As the Left marches towards single payer, how would universal Medicare affect EM compensation?

[Money Moniker]

My instinct is to believe Single Payer would decimate physician income in the United States, but I saw an attending in another thread mention that CMGs support a shift towards this model as it would supposedly lead to more, not less, money being channeled through emergency rooms. I suppose out of all the specialties EM would take the smallest hit from such a transformation, since so many of your patients currently don't pay a dime. On the other hand, not many total joint replacements etc are being done gratis as it stands, so fields like Ortho have all downside and no upside from single payer.

I guess the answer here depends on the following: will the financial gain from turning current no-pays and Medicaid patients into Medicare patients outweigh the financial hit from turning the privately insured into Medicare patients? Obviously this would be greatly site dependent, as sites which have a terrible payer mix today would likely benefit, while EDs near tony suburbs would take a huge hit, but I'm curious what you guys think would be the overall impact on EM compensation under universal Medicare, given that as attendings you have actually seen revenue flows by patient type out there in the real world.

(Obviously doctors would be screwed regardless, because even if your salary only goes down by 10-20% under single payer, what's left would face massively increased taxation to fund the socialized system. Doctors are in the worst position possible here: have enough money to be worth fleecing but not enough to buy yourself out of it like the rich).

In another sign of the increased prominence of single-payer among Democrats, many lawmakers seen as top contenders for the party’s presidential nomination in 2020, including Sens. Kamala Harris (D-Calif.), Cory Booker (D-N.J.), and Elizabeth Warren (D-Mass.), are backing Sanders’s latest Medicare for all bill...

...“I don’t think there’s any question that a lot of Democrats think this is very safe ground now,” said Rep. John Yarmuth (D-Ky.), who signed onto a Medicare for all bill in the House, along with 120 other Democrats, which is a majority of the conference...

...“I think it’s pretty clear that this where we are going as a party,” Jim Manley, a former staffer for Sens. Ted Kennedy (D-Mass.) and Harry Reid (D-Nev.), said of single-payer.

thehillcom/policy/healthcare/375376-democrats-march-toward-single-payer-health-care

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[GeneralVeers]

I'm against almost everything the CMGs support. What is good for them financially, is not necessarily good for the physicians. They are looking at cost-savings on the billing/collections side of things, while probably charging the physicians the same amount per patient for "services".

 

[Angry Birds]

I believe in universal Medicare. But even I have to admit: it will likely lead to a huge hit to our salaries.

There is very little to wonder about this. Every other industrialized Western country in the world has some form of universal healthcare, and none of the ER doctors in those countries get paid well, especially in comparison to us.

 

[GeneralVeers]

I believe in universal Medicare. But even I have to admit: it will likely lead to a huge hit to our salaries.

There is very little to wonder about this. Every other industrialized Western country in the world has some form of universal healthcare, and none of the ER doctors in those countries get paid well, especially in comparison to us.

Interesting hypothetical for you: Would you be willing to take a 50% pay cut in order to have a more "moral" society that provides free healthcare to everyone?

 

[NYEMMED]

I believe in universal Medicare. But even I have to admit: it will likely lead to a huge hit to our salaries.

There is very little to wonder about this. Every other industrialized Western country in the world has some form of universal healthcare, and none of the ER doctors in those countries get paid well, especially in comparison to us.

Many of these countries have free medical school, a state pension, and some sort of state run malpractice claims organization (not the court system)

With that in mind a pay cut may not be bad, but it needs to come with the above to match other countries

 

[Birdstrike]

My instinct is to believe Single Payer would decimate physician income in the United States, but I saw an attending in another thread mention that CMGs support a shift towards this model as it would supposedly lead to more, not less, money being channeled through emergency rooms. I suppose out of all the specialties EM would take the smallest hit from such a transformation, since so many of your patients currently don't pay a dime. On the other hand, not many total joint replacements etc are being done gratis as it stands, so fields like Ortho have all downside and no upside from single payer.

I guess the answer here depends on the following: will the financial gain from turning current no-pays and Medicaid patients into Medicare patients outweigh the financial hit from turning the privately insured into Medicare patients? Obviously this would be greatly site dependent, as sites which have a terrible payer mix today would likely benefit, while EDs near tony suburbs would take a huge hit, but I'm curious what you guys think would be the overall impact on EM compensation under universal Medicare, given that as attendings you have actually seen revenue flows by patient type out there in the real world.

(Obviously doctors would be screwed regardless, because even if your salary only goes down by 10-20% under single payer, what's left would face massively increased taxation to fund the socialized system. Doctors are in the worst position possible here: have enough money to be worth fleecing but not enough to buy yourself out of it like the rich).



thehillcom/policy/healthcare/375376-democrats-march-toward-single-payer-health-care

I'm not sure the Left is marching towards anything, right now. They don't run Congress, the White House, or Supreme Court. If fact, they don't run much of anything on the national level. Although there's no doubt the political Left would like to march towards single payer and would certainly resume it if they regain power, you can rest easy in that their march, has been halted, at least for the moment.

So don't assume the march towards single payer is necessarily inevitable. Also, don't assume "doctors will be screwed" as things move forward. We're a smart and crafty group, and we'll find a way to be successful and thrive, no matter what changes are thrown at us.

 

[gamerEMdoc]

Boy would a single payer system make the job easier though. Imagine losing all financial incentive to work hard. Imagine if you had no incentive AND full tort protection like government docs do now? You may make less, but those 0.5 patient per hour shifts with 100 patients in the waiting room while you nap sure would be more restful.

