Models for paying doctors and other medical professionals

Pros and cons of a single-payer system

a/​k/​a Problems with the current health insurance system

Poll: Most Americans want to replace Obamacare with single-payer — including many Republicans (Philip Bump, Washington Post, 5-16-16) Gallup poll: Three-way tie between Single-payer, Repeal Affordable Care Act, Keep Affordable Care Act. "Well over half of Americans want to replace Obamacare with a single-payer system. That figure, amazingly, includes 41 percent of Republicans and Republican-leaning independents — even though the wording of the question specifies that the program would be "federally funded." (Mind you, more than half of Republicans oppose the idea.)...Democrats are happy with the ACA but would love single-payer. Republicans hate the ACA and a majority still oppose a federally funded program."

Why Is Obamacare Complicated? (Paul Krugman, Op Ed, NY Times 10-28-13) "Obamacare isn’t complicated because government social insurance programs have to be complicated: neither Social Security nor Medicare are complex in structure. It’s complicated because political constraints made a straightforward single-payer system unachievable....Konczal is right to say that the implementation problems aren’t revealing problems with the idea of social insurance; they’re revealing the price we pay for insisting on keeping insurance companies in the mix, when they serve little useful purpose."

Behind the Challenges to Universal Health Coverage (Drew Altman, Wall Street Journal, 2-11-16) "Sen. Bernie Sanders has acknowledged that single-payer health care is not politically feasible in the foreseeable future and has said that it is unlikely without, among other things, campaign finance reform first....The makeup of the uninsured population and political realities suggest that the most likely path to universal coverage is a series of incremental steps–implemented in combination or sequentially–that build on the progress made by the ACA and chip away at the remaining uninsured in the U.S. group by group."
Bernie Sanders’ Health-Care Plan Would Provide ‘Medicare for All’ (Ally Boguhn, RH Reality Check, 1-19-16) "Sanders’ “Medicare-for-all” proposal detailed the candidate’s long-awaited plan to do away with the ACA and replace it with a universal single-payer system—a plan once supported by Hillary Clinton. The plan promises to eliminate all co-pays and deductibles, claiming that the average family of four would pay $466 per year for the program." Hillary Clinton has "faced scrutiny over her change-of-heart on universal health care by those who note that the former secretary of state, who previously backed a single-payer system, has accepted millions in speaking fees from the health industry in recent years."
A Superior System: Single Payer Legislation vs. Affordable Care Act (PDF, Physicians for a National Health Program) A chart that provides clarity on the issues.
What is Single-Payer? (Physicians for a National Health Program). See answers to FAQs about single payer.
Getting There from Here: How should Obama reform health care? (Atul Gawande, New Yorker, 1-26-09) Gawande doesn't favor single-payer health care--he believes we can build new systems on what we already have.. Such systems should have three attributes: it should leave "no one uncovered—medical debt must disappear as a cause of personal bankruptcy in America"; it should no longer be an economic catastrophe for employers"; and "it should hold doctors, nurses, hospitals, drug and device companies, and insurers collectively responsible for making care better, safer, and less costly."
A pro-single payer doctor’s concerns about Obamacare (Adam Gaffney, MD,4-11-14 on Salon, posted by Physicians for a National Health Program)
Did the SCOTUS Obamacare Ruling Open the Door for a Single-Payer System? (Crystal Shepeard, Care2, Truthout, 8-4-15) " a bit of karmic retribution, opponents' efforts to stop Obamacare has led to further consolidation with the federal government and may have just opened the door to their worst nightmare – a single payer healthcare system."
Himmelstein responds to Gawande on single payer (Don McCanne, MD, Physicians for a National Health Program, 2-12-09, writes about what's wrong with Gawande's argument)
What is Single Payer? (Physicians for a National Health Program, PNHP) See also Articles of Interest.
Surprise Medical Bills: ER Is In Network, But Doctor Isn't (Carrie Feibel, All Things Considered, NPR, 11-11-14) It would be like going into a restaurant, and ordering a meal and then getting a bill from the waiter, and from the restaurant separately, and the cook separately and the busboy separately.
Why markets can’t cure healthcare by Paul Krugman (The Conscience of a Liberal, NY Times, 7-25-09). "Consumer choice is nonsense when it comes to health care. And you can’t just trust insurance companies either — they’re not in business for their health, or yours.... insurers try to deny as many claims as possible, and that they try to avoid covering people who are actually likely to need care....HMOs have been highly limited in their ability to achieve cost-effectiveness because people don’t trust them — they’re profit-making institutions, and your treatment is their cost."
Surprise Medical Bills Take Advantage of Texans (Center for Public Policy Priorities, Texas) Little known practice of "balance billing" creates a "second emergency" for ER patients. “Balance billing” occurs when a consumer receives out-of-network health care services and is directly billed by the provider for the balance of what the insurer didn’t pay--in other words, the difference between the provider’s billed charge and the amount the insurer pays.
Assaulted by "Health Care" (Sandra Shea, Pulse, 1-23-15) "All told, I've had eleven surgeries and fourteen colonoscopies. Paperwork is practically my middle name. But the last twenty-four hours have been ridiculous. In that time, I've had three different encounters with healthcare billing--each absurd in its own way, and each more challenging than the last."
That CT scan costs how much? (Consumer Reports, July 2012) Health-care prices are all over the map, even within your plan’s network
Surprise Medical Bills (Consumer Reports). One way in which out-of-control health care costs manifests itself is surprise out-of-network bills. New York State took this issue head on, passing strong legislation that aims to protect consumers from these surprise bills. Links to many resources, articles on topic.
Guaranteed Health Care (National Nurses United). We don't need insurance. We need Medicaid for all. See article When health insurers play games, patients lose (David Lazarus, 4-18-14). A doctor jumps through numerous hoops to get UnitedHealthcare to pay for a patient's breast reduction — only to finally be told the surgery wasn't covered by her policy.
Woman taken to 'wrong' hospital faces bankruptcy (Adam Schrager,, 11-10-14)
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Retainer or concierge medicine and other new models for paying doctors

