Editor's Note -
There is a great deal of apprehension among many physicians and physician groups (assuming corporate "persons" can be apprehensive) about what a "universal" or "single payer" health care plan would mean for their own incomes.
The following paper authored by Maine AllCare volunteer Dan Bryant raises real questions suggesting that these fears are over-blown, or just plain wrong.
Single-payer Health Care: Financial Implications for a Physician
Abstract
When considering proposed reforms of the U.S. health care system, some physicians dismiss the single-payer model (Medicare for All or state-based universal health care proposals) out of concern that their reimbursement and thus their income would be reduced. This study is an effort to quantitate that concern in the case of state-based plans and, in so doing, to suggest a template for evaluating the financial consequences for physicians of single-payer health care reform in general. To put the data into concrete, practical terms, I envision a hypothetical primary care physician's practice and develop its plausible financial components in the present multi-payer system and in five proposed state-based, single-payer systems. The calculations reveal that in all five single-payer plans evaluated, the hypothetical physician's Total Net Income (take-home pay) would exceed that in the current multi-payer system. Whether these results apply to actual practices or not, they suggest that, when considering the financial impact of single-payer reform on their practices, physicians should consider all the financial consequences of such reform, not just the proposed reimbursement level. More quantitative analyses of these important financial variables in different practice settings must be pursued.
The single-payer health care model (publicly funded, privately provided universal health care), both national and state-based, has been much discussed in the United States since the early 1980s,1 and polls2,3 have shown increasing public support for the concept. Physician support has also been growing,4 manifested by Physicians for a National Health Program advocacy, the American College of Physicians’ recent announcement5 of openness to a single-payer system, endorsement by the Society of General Internal Medicine,6 and the Vermont Medical Association's 2020 resolution7 in support of a “single-payer national health program.” Not all physicians support such reform, however, as indicated by the American Medical Association's vote at its annual meeting in Chicago in 2019 to reaffirm its opposition to a single-payer health care system, and by the membership of medical organizations such as the Association of Neurological Surgeons and the Congress of Neurological Surgeons in the (anti-Medicare for All) Partnership for America's Health Care Future. Reasons for physician suspicion of single-payer plans are many, including concerns over rationing, unaffordability (presumably for both physicians and patients), patient privacy, unconstitutionality, and so forth.8 A recurring concern is potential loss of income due to reduction of provider reimbursement, perhaps to Medicare levels. A 2019 Medscape poll of attitudes toward Medicare for All found that “[m]ore than half of providers across all four categories said they were concerned or somewhat concerned that Medicare for All could reduce physician compensation. The breakdown for this worry was 59% for physicians….”.9 Physicians may find it unseemly to complain publicly about reimbursement concerns, but in my private conversations with colleagues, those concerns come up often.
Advocates for single-payer reform counter this focus on reimbursement by pointing to the potential for practice savings in a single-payer system: simplified billing, relief from responsibility for a health benefit for themselves and their employes, and reduced malpractice and other costs. However, despite national studies10,11 of excessive billing and insurance-related (BIR) expenses for physicians in the current system, a study of the effect of Canada's single-payer Medicare system on physician income,12 and a study of the effect of the Medicare for All model on physician income in general,13 to date, there have not been quantitative studies of the degree to which these savings might—or might not—compensate for reduced compensation in an individual practice. The current study is an effort to develop a format for addressing that deficiency.
Methods
To examine the financial implications for physicians of implementation of a single-payer plan, I studied state-based plans because they provide more funding detail than national plans do, and for reasons of space, I limited the number to five recent or widely discussed plans. (No calculations were made prior to selection, which was thus unbiased.) I then developed a simple, plausible practice scenario—a hypothetical solo primary care practitioner's LLC practice supported by a staff of three: one full-time equivalent (FTE) each for nurse, receptionist, and bookkeeper (BIR department). (According to a 2014 study,14 the ratio of clinical and administrative staff to physician in one- or two-person practices is 5:32. If this ratio, rather than 3:0, were used in this analysis, the physician's Total Health Insurance-Related Expenses would be greater in the systems studied.) This model is not meant to capture the experience of an actual current practice, or to apply to practices in general, but rather to suggest how medical practices, specialist as well as primary care, could compare their finances in the current multi-payer system with what they might be in single-payer systems. In Column 1 of the Table 1, relevant Financial Elements of the hypothetical practice are listed, while the subsequent columns contain corresponding estimates for the practice in the Current System (multi-payer) and in five proposed Single-Payer Plans. Initial Net Income is the difference between the Gross Practice Income (set arbitrarily at Medicare rates) and Total Expenses in the various systems, while Total Net Income takes into account New Potential Net Income from freed-up administrative time.