 

[s109442]

I'm not sure the Left is marching towards anything, right now. They don't run Congress, the White House, or Supreme Court. If fact, they don't run much of anything on the national level. Although there's no doubt the political Left would like to march towards single payer and would certainly resume it if they regain power, you can rest easy in that their march, has been halted, at least for the moment.

So don't assume the march towards single payer is necessarily inevitable. Also, don't assume "doctors will be screwed" as things move forward. We're a smart and crafty group, and we'll find a way to be successful and thrive, no matter what changes are thrown at us.

I agree and I just got a nice little raise last week, salaries are still increasing in the rural Midwest, as they should lol.

 

[Birdstrike]

Boy would a single payer system make the job easier though. Imagine losing all financial incentive to work hard. Imagine if you had no incentive AND full tort protection like government docs do now? You may make less, but those 0.5 patient per hour shifts with 100 patients in the waiting room while you nap sure would be more restful.

How so?

Financial incentives wouldn't change, with single payer. Your employer wouldn't change, you still wouldn't work for the government or have any reason to expect additional tort reform. It would simply mean all your patients have a single insurance company, Medicare, instead of a smorgasbord of different ones, private and public. No more Blue Cross, United Health Care, Cigna or the others. Only, Medicare, for better or for worse. But that's it. None of the other things you mentioned would change. There's absolutely nothing about single payer, that would eliminate metrics, CMGs, fee for service, administrators, patient satisfactions surveys, billboards that promise a 15-minute-or-less wait time, or things like that. In fact, much of the metrics are/have been pushed (MIPS, MACRA, meaningful use, 'performance based' pay) by Medicare, which would be an empowered monopoly, as the only payer.

Single payer might make life simpler for your and my groups' billers, I suppose, since they'd only having to deal with one insurance company and one set of rules. And it might make life a little easier for outpatient MD's office staff, I suppose, since there would be less games to play fighting 10 different insurance companies for pre-approvals for outpatient testing, treatment and brand name medications. I suppose you could argue whether or not you would personally want yourself and your family to be on Medicare, with no private market options, if care was rationed to save enough money for everyone to be covered, or if being on Medicare is better or worse for you. But I honestly don't see how it would make EM docs jobs any different, good or bad.

Perhaps you were talking about true socialized medicine, where there is not only 1 single payer (the Federal government) but all private medical employers, hospitals, insurance companies and such, are outlawed, and everything is owned, run, operated by, and all doctors work for, the Federal government?

 

[GeneralVeers]

Birdstrike nailed it above. Our jobs won't be any easier, and our pay certainly won't go out. The only ones positioned to take advantage are the CMGs who will see their costs go down. They certainly won't take any financial hit, as they will pass off any reimbursement decrease to the docs.

 

[Dr Mantis Toboggan]

Taxes will greatly increase as well. Cannot have Western European social services without their level of taxation (not to mention a far less healthy population who will utilize services at a much greater rate).

Birdstrike nailed it above. Our jobs won't be any easier, and our pay certainly won't go out. The only ones positioned to take advantage are the CMGs who will see their costs go down. They certainly won't take any financial hit, as they will pass off any reimbursement decrease to the docs.

 

[TheComebacKid]

So don't assume the march towards single payer is necessarily inevitable. Also, don't assume "doctors will be screwed" as things move forward. We're a smart and crafty group, and we'll find a way to be successful and thrive, no matter what changes are thrown at us.

Not to be confrontational, but I wholeheartedly disagree.

Physicians are the most spineless pushovers there are in medicine. We are literally one of the most important links in the chain i.e. the healthcare system does not function without us. Yet we allow hospital administrators (who perform ZERO patient care) to dictate what happens in the ED. We allow mid level providers to completely take over medicine. We allow the unregulated growth of EM residency positions without any thought as to how this will affect the long term viability of our specialty. We allow insurance companies like Anthem to deny payment for ED visits that were in hindsight deemed unnecessary. The list goes on and on.

I think we as physicians erroneously perceive ourselves as the physicians of the 60s that were at the top of the hospital, highly respected by the community. That unfortunately is no longer the case. I can't even enter a patient's room in the ICU today without "making sure it's okay" with the nurse first. It's a complete and utter joke.

If and when we move to a single payer system, I'm willing to bet physicians will do little to nothing to stop it.

#thoughtsfromaPGY2inthemiddleofwinter

 

[USCDiver]

Taxes might go up but costs for fringe benefits and the 8% fee to billing companies would go away, so maybe a wash.

 

[gamerEMdoc]

How so?

Financial incentives wouldn't change, with single payer. Your employer wouldn't change, you still wouldn't work for the government or have any reason to expect additional tort reform. It would simply mean all your patients have a single insurance company, Medicare, instead of a smorgasbord of different ones, private and public. No more Blue Cross, United Health Care, Cigna or the others. Only, Medicare, for better or for worse. But that's it. None of the other things you mentioned would change. There's absolutely nothing about single payer, that would eliminate metrics, CMGs, fee for service, administrators, patient satisfactions surveys, billboards that promise a 15-minute-or-less wait time, or things like that. In fact, much of the metrics are/have been pushed (MIPS, MACRA, meaningful use, 'performance based' pay) by Medicare, which would be an empowered monopoly, as the only payer.

