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

[VA Hopeful Dr]

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Is there evidence to support this? The most recent thing I saw was from a libertarian study showing an increase of about 30T over a decade.

Simply you can not offer more services and be cheaper without rationing. Seems to me this would be common sense.

The argument is that the extra 30 trillion is less than what it costs to insure those people privately over the same time period.

The study authors have come out and essentially said that the data doesn't say that, but there you are.

 

[miacomet]

I meant cheap to the insurance company.

I promise even Medicaid pays more for an ED visit than for an UC visit.

Of course it does. I never disputed that. But it doesn't cost the patient more, unlike with private insurance. So those folks are more likely to go to the ER for minor issues. In my state, for example, Medicaid charges copays for both ER and PCP/UC visits, but you don't have to pay upfront for the ER, making it cheaper for most beneficiaries. With $150 copays from private insurance, there is already a huge disincentive to go to the ER unless patients are really worried.

 

[el_duderino]

Then let triage turn people away at the ED doors and send them to a walk-in clinic or UC.

 

[VA Hopeful Dr]

Of course it does. I never disputed that. But it doesn't cost the patient more, unlike with private insurance. So those folks are more likely to go to the ER for minor issues. In my state, for example, Medicaid charges copays for both ER and PCP/UC visits, but you don't have to pay upfront for the ER, making it cheaper for most beneficiaries. With $150 copays from private insurance, there is already a huge disincentive to go to the ER unless patients are really worried.

You specifically said "Those visits are cheap." Your next statement was about insurance companies. So I'm not sure where cost to patient comes in on this from what I was saying originally which was a hypothetical "If I ran the insurance company".

 

[VA Hopeful Dr]

Then let triage turn people away at the ED doors and send them to a walk-in clinic or UC.

Can't. That 1 in 10,000 that seems like something stupid but is actually serious. You'll be sued if you send them away without an evaluation. And if you don't even provide a medical screening exam (which isn't triage, to my understanding), the Feds will also come down on you.

 

[Apollyon]

Then let triage turn people away at the ED doors and send them to a walk-in clinic or UC.

It's called "EMTALA". Look it up. Read it. Know it. Live it.

 

[el_duderino]

EMTALA is irrelevant. There's no need for it in a system with universal coverage.

 

[Apollyon]

EMTALA is irrelevant. There's no need for it in a system with universal coverage.

It would be, if there was universal coverage. However, right now, it certainly is NOT irrelevant.

 

[VA Hopeful Dr]

It would be, if there was universal coverage. However, right now, it certainly is NOT irrelevant.

Pretty sure the lawyers won't let it go away, the federal government may not come after you but if you miss something without doing a full medical screening exam you're still screwed Universal coverage or not.

 

[EctopicFetus]

Then let triage turn people away at the ED doors and send them to a walk-in clinic or UC.

bad PR, high risk etc.

 

[EctopicFetus]

EMTALA is irrelevant. There's no need for it in a system with universal coverage.

You apparently never lived near the border. What do you do for non citizens? Or are you proposing we provide free healthcare for anyone on us soil?

Why not start with something easy like food, clothing and shelter for all?

 

[leviathan]

Is there evidence to support this? The most recent thing I saw was from a libertarian study showing an increase of about 30T over a decade.

The evidence I'm proposing is that every developed country in the world has universal coverage for a fraction of what the US currently pays, which may suggest that a single-payer system is far more efficient and cost-effective.

Simply you can not offer more services and be cheaper without rationing. Seems to me this would be common sense.

That's not common sense for numerous reasons. I already said many earlier.