| Financial Elements | Current System | Single-Payer Plans | ||||
|---|---|---|---|---|---|---|
| ColoradoCare (2015) | Mass. Health Care Trust (2021) | Ohio Health Care Plan (2019) | Penn. Health Care Plan (2017) | Green Mountain Care (2011) | ||
| Gross Practice Income | $500 000 | $458 000 | $458 000 | $458 000 | $458 000 | $458 000 |
| Staff Health Insurance Cost | 37 735 | 0 | 0 | 0 | 0 | 0 |
| Physician Health Insurance Cost | 21 342 | 0 | 0 | 0 | 0 | 0 |
| BIR Expense (bookkeeper) | 44 686 | 22 343 | 22 343 | 22 343 | 22 343 | 22 343 |
| Physician Personal Income Prior to Taxes | 250 000 | 289 420 | 289 420 | 289 420 | 289 420 | 289 420 |
| Single-Payer Payroll Tax | 0 | 11 258 | 9258 | 4334 | 11 258 | 14 410 |
| Single-Payer Gross Receipts Tax | 0 | 0 | 0 | 13 740 | 0 | 0 |
| Physician Single-Payer Income Tax | 0 | 28 942 | 26 942 | 4471 | 8683 | 0 |
| Staff Single-Payer Income Tax | 0 | 0 | 0 | 0 | 3377 | 0 |
| Total Health Insurance-Related Expenses | 103 763 | 62 543 | 58 543 | 44 888 | 45 661 | 36 753 |
| Non-Health Insurance-Related Expenses | 146 237 | 146 237 | 146 237 | 146 237 | 146 237 | 146 237 |
| Total Expenses | 250 000 | 208 780 | 204 780 | 191 125 | 191 898 | 182 990 |
| Initial Net Income | 250 000 | 249 220 | 253 220 | 266 875 | 266 102 | 275 010 |
| New Potential Net Income | 0 | 12 515 | 12 716 | 13 402 | 13 533 | 13 811 |
| Total Net Income | $250 000 | $261 735 | $265 936 | $280 277 | $279 635 | $288 821 |
No one figure can represent all practices, so the starting figures used in the table for the Current System are gross roundings of findings from a 2020 primary care study indicating average income for primary care providers of $241 728 (all dollar amounts in U.S. Dollars) and average gross revenue of $542 19015: Gross Practice Income, $500 000; Physician Personal Income, $250 000; and resulting Total Expenses, $250 000. The revenues are approximated as a mix16 of Medicare, Medicaid, and commercial insurance payments averaging 22% from Medicare (0.22 × $500 000 = $110 000), 17% from Medicaid (0.17 × $500 000 = $85 000), and 61% from commercial insurance and “other” (0.61 × $500 000 = $305 000). Other pertinent financial elements for the Current System and the Single-Payer Plans are developed as follows and displayed in the remainder of the Table 1.
In the Current System, the physician/owner's expenses relating to health insurance coverage (Total Health Insurance-Related Expenses) consist of three elements: Staff Health Insurance Cost, Physician Health Insurance Cost, and BIR Expense (bookkeeper).
Staff Health Insurance Cost is taken from Kaiser Family Foundation data17 showing that in 2020, an employer's share of family coverage for an employee was $15 754 and for individual coverage was $6227. If two of the staff had family coverage and one had individual coverage, that employer cost for the health benefit would total $37 735. Physician Health Insurance Cost is assumed to be that of a family plan, the average cost of which, according to the Kaiser Family Foundation, was $21 342 in 2020. Total health insurance cost is thus $59 077.
BIR Expense is considered that of the bookkeeper, whose salary, according to Salary.com,18 would have been $44 686 on average in 2021, or a BIR cost that in this simple scenario is 9% of revenues ($44 686/$500 000). Additional costs of billing software, consultations, and physician time spent on negotiating contracts, prior authorizations, appeals of payment denials, etc, are not included and would increase BIR costs to closer to the 13%19 to 14%20 of revenues reported in the literature.
Given total expenses of $250 000 and Total Health Insurance-Related Expenses of $103 763, the remaining Non-Health Insurance-Related Expenses (labor costs, rent, utilities, etc) is calculated to be $146 237 ($250 000 minus $103 763).
Initial Net Income is calculated as Gross Practice Income minus the sum of Total Health Insurance-Related Expenses and Non-Health Insurance-Related Expenses.