Single payer might make life simpler for your and my groups' billers, I suppose, since they'd only having to deal with one insurance company and one set of rules. And it might make life a little easier for outpatient MD's office staff, I suppose, since there would be less games to play fighting 10 different insurance companies for pre-approvals for outpatient testing, treatment and brand name medications. I suppose you could argue whether or not you would personally want yourself and your family to be on Medicare, with no private market options, if care was rationed to save enough money for everyone to be covered, or if being on Medicare is better or worse for you. But I honestly don't see how it would make EM docs jobs any different, good or bad.

Perhaps you were talking about true socialized medicine, where there is not only 1 single payer (the Federal government) but all private medical employers, hospitals, insurance companies and such, are outlawed, and everything is owned, run, operated by, and all doctors work for, the Federal government?

Yeah I was refering to a socialized universal healthcare more than single payer.

 

[gamerEMdoc]

Not to be confrontational, but I wholeheartedly disagree.

Physicians are the most spineless pushovers there are in medicine. We are literally one of the most important links in the chain i.e. the healthcare system does not function without us. Yet we allow hospital administrators (who perform ZERO patient care) to dictate what happens in the ED. We allow mid level providers to completely take over medicine. We allow the unregulated growth of EM residency positions without any thought as to how this will affect the long term viability of our specialty. We allow insurance companies like Anthem to deny payment for ED visits that were in hindsight deemed unnecessary. The list goes on and on.

I think we as physicians erroneously perceive ourselves as the physicians of the 60s that were at the top of the hospital, highly respected by the community. That unfortunately is no longer the case. I can't even enter a patient's room in the ICU today without "making sure it's okay" with the nurse first. It's a complete and utter joke.

If and when we move to a single payer system, I'm willing to bet physicians will do little to nothing to stop it.

#thoughtsfromaPGY2inthemiddleofwinter

Sooooooo painfully true.

 

[Angry Birds]

Interesting hypothetical for you: Would you be willing to take a 50% pay cut in order to have a more "moral" society that provides free healthcare to everyone?

First, I really wouldn't use the term "free healthcare," since most of us would be paying for it through our taxes.

With regard to your hypothetical question, it's a good one. I do not deny that there can be a conflict between personal interest and moral sense, and that this conflict can sometimes manifest itself as hypocrisy.

However, I would say that it would be unfair to us to just suddenly switch to the European model, without accounting for our huge student debts, low residency salaries, etc. As NYEMMED mentioned, "Many of these [European] countries have free medical school [and undergraduate education], a state pension, and some sort of state run malpractice claims organization (not the court system)."

Right now, in our American system, we are saddled by huge debts and low residency salaries, and then a very delayed payoff at the end of all that. Meanwhile, in most European countries, this is not the case: you go to school for free, and make a more decent wage and have better hours during your training. To combine the worst of both systems--i.e. the high debt and low residency salaries of the U.S. system with the lower attending salaries of the European system--would be pretty crappy for us, even if it would be a boon for the society overall. In this scenario, we would be the sacrificial lambs, while the new crop of medical students go through the European-style system.

In other words, for your scenario to be truly an apples to apples comparison, you'd have to have free medical school and a better residency salary, etc. In that case, many people would still choose to go into medicine, as is the case (obviously) in European countries. As for me specifically, would I still go into medicine? Probably not. But, I wouldn't have gone into medicine again if I could go back in time, as I've mentioned numerous times before on this forum. I find the study of medicine to be boring (whereas the practice of medicine is a bit less boring), and it would probably make even less sense for me to study it if the salary was lower. However, I am currently transiting to a humanities field in which the salary *is* lower, so money is not the end-all be-all for me.

 

[Birdstrike]

Not to be confrontational, but I wholeheartedly disagree.

Physicians are the most spineless pushovers there are in medicine. We are literally one of the most important links in the chain i.e. the healthcare system does not function without us. Yet we allow hospital administrators (who perform ZERO patient care) to dictate what happens in the ED. We allow mid level providers to completely take over medicine. We allow the unregulated growth of EM residency positions without any thought as to how this will affect the long term viability of our specialty. We allow insurance companies like Anthem to deny payment for ED visits that were in hindsight deemed unnecessary. The list goes on and on.

I think we as physicians erroneously perceive ourselves as the physicians of the 60s that were at the top of the hospital, highly respected by the community. That unfortunately is no longer the case. I can't even enter a patient's room in the ICU today without "making sure it's okay" with the nurse first. It's a complete and utter joke.

If and when we move to a single payer system, I'm willing to bet physicians will do little to nothing to stop it.

#thoughtsfromaPGY2inthemiddleofwinter

Forget single payer for a minute. Are you really willing to commit to sitting back and letting someone destroy your success and keep you from thriving because of systemic changes you can't control?

I'm not.

Perhaps you and I have different definitions of "successful" and "thriving" but I'm not going to sit back and let my career success be destroyed by someone else. I'll change and influence what I can, and I'm going to adapt to what I can't. If the system goes throw changes that are unfavorable, I'll make an adaptation. And I'll stay committed to thriving, someway, somehow, regardless of the changes around me. Granted, it took me half a lifetime to get to this point, but that's my current view on all this.

Optimism, combined with a confidence and an insistence to make Medicine work for me, as opposed to allowing it to feed off of me. It took more brains & determination than 99.9% of the population for you to get where you’re at. Use that to make Medicine work, for you, not the other way around.

