I’m an MD who trained in NYC. I have also had emergency surgery in the NHS at one of their most prestigious hospitals in London and so I feel like I’ve seen the system a little bit from the inside.
It was far cheaper for me than it would have been as a Brit in the USA, but the standard of care was lower. They didn’t have some technical and staffing resources late in the afternoon that would be a baseline in any of the hospitals I’ve been at in the USA. The English doctors were just kind of apologetic and bashful about it, talking to someone they knew was an American doctor who knew what kind of specific diagnostic algorithm was appropriate.
The NHS hospital did have really excellent amounts of ancillary staff. Someone brought coffee and tea to me like 3-4 times a day, it wasn’t hard to get my luggage delivered to my bed, etc. Not like that in the USA from what I’ve seen.
The NYC hospitals are somewhat financially strained as it is. Especially the public hospitals (Bellevue, Elmhurst, Metropolitan).
Also related would be care at the VA hospitals, which is slower/worse than care at NYC flagship hospitals. But as a society we don’t want to prioritize or pay for good care for veterans, so it is what it is.
I predict this will continue to basically just produce a more two-tiered system in the US. Most doctors who have a choice (large group practices) will take the wealthy patients with private insurance, and the big hospitals and whomever else who don’t have a choice will be forced to accept the NY single payers (basically the existing model, where the poor and 65+ are already covered under Medicaid and Medicare already). It will likely strain these systems even further, as reimbursements from Medicaid/Medicaid are insufficient to run large health systems which depend on higher rates from private insurers (payor mix). Good luck there.
In NYC even more physicians and group practices will try to go to alternate models such as cash-only. Try being on Medicaid or Medicare and finding an outpatient psychiatrist in NYC now as it is. This will extend to more PCPs, chronic disease specialists, etc.
Some patients will get better and more affordable care, but some will also get much worse care. It will be interesting to see what happens. I’m not necessarily opposed, but this is absolutely not going to be a clear and decisive win on all fronts as some commenters are suggesting. The US healthcare system, if you have private insurance, is the best in the world already in terms of level of service and access to rapid specialty and high-end care.
I'm on NY State insurance rn while unemployed and it fucking owns. All the doctor's appts and procedures I've had the last year or so have been amazing, mostly through Langone, and the doctor's have been super thorough and attentive.
It's the highest number of (much needed) appts Ive had in the last 10 years combined and at 0 copay. Yes, taxes, but idgaf seeing as the private employer based insurance I had took a big chunk out of my checks, had to pay co-pays, and I had to pay out the ass for my prescriptions.
This is a huge win if passed for anyone in the state, regardless of income, seeing as it would be a huge safety net. The rug could pulled on anyone of any background tomorrow, yet they'd have their covered in the best way possible.
Nice. Yeah maybe this will be a win. I’m overall more for it than against it. Just think there are some downsides. Glad to hear you have had a good time on the NY State insurance. Is it Medicaid? Langone actually has the best (most private) payor mix of any of the hospitals in NYC, I believe primarily from geographic reasons. Did you get to compare to Bellevue at all? Curious on your perspective there. Hope you’re doing okay.
Thanks man. Doing alright and hope the same for you.
It is medicaid and Langone's network is actually spread throughout the city, even at Bellevue! Actually got an appt there coming up and the Dr I'm seeing there has been the best. Top notch
This is a good take. Single payer might work in the USA using HMO plans funded by taxes, income/asset linked tiers of coinsurance, tax increases, major efficiency corrections, reduced barriers to entry, and mix of deregulation and regulation to increase competition.
Also, the US healthcare system is the excellent and one of the world's best if :
A) you have good insurance or medicaid/medicare in the right place.
B) you have transport to potentially drive some distance to deal with occasional wait times or to find in-network providers
C) you can navigate the sometimes byzantine billing nightmares that can occur where your coverage is denied on medically necessary or contractually covered care; or your enrollment in a subsidized program is denied, late; or you are indigent, incapacitated or elderly need an advocate to assure you get enrolled in correct coverage.
So it depends what you mean by 'best'.
In most developed countries, if your situation is ideal you can get fantastic healthcare, and that seems to be the point you are making.
There are some niche fields where the USA is demonstrably the best - pediatric oncology surgery, some difficult transplants, and novel cancer therapies come to mind. But I think it is hard to argue that it is anywhere near the best on the metrics usually used to judge a healthcare system, which other people have posted about.
In my experience, it also suffers from thinking it is the best and patients expecting it to be best. I have seen some patients get quite excessive and even unusual treatment in hallowed healthcare institutions in the USA.
If we go by data, the US healthcare system is the most expensive (not arguable) and is not even in the top 5 among developed countries in the most important measures. Also a doc, though that is not really relevant for this discussion.
one of these references is from an US insurance company who you would think would be biased for US healthcare
I said “if you have private insurance,” which I think is the key qualifier. One of the other commenters expanded upon it well below.
