Why We Need a Single-Payer Healthcare System: A Geriatric Psychiatrist’s View From The Trenches – Part One
Opponents to a single-payer healthcare system often invoke the specter of government intruding into the medical examination room and directly meddling in the doctor-patient relationship. Such objections usually include dire warnings about the government restricting the choice of personal physician and dictating which treatments doctors can provide. From my vantage point as a practicing geriatric psychiatrist, this transparent demagoguery is a straw man propped up by defenders of the insurance industry.
Don’t get me wrong. I am not an apologist for government healthcare. Medicare, a government-run program that happens to be the largest insurance company in the world, certainly has more than its share of problems. In future posts, I intend to discuss the numerous obstacles that Medicare imposes to the delivery of geriatric mental healthcare. And I have little confidence that the government can implement a single-payer system that will promote access to the geriatric psychiatry services older Americans increasingly need but cannot find. It’s just that I doubt that a government-run, single payer system could be any worse than our current system. From my vantage point, fears what a government-run healthcare system might do pale in comparison with what the commercial insurance companies already do. In this series of posts, I intend to cite examples of this from my practice.
Practicing geriatric psychiatry affords an unusual perspective on this issue. On one hand, many geriatric psychiatry practices, mine included, to some extent already exist in a single payer universe. The vast majority of our patients are Medicare beneficiaries (about 95% for my practice), making Medicare the de facto single payer. On the other hand, Medicare patients usually have some form of supplement plan that covers their Medicare co-payment. Commercial insurance companies are the largest sponsors of such Medicare supplement insurance. Thus, a typical geriatric practice might receive 75% of its revenue from Medicare and face fighting with a dozen or more commercial insurance companies to collect the other 25%. Try to imagine the effort required to negotiate this mess, day to day. This brings me to the example I want to cite in this post.
Recently I hired a nurse practitioner for my practice. The processes for obtaining the requisite National Provider Identifier number (NPI) and Drug Enforcement Agency (DEA) controlled substance registration and enrolling her as a provider in Medicare and Medicaid were simple, straightforward, and reasonably quick. The government bureaucracies and contractors turned out to be fairly easy to deal with! The commercial insurance companies, in contrast, have been impossible. Each has its own byzantine provider enrollment procedure. And it’s not that the personnel in the provider relations departments don’t want to help. The problem is that the system is so confusing that they don’t understand all the issues; too often they do not know the answers or provide wrong information.
My experience with one particular plan is illustrative. This plan has a line of commercial HMO products, a Medicare Advantage plan, and two Medicare supplement plans. The provider relations department was very knowledgeable about the HMO and Medicare Advantage products, but they were unaware of the existence of the company’s Medicare supplement plan. It found myself in the position of needing to convince them of the existence of their company’s own product.
The next hurdle was even more vexing. They gave me clear instructions for submitting claims for the nurse practitioner to their HMO and Medicare Advantage plans, and told me to apply the same procedure for Medicare supplement claims. The instructions they gave me were incompatible with Medicare billing procedures. They directed me to submit claims to Medicare in a manner that would cross over to their plan without problems but would be tantamount to filing a false claim with Medicare. The people working for the insurance company were not conversant with the Medicare requirements related to the Medicare supplement product they sell. I am still waiting for clarification from the insurance company regarding the proper procedure.
Scenarios like this one are typical. There are too many plans with idiosyncratic and often contradictory rules and requirements that are constantly subject to change. If the plans’ own personnel do not understand their products, how are their members or Medicare beneficiaries supposed to? And what about providers? Medical practices may deal with ten insurance companies, each of which might offer five to ten plans. Frequently these plans’ mental health coverage policies are in conflict with Medicare regulations. Keeping up with all these payers is impossible.
The Obama administration has taken a helpful first step by requiring Medicare Advantage plans to offer fewer options that are less confusing to beneficiaries. This will also help providers by lessening the hassle they encounter and the expense they incur finding their way through the health insurance plan maze. Much of the administration’s hopes for financing healthcare reform depend upon savings realized by eliminating waste in healthcare. Consolidating the system ultimately to a single payer system, with one set of rules and one set of procedures, will accomplish this goal by eliminating the waste associated with the administrative costs of this confusing patchwork quilt of a non-system we currently live with.