1 - you are not offering more services necessarily. All the uninsured people are still getting medical care; they just dump the costs onto you and other insured people who now have to pay higher premiums. They also dump way higher costs because they didn't have preventive care from a PCP who could have controlled their medical issues. They also go to the ED for their care which is way more expensive than if they had a PCP.
#2 - The services you are offering can be offered cheaper when they are delivered far more cost-effectively. With just one insurance company, way more money out of every dollar spent goes to actual delivery of health care rather than administrative costs.
#3 - Rationing does occur, but that's not a bad thing. Medical care that is not evidence-based, effective, or time-sensitive is rationed. For example, you aren't going to be allowed to order an MRI of someone's spine as the initial workup for lower back pain unless they have red flags. In a private system, that kind of bad medical care is encouraged because their mindset is who the F*@# cares, it means more money for the hospital, more money for the radiologist, and the patient's insurance company will just pay for it. Nobody cares about what later happens to the cost of private insurance or premiums which inevitably go way up. From an individual perspective, my health insurance costs are so much lower that if I want something done urgently I could still just pay for it privately, and still end up paying way less than if I was in the US.

These are just some reasons for why it's more effective, and explains why every other country seems to offer care for a fraction of the US. If you disagree, I am curious to hear all the reasons why it costs more money for medical care in the US. Having a larger country doesn't really make sense to me as to why that would be more expensive either. If anything that could make it cheaper due to economies of scale.

 

[leviathan]

You apparently never lived near the border. What do you do for non citizens? Or are you proposing we provide free healthcare for anyone on us soil?

Why not start with something easy like food, clothing and shelter for all?

We don't provide free medical care for uninsured people. They pay out of pocket. To reply to your other comment, we have many Saudi patients in our hospitals as well, who now just left due to the spaz the Saudi govt just had over a tweet.

 

[leviathan]

Inappropriate use of the ED is definitely an issue in Canada. There have been debates over whether to introduce a copay, though the argument against was we don't want to discourage poor people with legitimate medical problems from showing up. Ultimately, people with non-urgent problems are triaged as CTAS 5 and wait around for 3 hours then learn that it's more effective to book an appointment with your family MD or go to an urgent care centre.

 

[EctopicFetus]

EMTALA is irrelevant. There's no need for it in a system with universal coverage.

EMTALA is mostly about money but not all.

 

[EctopicFetus]

The evidence I'm proposing is that every developed country in the world has universal coverage for a fraction of what the US currently pays, which may suggest that a single-payer system is far more efficient and cost-effective.


That's not common sense for numerous reasons. I already said many earlier.

1 - you are not offering more services necessarily. All the uninsured people are still getting medical care; they just dump the costs onto you and other insured people who now have to pay higher premiums. They also dump way higher costs because they didn't have preventive care from a PCP who could have controlled their medical issues. They also go to the ED for their care which is way more expensive than if they had a PCP.
#2 - The services you are offering can be offered cheaper when they are delivered far more cost-effectively. With just one insurance company, way more money out of every dollar spent goes to actual delivery of health care rather than administrative costs.
#3 - Rationing does occur, but that's not a bad thing. Medical care that is not evidence-based, effective, or time-sensitive is rationed. For example, you aren't going to be allowed to order an MRI of someone's spine as the initial workup for lower back pain unless they have red flags. In a private system, that kind of bad medical care is encouraged because their mindset is who the F*@# cares, it means more money for the hospital, more money for the radiologist, and the patient's insurance company will just pay for it. Nobody cares about what later happens to the cost of private insurance or premiums which inevitably go way up. From an individual perspective, my health insurance costs are so much lower that if I want something done urgently I could still just pay for it privately, and still end up paying way less than if I was in the US.

These are just some reasons for why it's more effective, and explains why every other country seems to offer care for a fraction of the US. If you disagree, I am curious to hear all the reasons why it costs more money for medical care in the US. Having a larger country doesn't really make sense to me as to why that would be more expensive either. If anything that could make it cheaper due to economies of scale.

Lest break this down piece by piece. First, i think we have plenty of room to improve.

now those other countries have long waits they dont do all the stuff we do here and they ration based on spending. Most have close to 0 student debt. I’m not just talking medical school but undergrad also. Many of those countries mint their physicians way earlier than we do ours.

you are offering more services. your own post is contradictory. Which screening exams wont we do? Do you remember what happened when it was suggested that mammogram screening for all wasn’t cost effective? Do you have any evidence to prove that the preventive care you suggest is cost effective? Sure you can pull 1 case or make up an example but when applied to a large group of people I have my doubts. A bunch of adults with no medical complaints likely dont need much if any medical care and surely they dont need “annual” exams. For that matter neither do kids (look it up).