At Forest Direct Primary Care, the doctor is in; insurance is out (Amy Trent, News Advance, 11-1-14) "Unlike concierge medicine, which caters to the wealthy with pricey membership fees, this is direct primary care, a small but growing field where patient loads are small — about a fourth of the number the average family physician cares for, according to national statistics — and fees are affordable, $75 to $150 a month." And the doctor does make house calls.
Ethical Concierge Medicine? (William Martinez and Thomas H. Gallagher, Virtual Mentor, AMA) "Frustrated by excessive paperwork, large patient loads, short visits, and diminished income, some primary care physicians have limited their involvement with traditional health insurance plans and embraced a less conventional model of medical practice known as “concierge medicine” or “retainer medicine.” These medical practices generally limit their physicians to somewhere between 300 to 800 patients, rather than the 2,000-plus panel sizes typical of traditional primary care physicians, and charge participating patients an upfront annual fee varying from less than $1,000 to more than $5,000." Discusses the practical and ethical implications of changing to such a practice. Not everyone can afford it, for example.
Concierge Medicine and Your HSA (American Health Value) "However, HSA funds can only be used for qualified expenses that have already happened. They cannot be used in anticipation of future expenses. For this reason, a concierge fee cannot be paid from an HSA....If your physician provides an invoice showing the actual cost of qualified medical expenses received under your concierge agreement, you can reimburse yourself for that $1,000 from your HSA."
Pros and Cons of Concierge Medicine (Jen Wieczner, WSJ, 11-10-13) 'Because concierge doctors aren't at the mercy of insurance companies, they say they take on fewer patients and spend more time with each, often guaranteeing appointments within 24 hours. They also don't need patients to come into the office to get paid, so they can provide care via video, email and phone. One of the great conveniences that private physicians offer is virtual conversations, as in "text me a photo of your tick bite." ...But the lower-cost concierge practices keep their rates low by focusing on simple services—you won't find advanced medical technology, and you'll have to go elsewhere (and pay extra) for screenings like MRIs."
Retainer medicine: an ethically legitimate form of practice that can improve primary care. (Ann Intern Med. 2011 Nov 1;155(9):633-5. doi: 10.7326/​0003-4819-155-9-201111010-00013.)
Why concierge medicine will get bigger (Elizabeth O'Brien, Retire Well, MarketWatch,1-17-13) If you’ve joined a concierge medical practice, recent trends in the worlds of health care and insurance may have you feeling good about your decision. If you haven’t signed up with one of these practices—also called “boutique,” “personalized” or “private-physician” practices—some of those same trends may lead you to consider it down the road.
Are Retainer-Based Medical Expenses Tax Deductible? (Zacks) http:/​/​​retainerbased-medical-expenses-tax-deductible-9307.html
The Future of Healthcare Could Be in Concierge Medicine (Nina Lincoff, Healthline, 6-30-15) Concierge medicine allows doctors to charge a flat monthly fee for services. It’s an idea that finally might be catching on.
Physicians Abandon Insurance for 'Blue Collar' Concierge Model Once the bastion of high-end specialists, more and more primary-care and family physicians are launching concierge practices for middle- and lower-income patients.
Don't blame doctors for going concierge (, 2-23-14) Nothing cuts the cord between the doctor and her patient like the mention of money. Yet, doctors all over the country are rushing to become “concierge physicians.” The more you pay, the closer you can get to the doctor. For $1000 a year, you can be part of the club. Pay $2000 annually and you can have the doctor’s email. Pay $3000 and you can text or call her cell.
My Doctor, the Concierge (Merrill Markoe, Time, 2-6-14) orget the Hippocratic oath--welcome to a world of Gold and Platinum patients
Enhanced Medical Care for an Annual Fee (Ginia Bellafante, NY Times, 12-6-13) "The health care market in New York is sufficiently unusual that members of the affluent classes routinely question the merits of doctors who do take insurance. How could the doctor satisfied to receive a $20 co-pay also be the doctor skilled enough to know that your palm’s itch is really the early sign of something rare and disfiguring? This psychology, along with the cost-cutting strategies pursued by insurance companies over the years, have driven the field of concierge medicine — typically, boutique general practices that charge premiums for enhanced attention." "The risk of course is that these sort of practices multiply and become a new norm for the very rich, aggravating not only the development of a two- (or really three-) tiered medical system but also creating a science-fiction metropolis in which only the best-off remain, living the longest and healthiest lives, never looking a day older than Mary-Kate Olsen, and moving into luxury condominiums built with CT scanners."
Concierge Medicine will get massive boost from Obamacare (Dike Drummond, Happy MD)
6 Things to Know About
Concierge Medicine
(Lisa Gerstner, Kiplinger, Sept. 2012) You can avoid packed waiting rooms—if you're willing to pay extra.
Concierge Medicine Journal
Concierge Medicine Today (another trade journal)
http:/​/​​Bethesda-Magazine/​January-February-2013/​Theres-a-Doctor-in-the-House/​ (Rita Rubin, Bethesda Magazine, Jan-Feb 2013) It’s a new-old idea: Physicians who don’t make you come to them—they come to you. An increasing number of concierge medicine practices are offering house calls to patients in wealthier parts of the country.
Everyone Should Have A Concierge Doctor If doctors could be completely freed from the shackles of third party payment, they could take full advantage of phone, email and telemedicine (time spent on which they are not currently reimbursed).
The Case for Concierge Medicine (Richard Gunderman, The Atlantic, 7-16-14) Critics see such models as promoting a two-tiered system of healthcare, in which those with more money get better care.In the trade-off between more patients and more personalized care, growing numbers of physicians are choosing the latter
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Dealing with physician (and other healthcare professional) shortages