Five proposed state-based Single-Payer Plans, selected, without an eye to results but merely from among those that include enough specifics to make the needed calculations, and limited to five because of space limitations, are then considered: ColoradoCare,21 Massachusetts Health Care Trust,22 Ohio Health Care Plan,23 Pennsylvania Health Care Plan,24 and Green Mountain Care (Vermont).25
In all five of these systems, to address the concern about reduced reimbursement, I assume the physician would be paid at Medicare rates, resulting in a reduction in Gross Practice Income from the original $500 000 to $458 000. This figure is arrived at by combining the payer mix noted above with the estimate26 that private insurers pay 143% of Medicare rates for physicians and data27 showing that Medicaid pays 63% of Medicare rates for physicians in my state of Maine specifically. Thus, this physician's reimbursement for Medicare patients would stay at $110 000, for patients previously on Medicaid would increase from $85 000 to $135 000, and for previously commercially-insured patients would decrease from $305 000 to $213 000; and the $500 000 total would, as a result, decrease to $458 000—a decrease in reimbursement of $42 000, or 8%.
BIR Expense in the single-payer plans is assigned a value half that of the Current System expense ($22 343). This conservative reduction is a rough average of published estimates of BIR savings of 75%,28 of “on the order of one-third to one-half of current spending”,29 and of “between 33% and 53%”30 due to simplification of billing.
Given BIR Expense of $22 343 in the single-payer scenarios, and Non-Health Insurance-Related Expenses of $146 237, the Physician Personal Income Prior to Taxes in those scenarios is $289 420 ($458 000 minus $146 237 minus $22 343); that is the income to which the Physician Single-Payer Income Tax rates specified in the various plans are applied.
The Single-Payer Payroll Taxes1 and the Single-Payer Gross Receipts Tax2 are also those resulting from the rates specified in the various plans. According to Salary.com,31 the average salary of an office nurse is $53 343 and of a physician office receptionist is $36 890. Total payroll for the three staff (0.5 FTE bookkeeper) is thus $112 576. It is assumed the physician/owner will pay their employes’ share of payroll taxes in the various plans (but not in the Current System). For purposes of this study, other payroll expenses (FICA, workers’ compensation, etc) are disregarded. Because the practice is set as an LLC, the physician/owner's income is assumed to “pass through” to their personal Form 1040 and thus be subject to income but not payroll tax.
Single-Payer Income Taxes imposed by most of the plans examined are those calculated from the rates specified in the respective plans3. Only one of the plans (Pennsylvania) imposes an income tax on workers, which, at a rate of 3%, comes to $3377 for the three employes. It is assumed that the physician would pay that tax.
New Potential Net Income is income from billable hours freed up by reduced insurance-related administrative time. According to Woolhandler and Himmelstein,10 writing in 2014, “The average doctor spent 8.7 h per week (16.6% of working hours) on administration.” If just two of these hours per week were freed from insurance responsibilities, they could be spent seeing patients instead, adding approximately 100 newly billable hours per year. At $230 per hour (Gross Income of $458 000 per year equates to $230 per hour for a physician working 40 h a week), that would produce additional gross income of $23 000. Given that these new patient encounters would generate new expenses, New Potential Net Income is reduced to the product of this amount and the ratio of Initial Net Income to Gross Practice Income.
Results
As shown in the Gross Practice Income row of the Table 1, as a consequence of setting remuneration at Medicare rates, Gross Practice Income is lower in the Single-Payer Plans than in the Current System, while the Physician Personal Income Prior to Taxes row income is higher due to the savings listed in the Staff Health Insurance Cost, Physician Health Insurance Cost, and BIR Expense (bookkeeper) rows. Those Total Health Insurance-Related Expenses, together with the Non-Health Insurance-Related Expenses, are then subtracted from Gross Practice Income to produce the Initial Net Income. It is evident that in four of the state-based single-payer schemes, Initial Net Income would be greater than the $250 000 designated in the Current System, while in one (ColoradoCare) it would fall $780 short. In addition, if some of the time estimated to be freed up from health insurance-related duties in the single-payer plans were spent on seeing additional patients, Total Net Income would be higher in all.
