Single payer system

[doctalaughs]

I would be in support of changing medicaid to a universal, automatic very basic insurance program - ie free vaccines, birth control and very limited generic formulary for everyone. Only interventions that are highly effective with superb evidence with very low NNT are covered. But beyond that you basically pay for private insurance and you get what you pay for. People would have to realize that basic insurance doesnt cover everything and admit it’s a two-tier system with no exceptions. We basically already have a very inefficient random multi-tiered system that makes no sense.

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[el_duderino]

I would be in support of changing medicaid to a universal, automatic very basic insurance program - ie free vaccines, birth control and very limited generic formulary for everyone. Only interventions that are highly effective with superb evidence with very low NNT are covered. But beyond that you basically pay for private insurance and you get what you pay for. People would have to realize that basic insurance doesnt cover everything and admit it’s a two-tier system with no exceptions. We basically already have a very inefficient random multi-tiered system that makes no sense.

I like the sound of that. This is more or less what I've argued for in the past.

 

[timgasman]

So it’s pretty much a forgone conclusion that a single payer is coming. What will this do to reimbursements/our income? Doesn’t Medicare/Medicaid pay about 50% of private payers for Anesthesia services? I believe for surgical subspecialties it’s closer to 75%, so we are the ones who are going to get hit harder than anyone. Also, this is all pure speculation, but when do you believe this crossover is going to take place? I’m thinking 2021 once the New Democratic President takes office whomever that may be. No way in hell trump wins again.

Berkshire Hathaway's Charlie Munger says single payer healthcare will come when Democrats take control

I wouldn't worry too much about single payer. In Europe they have a parallel all-cash, private system. Here we have a weird hybrid system that doesn't make anyone happy.

 

[deleted50478]

I would be in support of changing medicaid to a universal, automatic very basic insurance program - ie free vaccines, birth control and very limited generic formulary for everyone. Only interventions that are highly effective with superb evidence with very low NNT are covered. But beyond that you basically pay for private insurance and you get what you pay for. People would have to realize that basic insurance doesnt cover everything and admit it’s a two-tier system with no exceptions. We basically already have a very inefficient random multi-tiered system that makes no sense.

I wouldn’t make Medicaid universal, but I agree with the concept. It’d be better to provide basic cost effective coverage to all US citizens than the wasteful mess we have now. Cost savings from cutting futile care, preventing non-emergent ER care, and simplifying billing and coding would allow a universal basic single payer system to provide better care to more people at a lower cost than Medicaid+Medicare+NoPayCare.

 

[d9sccr]

This whole preventive medicine stuff (which I support) makes the huge assumption people are going to actually do the things you layout for them (i.e. get your BMI down to something less than 35 or lower, bring your A1c down to a reasonable number, quit smoking, limit EtOH, etc, etc.). Are you just going to cutoff anyone that doesn't follow those rules? Maybe add a statin and ACEi to drinking water?

 

[Impromptu]

In 2023 many of the MACRA legislation changes in reimbursement will become fully implemented. I think the golden age for Anesthesiologist compensation has already passed, and will only decrease. Having been my company's recruiter for the past 2 years, I have told many CRNAs looking for jobs that this is the golden age of CRNA reimbursement. Reimbursement will be cut drastically in 2023, so make as much as you can right now, because there will be nationwide drastic cuts in salary in 2023.

At that point, I think there will build up enough resentment for the system that there will be support for some version of single payor to occur.

The 2023 reckoning might be deferred, like the sustainable growth rate was deferred until MACRA came along decades later. But maybe not. Just make as much as you can while you can.

 

[doctalaughs]

I like the sound of that. This is more or less what I've argued for in the past.

That would be fine, but you then have to accept we would flat-out deny "life saving" treatments to those on the public system. So no, the person with public health insurance wouldn't get the 100,000-dollar-a-month lifetime new targeted cancer drug with a 20% long-term remission chance, even if it's considered "standard-of-care." Unfortunately the American public isn't ready to admit that. Instead we offer this to medicaid patients for free while middle-class Americans with high-deductibles generally have to bankrupt themselves and land in medicaid in order to get it.

This whole preventive medicine stuff (which I support) makes the huge assumption people are going to actually do the things you layout for them (i.e. get your BMI down to something less than 35 or lower, bring your A1c down to a reasonable number, quit smoking, limit EtOH, etc, etc.). Are you just going to cutoff anyone that doesn't follow those rules? Maybe add a statin and ACEi to drinking water?

Beyond vaccines (and maybe smoking cessation programs), preventative medicine largely is unproven to save the system any money. It might be the right thing to do, but saving money can only be done by aggressive rationing and denying care that isn't efficient as a system. So yes, we should have strict rules that you don't get certain care unless you do XYZ.