The pediatricians fight for this cause well you know.. its how they run their business. More proof that care isnt all that helpful is the proliferation of urgent Cares and minute clinic setups by people who are just barely above the status of ******ed.

You mention more efficient care delivery. Under the ACA insurance companies have to spend 85% of their premium money on medical care. They still squeeze out a profit. Medicare fraud and abuse is roughly 6%. Oh and while it is cute to think how lean Medicare/Medicaid are remember they outsource much of this to 3rd parties like those same insurance companies you dont like. You know why? Those guys can do it for the same money, make a profit and still deliver a product.

Lastly, much of the costs of Medicare / Medicaid are from the super users. We can just ration their care and get the same result. One of my wife’s friends had a baby with tracheomalacia among other problems. This kids soaked up well over $2m in medical care before he was 2. This is a kid who will never talk or be a productive member of society. In your proposed system I assume we tell her, hey lady too bad.

 

[EctopicFetus]

We don't provide free medical care for uninsured people. They pay out of pocket. To reply to your other comment, we have many Saudi patients in our hospitals as well, who now just left due to the spaz the Saudi govt just had over a tweet.

In America they dont. The average collection from a self pay patient is between $6 and 15. hat happens in real life is 1 person pays their $600 bill and 50 pay 0.

 

[leviathan]

Lest break this down piece by piece. First, i think we have plenty of room to improve.

now those other countries have long waits they dont do all the stuff we do here and they ration based on spending. Most have close to 0 student debt. I’m not just talking medical school but undergrad also. Many of those countries mint their physicians way earlier than we do ours.

you are offering more services. your own post is contradictory. Which screening exams wont we do? Do you remember what happened when it was suggested that mammogram screening for all wasn’t cost effective? Do you have any evidence to prove that the preventive care you suggest is cost effective? Sure you can pull 1 case or make up an example but when applied to a large group of people I have my doubts. A bunch of adults with no medical complaints likely dont need much if any medical care and surely they dont need “annual” exams. For that matter neither do kids (look it up).

The pediatricians fight for this cause well you know.. its how they run their business. More proof that care isnt all that helpful is the proliferation of urgent Cares and minute clinic setups by people who are just barely above the status of ******ed.

You mention more efficient care delivery. Under the ACA insurance companies have to spend 85% of their premium money on medical care. They still squeeze out a profit. Medicare fraud and abuse is roughly 6%. Oh and while it is cute to think how lean Medicare/Medicaid are remember they outsource much of this to 3rd parties like those same insurance companies you dont like. You know why? Those guys can do it for the same money, make a profit and still deliver a product.

Lastly, much of the costs of Medicare / Medicaid are from the super users. We can just ration their care and get the same result. One of my wife’s friends had a baby with tracheomalacia among other problems. This kids soaked up well over $2m in medical care before he was 2. This is a kid who will never talk or be a productive member of society. In your proposed system I assume we tell her, hey lady too bad.

I'm confused by the part about preventive care/screening you mentioned. A diabetic who is likely asymptomatic needs regular medical care as an easy example of someone who will end up costing way more in the long run with uncontrolled blood sugars. Hypertension is asymptomatic and has a similar potential for long-term harm. Cancer screening as you mentioned may or may not be cost-effective to screen for, though mortality reduction is still there for some screening. It's funny you mention cancer screening, as the places I've ever worked don't offer screening colonoscopies to average-risk patients, instead offering biannual stool FIT testing. I haven't had a chance to review the data myself but I feel like a colonoscopy should be the gold standard, so maybe this is an area we are getting inappropriately "rationed".

As to your other comments. I don't have a "proposed system" rather a real system that we use. We look after lots of kids with chronic illnesses in Canada and never tell them "too bad". Yet even with treating these patients, our insurance is half the price. The death panels and rationing fear mongering you hear about on Fox news doesn't happen. However, the rationing of preventing people from being ****ty doctors and wasting money on inappropriate testing does happen. You can still order inapproriate tests, but you have to get special authorization and explain why your patient doesn't fit the usual guidelines.