Discussion
If a single-payer plan at the national level or, as discussed in this study, state level were brought before the voters, physician support would be essential to its passage and long-term success. In order to win that support, single-payer plan advocates would have to address physician concerns about single-payer, such as those mentioned in the introduction to this article. This article focuses on one of the major concerns, potentially reduced provider reimbursement, and in the analysis sets reimbursement rates to Medicare's to examine that concern. As noted in the Methods section, on average, private insurers pay 143% of Medicare rates, meaning that a single-payer plan would pay about 70% of commercial rates. But the physician in this study, like most physicians, sees a mix of Medicare, Medicaid, and commercially insured patients and would experience only an 8% decrease in reimbursement. (In contrast, a Rand analysis32 found that “the all-payer average rate under the Medicare for All plan in 2019 would be 107% of current Medicare rates for physician payment,” a rate that, if applied in this study, would produce an even larger Total Net Income than that found.) What is more important than reimbursement, though, is how much of that reimbursement is left for the physician after they have paid all the expenses, including Total Health Insurance-Related Expenses, of the particular system in which they are working.
As shown in the table, in the present multi-payer system, the hypothetical physician/employer has three main health insurance-related costs: Staff Health Insurance Cost, Physician Health Insurance Cost, and BIR Expense (the cost of a full-time bookkeeper to handle billing for services covered under multiple payers’ various plans). In the single-payer plans, the first two costs are eliminated and replaced by various taxes, while the BIR costs are halved, representing a savings of 5% of revenues ($22 343/$458 000). This is actually a more modest administrative savings than the median single-payer administrative savings of 8.8% found by Cai and colleagues in their systematic review33 of projected costs of single-payer health care financing.
The funding taxes proposed by single-payer plans are the basis for one of single-payer opponents’ major arguments. In the proposed state plans reviewed for this study, the combined taxes for which the physician would be responsible run from $14 410 (Vermont) to $40 200 (Colorado). As draconian as those sound when quoted out of context, the highest total taxes approximate what this physician pays now just to insure staff, and they are far less than their current Total Health Insurance-Related Expenses ($103 763).
Estimation of payroll tax is especially difficult in analyses such as this because few plans define the phrase, and application of the tax would vary with the business structure of the physician's practice. For this study, the LLC model was chosen because of its relative simplicity and because, according to the American Medical Association,34 the LLC or S Corporation model is the business structure for more than half of private practices. In the C Corporation model, the physician/owner's pay would be included in payroll.
The time saving referenced in the New Potential Income row is of interest not only because it could allow the physician to increase their income further, but because it could help address the issue of physician burnout, found to be largely related to the administrative complexity of our present system.35 This time saving would also help to address the potential physician shortage problem discussed by the Congressional Budget Office in its 2019 report on single-payer health care systems.36
As seen in the Initial Net Income row of the table, when Total Health Insurance-Related and Non-Health Insurance-Related Expenses are subtracted from physician Gross Income, the physician's Initial Net Income in four of the five single-payer plans examined would match or exceed Initial Net Income in the current health care system; Total Net Income would do so in all. Some could argue that the physician should shift all their commercial premium savings to staff in the form of increased wages, but, in the face of decreased reimbursement, the physician does pay the staff's health care tax expenses that replace previous premiums; and in general, when other practice expenses are reduced, physicians don't automatically increase staff wages. Of course, given the favorable physician finances found in this analysis, the physician would have the option of sharing additional savings with staff.
It should be noted that in this study, I have used conservative figures for BIR costs as a percentage of revenue (9% in the Current System: $44 686/$500 000) and for percentage decrease in BIR costs (50%) due to single-payer efficiencies. However, the most sophisticated empirical research suggests that total BIR costs currently represent 13 to 14% of revenue (see Jiwani and Kahn references) and that the percentage of BIR savings in a single-payer system could be as much as 75% (see Morra reference). If those higher BIR costs and savings turn out to apply, this hypothetical physician's Total Net Income could be significantly higher than that found. In addition, with this kind of reform, demand for primary care is likely to increase modestly (due to supply-side constraints37) and doctors are likely to prioritize sicker patients. Both are likely to increase revenue, and, as many primary care physicians are women and members of minorities, this would help to address gender and racial pay gaps in medicine. Gaffney, Himmelstein, and Woolhandler, in their critique of the Congressional Budget Office estimate of physician finances in a national single-payer system, conclude that “payments to clinicians would rise in all five scenarios…. We estimate this translates into an additional $39 816–$157 412 in revenue per practicing physician”.38 Indeed, HR 1976, the Medicare for All Act of 2021 (Section 612), specifies that a “physician practice review board” will assure “fair reimbursements for physician-delivered items and services.” The specifics of how physicians in general, including salaried employes, will be affected is up to legislative specifics and individual corporations, yet it is possible to design a system in which average physician pay increases under single-payer.