 

[el_duderino]

Interesting hypothetical for you: Would you be willing to take a 50% pay cut in order to have a more "moral" society that provides free healthcare to everyone?

I have to, otherwise I'm not being intellectually honest. That's super, super hard to say. That's a big change in my potential lifestyle.

Hopefully, this plan would offer some kind of relief for outstanding medical school loans, but that's probably a pipe dream.

 

[TheComebacKid]

Forget single payer for a minute. Are you really willing to commit to sitting back and letting someone destroy your success and keep you from thriving because of systemic changes you can't control?

I'm not.

Perhaps you and I have different definitions of "successful" and "thriving" but I'm not going to sit back and let my career success be destroyed by someone else. I'll change and influence what I can, and I'm going to adapt to what I can't. If the system goes throw changes that are unfavorable, I'll make an adaptation. And I'll stay committed to thriving, someway, somehow, regardless of the changes around me. Granted, it took me half a lifetime to get to this point, but that's my current view on all this.

Optimism, combined with a confidence and an insistence to make Medicine work for me, as opposed to allowing it to feed off of me.

I applaud your optimism and determination, I really do. And quite frankly, I'm glad there are people like you in our specialty with some experience under their belt who can help lead us going forward.

However, your term "adaptation" to me is synonymous with " agreeing to check more clicky boxes and do more documentation" so I can have a job in a location where I want to work and manage to pay off my 300K in student debt. At the end of the day, we are the mercy of the hospital and political overlords. Should we stand up fight? Of course we should. I'm not saying we should allow ourselves to be taken advantage of. But when it comes to providing better quality care for our patients, and a better career and quality of life for ourselves, I would argue that we haven't "adapted" over the years, but instead, we have succumbed to the demands of those above us. Because, to be blunt, cash is king and our jobs have been transformed to work for a cash making business.

I know I am painting a very bleak and apocalyptic picture of things, and agreed, there are some things that we do well as physicians. But overall, more physicians commit suicide now than ever before. We invest more dollars into patient care without any really significant improvement in mortality. We are now more expendable than ever before because of mid levels taking over. Despite your optimism, after speaking with many veterans in the field, it feels like medicine already has been destroyed by others.

 

[Money Moniker]

I didn't mean to stir a hornet's nest of theoreticals with this thread. Imposing universal medicare would clearly cause an avalanche of unpredictable changes to virtually every facet of society, not just EM compensation, but my question was much more limited in scope. It boils down to the following math equation:

ax+by+cz=$

where (a) is the "average" reimbursement of "self pay" and medicaid patients, (b) is average reimbursement of medicare patients, and c is average reimbursement of privately insured patients, while x,y, and z are the number of patients in each category that roll through the ED per year. Multiply it out and you get $, the total annual revenue generated by the ED.

So, ax+by+cz=$ represents the revenue today. My question, for those of you who have seen the numbers in your own EDs, is how much would the revenue shrink if the equation above was replaced by b(x+y+z)=$ in a situation where all your self pay, medicaid, and private insurance patients were replaced by medicare patients?

 

[gamerEMdoc]

Yeah, I wonder how much the cost in taxes to pay for the system would be offset by the employers savings of not having to pay for healthcare for their employees, and therefore (hopefully) higher salaries for everyone. I still think it would be a net loss for docs, no doubt.

 

[clibby]

I didn't mean to stir a hornet's nest of theoreticals with this thread.

You started a thread with a leading title starting with “As the left marches towards...” and then claim the moderate middle ground by reframing the topic. The thread was politically charged from the title alone.

Imposing universal medicare would clearly cause an avalanche of unpredictable changes to virtually every facet of society, not just EM compensation, but my question was much more limited in scope. It boils down to the following math equation:

ax+by+cz=$

where (a) is the "average" reimbursement of "self pay" and medicaid patients, (b) is average reimbursement of medicare patients, and c is average reimbursement of privately insured patients, while x,y, and z are the number of patients in each category that roll through the ED per year. Multiply it out and you get $, the total annual revenue generated by the ED.

So, ax+by+cz=$ represents the revenue today. My question, for those of you who have seen the numbers in your own EDs, is how much would the revenue shrink if the equation above was replaced by b(x+y+z)=$ in a situation where all your self pay, medicaid, and private insurance patients were replaced by medicare patients?

To answer your question bluntly: c would go down, b may or may not stay the same, and a would go up. The end result is entirely up to the system designed and everyone has their own version of single payer in their head to fill in the gaps.

If you want to have a discussion on reforming something that most people here realize is a bit complicated, then you we need to discuss an actual plan. What would the regulatory and reimbursement structures be in your proposed Medicare for all? When it comes to reimbursement issues, we would need to discuss actual proposals including numbers. Otherwise everyone just assumes the change will be perfect or apocalyptic depending on their current impression of “single payer” that they associate with healthcare despite the various ways single payer systems can work.

 

[Money Moniker]

You started a thread with a leading title starting with “As the left marches towards...” and then claim the moderate middle ground by reframing the topic. The thread was politically charged from the title alone.



To answer your question bluntly: c would go down, b may or may not stay the same, and a would go up. The end result is entirely up to the system designed and everyone has their own version of single payer in their head to fill in the gaps.

If you want to have a discussion on reforming something that most people here realize is a bit complicated, then you we need to discuss an actual plan. What would the regulatory and reimbursement structures be in your proposed Medicare for all? When it comes to reimbursement issues, we would need to discuss actual proposals including numbers. Otherwise everyone just assumes the change will be perfect or apocalyptic depending on their current impression of “single payer” that they associate with healthcare despite the various ways single payer systems can work.

