parties (with patient anonymity insured, of course).
Oh I can. They were transitioning to one right when I had my daughter. What’s a real knee slapper is my husband and I both were more help to the nurses trying to get it to work than the consultants. We are both technical so…
There have been attempts to standardize:
https://en.wikipedia.org/wiki/Fast_Healthcare_Interoperability_Resources
the problem is that EMR is a big business and there are huge players that don’t want open standards. They want to lock you into their system. Its the old vendor lock in trick. Its gets so difficult to leave you have to pay any price (*cough* Salesforce, Oracle).
If you think you have it bad, do an image search for “Oscar Canada EMR” its one of the more popular EMR here. It looks like the guidance software from sputnik. (I used to work at a startup that was trying to modernize CND EMRs (we failed, Oscar won)).
If I remember correctly one of the big wigs at Cerner was a huge Hillary supporter.
Making the cost prohibitive for many small medical practices, forcing them out of business or causing them to be bought out by larger organizations, and resulting in less diversity and competition in medicine. Lots of the O care rules had a similar effect.
Back in the last century, I was assigned to a client whose medical billing software was pirated by another outfit. I looked at a printout of the code from the infringing software. The programmer had carefully renamed the variables and even rewrote one module in a different programming language but he left in all the notes and REM statements that referenced the original variable names. Kinda tough to explain when questioned in the deposition. Neither the original nor the pirated copy (which had some improvements) was a terribly powerful or flexible application. I thought at the time if this is the state of the art in that industry, doctors must not be very demanding consumers.
Yes, I think that’s when doctors went from being independent professionals to employees.
In my state, the state medical association’s main revenue source is typically FROM insurance companies-so they won’t fight them if at all possible.
The first casualties were the private health insurance companies.
Except “A new study reveals the US could save $600 billion in administrative costs by switching to a single-payer, Medicare For All system“
Yes, the federal government has proven over and over that it can do everything more efficiently than the private sector.
A lot of private insurers’ admin is to ensure they turn a profit. Universal single payer doesn’t have that objective. So it isn’t really apples to apples.
I’m glad you brought up that study. It’s extremely flawed but worth discussing. They assumed that if we moved to a Canada like single payor, the administrative burden would go away. Unfortunately that’s just not the case here in the US. Much of the administrative burden is actually a direct result of Medicare policy. I can tell you both from anecdote (I take almost exclusively Medicare/Medicaid) and from research. Many studies have shown the inefficiencies induced by Medicare, such as Value Based Purchasing, MIPS, CPOE and P4P have cost the system loads of money. Additionally, they harm patients, such as the readmission reduction program which increased mortality for CHF.
You’re correct that private insurers induce an administrative burden to cut costs. However, it’s mostly put on physicians because there is no competition. If insurers had to compete for patients and physicians, that burden would be placed elsewhere. While the insurers may be motivated to reduce costs, the government has numerous conflicting motivations. This includes mandates to reduce cost while improving outcomes, decreasing “wasteful” spending and keeping patients satisfied. This creates a milieu of contradictory metrics to which physicians and hospitals are beholden. All of which gets passed down to the physicians and nurses in the form of endless bureaucratic busywork.
one last anecdote: a Canadian doc was doing fellowship here. He was astounded by the administrative busywork put on American physicians. We were going through a list of tasks he had to get done. Aside from one phone call about a denied MRI, all his busywork was directly in place from Medicare regulations. That’s why I don’t trust Medicare to actually reduce administrative costs.
Sounds like just switching over without addressing some of those bureaucratic issues wouldn’t work well.
I am not familiar with the equivalent for Australian (also confusingly called) Medicare – but Australia spends about 9% of gdp on health care, and the far lower involvement of private insurance companies (because of single payer) is one of the reasons for that. I can’t find anything on how much it costs to administer Medicare here, but basically there’s no jiggery pokery about what you’re covered for, how much is covered by insurance based on your policy, how much you’re responsible for, etc. It’s all standard, but it’s also clearly less resource hungry to administer.
I could go on and on about this. People don’t have the slightest idea about how to think about it and still get everybody covered. They don’t understand insurance theory. They don’t understand how screwed up it became after World War II. They don’t understand why you don’t want the government owning the means of production or interfering with it too much. They don’t understand what reserving for the future means in a system like this. They don’t understand that the ACA is effectively forcing regressive taxation on most people.
It’s one hell of a political problem.
The GOP had eight years to get ready for the moment in two years to fix it and they completely blew it. Three senators in 100 congressman lied about wiping out the ACA.
Dr Craniotomy, Got to second the Good Doctor Bastiat. Really great post!
Fake John/Jill: “The Democrats have been very public about hunting down Trump supporters after Trump loses the election. ” Very Chilling but unfortunately very true. We all need to understand what we up against.
Crabtree: “Does the complete inability of Progressives to learn from their mistakes blow anyone else’s mind (besides mine)?” It’s a feature not a bug to the Progressives. All part of the plan to make the middle class dependent on the Police Welfare State.
“The EMR companies got monopoly power and then fought the interoperability rules until they were adjusted for their rent-seeking needs”
One of the aims of Nationalized Health Care is not greater effectiveness or efficiency but building a well endowed, well paid Health Care bureaucracy that will regularly kick back large sums of money to the Democratic Party in the form of payoffs for politically scratching their collective backs. If you look at the Educational establishment and the budding Homeless bureaucracy that is what has happened and those are their goals.
Kodak “Making the cost prohibitive for many small medical practices, forcing them out of business or causing them to be bought out by larger organizations, and resulting in less diversity and competition in medicine. Lots of the O care rules had a similar effect.”
Again part of the plan. The Dems and The RINO’s don’t want independent professionals or small business and will do everything to force them out of business. The goal is to drive them into the Corporatist/ Big Government structure so they can be more easily controlled.
Australia isn’t a true “single payor.” You said it yourself, they have the option of private insurance. Most countries with universal coverage are not single payor. Only Canada and Taiwan, of the developed nations, are actually true single payor systems, where no private insurance is allowed.
The jiggery pokery to which you refer is the result of Americans being unwilling to compromise. Access, cost and quality all have trade offs, yet we want to have them all. In order to control costs, someone has to put a limit on what is covered. There must be some downward pressure on spending or it will forever increase. In a simple system, it means putting hard limits on coverage, thus limiting access and quality. In America, it means a convoluted system of metrics, CPT codes and RVUs.
Yes, that’s true. Everybody is covered by Medicare, and then they can buy additional insurance on top of that (which works with a contribution from Medicare if it’s used). Universal coverage by Medicare discliplines private pricing.
To be honest I don’t think being overly ideological about these things (all private everything or all public everything) produces the best results.