This study could be followed up with two further projects to make the conclusions more relevant to actual practice situations: (a) companion studies of physicians in other practice settings, such as partnerships and hospital employment, and (b) development of an interactive spreadsheet allowing physicians to enter their own financial numbers (expenses, gross and net income, payer mix, etc) and see what their automatically calculated incomes might be in various single-payer plans.
Limitations
1.
The results of this analysis, although not its form, depend to a large extent on the assumptions made.
2.
The plans studied did not include specific costs, meaning that actual funding needs could not be verified.
3.
To simplify this analysis, a primary care setting was chosen. Results could be different for specialty practices, in which procedures play a large role, but the process used here should be applicable. Also, a number of potentially significant variables were ignored: additional savings for the physician in a single-payer plan, such as reduced malpractice, disability, homeowner's, auto, property, and workers’ compensation insurance, and elimination of un-reimbursed care; other taxes (excise, inheritance, etc) mentioned in some of the plans; and other physician income (eg, investments, side businesses, rents) that could be subject to health care taxes.
4.
The results of this study may not be generalizable to other practice models for two reasons: (a) as pointed out in the introductory section and the Discussion section, the solo practitioner LLC model chosen for the study is unique, and results could be different for physicians practicing in partnership, corporation, hospital employment, salary or capitation arrangement, group or specialty practice, or other settings or for physicians with a different payer mix; and (b) almost half of the health insurance-related savings found result from elimination of the health benefit for staff, a benefit that some practices may not offer or may not offer to the same degree.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Footnotes
1.
Colorado: “With premium tax rates of 3.33% for employees, 6.67% for employers…”; Massachusetts: “[1] An employer payroll tax of 7.5% will be assessed, exempting the first $20 000 of payroll per establishment… [2] An employee payroll tax of 2.5% will be assessed, exempting the first $20 000 of income…”; Ohio: “Receipts from taxes levied on employers’ payrolls to be paid by employers. The tax rate in the first year shall not exceed three and eighty-five hundredths percent of the payroll”; Pennsylvania: “… a tax of 10% is imposed on payroll amounts generated as a result of an employer conducting business activity within this Commonwealth”; Vermont: Option 1B Standard Plan: 9.6% Employer, 3.2% Employee [total 12.8%]
2.
Ohio: “Receipts from additional taxes levied on businesses’ gross receipts. The tax rate in the first year shall not exceed three per cent of the gross receipts.”
3.
Colorado: “10% for non-payroll income”; Massachusetts: “A payroll tax on the self-employed of 10% will be assessed, exempting the first $20 000 of payroll per self-employed resident” [Interpreted as equivalent of income tax]; Ohio: “Receipts from additional income taxes, equal to five per cent of all of an individual's Ohio adjusted gross income, less the exemptions allowed under section 5747.025 of the Revised Code, in excess of two hundred thousand dollars”; Pennsylvania: “Personal income tax…. Rate.-- the tax imposed by subsection (a) shall be at the rate of 3%”; Vermont: none.
References
10. Woolhandler S, Himmelstein DU. Administrative work consumes one-sixth of U.S. physicians’ working hours and lowers their career satisfaction. Int J Health Serv. 2014;44(4):635–642.
11. Tseng P, Kaplan RS, Richman BD, Shah MA, Schulman KA. Administrative costs associated with physician billing and insurance-related activities at an academic health care system. JAMA. 2018;319(7):691–697.
12. Duffin J. The impact of single-payer health care on physician income in Canada, 1850-2005. Am J Public Health. 2011;101(7):1198–1208.
14. Peikes DN, Reid RJ, Day TJ, et al. Staffing Patterns of Primary Care Practices in the Comprehensive Primary Care Initiative. Ann Fam Med. 2014;12(2):142–149.
15. Basu S, Phillips RS, Phillips R, Peterson LD, Landon BE. Primary Care Practice Finances in the United States amid the COVID-19 Pandemic. Health Aff. 2020;39(9):1605–1614.
19. Jiwani A, Himmelstein D, Woolhandler S, Kahn J. Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence. BMC Health Serv Res. 2014;14(1):556. https://doi.org/10.1186/s12913-014-0556-7
20. Kahn J, Kronick R, Kreger M, Gans D. The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals. Health Aff (Millwood). 2005;24(6):1629–1639.
27. Zuckerman S, Skopec L, Aarons J. Medicaid physician fees remained substantially below fees paid by Medicare in 2019. Health Aff. 2021;40(2):343–348.
28. Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US physician practices versus canadians: spending nearly four times as much money interacting with payers. Health Aff. 2011;30(8):1443–1450.
30. Scheinker D, Richman BD, Milstein A, Schulman KA. Reducing administrative costs in US health care: assessing single-payer and its alternatives. Health Serv Res. 2021;56(4):615–625.
37. Gaffney A, Himmelstein DU, Woolhandler S, Kahn JG. Pricing universal health care: how much would the use of medical care rise? Health Aff. 2021;40(1):105–112.
Biographies
Daniel C. Bryant, MD, graduated from Columbia University College of Physicians and Surgeons (now Vagelos College of Physicians and Surgeons) in 1965. After residency in internal medicine at Barnes Hospital in St. Louis, Missouri, and the Maine Medical Center in Portland, Maine, he practiced office and hospital medicine in Portland, initially in a partnership and then with InterMed, the largest physician-owned primary care practice in Maine. Since retiring, he has pursued an interest in health care policy.
Supplementary Material
My podcast link (no limits): https://www.scipod.global/daniel-bryant-m-d-single-payer-health-care-financial-implications-for-a-physician/
Cai article: How Would Medicare for All Affect Physician Revenue?
Dan
How Would Medicare for All Affect Physician Revenue?
Journal of General Internal Medicine volume 37, pages 671–672 (2022)
Organized medicine in the USA is shifting its position toward single-payer reform, one version of which, “Medicare for All,” has gained substantial support in Congress. The American Medical Association recently left the Partnership for America’s Healthcare Future, a lobbying group that spent more than one hundred million dollars annually opposing both a public option and Medicare for All in federal election campaigns. In 2020, the American College of Physicians and the Society of General Internal Medicine went a step further, endorsing both public option and single-payer reforms.
Yet, physician opinion on Medicare for All remains split, with most doctors concerned that such reform might decrease their income. While physicians are highly paid, these concerns are understandable given the burden of student debt, the length of medical training, and Medicare’s lower fees relative to private insurers’.
Are such concerns supported by evidence? The nonpartisan Congressional Budget Office (CBO) recently estimated payments to physicians in 2030 under current policies and five options for Medicare for All. It projects that without reform the weighted average of public and private payments to physicians will increase to 116% of the 2019 weighted average, versus between 108% and 117% under the various Medicare for All options analyzed.1 But because the CBO expects Medicare for All to increase society-wide utilization of care, it also predicts that providers’ total revenues would increase, even if fee levels were to decline.
More specifically, the CBO projects that in 2030 providers’ total outpatient revenues would be between 5 and 9% higher under Medicare for All than without reform; physician services currently account for 78% of such revenue.1,2 These estimates assume that Medicare for All would not significantly alter the supply of physicians, which is currently limited by the supply of residency and medical school spots.1
Some scholars project even larger boosts to physicians’ take-home pay because the CBO estimates may understate practices’ savings from streamlined billing. If, as studies suggest, Medicare for All would free up roughly 5% of doctors’ work hours currently spent on billing, allowing them to increase patient care, per-physician revenue could rise by between $39,816 and $157,412 annually.2 While those figures may be an overestimate, since some providers might choose to spend the freed-up time on leisure activities rather than increased patient care, they may underestimate revenue changes, as fee-for-service providers have, in the past, responded to decreased Medicare reimbursement rates by increasing volume of services.1 The latter won’t apply to salaried providers, such as those working in capitated healthcare systems, but these providers are still likely to feel the benefits of administrative streamlining.
Other prominent economic analyses of Medicare for All have also projected net increases in physicians’ revenue, even if current Medicare payment rates do not increase.3 Yet despite projecting increases in physicians’ revenues, almost all estimates of the overall costs of single-payer reform project savings, due to savings from administrative simplification.3 Hence, it appears possible to design a single-payer reform that would offer universal coverage without cost sharing, while increasing net revenue to providers and decreasing national health expenditures. 3
History offers hopeful messages about the likely effect of single-payer reform on doctors’ incomes. When Canada transitioned to single-payer in the mid-20th century, physician income increased, and physicians remained the highest paid professionals in the nation.4 Since then, physician income in Canada has grown faster than the incomes of other workers. Yet, caution is warranted in interpreting these trends, which may not be duplicated in a reform initiated five decades or more after Canada’s system was fully implemented in 1971. Medicare’s history offers mixed lessons. Limitation on increases in Medicare’s payments to physicians (known as the sustainable growth rate or SGR) included in the 1997 Balanced Budget Act threatened sharp cuts in Medicare’s fee schedule. Yet Congress annually overrode the threatened cuts, and eventually repealed the SGR formula.