I literally just read an article in the The Hill titled "Democrats march towards single payer" and tried to incorporate it in my title but had to change "Democrats" to "Left" due to character limits in thread titles. I'll freely admit I'm on the right of the political spectrum but I thought I did a good enough job keeping the OP politically neutral, since again, I'm just looking to crunch numbers here, not get into a useless political debate.

As to the actual plan, I'm referring to the legislation Bernie Sanders submitted in late 2017, which seems to have the backing of the power players within the Democratic party. I believe Sanders' plan calls for making everyone eligible for Medicare but otherwise leaves Medicare more or less as it exists today. Amusingly, the tax plan that would be needed to finance this transformation is not part of the bill and would have to be figured out "later," but for the purposes of this thread the Sanders plan is the best thing we have to try to calculate our potential hit.

 

[Birdstrike]

I applaud your optimism and determination, I really do. And quite frankly, I'm glad there are people like you in our specialty with some experience under their belt who can help lead us going forward.

However, your term "adaptation" to me is synonymous with " agreeing to check more clicky boxes and do more documentation" so I can have a job in a location where I want to work and manage to pay off my 300K in student debt. At the end of the day, we are the mercy of the hospital and political overlords. Should we stand up fight? Of course we should. I'm not saying we should allow ourselves to be taken advantage of. But when it comes to providing better quality care for our patients, and a better career and quality of life for ourselves, I would argue that we haven't "adapted" over the years, but instead, we have succumbed to the demands of those above us. Because, to be blunt, cash is king and our jobs have been transformed to work for a cash making business.

I know I am painting a very bleak and apocalyptic picture of things, and agreed, there are some things that we do well as physicians. But overall, more physicians commit suicide now than ever before. We invest more dollars into patient care without any really significant improvement in mortality. We are now more expendable than ever before because of mid levels taking over. Despite your optimism, after speaking with many veterans in the field, it feels like medicine already has been destroyed by others.

First of all, realize I was thinking things identical to this as a PGY 2. I was posting things exactly like this 8 years ago, after having been out in practice for several years. I'm not discounting what you're saying. And by adapting I do not mean checking "check more clicky boxes and doing more documentation" unless that's what you need it to be. What I am saying, is there's a better way, without having to think you need to uproot the whole "system" as it is.

Let me get specific. Not too long ago, I met up with some people I did residency with. One did a Hospice and Palliative care fellowship. He works a lot less EM shifts, likes Palliative as a way to decompress from the fast pace of EM shifts. He's much happier and less stressed. Another guy did a cardiovascular EM fellowship, and runs an ED obs unit. It's allowed him to reduce his ED shifts to about 8 per month. He seems a lot happier. Another guy has branched out into some admin, a little bit of telemedicine and has otherwise reduced the density of his ED shifts. He seems lighter, happier, less stressed than I remember him in residency. Another did a hyperbarics fellowship. Now he runs his own, dropped from full time, to 6, then 4 and soon 2 ED shifts per month. The rest of the time is running the fellowship, teaching, and doing his hyperbarics stuff. I did an interventional Pain fellowship. I've reduced my ED shifts to zero. I never work after 5 pm or before 7:30 am. I never work nights weekends and holidays. My stress has decreased 90%. The hospital based administrative BS has decreased 99.9%. I only work 4.5 days per week. I make more money that I did in the ED. 2 days per week I do only procedures and those days are fun and 98% stress free. My 2.5 clinic days per week can get boring. Working hard to prescribe as few opiates as possible during a national opiate epidemic takes a lot of discipline. Soon, I'll be teaching residents. I take an active role in helping run my 40-provider medical group and I'm a shareholder with a still small, but growing piece of the company. But on balance my worst day, is better than an average day in the ED. I'm always rested, my burnout is gone and I'm much happier.

I don't know that any of use envisioned going down these roads as medical students or even as PGY2s. But we're all happier. And we're all ER doctors, all still board certified in EM and are all either practicing general EM or an official subspecialty of it. And all of our adaptations have worked for each of us, individually. None of these adaptations have involved doing more pointless box checking. Don't get me wrong: Our medical system will continue to carry on, totally f--ked up. All I'm saying is, it will get better for you, because #1, residency will end, and #2, you're going to make it better, for yourself.

 

[beekle]

How would it effect salaries to have the entities that buy our services consolidate into one giant behemoth? It would lower them. It's basic economics.

The bigger point is - it doesn't matter. Not going to happen - we've fallen into what is called the 'policy trap'. Enough people are happy with their health insurance and health coverage that single payor will be near impossible to implement. Tell someone on medicare they will have to give up their insurance which will be replaced by this massive government entity. Tell someone who has employer sponsored insurance (take all physicians for example) and tell them it will change. Tell a Veteran we'll change to a single payer system and she'll lose access to her VA. We've made enough people happy with their coverage that taking it to single payer would require pissing off a critical mass of people which is large enough to shut any political movement down. We couldn't even get a public option on the exchanges because so many conservatives were afraid it was the first step to single payer. Not going to happen.