I’m not making an argument for cost-effectiveness either.
We can get private insurance to pay for elective surgeries, new medications, etc. that are either not covered in other countries or have extremely long wait periods. And the higher reimbursement I think is helpful for providing staffing and paying for equipment that they (in my admittedly n of 1 experience) simply didn’t have for me. I suppose it is a tradeoff.
I don't think the NHS is a great example... things can surely be better than that.
Incentives are a complicated issue in healthcare.
In Australia there is a 'two-tiered' system in the sense that there is a large public system funded federally and by states that provides access to anyone and everyone, and a private system where most people have private insurance and also pay additional fees. There is no insurance linked to employment.
Primary care can be accessed for free or depending on where you live, often involves paying a gap for each visit.
What doesn't happen is that all the best and most experienced doctors/nurses go and work in private. Almost all the doctors worth seeing work in the public system as well. Why? Well, it differs for each person but some combination of status, access to a professional network, collegiality, access infrastructure and expertise, job flexibility and the fact that it acts as a referral stream to 'take patients private'. The facilities in the public system are 'the best' becaue they still handle all the complicated and difficult care (Oncology, Transplants, Dialysis etc), despite what the private hospitals say in their brochures.
My point is that if you make some adjustments, bake in some infrastructure funding, and make smart use of non-financial incentives, you can avoid creating a two-tiered system and build enduring capacity and quality in a single payer system.
> It will likely strain these systems even further, as reimbursements from Medicaid/Medicaid are insufficient to run large health systems which depend on higher rates from private insurers
Time ran an article a few years ago about hospital billing and whatnot. One of the things that they pointed out was that Medicare reimbursement rates were based on the actual cost to provide the service. If the problem is that Medicare doesn't pay enough extra to subsidize indigent care then having medicare-for-all would address that as it would reduce the number of uninsured.
> In NYC even more physicians and group practices will try to go to alternate models such as cash-only. Try being on Medicaid or Medicare and finding an outpatient psychiatrist in NYC now as it is. This will extend to more PCPs, chronic disease specialists, etc.
As opposed to what's already happening? Keep in mind that the southeast part of San Francisco already has relatively poor access to health care. A few years ago Sutter decided to revamp Saint Luke's hospital in Bernal Heights. St. Luke's used to be a community hospital where you'd go for primary and emergency care. Sutter changed that all up and stocked the offices almost exclusively with specialists (because that's where the money is).
> The US healthcare system, if you have private insurance, is the best in the world already in terms of level of service and access to rapid specialty and high-end care.
I'm sorry, what? Back when I had Blue Cross/Shield I had to book an ultrasound something like three months in advance. In San Francisco. At the time I was seeing a fee-for-service GP. If I'd wanted to switch to an in-network GP the wait at UCSF was like nine months. Finding a GP that takes both new patients and insurance was not easy – in fact I didn't as my GP was amazing.
1. It’s just a fact that if all reimbursement was currently Medicare-level, the existing hospital systems in NYC would run a massive deficit and couldn’t provide the services they do now. They wouldn’t be in business barring massive reductions in staffing, hours, services, salaries, etc.
I don’t know what you read in the NYT but this is well-known in healthcare. Hospitals lose money on Medicaid/Medicare patients in general and make it up on private insurance (also in general) in order to hopefully pull in a surplus each year. Look up the idea of “payor mix.” Private insurance reimbursement varies widely but is typically a multiple of Medicare/Medicaid.
2. Yes - it is already happening. I think it would likely get worse. I don’t think single payer insurance is going to cause a renaissance of PCPs, especially if the overall reimbursement for that kind of service goes down. Probably the other direction. Maybe I’m wrong.
3. I’m not exactly sure what happened at UCSF with your ultrasound. Not familiar with SF really. But you can look up mean wait time for most elective procedures in the USA vs. Canada or USA vs. the UK. Or access to new therapies.
From my experience working at a private insurer, (1) is, unfortunately for the body politic, more complicated than meets the eye.
The payor mix narrative has attractive qualities: it makes the private insurance companies sound like they're subsidizing care, the logical implication is that if we made these atlases shrug with M4A, the local PCP would go bankrupt. In reality, the narrative is at best reductionist and at worst misleading. But it rhymes with the truth, so it has a lot of mileage.
Private insurance reimbursements are negotiated in multiples of medicare because insurers and hospital groups alike expend tremendous amounts of money each year in administrative costs to challenge claims back and forth.
A surprising proportion of private insurance payouts are never reimbursed at the negotiated price. But hospital groups are OK with this, because it allows them to deduct the difference as a loss. Accountants rejoice!
