What do nurses have to gain from single payer healthcare?

[Strider_91]

http://www.mercurynews.com/2017/06/01/california-senate-passes-single-payer-health-care-plan/


Basically the California nursing association lobbied hard to push his through. What do the nurses have to gain from single payer healthcare?

My gut tells me this is going to be used to have mid levels practicing independently, especially CRNA.

Am I paranoid?

Would single payer be bad for physicians? Seems to me like it may not be that bad. Apparently in Canada it is pretty easy to go out and hang your shingle thanks to no billing overhead.

[The White Coat Investor]

Wacky things happen in California politics. Some of those have contributed to its current toxic environment for physician finances.

But at any rate, I don't think single payor is terrible and it may just be the solution to our health care woes, once we've tried everything else. My med school classmate practicing FP in Canada (and making much more than most FPs here) swears by it. He turns in a bill and it gets paid that day. Crazy idea, I know.

It is interesting to think of the repercussions of legislating an entire industry out of existence.

[Strider_91]

do you think that a "Medicare for all" type plan similar to the Canadians can bring back the solo practitioner?

It seems to me it would be easier to go rogue and hang up your own shingle if you didn't have to worry about billing or collecting money. The overhead would be super low and you wouldn't have to spend a significant amount of time getting prior auths. Just learn the set of rules for Medicare and practice within those limits.

It has the added benefit of bringing down the insurance companies which I hate with a passion, but the thought of government run anything scares me. It's one of those things where there is probably no going back no matter how awful it is once it is implemented.

[Zaphod]

Strider_91 wrote:

do you think that a “Medicare for all” type plan similar to the Canadians can bring back the solo practitioner?

It seems to me it would be easier to go rogue and hang up your own shingle if you didn’t have to worry about billing or collecting money. The overhead would be super low and you wouldn’t have to spend a significant amount of time getting prior auths. Just learn the set of rules for Medicare and practice within those limits.

It has the added benefit of bringing down the insurance companies which I hate with a passion, but the thought of government run anything scares me. It’s one of those things where there is probably no going back no matter how awful it is once it is implemented.

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There are perfectly great government programs, a broad brush makes no sense. I'll take government infrastructure over a toll road any day. Lots of low to no immediate return of profit that just screams government. There are places for both.

I dont think single payer will do anything to hasten or decrease the adaption of NP/PAs taking over primary care. Actually any true market solution will increase it as its cheaper and more available to customers and overall satisfaction would increase. I think doctors are kidding themselves acting as if the quality/difficulty level for the majority of things warrants a physician. Its going to happen, no stopping it.

[shantster]

The White Coat Investor wrote:

My med school classmate practicing FP in Canada (and making much more than most FPs here) swears by it. He turns in a bill and it gets paid that day. Crazy idea, I know.

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Even crazier to think that I wouldn't have to look at what insurance company the patient has prior to making medical decisions. In my area, there's very little straight Medicare - it's all managed by a few different private companies.

[shantster]

Strider_91 wrote:

do you think that a “Medicare for all” type plan similar to the Canadians can bring back the solo practitioner?

It seems to me it would be easier to go rogue and hang up your own shingle if you didn’t have to worry about billing or collecting money. The overhead would be super low and you wouldn’t have to spend a significant amount of time getting prior auths. Just learn the set of rules for Medicare and practice within those limits.

It has the added benefit of bringing down the insurance companies which I hate with a passion, but the thought of government run anything scares me. It’s one of those things where there is probably no going back no matter how awful it is once it is implemented.

Click to expand...

You must live in an area where everyone has straight Medicare part A. In my area, probably 80-85% of patients have some managed Medicare product so you still have to learn the rules for each company and get prior auth. Straight Medicare is so nice in comparison.

[ENT Doc]

Strider_91 wrote:

http://www.mercurynews.com/2017/06/01/california-senate-passes-single-payer-health-care-plan/

Basically the California nursing association lobbied hard to push his through. What do the nurses have to gain from single payer healthcare?

My gut tells me this is going to be used to have mid levels practicing independently, especially CRNA.

Am I paranoid?

Would single payer be bad for physicians? Seems to me like it may not be that bad. Apparently in Canada it is pretty easy to go out and hang your shingle thanks to no billing overhead.

Click to expand...

Nurses are salaried.  They don't get paid for doing more work.  So naturally it's easier for them to accept a single payer system.  Add to this that they are left leaning and heavily unionized, so under a single payer system they pull more strings.

A single payer system isn't necessarily bad, as long as it wasn't run by our government.  A better system would be a self-insured ACO model (competition on value...novel concept), but the trouble is negotiating contracts with the private side.  Nothing our government does is on time, on budget, or as promised.  Name me one big government program that is in good fiscal health.  No doubt we can be better.  But there are deficiencies in every government run system, not the least of which is governmental creep.  Our federal government is 21% of GDP.  Most of those European countries are in the 40's and 50's.  Some don't just have paid parental leave available - they mandate it.  We accomplish great things because people have the capital and freedom to create, IMO.

Lastly, this bill is DOA.  It doesn't include any funding.  When the reality of no free lunch hits the legislature, and they realize they'll have to face their districts proposing 15% payroll tax hikes they'll crumble.  Some will use double counting, one-sided booking keeping, and all sorts of shenanigans to support their biased position.  But requiring 2/3 vote in both chambers?  Ha.  Do they realize the other states trying this (in far better fiscal health by the way) failed or couldn't even get it off the ground?  On an ethical level, I think it's nonsense to force every healthcare worker into government employment, most of whom against their will. I wouldn't wish that bureaucratic morass on my worst enemy.

