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Physicians warming to a single-payer system



For Kaiser Health News

Single-payer healthcare is still a controversial idea in the U.S., but a majority of physicians are moving to support it, a new survey finds.

Fifty-six percent of doctors registered either strong support or were somewhat supportive of a single-payer health system, according to the survey by Merritt Hawkins, a physician-recruitment firm. In its 2008 survey, opinions ran the opposite way — 58 percent opposed single-payer. What’s changed?

Red tape, doctors tell Merritt Hawkins. Phillip Miller, the firm’s vice president for communications, said that in the thousands of conversations its employees have with doctors each year, physicians often say they are tired of dealing with billing and paperwork, which takes time away from patients.

“Physicians long for the relative clarity and simplicity of single-payer. In their minds, it would create less distractions, taking care of patients — not reimbursement,” Miller said.

In a single-payer system, a public entity, such as the government, would pay all the medical bills for a certain population, rather than insurance companies doing that work.

A long-term trend away from physicians owning their practices may be another reason that single-payer is winning some over. Last year was the first in which fewer than half of practicing physicians owned their practice — 47.1 percent — according to the American Medical Association’s surveys in 2012, 2014 and 2016. Many doctors are today employed by hospitals or healthcare institutions, rather than working for themselves in traditional solo or small-group private practices. Those doctors might be less invested in who pays the invoices, Miller said.

There’s also a growing sense of inevitability, Miller said, as more doctors assume that single-payer is on the horizon.

“I would say there is a sense of frustration, a sense of maybe resignation that we’re moving in that direction, let’s go there and get it over with,” he said.

Merritt Hawkins emailed its survey Aug. 3 and received responses from 1,003 doctors. The margin of sampling error is plus or minus 3.1 percentage points.

The Affordable Care Act established the principle that everyone deserves health coverage, said Shawn Martin, senior vice president for advocacy at the American Academy of Family Physicians. Inside the medical profession, the conversation has changed to how best to provide universal coverage, he said.

“That’s the debate we’re moving into, that’s why you’re seeing a renewed interest in single-payer,” Martin said.

Dr. Steven Schroeder, who chaired a national commission in 2013 that studied how physicians are paid, said the attitude of medical students is also shifting.

Schroeder has taught medicine at the University of California-San Francisco Medical Center since 1971 and has noticed students’ increasing support for a single-payer system, an attitude they likely carry into their professional careers.

“Most of the medical students here don’t understand why the rest of the country doesn’t support it,” said Schroeder.

The Merritt Hawkins’ s findings follow two similar surveys this year.

In February, a LinkedIn survey of 500 doctors found that 48 percent supported a “Medicare for all” type of system, and 32 percent opposed the idea.

The second, released by the Chicago Medical Society in June, reported that 56 percent of doctors in that area picked single-payer as the “best care to the greatest number of people.” More than 1,000 doctors were surveyed.

Since June 2016, more than 2,500 doctors have endorsed a proposal published in the American Journal of Public Health calling for a single-payer to replace the Affordable Care Act. The plan was drafted by the Physicians for a National Health Program (PNHP), which says it represents 21,600 doctors, medical students and health professionals who support single-payer.

Clare Fauke, a communications specialist for the organization, said the group added 1,065 members in the past year and membership is now the highest since PNHP began in 1987.

Study deconstructs physician-generated hospital revenue


Despite the recent growth of value-based reimbursement,  the average net revenue each physician generates for his or her hospital rose 7.7 percent, to $1,560,688 at the start of 2016 from $1,448,458 in 2013, says a new report from physician-search firm Merritt Hawkins.

“The 2016 survey suggests that emerging global/value-based payments have yet to reduce the revenue-generating power of physician specialists,” the report stated. The fee-for-service model remains overwhelmingly dominant. It has helped make the U.S. healthcare system by far the world’s most expensive.

The money involved included net inpatient and outpatient revenue derived from patient referrals, tests, prescriptions and procedures performed or ordered in the hospital.

Medscape summarized part of the report:

“Four types of procedural specialists — orthopedic surgeons, invasive cardiologists, neurological surgeons, and general surgeons — all generated more than $2 million a year in net revenue for their hospitals in 2016….At the top were orthopedic surgeons, who generated an average of $2,746,605 on behalf of their affiliated hospitals, which is up slightly from the 2013 figure.”

“Just behind the orthopedic surgeons were invasive cardiologists, who generated an average net revenue of $2,448,136 in 2016, compared with $2,169,643 in 2013. Neurosurgeons racked up an average net of $2,445,810, which is a big jump from $1,684,523 in 2013. …General surgeons contributed $2,169,673, which is a marked increase from $1,860,566 in 2013.”

But net revenue generated by primary-care physicians  fell 10.5 percent from 2013. Hospital revenue from family practices dropped more than 38 percent  and from pediatricians more than 18 percent.

However, general internists’ contribution to hospital net revenue stayed virtually unchanged.

Merritt Hawkins said that the decline in primary-care physicians’ contributions to revenue “may be a result of risk-bearing reimbursement models, where primary-care physicians and their employers are penalized for exceeding budgets.”


Access to physicians means more than their numbers


Adequate access to physicians doesn’t just mean the number of physicians in an area.

For a study it did,  the consulting and physician-search firm Merritt Hawkins considered 32 other factors besides just a state’s physician supply, such as the percentage of residents without health insurance, the poverty rate, the percentage of physicians who accept Medicaid patients, nurse practitioners per capita, and retail clinics per capita.

Merritt Hawkins said that patients in the Northeast enjoy the best access to physicians.”The general pattern is, the more affluent states have the best access, and the less affluent have the least,”  Phillip Miller, vice president of communications at Merritt Hawkins, told Medscape.

Previous Merritt Hawkins studies have found that Massachusetts led all states in access, even though Boston had the longest wait times for physician appointments among major U.S. cities.

“Where you have near-universal insurance coverage, that creates a lot of demand,” Mr, Miller told Medscape. For measuring access, his firm decided that “we’d rather have people covered who are standing in line for a doctor than people not standing in line at all.”

In addition to Massachusetts, the top 10 states with the greatest access to physicians are, in descending order: New Hampshire, Vermont, Delaware, Maryland, Minnesota, Pennsylvania, Rhode Island, Maine and Connecticut.




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