To be clear, I'm not saying you should adopt our health care system. We have a ton of issues with wait times and access, I'm not denying that at all. But maybe there is a way to provide a two-tiered system like many other countries have that would be better than the current system. Definitely if you look at satisfaction scores with healthcare systems, they're much higher outside of the US.

 

[d2305]

The second biggest economy in the world doesn't have universal coverage. One better have some RMB for ER visits.

 

[VA Hopeful Dr]

I'm confused by the part about preventive care/screening you mentioned. A diabetic who is likely asymptomatic needs regular medical care as an easy example of someone who will end up costing way more in the long run with uncontrolled blood sugars. Hypertension is asymptomatic and has a similar potential for long-term harm. Cancer screening as you mentioned may or may not be cost-effective to screen for, though mortality reduction is still there for some screening. It's funny you mention cancer screening, as the places I've ever worked don't offer screening colonoscopies to average-risk patients, instead offering biannual stool FIT testing. I haven't had a chance to review the data myself but I feel like a colonoscopy should be the gold standard, so maybe this is an area we are getting inappropriately "rationed".

As to your other comments. I don't have a "proposed system" rather a real system that we use. We look after lots of kids with chronic illnesses in Canada and never tell them "too bad". Yet even with treating these patients, our insurance is half the price. The death panels and rationing fear mongering you hear about on Fox news doesn't happen. However, the rationing of preventing people from being ****ty doctors and wasting money on inappropriate testing does happen. You can still order inapproriate tests, but you have to get special authorization and explain why your patient doesn't fit the usual guidelines.

To be clear, I'm not saying you should adopt our health care system. We have a ton of issues with wait times and access, I'm not denying that at all. But maybe there is a way to provide a two-tiered system like many other countries have that would be better than the current system. Definitely if you look at satisfaction scores with healthcare systems, they're much higher outside of the US.

Wasn't there a study awhile back that showed its actually more expensive to manage chronic diseases over time compared to the complications of not treating them since the latter case usually results in an earlier death?

 

[EctopicFetus]

My point is screening isnt cheap. Sure it isnt PC but people dying is cheaper for the system. There is a 0.0% chance that universal coverage is cheaper than out current system unless you cut pay/reimbursement. Simple as that.

Regarding cancer screening..
Time to stop mammography screening?
The recommendations on mammography screening are even more conservative than the change in policy suggested by the US Preventive Services Task Force in 2009, which created an uproar in the United States from people interested in maintaining the status quo.

I remember this. Health Care in the US is political. In the end much of what is done is not financially smart. Reality no matter how gruesome.. Diagnosing someone with stage 4 cancer and 6 months to live is way cheaper than stage 1 with multilpe relapses, multiple rounds of chemo and radiation therapy.

Without a major cultural shift it wont happen. That shift includes what to expect from your doctor (if reading this forum doesnt make you feel it is unlikely i advise you practice in the US to get a taste), willingness to pay higher taxes or expand our debt even further. I think our interest to raise taxes is low. Even obamacare required a bunch of BS shenanigans to help offset the cost which was still over $1T over a decade.

 

[leviathan]

That's an interesting idea about it being cheaper to not prevent disease in the first place as they will die. It's another way to look at it that I hadn't considered. I'd have to look at actual data to see if that pans out in reality or not as my idea holds just as much weight. I see your point about screening too, but I'm not sure if a hemicolectomy for stage 1 colorectal CA is cheaper than a few years of chemo, rads, ICU stays or someone getting crazy and doing a Sugar Baker and having a prolonged ICU stay (we do them at my centre, allegedly they're curative in a small subset of patients, but man , that is a ****ty surgery!). Again, the argument can be made in both directions.

As I questioned before, I really don't understand why the US is so much more expensive than every other country in the world which offers universal care +/- a second private tier, unless it's something about the current insurance system and hospital setup that you have. It would just be too much of a coincidence that every other country in the world is so much cheaper when the only common denominator is a universal system. Maybe someone can provide some evidence or articles that explain the other reasons why the US costs more. Maybe one reason is as you said, the margin for error is so exceedingly low that you guys overinvestigate and overtreat things to minimize legal risk (though ironically many investigations and treatments cause more harm to the patient that you aren't liable for).

