Revolutionizing America's healthcare payments

Single payer. Medicare for all. Public option. These are all terms bandied about by presidential candidates and healthcare experts, but what do they really mean?

At face value, they sound good for patients, who would no longer have to worry about paying for the care they need. Increased use of primary care services could help lower overall healthcare costs as chronic patients get regular checkups and patients no longer delay care due to cost concerns.

For these and other reasons, the American College of Physicians (ACP) released its own guidance endorsing many of the concepts of a single-payer system-one where private health insurance would be replaced by the government-or a system where people could opt-in to Medicare, effectively making it a competitor for private insurance, which would then be heavily regulated.

Much has been discussed about the benefits for patients, but what would a single-payer system mean for doctors? How would it affect their reimbursements, their administrative burden, and their level of burnout? Experts say dissecting the specifics can be challenging, because the definition of each concept varies depending on who’s talking, even if they use the same terminology. But if enacted the broad changes would be significant, including some that may surprise many physicians.

Billing and reimbursement changes

One of the advantages of a single-payer system for physicians in private practice would be simplified billing.

“Each payer often uses its own standards for submitting a claim, and all have different payment policies,” says Anders Gilberg, MGA, senior vice president of government affairs for the Medical Group Management Association. This billing complexity often requires the use of a clearinghouse to adjudicate all the various policies, something that would not be needed if there were only one payer with one set of rules to follow.

“The administrative burden would be lower compared to having all these different systems, but how that plays out depends on what the final plan would look like,” says Jodi Liu, Ph.D., a healthcare policy researcher for the Rand Corp. “All payments would be processed through one fee schedule. There is quite a lot of administrative staff needed to deal with billing and processing, who may no longer be needed. For practices seeing patients with private insurance now, they are likely to see decreased payments, so some of this may be offset by savings in administration.”

The possibility of lower reimbursements through either reduced government payments or the loss of typically higher-paying commercial insurers is something physicians need to consider, says Gary Price, MD, president of The Physicians Foundation. “I suspect that because of the program’s huge costs, doctors will be under more pressure to see more patients in less time,” Price says, adding that he doubts any administrative cost savings will be enough to make up for falling reimbursements. “You may still need someone to deal with glitches, even if it’s all Medicare billing.”

Robert McLean, MD, FACP, president of the ACP, says that switching to a single payer system would also require a rethinking of the current Medicare rates to make it work. “People should not be afraid that we are going to switch over and everyone just gets stuck with the current Medicare rates and told to suck it up,” says McClean. Physicians should have input on what rates should be, and with the reduction of administration across the entire system-plus the elimination of insurance company expenses-there should be more money to pay physicians.
“Patients are paying more, but the insurance companies are making a lot of money off the all the backs of patients, who have higher copays and deductibles,” says McLean. “Any system needs to be fair and reasonable and avoid all the cost shifting.”

In the current system, doctors in private practice can opt out of Medicare and, depending on their financial situation, can also choose not to do business with any commercial payers that are overly burdensome. “What remains to be seen is whether doctors would have the opportunity to opt out of a single-payer system and would they have any free-market negotiating power,” says Gilberg. “There is speculation that if physicians were allowed to opt out, you would create a dual system where the people with money would have better access to specialists, sub-specialists and certain experts in various fields, while the others would be covered by the single-payer system. This brings up questions about access to care and timeliness.”

A single-payer system with government-controlled reimbursement rates may also affect how doctors are trained and how that training is financed. “If you go to medical school today, you’re likely to come out with excess of $200,000 in debt,” says Gilberg. “If we went to a single payer system and reduced the salaries of physicians, we would also have to reform the entire way physicians are trained in this country and subsidize that. If they’re trained in the system, are they required to stay in the system?”

Price says the effect of a single-payer system on specialty choice by medical students is also unknown, and those specialties requiring a longer commitment will need to collect increased reimbursement somehow. But McLean says the reimbursement for primary care also needs to increase, because there is already a shortage of primary care physicians, and more will be needed to help people stay out of the hospital and provide more cost-effective care. “Does that necessarily mean that the specialist needs to get paid less? The answer is no,” says McLean. With insurance companies taking 20 to 30 percent of every healthcare dollar, he says there is plenty of money that can be allotted to decreasing costs for patients and appropriately paying doctors.