Is it wrong to put your own financial interests above your concern for the health of the uninsured? I don't know. We bet big on a medical education... we spent 11+ years working at this. We want that investment to pay off. If you made it through you've likely got the IQ and the grit to have made a whole bunch of money elsewhere. But instead here you are. If you're bitter about answering to non-clinical administrator MBAs or policy wonks in the Capitol, I'd suggest you start developing the skill-set to be at the table with the decision makers instead of getting various bodily fluids on yourself at the bedside.

 

[EctopicFetus]

Not to be confrontational, but I wholeheartedly disagree.

Physicians are the most spineless pushovers there are in medicine. We are literally one of the most important links in the chain i.e. the healthcare system does not function without us. Yet we allow hospital administrators (who perform ZERO patient care) to dictate what happens in the ED. We allow mid level providers to completely take over medicine. We allow the unregulated growth of EM residency positions without any thought as to how this will affect the long term viability of our specialty. We allow insurance companies like Anthem to deny payment for ED visits that were in hindsight deemed unnecessary. The list goes on and on.

I think we as physicians erroneously perceive ourselves as the physicians of the 60s that were at the top of the hospital, highly respected by the community. That unfortunately is no longer the case. I can't even enter a patient's room in the ICU today without "making sure it's okay" with the nurse first. It's a complete and utter joke.

If and when we move to a single payer system, I'm willing to bet physicians will do little to nothing to stop it.

#thoughtsfromaPGY2inthemiddleofwinter

Its because you are a resident. Go to a community shop. I go where I want when I want in the hospital. As an ED doc in the ICU you are an outsider and nothing but a cog that will be replaced when your brief rotation ends.

In a real job, you are on the med staff, in most places these still have some power.

With regard to residencies, administrators, and MLPs you are right.

However with regard to MLPs I will have to admit I like mine. They fund my retirement. They work for me.

 

[EctopicFetus]

I didn't mean to stir a hornet's nest of theoreticals with this thread. Imposing universal medicare would clearly cause an avalanche of unpredictable changes to virtually every facet of society, not just EM compensation, but my question was much more limited in scope. It boils down to the following math equation:

ax+by+cz=$

where (a) is the "average" reimbursement of "self pay" and medicaid patients, (b) is average reimbursement of medicare patients, and c is average reimbursement of privately insured patients, while x,y, and z are the number of patients in each category that roll through the ED per year. Multiply it out and you get $, the total annual revenue generated by the ED.

So, ax+by+cz=$ represents the revenue today. My question, for those of you who have seen the numbers in your own EDs, is how much would the revenue shrink if the equation above was replaced by b(x+y+z)=$ in a situation where all your self pay, medicaid, and private insurance patients were replaced by medicare patients?

Its simpler than this.. Whats your $ per RVU. Most ED groups it is $30-40. Medicare in 2018 is $35.99..

Depending on where you are there will always be self pay (illegals) or others who dont bother signing up.

Keep in mind BCBS, United, Cigna, Humana etc all need a commercial system as well. Doubt the government wipes out $300B+ in market cap and jobs without a real discussion.

IF we go single payer it will take 20-25 years it will be slow. The process will be the opposite of what is mentioned. Will be free med school first, then higher residency pay, then lower pay to docs.

I think those who think we can quickly make this happen woefully misunderstand the abortion that is CMS and the VA. They cant make the current system work. A bigger version of it is even more of a $hit show.

 

[Apollyon]

It "affects" you; it does not "effect" you.

Just sayin'.

 

[Money Moniker]

Its simpler than this.. Whats your $ per RVU. Most ED groups it is $30-40. Medicare in 2018 is $35.99..

Depending on where you are there will always be self pay (illegals) or others who dont bother signing up.

Keep in mind BCBS, United, Cigna, Humana etc all need a commercial system as well. Doubt the government wipes out $300B+ in market cap and jobs without a real discussion.

IF we go single payer it will take 20-25 years it will be slow. The process will be the opposite of what is mentioned. Will be free med school first, then higher residency pay, then lower pay to docs.

I think those who think we can quickly make this happen woefully misunderstand the abortion that is CMS and the VA. They cant make the current system work. A bigger version of it is even more of a $hit show.

Thanks for the RVU data, that makes it seem like universal Medicare wouldn't move the needle all that much on EM docs' ability to generate revenue. For what it's worth, Sanders' plan calls for making illegals eligible for Medicare as well, and given how insanely to the left the Democrats have moved on immigration since the 2016 election, I highly doubt anyone in that party would try to change it. I certainly hope you are correct that the disruption to most people's existing coverage that imposing single payer would create will discourage the Democrats from even trying it, but they may calculate that shifting demographics and identity politics assure them of long term electoral dominance regardless of how much chaos their policies cause.

It "affects" you; it does not "effect" you.

Just sayin'.

LOL, wut? Did you simply assume I must have made that grammatical error, despite the fact that I didn't? No offense taken, but read that title again

 

[Hamhock]

LOL, wut? Did you simply assume I must have made that grammatical error, despite the fact that I didn't? No offense taken, but read that title again

His hobby horse will keep going. It's tough to suppress reflex.

HH

(sorry, Apollyon)

 

[iqe2010]

Universal Healthcare is just a political talking point. Much like the whole "Russia Collusion" thing. Nothing is going to come of it. Dems don't want single payer anymore than repubs do, actually. Bernie Sanders Medicare for all bill is just political fluff.

Furthermore, all Obama wanted was a public option. Before he became president he said that universal healthcare wasn't feasible, but he thought the federal government should serve as a "last option" for people unable to obtain care elsewhere.