 

[Money Moniker]

In 2023 many of the MACRA legislation changes in reimbursement will become fully implemented. I think the golden age for Anesthesiologist compensation has already passed, and will only decrease. Having been my company's recruiter for the past 2 years, I have told many CRNAs looking for jobs that this is the golden age of CRNA reimbursement. Reimbursement will be cut drastically in 2023, so make as much as you can right now, because there will be nationwide drastic cuts in salary in 2023.

At that point, I think there will build up enough resentment for the system that there will be support for some version of single payor to occur.

The 2023 reckoning might be deferred, like the sustainable growth rate was deferred until MACRA came along decades later. But maybe not. Just make as much as you can while you can.

Jeezus...2023 is exactly the year I will finish residency assuming I do the shortest one (EM or IM). Can you elaborate a bit on what changes will be brought on my MACRA at that point, and whether these changes will nerf some fields more than others?

 

[SolidWater]

In 2023 many of the MACRA legislation changes in reimbursement will become fully implemented. I think the golden age for Anesthesiologist compensation has already passed, and will only decrease. Having been my company's recruiter for the past 2 years, I have told many CRNAs looking for jobs that this is the golden age of CRNA reimbursement. Reimbursement will be cut drastically in 2023, so make as much as you can right now, because there will be nationwide drastic cuts in salary in 2023.

At that point, I think there will build up enough resentment for the system that there will be support for some version of single payor to occur.

The 2023 reckoning might be deferred, like the sustainable growth rate was deferred until MACRA came along decades later. But maybe not. Just make as much as you can while you can.

But isn't MIPS/MACRA something that doesn't even logically apply to anesthesia? It seems inapplicable or unsustainable for the profession (so will it be revised, dismissed?). How do you report quality to CMS for a service that's basically either on (survived procedure) or off (died)?

Also, it won't just be anesthesia hit by it, right? It's such a bloated piece of legislation (like they all are), that I think we've all collectively given up on understanding and fighting.

But we need to push back. These continuing small defeats (legislation) that are hitting our profession (not just anesth, but physicians) are slowly chipping away and have been for decades. Seems like it's time to be more vigilant and push back.

Easier said than done, I get it, but some of us (myself included) are at this crux where we undertook over $400k in debt to go through the required schooling, testing, licensing, training to become an MD, and now we're facing reduced reimbursement. I need to be able to pay back my federal loans (which they're charging ~6% on from time of disbursement in recent years).

Shows how bad we are compared (at lobbying, etc) to the financial industry: they got bailed out at 0% for ****ing over other people. We actually help out and get stiffed with 6%.

 

[Twiggidy]

We pay for an illegal immigrant’s interpreter, obstetric care, epidural, possibly c section, and a few days in the hospital (and we usually pay for all that with several pregnancies) but we don’t pay for a bus ride across the border.

But follow through on this thought......the kid even gets a US birth certificate. And let's be real, the only people coming here to do that aren't the one's from south of the border.

 

[deleted50478]

But follow through on this thought......the kid even gets a US birth certificate. And let's be real, the only people coming here to do that aren't the one's from south of the border.

Yeah. They shouldn’t become US citizens just because their parents broke the law. Birth right citizenship was for freed slaves not illegal immigrants. Time got that **** to go.

 

[resp228]

Just an observation, but it's interesting that certain single payer systems such as Canada, Australia have been able to expand access while maintaining high physician compensation. Anesthesiology remains fee for service in Canada, many physicians incorporate their own practice, you don't work for a "corporate management group", and the different specialty societies negotiate with the government for fair compensation. Their system is not perfect, but as a medical student who likely won't have the same opportunity for private practice as anesthesiologists had in the past, a single payer system does not seem as bad as what is being described here.

 

[parcus]

Just an observation, but it's interesting that certain single payer systems such as Canada, Australia have been able to expand access while maintaining high physician compensation. Anesthesiology remains fee for service in Canada, many physicians incorporate their own practice, you don't work for a "corporate management group", and the different specialty societies negotiate with the government for fair compensation. Their system is not perfect, but as a medical student who likely won't have the same opportunity for private practice as anesthesiologists had in the past, a single payer system does not seem as bad as what is being described here.

I heard that happens at least partially due to high pay in the US, which caused a shortage in Canada, forcing them to increase compensation. in countries where doctors can’t easily leave, the pay is much lower.