Patient care and quality measures

How doctors care for patients may also be changed under a single-payer system, experts say. “Would they still be able to determine what care they can provide the same way they do now?” says Liu. “The two proposals in Congress now provide comprehensive care for the services that you would expect, but there would need to be some way to figure out what care patients could receive. As new therapies and treatments come out, how would they be covered, as there are a lot of cost implications to the system.”

Also unknown is what would happen to prior authorizations. A single-payer system would result in one set of patient treatment guidelines, which might reduce doctors’ administrative burden, but authorizations from Medicare may still be required for some non-standard treatments or drugs, experts say.

Gilberg says that for any system to be effective, more money would have to be invested in preventive care, but the system would also likely include quality metrics to measure doctor effectiveness, whether through something similar to the current MIPS program or something new.
“Most physicians’ gut feelings are that quality measures would get exponentially worse in a single-payer system,” says Price. “The burden is unnecessary regulations and silly quality measures at the patient-care level, and it adds to burnout. This is a huge problem area already, and I think single-payer would make it worse.”

The ACP plan calls for a revamped system of quality measures developed with more input from physicians. “Yes, quality metrics need to be there, but we need to be helping to drive that because they are tremendously tricky,” says McLean.

But the ACP also recommends a system with a much more comprehensive way to address how social determinants are affecting a patient’s overall health. “Whether it’s people getting food or shelter or whatever it is, we need to recognize that these play a significant role in our population’s health, which has a significant role in our individual patient’s health,” says McLean. For example, a system that addresses the source of bad air in public housing is a lot cheaper than paying for repeated emergency department visits by asthmatic patients, he says. This also benefits doctors. “I’m not being overwhelmed with people with ED visit follow-ups and can now spend more time on the complex medical illnesses that aren’t necessarily environmentally related,” says McLean.

Feasibility

Moving the country from its current way of paying for healthcare to a single-payer system would be complicated and could create some additional risks to patients. “You would have to be really careful, because moving people slowly to a single-payer system, that would remove some of the financial viability of the insurance market,” says Gilberg. Some companies might go out of business or drastically narrow their networks, he adds. “There is the potential for all kinds of unintended consequences.”

Liu says that any transition is likely to take up to two years, and politicians would have to carefully craft plans to cover any gaps for patients who lose their commercial insurance because of disruptions to the insurance market.

The changes that came about from the Affordable Care Act offer some insight into the types of challenges the government may face in any switch, ranging from buggy websites to a skeptical public. “I would hope the government planners would be wise enough to implement it in a way that those things wouldn’t happen, but I would be shocked if there weren’t a lot of headaches,” says Price. “Personally, I think the speed it’s implemented will be determined by the legislators’ willingness to finance it. The financing piece is really the limiting factor.”

With the current split control of the U.S. Senate and House of Representatives, the likelihood remains low that any major change will take place, and even if the Democrats could gain control of the Senate, any changes they make could be undone by the next change of power.

“If it’s not done in a bipartisan manner, then invariably you are going to have some political change over time,” says Gilberg, who points out that after Republicans took power after the passage of the Affordable Care Act, they have slowly eroded it. Other than the Medicaid expansion, a large part of it has been mitigated. “I’m somewhat suspect of our ability as a country to do something this dramatic.”

McLean says any change won’t be easy, but the time is ripe. “I think when questions about their insurance are asked the right way, patients realize how unhappy they are with their coverage,” says McLean. “Statistics show that about 25 to 30 percent of all bankruptcies are due to healthcare bills. Everyone is one catastrophic illness away from a potential bankruptcy.”

The ACA provided some reassurance that pre-existing conditions could not be used to exclude patients from the insurance market, but he says there weren’t enough cost controls to make the insurance affordable.

“I think people were enticed by the promise of a better healthcare system with the ACA, and having that partially take place, then be subsequently stripped away has a lot of people really angry and frustrated,” says McLean. “I think the level of dissatisfaction among the people of this country is higher than people might realize. But that needs to be reflected up to the legislators for things to be done, and that’s a tough one.”