ACA was the most significant healthcare policy enacted since Medicare was implemented in 1965, and all it basically did was eliminate insurance underwriting and expand Medicaid in 35 states. Which lead to ~20 million more people gaining medical coverage.

That's the closest we're gonna get to universal healthcare.

 

[GeneralVeers]

ACA was the most significant healthcare policy enacted since Medicare was implemented in 1965, and all it basically did was eliminate insurance underwriting and expand Medicaid in 35 states. Which lead to ~20 million more people gaining medical coverage.

That's the closest we're gonna get to universal healthcare.

You mean the insurance plans with copays that are too expensive to actually use? Or the medicaid expansion which no doctors accept and force you to the ED for care?

 

[Apollyon]

LOL, wut? Did you simply assume I must have made that grammatical error, despite the fact that I didn't? No offense taken, but read that title again

Whoa, slow your roll there. It wasn't you. Just look in the thread. But, why would you jump so much? I was distracted a bit last night when I posted that, because, usually (as my post history bears out), I "name names".

As for @Hamhock, the reflex to be a prig is likewise difficult to suppress.

 

[iqe2010]

You mean the insurance plans with copays that are too expensive to actually use? Or the medicaid expansion which no doctors accept and force you to the ED for care?

Without a subsidy the ACA plans very much do suck. But that's what happens when an insurance company is forced to give you something.

I know plenty of docs that accept Medicaid. However I live in a poor, rural area (in a state that didn't expand Medicaid, actually). For large metro areas it's probably different. Medicaid expansion was actually a good thing for rural America.

I like the Medicaid expansion. Especially for college students who have uninsured parents and those currently looking for a job/recently fired.

 

[Mad Jack]

Boy would a single payer system make the job easier though. Imagine losing all financial incentive to work hard. Imagine if you had no incentive AND full tort protection like government docs do now? You may make less, but those 0.5 patient per hour shifts with 100 patients in the waiting room while you nap sure would be more restful.

Read about UK A&E departments, they're hell on earth

 

[EctopicFetus]

You guys miss the point. Universal healthcare depending on the version will also move us closer to one true king (we are 95% of the way there). At that point he who controls the money will really own your ass. In the ED they already own our ass.

Keep in mind a few things almost no hospital out there is at Medicare break even. Meaning for all the Medicare patients that are admitted they are losing money.

Universal or single payer would have to raise what they are paying hospitals. A few months ago the AHA said they were losing 10% per admitted Medicare beneficiary. Thats not a feasible system.

 

[el_duderino]

You guys miss the point. Universal healthcare depending on the version will also move us closer to one true king (we are 95% of the way there). At that point he who controls the money will really own your ass. In the ED they already own our ass.

Keep in mind a few things almost no hospital out there is at Medicare break even. Meaning for all the Medicare patients that are admitted they are losing money.

Universal or single payer would have to raise what they are paying hospitals. A few months ago the AHA said they were losing 10% per admitted Medicare beneficiary. Thats not a feasible system.

Just imagine the cost savings for hospitals if they could eliminate all the people that deal with the hundreds of insurance companies out there. Lawyers, administrators, billing people, IT staff to maintain dozens of connections and systems. There's so much waste built into the system at every level at every institution to deal with the thousands of isnnsurance companies across the nation.

 

[EctopicFetus]

Just imagine the cost savings for hospitals if they could eliminate all the people that deal with the hundreds of insurance companies out there. Lawyers, administrators, billing people, IT staff to maintain dozens of connections and systems. There's so much waste built into the system at every level at every institution to deal with the thousands of isnnsurance companies across the nation.

LOL.. you know who the biggest headache is? Medicare? You know who loves administrators? Medicare. YOu know who pushed EMRs? The government. Do you think we wont have to bill people anymore? Fee for service will stay. Otherwise we will have waits that will be years.

The government loves bloat and waste. need proof? MIPS / MACRA and every other thing the government pushes out there in healthcare.

 

[hoot504]

Bernie Sanders' Medicare-for-All Plan Will Cost $32 Trillion Over 10 Years

But the Mercatus study is roughly in line with other assessments of how much it would cost to implement a single-payer health care program in America. A 2016 study from the Center for Health and Economy, a centrist health policy think tank, said Sanders' Medicare-for-all plan would add $27 trillion* to the federal budget deficit over the first decade. An Emory University analysis of Sanders' plan estimated that it would require $25 trillion in new federal funding.

Interesting article (though perhaps not 'new' news, or even surprising). With a price-tag this exorbitant, I don't think the question of whether passing legislation like this is responsible is even up for debate, but will the average voter/politician care?

 

[GeneralVeers]

Bernie Sanders' Medicare-for-All Plan Will Cost $32 Trillion Over 10 Years

.
Interesting article (though perhaps not 'new' news, or even surprising). With a price-tag this exorbitant, I don't think the question of whether passing legislation like this is responsible is even up for debate, but will the average voter/politician care?

Legislation like Bernie proposes will never pass. Even in ultra-socialist loony-bin California they couldn't pass free healthcare for all, once they found the cost of $400 million was double the entire existing state budget. Silicon Valley and the wealthy in LA just don't have enough money to tax to pay for it all. Their approach nationally has been step-wise, and they are gradually taking "bites" out of healthcare spending and moving it to government. Right now 40% of health spending is from the government, and that share will likely increase (but never decrease). Obamacare's goal was to push people towards a future "public option" that would be provided when the private health insurers failed to keep costs in line, as expected. Gradually that would shift more and more people to government-run care until it represented the majority of health spending. Unfortunately for the Left, the 2016 blew their plans out of the water and they are likely set back until at least 2021-22 now assuming Trump isn't re-elected. If he is, then we get another 4 year reprieve from the expansion of public healthcare.

