I recently shared the link to an op-ed on social media explaining why, in the author’s opinion, establishment of a single payer system in the U.S. is almost inevitable. In response, a fellow Tennessee family physician who is only a few years out of residency commented that he hopes that doesn’t happen until he retires.
When I pointed out what I saw as some of the distinct advantages of single payer Medicare for All – only one set of rules and regulations to adhere to, one standardized billing platform, no co-pays to collect, the potential for dramatically lower malpractice premiums – I was dismayed by his reply. He pointed out that, as a family physician seeing between 16 and 20 patients a day, he makes “specialist pay… due to the ability to have free market competition”. He went on to say that he loves telling medical students that he was able to pay off $200,000 in student loans within two years of finishing residency.
Upon further discussion, I learned that he sees very few TennCare (Tennessee’s managed care Medicaid) patients, and that he no longer accepts new ones due to it being a “very challenging population with terrible reimbursement, far below Medicare even”. My assumption is that he also does not see uninsured patients unless they can pay up front for all anticipated services.
I was particularly distressed by this interaction since I know, first-hand, that the individual expressing these sentiments is an excellent clinician who cares about providing the best care possible to his patients. Yet his comments belie the facts that generating a high income is an important priority for his practice and that he fears a single payer system would substantially hurt his bottom line.
There are some 1.4 million Tennesseans on TennCare; an additional 675,000 Tennessee residents are uninsured. Fortunately, many primary care clinicians across the state accept TennCare patients, and some care for uninsured patients, at least on a limited basis.
Plenty of Tennessee’s dedicated rural private practitioners help to meet that need, as do the many federally qualified health care centers (FQHCs) and faith-based charity clinics across the State. But those clinicians don’t, as a rule, boast of “specialist salaries” and hasty payment of student loan debts. They are meeting a critical need of the State’s population that many higher paid clinicians are not helping to address.
Specialty care is even more problematic for TennCare and uninsured patients, especially in some of the medical and surgical subspecialties. In my own experience, TennCare patients in our northeast corner of the State often have to travel 50 to 100 miles to see dermatologists, urologists, neurologists, and other specialists, even though there are plenty of those specialists seeing private pay patients in our immediate area. One argument that I’ve heard from some of those physicians is that their practices would be overwhelmed with TennCare patients if they were the only ones locally in their specialty accepting them.
I don’t begrudge physicians and other health care providers earning respectable salaries for working long and hard hours. The practice of medicine is a challenging profession which should be appropriately compensated, especially if high quality care is to be a priority. One could make the argument that, when compared with the salaries of many health care corporate executives, physicians as a whole are grossly underpaid. I happen to believe that it’s the executives who are grossly overpaid, but that’s a discussion for another article.
I like to think that medicine is still, first and foremost, a helping profession, not a business venture. Practicing medicine is a privilege granted to practitioners by society; I believe that, in return, physicians should have an obligation to serve society in a manner that is competent and caring, but also fair and just, not only for patients but also for other practitioners. Physicians who generate large incomes by restricting their practices to patients with the best paying insurance coverage (and those who can afford exorbitant out of pocket expenses) put the rest of their colleagues at a distinct economic disadvantage.
A single payer health care system would address this inequity by leveling the income playing field for clinicians. Having a standardized reimbursement schedule and uniform payment mechanisms would largely eliminate the opportunity for clinicians to cherry pick patients based on their income and insurance status. In essence, practitioners would be compensated based on the quantity and quality of the care they provide, not on the basis of which insurers they contract with. Patients would have the freedom to choose their physicians based on factors other than their ability to pay. Practices would thrive, or not, based on the quality of the care they provide and their reputation with the public.
Physicians fear that a single payer system would significantly reduce their salaries. While some clinicians who currently enjoy extraordinarily high incomes would potentially see substantial decreases in what they earn, it’s unlikely that most would suffer economically. As has been pointed out elsewhere, the fear that there would be a mass exodus of physicians from practicing medicine is generally unfounded. The devil is in the details as far as what payment schedules would look like with a single payer system.
None of the Democratic candidates who announced their support for Medicare for All has gotten this far “into the weeds” yet. Even Sen. Elizabeth Warren’s recent policy statement on the costs of Medicare for All only addresses physician reimbursement in broad terms. Moreover, it is highly unlikely that those tasked with determining payment rates would jeopardize the availability of health care by setting reimbursement rates that would result in large numbers of physicians leaving practice.
For these reasons I remain convinced that, for physicians, the prospect of greatly reduced administrative overhead and claims denials, absence of narrow networks requiring prior approvals, elimination of co-pays, and much lower malpractice premiums are more than enough of a trade off for the potentially modest salary reductions under a single payer system.
Dr. Raymond H. Feierabend is professor emeritus in the Department of Family Medicine at Quillen College of Medicine, East Tennessee State University.
