Single Payer IQ Test – Question 3: Under single payer, who will do the work?

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Answer: Younger and less experienced physicians, foreign physicians, subservient physicians, non-physicians—or possibly no one.

Having an insurance card doesn’t help if there are 50 people ahead of you in the waiting room—and the doctor is not in. Single payer is supposed to remove the barrier of having to pay for care, but none of the proposals create extra doctors. And of increased demand there can be no doubt. [1]

There’s a government-created lid on medical school spaces and residency training positions. There are increasing disincentives for the best and the brightest to enter or remain in the medical profession. Under Medicare, physician fees have been capped since the 1980s, not even keeping up with the deterioration in the value of the dollar, and commercial insurance payments may be tied to Medicare. Yet costly administrative demands, including recertification, increase relentlessly.

In some fields more than half the physicians have signs of burnout. [2] Faced with burgeoning administrative demands, physicians are closing their independent offices and becoming employees. Only 33% now identify as independent practice owners or partners, down from 48.5% in 2012. And in the U.S. we are losing the equivalent of a full medical school class per year to suicide. The Association of American Medical Colleges predicts a shortage of more than 90,000 physicians by 2025.

Increasingly, patients find that their appointment is with a “provider” who is not a physician. Personnel with far less training than a physician are staffing clinics and emergency rooms, doing post-operative visits, even doing wound repairs that require plastic surgery skills for a good result.

Hospitals are increasingly reliant on foreign-trained physicians, who may be well-trained in medicine but lacking in ability to communicate with patients and family.

Doctors will be contracted with, if not directly employed by the single payer. If there is only one employer, and no prospect of starting an independent business, workers risk their livelihood if they offend the payer. Unionization may seem to be the only recourse. [3] And the only effective weapon is the strike—as the junior doctors’ 2016 strike against the British National Health Service.

Scottish GPs are closing their practices in record numbers because NHS funding is insufficient to cover their expenses.

Personalized care may be viewed as discriminatory. Already, Medicare may demand all of a doctor’s records to ascertain whether private patients are getting preferential treatment. In the U.S. there may be penalties or private causes of action under the Office of Civil Rights for refusal to provide cross-hormone treatment for gender transition or other treatments a doctor may believe to be harmful or immoral. Canadian physicians are fighting for the right to decline to participate in euthanasia or abortion. Under single payer, a majority of 50% + 1 may override medical judgment and conscience.

Your doctor or prospective doctor may be lost to law school or business college, transfer to a non-patient care position, early retirement, a clock-punching, wage-slave attitude accommodation, emigration to a locale with more freedom (if one can be found), or even suicide.

Doctors may suffer exclusion by the single payer for reasons unrelated to integrity or competence, such as world-class NHS cardiothoracic surgeon Peter O’Keefe, who is now working as an Uber driver. He got sacked after calling attention to hospital safety problems. Sham peer review problems are leading to the destruction of medical careers the world over. [4,5] With the increasing consolidation of hospitals and expanded power of the U.S. federal government single payer, problems in one setting may terminate a doctor’s professional life. 

Take-home Lessons:

  • The push toward single payer is accompanying a reduction in the number of physicians, particularly independent physicians.
  • The question of “If I like my doctor, will I get to keep my doctor?” will be moot because even if you are seeing the same doctor, he will not be yours. He will be contracted with, if not formally employed by, the single payer.
  • Remember the old German proverb, dating from around the time of Martin Luther: “Wessen Brot ich esse, dessen Lied ich singe” (Whose bread I eat, his song I sing).
  • Also recall the Soviet “joke”: “They pretend to pay us; we pretend to work.”

References:

  1. Anderson A. The impact of the Affordable Care Act on the health care workforce. Heritage Backgrounder No. 2887; Mar 18, 2014.
  2. Held KS. Abuse of physicians: battered physician syndrome. J Am Phys Surg 2015:20:90-91. Available at: http://www.jpands.org/vol20no3/held.pdf.
  3. Dhand S. 5 things we can learn from the NHS doctor strike. KevinMD.com, Jun 15, 2016. Available at: http://www.kevinmd.com/blog/2016/06/5-things-can-learn-nhs-doctor-strike.html.
  4. Ng L-F, et al. A perspective on the emergence of healthcare sham peer reviews in Australia—past, present, and future. J Am Phys Surg 2016;21:118-123. Available at: http://www.jpands.org/vol21no4/ng.pdf.
  5. Huntoon LR. Sham peer review and the National Practitioner Data Bank. J Am Phys Surg 2017;22:66-71. Available at: http://www.jpands.org/vol22no3/huntoon.pdf.

Printable PDF of Question #3: https://goo.gl/yz7BYc

Single Payer IQ Test Question Archive: https://aapsonline.org/category/hcriq/

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