[Hank]

I think single payor healthcare sounds wonderful!  I nominate Ed Sanders in Cheboygan to foot the bill for all our medical bills.  Sure, Ed's hosed, but the rest of us won't have to pay our bills since he'll be the single payor.  (Wait, it doesn't work that way?  In addition to paying for my own family's medical expenses, I'll have to pay for several other families who may not even be in the country legally to begin with?)

I can see a role for socialized medicine for sensible low hanging fruit like annual exams, vaccinations, and other preventative work that costs far less than letting severe chronic conditions develop.  Beyond that, I'm not sure how much more the federal government should pay for each and every person living in the U.S.

One other question with single payor or state-funded medicine is whether doctors will be allowed to opt out.  Will you be allowed to be a private practice physician or surgeon who doesn't take part in Medicare for All?  (The original version of Hillarycare in the 1990's wouldn't have allowed doctors to opt out.)  Will you be allowed to retire earlier than 65 or 70?  What if you get an inheritance, a winning lottery ticket, or a heck of a book deal?  Compelling participation in a state-run market if you want to work at all seems problematic.  Requiring doctors to work for the state until they reach some advanced age would seem to raise possible 13th amendment issues.

Anyway, I can see several medical expenses that probably should be funded by my tax dollars.  Hell, I don't want my neighbors to incubate the next superbug that will kill us all, so I could even see a role for compulsory vaccinations if you want to attend public schools or get a high school diploma recognized by the state.  I'm just not sure that a new system based on compulsory physician labor and a "limitless" amounts of other people's money is a great idea.

P.S.  There's a pretty good argument that patients in the United States play an outsized role in paying for the cost of developing new blockbuster medicines.  There may be a free rider problem where US patients help recoup most of the costs of new drugs and Canadian and European patients don't do much more than cover the marginal cost of drugs sold in their markets.  If the "soak the Americans" model of pharmaceutical sales comes to an end, will we see a decline in blockbuster drug development?  Will NIH grants fill the void and drug research becomes a public-private partnership with far less profit to the shareholders and c-level executives of Big Pharma?  Who knows. 

[Strider_91]

I live in a pretty wealthy area (with my parents) so this would make sense. I honestly didn't even know there was more than one Medicare. What a disaster.

[Strider_91]

Hank,
Medicare for all does not mean that physicians would be government employees. You can still work for yourself and then you just bill Medicare and obviously need to comply with their parameters or else you don't get paid. I don't see why one couldn't go cash only in this system. This is how it is in Canada and many Canadian physicians seem to like it and their incomes are comparable to American physicians except there seems to be less of an interspecialty gap between the highest and lowest paid specialty. There overhead is also significantly lower.

You then have the U.K. Model which has the physicians as government employees which is essentially a nightmare. The physicians are poorly paid and often over worked. They do get a solid pension deal tho after they are indentured servants for x amount of years. Apparently citizens are crying about physician pensions though. Also, there schooling is shorter and way cheaper to become a physician.

I can't ever see america going the full government employee route for physicians. I can see the Canadian model though.

[The White Coat Investor]

The problem with Medicare is simply that the pay is too low. Double or triple the payments and I could support Medicare for All just fine.

[ENT Doc]

Strider_91 wrote:

You can still work for yourself and then you just bill Medicare and obviously need to comply with their parameters or else you don’t get paid

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"You can still work for yourself and then you just bill Medicare and obviously need to comply with their parameters or else you don’t get paid."

I hope you see the inconsistency in this statement.

And yes, we absolutely subsidize the rest of the world with pharma.  Were their investment projections to not include cash flow from America, where there aren't price controls, how many risky projects do you think they'd undertake?  The rest of the world should be thanking us and sending us a big check every year.

[ENT Doc]

Canada's healthcare system - a shining star:

http://www.torontosun.com/2017/02/16/canada-has-worst-erreferral-wait-times-in-11-developed-countries-report

https://www.usnews.com/news/best-countries/articles/2016-08-03/canadians-increasingly-come-to-us-for-health-care

Also, don't be fooled by the fact that their population is healthy.  As much as we pride ourselves on our ability to help people attain health, from a population health perspective the most important thing, by far, that contributes to this is healthy behaviors.  The medical system only contributes about 25% to population health.  This reason, more than any other, is why America consistently ranks poorly among OECD countries.  It's sad that the government-run, single-payer supporter thinks that this system will somehow transform their hamburger-guzzling, non exercising neighbor into a marathon runner - and peddles OECD statistics to support their narrative.

[fasteddie911]

I'm not sure if nurses have much to gain or lose from single-payer, at least not directly since most nurses are employees of someone, so I don't know what their financial angle could be.  Maybe their support of single-payer is legitimately out of the concern for patients.  Whether there's single-payer or not, I don't think it makes a difference as to mid-level encroachment.  As for single-payer, it seems it can come in a variety of flavors (not sure what california is going for) but at the national level, if medicare in it's current form was extended to everyone it may be preferable over our current system if certain criteria were met, imo.  With medicare, it'll be one insurance, one set of rules, which will simplify things.  Prices are somewhat established and they are pretty good about paying up, at least compared to private insurance.  I think they would certainly need to increase reimbursement rates, ease up on requirements and simplify things to make things easier for providers, and put mechanisms in place to prevent them imposing their will on providers in the future.

[VagabondMD]

Ah, single payer. Am I for it? Sure. Am I against it? Yup.

People talk about single payer as it as a panacea for a dysfunctional healthcare system. It could be, but the devil is in the details. It could just as easily make things worse as make things better.