Insurance is Driving Physicians Mad; Nearly Half Now Say They’d Prefer Single-Payer

Dr. Keith Paredes has seen it more times than he'd care to recall: A woman, bleeding heavily, comes to the ER. She needs an urgent surgical procedure, maybe even a blood transfusion, from a condition like untreated fibroids. She's there because she hasn't had a routine doctor visit for ages.

There are many reasons people put off going to the doctor. One of the big reasons is cost — a huge arc in the current debate about whether and how to repeal and replace Obamacare, which sought to increase the number of Americans with quality health insurance. Another is access, or finding a doctor who takes your insurance and has appointment openings. But whatever the reasons, the disconnect means that many people choose to become patients only in extreme circumstances and are then at the mercy of the system.

“It really debases and demeans and takes away your dignity to be shuffled around when you know you have something wrong with you,” said Dr. Paredes, an obstetrician-gynecologist in Lakeland, Fla., who practiced in a variety of healthcare settings before retiring two and a half years ago. “I think healthcare is something that should be available to everyone from cradle to grave.”

That’s one of the main reasons nearly half of the 500 doctors who responded to a February LinkedIn survey said they would support a single-payer healthcare system, or Medicare-like coverage for everyone, not just the elderly, instead of the current patchwork model of insurance coverage.

The reasons that patients delay care until they can’t wait any longer are complex. But a barrier doctors said they consistently see is a fragmented system: People either don’t have health insurance or can’t find a doctor who accepts their coverage.

The physician sentiment comes as Congress is locked in a debate about what to do about the Affordable Care Act. Republicans in the House last week pulled a bill that would have significantly altered the insurance landscape.

But for many physicians, the issue comes down to efficiency. In their responses, they cited the administrative hassle of working with multiple insurance companies, each with its own rules and billing procedures. And they pointed to some of the less visible costs, like patients who bounce from one healthcare provider to another as their health plans change.

A total of 48% of physicians said they would be in favor of single-payer healthcare, while 32% were opposed and 21% said they didn’t know.

Our survey was conducted Feb. 7-19 and reached 511 physicians in the U.S. A total of 449 respondents are currently practicing in patient care. They were chosen at random, and reflect a number of different specialties and years of experience.

And even though doctors acknowledged that they might take a financial hit under a single-payer system, many respondents said it would be more than mitigated by getting out of the collection business. In other words, even if they earned less, there would be more patient care and less of the aggravation that comes with negotiating with and tracking down payment from multiple insurance companies.

Billing and insurance related costs totaled $70 billion for physician practices in 2012, according to a study in the peer-reviewed journal BMC Health Services Research.

As many as 64% of doctors in LinkedIn’s survey said they have implemented measures to collect from patients with high deductible plans. One-third of respondents are offering payment plans and 26% are requiring payment up front. Nineteen percent have hired additional staff, like financial counselors, to handle payment issues.

Under the current system, patients who venture outside their insurance plan’s network of healthcare providers can find themselves on the hook for hefty copays. To help patients avoid that, doctors and their staff spend hours looking for in-network labs, pharmacies and physical therapists.

And then there’s the time spent dealing with insurance companies. More than half of the physicians in LinkedIn’s survey, or 54%, said their job includes negotiating with them, at an average of four hours per week: They have to call to get prior authorization to do a procedure. They have to call when their treatments are denied coverage. They have to change their prescribing plans when certain drugs aren’t covered.

“Time is money when you’re talking about those issues,” said Dr. Lori Andersen, a pediatrician in the greater Boston area.

In addition, while commercial insurance providers may be the most lucrative payers, they’re increasingly moving toward plans that require doctors to collect more money from patients before they can even submit a claim for reimbursement. As many as 29% of people with employer-sponsored health insurance are enrolled in a high-deductible plan, according to the Kaiser Family Foundation. And people with high-deductible plans are more likely to delay care for financial reasons.

“The U.S. system is very unique,” said Dr. Rohit Agrawal, a postdoctoral research fellow at Massachusetts General Hospital. “They spend the most in the world and they don’t get the best health outcomes. You have to provide holistic care, not just patchwork.”

There are also costs that are harder to quantify.

Few people remain with one insurance company their entire lives. Many people change plans as often as they change jobs. And as their careers advance, their medical information doesn’t always follow them. That means that patients may need to repeat tests, procedures and paperwork with each new medical visit. And without continuity of insurance coverage, people are also less likely to form a long-term relationship with a primary care provider.

“The patients I’m seeing in the emergency room, they’re referred from urgent care,” Dr. Andersen said. “There are no records. That creates very fractured care and very high service utilization.”

In addition, people without insurance can be pricey for the U.S. healthcare system. The cost of insulin, for instance, is nowhere as expensive as the cost of kidney damage from poorly-controlled diabetes.

“We see the people who are turned away from other places; we see the people who can’t get care other places,” said Dr. Sean Kivlehan, the associate director of the international emergency medicine fellowship at Brigham and Women’s Hospital in Boston. “People wait until they’re very ill. It’s way more expensive—significantly more expensive—to put a person in the ICU for a week at thousands of dollars a day.”

Doctors who are opposed to universal healthcare said they believe it would stifle innovation and reduce competition. Others said they fear it would give the government too much power over reimbursement rates or that they mistrust the government’s ability to create a viable single-payer system.

There is also a very practical reason a doctor may still prefer the free market. Unlike other countries with single payer healthcare, medical school in the United States is very expensive—79% of med students were graduating with more than $100,000 in debt, according to the Association of American Medical Colleges. US doctors need to generate a substantial income to pay that off—something that doctors in other countries don’t need to worry about.

“As a doctor, it’s really against my best interest to support single-payer healthcare,” Kivlehan said. “It reduces my earning potential. At the same time, it’s about human rights and taking care of people that need help—that is why I do this work.”

In their own words: Doctors offer their own perspectives on this topic

Reducing Healthcare Costs without Hurting Doctors or Patients

Health Care—a Shared Responsibility

American Physicians Want Medicare for All

Why a Government-run, Single Payer Healthcare Approach is Doomed to Fail

Photo Credits: @jingjingsoong / twenty20 and @meandering_mari / twenty20

?