 

[Twiggidy]

Just an observation, but it's interesting that certain single payer systems such as Canada, Australia have been able to expand access while maintaining high physician compensation. Anesthesiology remains fee for service in Canada, many physicians incorporate their own practice, you don't work for a "corporate management group", and the different specialty societies negotiate with the government for fair compensation. Their system is not perfect, but as a medical student who likely won't have the same opportunity for private practice as anesthesiologists had in the past, a single payer system does not seem as bad as what is being described here.

This is 'per se'. I'd take a shot in the dark that many private practice anesthesiologists who haven't been gobbled up by a treacherous AMC make more than anesthesiologist in Canada, the UK, and Australia. Not that they don't get a handsome wage in their on countries because I'm sure they do, it's just that we probably make more here. In those countries they've bought into a system that has been around for a long time Here, it would be a DRASTIC change and that's where most of the resistance lies. It wouldn't be an overnight change but for people who are still practicing and making close to 450k at 40 and then at 45 they're going to make 200k, well, you're going to have some pitchforks in the streets. That's in just the simplest terms. When you add it benefits, free or inexpensive education, and may some other free social services, maybe it isn't so bad to work in those systems, but the US doesn't have all of that, so doctors here aren't ready for it.

 

[pgg]

Yeah. They shouldn’t become US citizens just because their parents broke the law. Birth right citizenship was for freed slaves not illegal immigrants. Time got that **** to go.

There's no "unless your parents are criminals" clause in the 14th Amendment. Would take another Amendment to change that.

 

[nimbus]

But follow through on this thought......the kid even gets a US birth certificate. And let's be real, the only people coming here to do that aren't the one's from south of the border.

True. We’ve had several deliveries at my hospital of Chinese babies born to American surrogates. Their parents are rich. America, land of rental wombs.

 

[dhb]

making close to 450k at 40 and then at 45 they're going to make 200k

That will probably never happen overnight, over time maybe.
There are plenty of physician making 7 figures in western europe.

 

[deleted50478]

There's no "unless your parents are criminals" clause in the 14th Amendment. Would take another Amendment to change that.

Yes, it would take an Amendment. So what?
There’s no “unless your parents are criminals” clause because the writers couldn’t predict our current situation. The 14th Amendment should be updated to reflect modern reality.
Most of the time if you see a crime you could/should report it. This one you see every f-ing day on L&D and you are supposed to ignore it.

 

[CheGuevaraMD]

Frankly, it's far too late for physicians to alter the course of reform. Heatlhcare inflation is threatening the future of our nation-state (healthcare spending is the largest spending category in the federal budget), and hurting middle class families (most of all increased employee compensation goes to insurance premiums).

This is like professors organizing against cuts to tuition prices -- no one cares. Once your customer is tapped out (i.e. the student or the patient/government), you're going to face a loss in income. No way around that.

 

[pgg]

Yes, it would take an Amendment. So what?

It's a very high bar, that's all.

 

[el_duderino]

The founders couldn't predict a situation where people could be born to illegal immigrants within the borders of the country?

They could predict a future full of semiautomatic rifles and handguns though, right?

Jesus.

 

[nimbus]

Yes, it would take an Amendment. So what?
There’s no “unless your parents are criminals” clause because the writers couldn’t predict our current situation. The 14th Amendment should be updated to reflect modern reality.
Most of the time if you see a crime you could/should report it. This one you see every f-ing day on L&D and you are supposed to ignore it.

It’s not currently a crime to have illegal immigrants as parents. That baby is protected and has all the rights that you and I enjoy.

 

[deleted50478]

The founders couldn't predict a situation where people could be born to illegal immigrants within the borders of the country?

They could predict a future full of semiautomatic rifles and handguns though, right?

Jesus.

It wasn’t the founders but anyway, no, they could not have predicted that the law they wrote to protect freed slaves would be used to grant citizenship to over 5 million children of illegal immigrants and to anchor 20-30 illegal immigrants to this country. No, I don’t think that was predictable in the 1860s.

 

[deleted50478]

It’s not currently a crime to have illegal immigrants as parents. That baby is protected and has all the rights that you and I enjoy.

Yeah. It just shouldn’t. I wish that baby all the best back in whatever country it’s parents come from. There’s just no reason to reward the parents’ crime. Protecting the children of illegal immigrants was not the intention of the 14th Amendment.

 

[pgg]

The founders couldn't predict a situation where people could be born to illegal immigrants within the borders of the country?

Which founders do you think had a hand in drafting the 14th Amendment?

They could predict a future full of semiautomatic rifles and handguns though, right?

Irrelevant, no prediction necessary; they merely wanted a country in which the citizens could freely own and bear the same weapons of war as the regular army.

Jesus.

Seems appropriate -