How would increases in revenue projected by the CBO be distributed among various physician specialties? Since both Congressional Medicare for All bills provide comprehensive benefits with little or no cost sharing (copayments or deductibles), individuals who currently cannot get medical care because of cost would increase their utilization of care. As a result, doctors who serve patients who are undertreated at present may experience the greatest increases in demand for their services, and in their revenues. Primary care providers are likely to fall into this category, given the degree to which hypertension, diabetes, hyperlipidemia, and other chronic conditions are currently undertreated. Anticipating this, the Congressional legislation would set aside funding to establish an Office of Primary Care, charged with developing policies to increase the number of primary care practitioners.
Although primary care doctors might get the biggest income boosts under single payer, specialists would continue to be high earners. The 1966 implementation of Medicaid/Medicare resulted in an increase in per-capita surgical procedures among the elderly. 5 In Canada, the specialist:primary care income ratio has remained quite high; in 2019, gross clinical payments to thoracic surgeons averaged $588,000 (Canadian dollars) compared to $280,000 for family medicine physicians. Malpractice insurance costs, currently the highest for proceduralists, would likely fall as they did in Canada, since patients would no longer have to sue to cover future medical costs. And in many doctors’ practices, the case mix is likely to change for the better. As patients with unmet medical needs increase their utilization, the limited supply of hospital beds and physicians would likely cause a modest decrease in the delivery of low-value services.5 In essence, doctors could shift their efforts to address the greatest needs, without fear of losing income. To prevent waitlists, an increase in residency training programs may be necessary.
Medicare for All may also decrease inequities in physician pay. Increased demand and federal funding for primary care may modestly mitigate the racial and gender pay gaps in medicine, as nonwhite and non-male physicians are more likely to specialize in primary care fields.6 In addition, using a funding scheme called “global budgeting,” Medicare for All would likely increase revenue for underfunded safety net hospitals and clinics, which disproportionately employ physicians of color. 7 However, the root causes of such pay disparities are racism and sexism, and thus, even with Medicare for All, additional anti-racist and anti-sexist reforms will be needed in the workplace.
Proposals for a Medicare “public option” or “Medicare Advantage for All” would sacrifice most of the administrative savings that Medicare for All could garner, making universal first dollar coverage unaffordable, minimizing increases in the utilization of care, and hence physicians’ practice revenues. Additionally, current fee schedules would likely persist under a public option reform, preserving the status quo that offers outsized rewards for performing procedures and caring for privately insured patients.
In sum, the available evidence—including the CBO’s authoritative estimate—suggests that physicians would prosper under single-payer reform. By supporting Medicare for All, physicians—and organized medicine—can get a twofer: acting in physicians’ self-interest while advancing legislation that would be enormously beneficial to patients.
References
How CBO Analyzes the Costs of Proposals for Single-Payer Health Care Systems That Are Based on Medicare’s Fee-for-Service Program: Working Paper 2020-08 [Internet]. Congressional Budget Office; [cited 2021 Jan 30]. Available from: https://www.cbo.gov/publication/56898
Gaffney A, Woolhandler S, Himmelstein D. Congressional Budget Office Scores Medicare-for-All: Universal Coverage for Less Spending [Internet]. Health Affairs Blog. February 16 2021. Available from: https://www.healthaffairs.org/do/10.1377/hblog20210210.190243/full/
Cai C, Runte J, Ostrer I, Berry K, Ponce N, Rodriguez M, et al. Projected costs of single-payer healthcare financing in the United States: a systematic review of economic analyses. PLoS Med 2020;17(1):e1003013.
Duffin J. The impact of single-payer health care on physician income in Canada, 1850-2005. Am J Public Health 2011;101(7):1198–208.
Gaffney A, McCormick D, Bor D, Woolhandler S, Himmelstein D. Coverage Expansions and utilization of physician care: evidence from the 2014 Affordable Care Act and 1966 Medicare/Medicaid Expansions. Am J Public Health 2019;109(12):1694–701.
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Why Is Finland the Happiest Country on Earth? The Answer Is Complicated.
On March 20, the United Nations Sustainable Development Solutions Network released its annual World Happiness Report, which rates well-being in countries around the world. For the sixth year in a row, Finland was ranked at the very top.
But Finns themselves say the ranking points to a more complex reality.