Physician Shortages in the Specialties Taking a Toll (Bonnie Darves, New England Journal of Medicine, March 2011) In the persisting, sometimes heated national conversation about physician shortages, the focus and headline-grabbing reports have largely centered on the dearth of primary care physicians and attendant access problems. "In its June 2010 report on non-primary care specialty shortages, AAMC’s Center for Workforce Studies ventured a dire prediction for the decade ahead: a current deficit of 33 percent in surgical specialties, and an undersupply of 33,100 surgeons and other specialists by 2015, increasing to 46,100 by 2020. The AAMC expects the primary care physician shortage to top 45,000 by 2020. The forecast from the Health Resources and Services Administration (HRSA) is even more unsettling. The government agency calls for a shortage of 62,400 in the non-primary care specialties by 2020. In addition, one third of U.S. practicing physicians are expected to retire over the next decade."
The government was trying to fix the transplant system. But it got complicated. (Michelle Andrews, WaPo, 6-12-16) A well-intended policy has unintentionally created perverse incentives. To get or keep a good performance rating from the federal government, transplant centers have been labeling some patients “too sick to transplant” and dropping from the waitlist some who may have been viable candidates, a decade-long study found. The researchers also determined that, despite the centers’ actions, one-year survival rates for transplant recipients didn’t improve.
Doctor Shortage Likely to Worsen With Health Law (Annie Lowrey and Robert Pear, NY Times, 7-28-12) Quotes many on how to deal with the problem.
How Congress causes (and could fix) the doctor shortage (Sarah Kliff, Wonkblog, Wash Post, 8-29-12) The residency program to train doctors has, for decades, largely been financed by Medicare. Back in 1997, when Medicare costs were skyrocketing, Congress passed the Balanced Budget Amendment. Among its many provisions to control Medicare cost growth, it included a hard cap on how many residencies it would fund. That residency cap remains in place right now. It is a lot of the explanation for why we have too few doctors."
What Should Be Done to Fix the Predicted U.S. Doctor Shortage? (The Experts, Wall Street Journal, 6-20-13). Kathleen Potempa : Let nurses provide primary care. George Halvorson : Relieve doctors of their student-loan debts. Murali Doraiswamy: Don't focus on supply. Focus on demand. Train more psychiatrists. Harlan Krumholz : Our assumptions could be impairing us. Fred Hassan : Make it easier to become a primary-care doctor in the U.S. Bob Wachter: There really isn't a doctor shortage in the U.S.; there is a doctor maldistribution, both geographically and by specialty. J.D. Kleinke : Increase the number of 'non-doctor' doctors. Gurpreet Dhaliwal : Lack of access to care is the greater problem. Leah Binder : An M.D. isn't always necessary for care. Atul Grover : Increase federal funding for residency training. John Sotos : Let doctors be doctors. Carol Cassella : If we want more doctors, we have to pay for more training. Peter Pronovost : Make being a doctor more rewarding. Susan DeVore : Leverage under-used care providers. David Blumenthal : Allow nurse practitioners to provide more care. Drew Harris : Market forces will help, to a degree. Pamela Barnes : Think about teams, not just doctors. Charles Denham : Stop stifling medical assistants. Helen Darling : Encourage a team effort.
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