At any rate, none of this affects me at all and I'm just an outsider looking in at your system with a lot of curiosity. I hope you guys can find solutions, whatever those might be.

 

[GeneralVeers]

As I questioned before, I really don't understand why the US is so much more expensive than every other country in the world which offers universal care +/- a second private tier, unless it's something about the current insurance system and hospital setup that you have. It would just be too much of a coincidence that every other country in the world is so much cheaper when the only common denominator is a universal system. Maybe someone can provide some evidence or articles that explain the other reasons why the US costs more. Maybe one reason is as you said, the margin for error is so exceedingly low that you guys overinvestigate and overtreat things to minimize legal risk (though ironically many investigations and treatments cause more harm to the patient that you aren't liable for).
.

You don't need a study. The reasons healthcare are more expensive in the U.S. are as follows:

1. Entitled, privileged population made up of hypochondriacs
2. Patient satisfaction
3. Legal Liability
4. Over-ordering of tests (see reasons 2 and 3)
5. Hospitals encouraging BS visits to make money
6. Limited discussion of end-of-life care, and advanced directives, along with cultural attitude of living as long as possible.
7. Latest, most advanced medications and surgical procedures.
8. No co-pays or disincentives to over-use and abuse by Medicaid/Medicare populations.

If we can tackle and eliminate reasons #2 and #3, it would allow us to work on reasons #4, and #5, and possibly #8. This could be done without resorting to single-payer or government monopoly.

 

[EctopicFetus]

That's an interesting idea about it being cheaper to not prevent disease in the first place as they will die. It's another way to look at it that I hadn't considered. I'd have to look at actual data to see if that pans out in reality or not as my idea holds just as much weight. I see your point about screening too, but I'm not sure if a hemicolectomy for stage 1 colorectal CA is cheaper than a few years of chemo, rads, ICU stays or someone getting crazy and doing a Sugar Baker and having a prolonged ICU stay (we do them at my centre, allegedly they're curative in a small subset of patients, but man , that is a ****ty surgery!). Again, the argument can be made in both directions.

As I questioned before, I really don't understand why the US is so much more expensive than every other country in the world which offers universal care +/- a second private tier, unless it's something about the current insurance system and hospital setup that you have. It would just be too much of a coincidence that every other country in the world is so much cheaper when the only common denominator is a universal system. Maybe someone can provide some evidence or articles that explain the other reasons why the US costs more. Maybe one reason is as you said, the margin for error is so exceedingly low that you guys overinvestigate and overtreat things to minimize legal risk (though ironically many investigations and treatments cause more harm to the patient that you aren't liable for).

At any rate, none of this affects me at all and I'm just an outsider looking in at your system with a lot of curiosity. I hope you guys can find solutions, whatever those might be.

Keep in mind we pay more for drugs than other countries. We also give everyone everything. Humira the top grossing drug in the US in 2016 had $5B in sales.

Average price of Humira by country 2015 | Statistic

The #1 drug by $$ sales is Humira. It costs 2x in the US as it does in the next cheapest country.

This story goes on and on and on.

Top pharma products by global sales 2017 | Statistic

Just look it up on a drug by drug basis. We use more and pay more for it. FWIW the pharma companies have the highest profit margins of any industry in the publicly traded markets. Medicare legally cant negotiate prices (which was a ******ed move by the republicans).

 

[Money Moniker]

 

[miacomet]

Bernie's "Medicare for All" plan would cut physician payments about 10 percent

 

[EctopicFetus]

Bernie's "Medicare for All" plan would cut physician payments about 10 percent

Plus more govt oversight AND burnout !

 

[GeneralVeers]

Bernie's "Medicare for All" plan would cut physician payments about 10 percent

And that is just to start. Once the plan really gets going, and the spending is much much higher than anticipated, that will soon become 20%, plus other creative "quality" measures to deny payments to doctors and hospitals.