 

[Apollyon]

$400 million, or $400 billion? The latter sounds more likely.

 

[GeneralVeers]

Legislation like Bernie proposes will never pass. Even in ultra-socialist loony-bin California they couldn't pass free healthcare for all, once they found the cost of $400 billion was double the entire existing state budget. Silicon Valley and the wealthy in LA just don't have enough money to tax to pay for it all. Their approach nationally has been step-wise, and they are gradually taking "bites" out of healthcare spending and moving it to government. Right now 40% of health spending is from the government, and that share will likely increase (but never decrease). Obamacare's goal was to push people towards a future "public option" that would be provided when the private health insurers failed to keep costs in line, as expected. Gradually that would shift more and more people to government-run care until it represented the majority of health spending. Unfortunately for the Left, the 2016 blew their plans out of the water and they are likely set back until at least 2021-22 now assuming Trump isn't re-elected. If he is, then we get another 4 year reprieve from the expansion of public healthcare..

 

[GeneralVeers]

$400 million, or $400 billion? The latter sounds more likely.

Thanks for the catch. I meant billion

 

[Birdstrike]

Bernie Sanders' Medicare-for-All Plan Will Cost $32 Trillion Over 10 Years

.
Interesting article (though perhaps not 'new' news, or even surprising). With a price-tag this exorbitant, I don't think the question of whether passing legislation like this is responsible is even up for debate, but will the average voter/politician care?

$32 trillion?
Is that all?

 

[Angry Birds]

$32 trillion?
Is that all?.

It's a huge number, but I think you'd have to compare it with what Americans are already spending on healthcare. According to this Atlantic article, we already spend $3.4 trillion per year on healthcare, which over 10 years is 34 trillion dollars.

It's also worthwhile to read Vox's response:

$32 trillion.

That is how much federal spending would increase over 10 years under Bernie Sanders’s Medicare-for-all bill, according to a brand-new estimate from the libertarian-leaning Mercatus Center at George Mason University.

Before you question the source (like Sanders did), you should know the left-leaning Urban Institute came up with the exact same number in 2016.

It sure sounds like a lot of money, and conservatives hopped all over the figure on Monday morning. But there are a lot of ways to think about $32 trillion — and one might be that it’s actually kind of a bargain.

Mercatus is projecting a $32 trillion increase in federal spending, above current projected government expenditures, from 2022 to 2031.

In terms of overall health care spending in the United States over the same period, however, they are actually projecting a slight reduction.

There is the rub. The federal government is going to spend a lot more money on health care, but the country is going to spend about the same.​

However, although I clearly lean liberal and theoretically approve of universal healthcare, I can't lie and say I'm not worried about how much my taxes are going to go up to pay for the people who I treat who don't work even though they are able-bodied and capable of working. I just took care of a young 30 year old man, muscular and in good shape. Asked him what he does for a living and he said "I'm on disability."

 

[hoot504]

That's an extra $3.2 trillion annually that needs to be extracted from the tax-payers of this country. Granted, money will not have to be spent on co-pays, premiums, etc. but as the Atlantic article you linked to points out, a huge chunk of our annual healthcare expenditure is due to a very small portion of the population. When the $3.2 trillion burden is dispersed, what that tells me is that a lot of people are going to see their taxes go way up without much (if any) month-to-month or even year-to-year benefit or change in their lives, other than a significantly increased tax bill. Hard to see that being (even remotely) popular, though of course it will all boil down to the details of the financing.

I'm also not sure if simply equating government spending with annual expenditure as a nation is comparable or relevant. None of these initiatives have got off the ground in the various states where the idea has been raised, and I'm sure that the same general mathematical rule applies.

 

[GeneralVeers]

That's an extra $3.2 trillion annually that needs to be extracted from the tax-payers of this country.

Right. It's another 3.2 trillion that will go from the private economy to the public economy with predictable results. Also when have public government health programs ever cost what the initial estimates proposed? Look at single payer system in Vermont or the proposed on in Colorado. Also Medicare and Medicaid...... $3.2 trillion could easily be $4 trillion or $5 trillion without significant rationing of care.

 

[WilcoWorld]

a lot of people are going to see their taxes go way up without much (if any) month-to-month or even year-to-year benefit or change in their lives

I guess that's where I disagree.

I think that living in a country where an unexpected health issue wouldn't bankrupt anyone is worth an increase in my taxes.

How much of an increase? Well, that's something worth discussing...

 

[WilcoWorld]

Right. It's another 3.2 trillion that will go from the private economy to the public economy with predictable results. Also when have public government health programs ever cost what the initial estimates proposed? Look at single payer system in Vermont or the proposed on in Colorado. Also Medicare and Medicaid...... $3.2 trillion could easily be $4 trillion or $5 trillion without significant rationing of care.

What % of the care that you administer is motivated by lack of follow up + fear of litigation?

 

[GeneralVeers]

What % of the care that you administer is motivated by lack of follow up + fear of litigation?

Most of the unnecessary testing I do is to limit patient complaint letters. I would have no problem using evidence-based medicine to not order the CT/X-ray/Antibiotics that are inappropriate.