Medicare/Medicaid prices are "low" because (1) the government has a strong bargaining position, (2) the population served by those fees has confounding variables of age and disability which raises the relative price of care (3) the government does not play claim-challenging games anywhere close to the extent of private insurers.
Private insurance companies and big hospital groups benefit the most from the status quo, and have the most to lose from medicare for all. But it would not be doom and gloom.
Medicare can adjust their prices to match the new population and tax base, hospital groups can stop running mini debt collection agencies, etc. There are real cost savings in M4A.
I think what's most likely to happen is an expansion of medicare advantage, (ma4a?). Since it's a program that effectively nationalizes the existing regime of private insurance.
> I don’t know what you read in the NYT but this is well-known in healthcare.
Time Magazine, not the New York Times. I don't know what you think but it's commonly known that the chargemaster is indeed bloated to cover things like indigent, uninsured patients. Here's the thing, people without money use the emergency department for primary care because they cannot be turned away. That's expensive. Getting those folks covered and away from the ER absolutely reduces costs.
> By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries.
So I'm not sure what you're talking about. Obviously Medicare doesn't exist to guarantee a profit. Whatever fee schedule is negotiated with private insurance companies does not actually reflect the cost of providing a service – the negotiated rates include things like profit and taking care of patients who can't pay.
> I’m not exactly sure what happened at UCSF with your ultrasound. Not familiar with SF really. But you can look up mean wait time for most elective procedures in the USA vs. Canada or USA vs. the UK. Or access to new therapies.
Dunno what to tell you. My experience was back in the mid-00s, and I doubt anything's improved since then. It didn't then (and doesn't now) take much effort to find people struggling just to find a doctor that takes insurance. I couldn't tell you why UCSF was so short of ultrasound techs, but yeah I potentially could've found an outside (but still in-network) provider on shorter notice. But then I would've been on the hook to deal with insurance billing hell. Even (especially) with UCSF I was getting screwed by their chaotic billing. Labs that were part of an office visit were officially covered by my insurance but as they were billed separately they were not considered part of the office visit (and therefor not covered).
Average wait time for an appointment as a new patient 24 days, worst metro area was Boston at 52 days. 45 days to see a cardiologist in Boston, 51 days to see an ob-gyn in Philly. We're already rationing care (by financial means instead of need), and that's largely due to insurance.
While there was a multi-month waitlist for a GP that took new patients and insurance, the fee-for-service practice I used could typically schedule even new patients same day or same week at least. Hell, their rates weren't even obscene as their practice was almost entirely MDs and a single receptionist. They didn't have to fund an army of people to battle insurance bureaucracy. Over the years my GP went out on her own practice for a bit, and then as her circumstances changed she went back to a practice she'd been with years before. From a patient POV the biggest problem she had was finding competent non-degreed office staff.
I can't say for certain that single payer (or even just a dominant federal government run system) would crate a "renaissance of PCPs", but anything that reduces the administrative burden will reduce the cost of running a medical practice and by extension will reduce the urge to focus on specialties.
It was far cheaper for me than it would have been as a Brit in the USA, but the standard of care was lower. They didn’t have some technical and staffing resources late in the afternoon that would be a baseline in any of the hospitals I’ve been at in the USA. The English doctors were just kind of apologetic and bashful about it, talking to someone they knew was an American doctor who knew what kind of specific diagnostic algorithm was appropriate.
The NHS hospital did have really excellent amounts of ancillary staff. Someone brought coffee and tea to me like 3-4 times a day, it wasn’t hard to get my luggage delivered to my bed, etc. Not like that in the USA from what I’ve seen.
The NYC hospitals are somewhat financially strained as it is. Especially the public hospitals (Bellevue, Elmhurst, Metropolitan).
Also related would be care at the VA hospitals, which is slower/worse than care at NYC flagship hospitals. But as a society we don’t want to prioritize or pay for good care for veterans, so it is what it is.
I predict this will continue to basically just produce a more two-tiered system in the US. Most doctors who have a choice (large group practices) will take the wealthy patients with private insurance, and the big hospitals and whomever else who don’t have a choice will be forced to accept the NY single payers (basically the existing model, where the poor and 65+ are already covered under Medicaid and Medicare already). It will likely strain these systems even further, as reimbursements from Medicaid/Medicaid are insufficient to run large health systems which depend on higher rates from private insurers (payor mix). Good luck there.
In NYC even more physicians and group practices will try to go to alternate models such as cash-only. Try being on Medicaid or Medicare and finding an outpatient psychiatrist in NYC now as it is. This will extend to more PCPs, chronic disease specialists, etc.
Some patients will get better and more affordable care, but some will also get much worse care. It will be interesting to see what happens. I’m not necessarily opposed, but this is absolutely not going to be a clear and decisive win on all fronts as some commenters are suggesting. The US healthcare system, if you have private insurance, is the best in the world already in terms of level of service and access to rapid specialty and high-end care.