It started again. Someone placed a long thread on Twitter about Medicare4All. Said someone’s heart is in the right place, but they sadly do not have a full understanding of Medicare and how Medicare is structured. I commented, and someone said something about a “Request For Papers.” It takes years to get anyone to listen to a female physician in the Academic medical leadership or to get published. So the blog post is my response with the papers. Frankly, I am the most qualified as a Family Medicine Physician and now Geriatrician to speak to this. I have cared for the full spectrum of the patient population and then spent the last few years only caring for Medicare beneficiaries. Even more qualifications: I have been a patient in the system and received the savings account devastating bills. I have avoided necessary care knowing the cost, even despite having some semblance of insurance.
Interestingly my first attempt ever at a blog post was this very long piece making the case for Universal Coverage (what many well intended souls advocate for when they tweet #Medicare4all). I also have already written about the dire need for Medicare Reform here. Feel free to do some background reading. For these purposes, and since this is a blog, I will keep it short, direct, and simple.
1) As a Democratic Society (ok that’s kinda debatable these days) and Nation founded on the concept that its citizens all have “certain unalienable rights; that among these are life, liberty, and the pursuit of happiness”, we should have a basic universal health system for achieving these unalienable rights.
2) Medicare’s payment structure has not been restructured since its inception and Medicare is failing the needs of both its beneficiaries and the physicians who serve them, and doing so with excessive financial costs to society.
- a. The Relative Value Unit calculation disproportionately rewards procedures (no matter how small) and high volume (or patient turnover) relative to time and cognitive services.
- b. Times have changed, technology has advanced, and the Medicare formula for covering care has not changed in over 40 years. Medicare encourages practicing medicine the way it was practiced in the 1970ies. It made sense then when we needed physicians taking the risk to develop new technologies and procedures to diagnose and treat things such as heart attacks or colon cancer. It was set up to encourage providers to give care in hospitals/ED’s and take risks. In 2018 however, the advances from the 1970ies have helped and now we have an entire generation of people aging/aged with cognitive disorders, major physical debility and chronic high care needs, almost none of which are hospital requiring. Today the way Medicare is structured is reflexive, short-sided, blind to advances in our technology with communication, and not what the population needs.
- c. Medicare is the reason there are not more primary care physicians, Geriatricians, and non-specialists who use their knowledge and time as their primary tool for diagnosing, treating and educating. If you pay someone to do one thing and not another, they’ll do what gets them paid (and their loans paid off). The lack of incentive to take the necessary time to build relationships with patients is also a large reason for the massive societal distrust of physicians. This is a tragedy as it has opened the path for highly unqualified and poorly trained persons who call themselves doctor to manipulate the public into paying them to provide their healthcare needs.
3) Medicare does get some things right, in particular recognizing the major differences in Inpatient (Hospital based) and Outpatient Care. It does this with Medicare A and Medicare B. So my official proposal will run with that. Inpatient care is fundamentally different from outpatient care. It is problem focused and acute. Whereas outpatient care must take into account the whole person, their goals and their realistic prognosis and should be aimed at prevention and keeping people out of the hospital/ED (it takes time more than fancy costly tests and procedures).
So here’s what needs to happen with Medicare for it to be turned into #Medicare4All.
On the Healthcare Delivery Side:
1) Eliminate the RVU system, all Billing Codes, and allow physicians to determine what kind of care is needed, what is medically relevant to document, and which Electronic Medical Record to use as the national EMR.
2) Provide student loan repayment for those physicians who choose to stay within the new Medicare4All system for a minimum number of years.
3) Physicians lead the team, make the decisions about what is medically necessary or not, and no physician gets paid less than a lower trained provider. So for example, whatever the specialty, no nurse practitioner or physician assistant in the Medicare4All gets paid more than the lowest paid physician. Compensate persons fairly relative to their level of expertise and training.
4) Hospital based physicians (inpatient, ED, surgeons, etc) under Medicare A are salaried for their inpatient/OR time relative to the risk associated with their work and years experience. Outpatient based practices (primary care or specialty consults) get paid from the Medicare B pot and should be allowed to set their own prices, whether it be just an hourly rate OR a monthly subscription such as with Direct Primary Care.
On the Healthcare Receiving Side: The patients/citizens/beneficiaries.
1) Everyone has “catastrophic coverage”. Meaning if a hospitalization or visit to the ED is needed, aside from a possible under $100 per day copay for hospitalizations lasting more than 7 days, the healthcare that falls under Medicare part A is covered in the Medicare4All system. Pregnancy and post-partum maternity care are also all covered under Medicare part A fully.
2) To allow for patient autonomy, choice, and better competition among physicians, Medicare B will be turned into a Health Savings Account (HSA) for every beneficiary. The yearly amounts put into this will be pro-rated by age as costs of care per person per year increases throughout one’s lifetime. For example, from birth – 18 years it could be $1000 per year into the HSA. By the time one is in their 70ies and up, it will need to be closer to 4,000$ per person per year. From that HSA, patients can choose to spend on their primary care needs, outpatient prescription drugs and elective care based on what physicians/practices are meeting their needs. Personally, I would choose a Direct Primary Care and pay likely under 50$ per month from my HSA for myself and my son to have access to physicians and our primary care needs met (without any interference from an insurance company…..and currently medicare is an insurance company). And much of what we would receive in care would come from non face-to-face provider time in communication utilizing technology (phone, text, email).
3) All vaccines, health education, and recommended preventative diagnostic tests (mammogram q 2 years at age 40, colonoscopy q 10 years starting at 50, pap smears, etc) will be covered and subsidized.
There are plenty of brilliant economists, epidemiologists, all sorts of “ists” who could be brought in to sort out the logistics, math, tech, necessary taxes (mind you if you’re not paying for employer based insurance than a small tax increase will still bring you out ahead). But this is where we, as a nation, should start if we are going to keep touting #Meidcare4All as the rally cry for Universal Coverage. If we don’t revamp Medicare and it does become the universal Insurer, then it will be a costly and epic failure for the health of our nation.
And yes, there are many more ideas I have and details that I can’t address in a blog. But we have to start somewhere.