“I wouldn’t say that I consider us very happy,” said Nina Hansen, 58, a high school English teacher from Kokkola, a midsize city on Finland’s west coast. “I’m a little suspicious of that word, actually.”
Ms. Hansen was one of more than a dozen Finns we spoke to — including a Zimbabwean immigrant, a folk metal violinist, a former Olympian and a retired dairy farmer — about what, supposedly, makes Finland so happy. Our subjects ranged in age from 13 to 88 and represented a variety of genders, sexual orientations, ethnic backgrounds and professions. They came from Kokkola as well as the capital, Helsinki; Turku, a city on the southwestern coast; and three villages in southern, eastern and western Finland.
While people praised Finland’s strong social safety net and spoke glowingly of the psychological benefits of nature and the personal joys of sports or music, they also talked about guilt, anxiety and loneliness. Rather than “happy,” they were more likely to characterize Finns as “quite gloomy,” “a little moody” or not given to unnecessary smiling.
Many also shared concerns about threats to their way of life, including possible gains by a far-right party in the country’s elections, the war in Ukraine and a tense relationship with Russia, which could worsen now that Finland is set to join NATO.
It turns out even the happiest people in the world aren’t that happy. But they are something more like content.
Finns derive satisfaction from leading sustainable lives and perceive financial success as being able to identify and meet basic needs, Arto O. Salonen, a professor at the University of Eastern Finland who has researched well-being in Finnish society, explained. “In other words,” he wrote in an email, “when you know what is enough, you are happy.”
The Art Couple Grateful for a Safety Net
“‘Happiness,’ sometimes it’s a light word and used like it’s only a smile on a face,” Teemu Kiiski, the chief executive of Finnish Design Shop, said. “But I think that this Nordic happiness is something more foundational.”
The high quality of life in Finland is deeply rooted in the nation’s welfare system, Mr. Kiiski, 47, who lives in Turku, said. “It makes people feel safe and secure, to not be left out of society.”
Public funding for education and the arts, including individual artist grants, gives people like his wife, Hertta, a mixed-media artist, the freedom to pursue their creative passions. “It also affects the kind of work that we make, because we don’t have to think of the commercial value of art,” Ms. Kiiski, 49, said. “So what a lot of the artists here make is very experimental.”
The Advocate Fighting to Be Heard
As a Black person in Finland — which is more than 90 percent white — Jani Toivola, 45, spent much of his life feeling isolated. “Too often, I think, you still feel, as a Black gay man in Finland, that you are the only person in the room,” Mr. Toivola said. His father, who was Kenyan, was absent for much of his life, and Mr. Toivola, whose mother is white, struggled to find Black role models he could relate to.
In 2011, he became the first Black member of Finland’s Parliament, where he helped lead the fight for the legalization of same-sex marriage.
After serving two terms, Mr. Toivola left politics to pursue acting, dancing and writing. He now lives in Helsinki with his husband and daughter and continues to advocate L.G.B.T.Q. rights in Finland. “As a gay man, I still think it is a miracle that I get to watch my daughter grow,” he said.
The Teenagers Raised to Be Content
The conventional wisdom is that it’s easier to be happy in a country like Finland where the government ensures a secure foundation on which to build a fulfilling life and a promising future. But that expectation can also create pressure to live up to the national reputation.
“We are very privileged and we know our privilege,” said Clara Paasimaki, 19, one of Ms. Hansen’s students in Kokkola, “so we are also scared to say that we are discontent with anything, because we know that we have it so much better than other people,” especially in non-Nordic countries.
Being sad or being not content with our life would be seen as ungrateful.
Clara Paasimaki
Frank Martela, a psychology researcher at Aalto University, agreed with Ms. Paasimaki’s assessment. “The fact that Finland has been ‘the happiest country on earth’ for six years in a row could start building pressure on people,” he wrote in an email. “If we Finns are all so happy, why am I not happy?”
He continued, “In that sense, dropping to be the second-happiest country could be good for the long-term happiness of Finland.”
The Finnish way of life is summed up in “sisu,” a trait said to be part of the national character. The word roughly translates to “grim determination in the face of hardships,” such as the country’s long winters: Even in adversity, a Finn is expected to persevere, without complaining.
“Back in the day when it wasn’t that easy to survive the winter, people had to struggle, and then it’s kind of been passed along the generations,” said Ms. Paasimaki’s classmate Matias From, 18. “Our parents were this way. Our grandparents were this way. Tough and not worrying about everything. Just living life.”
The Entrepreneur Who Misses the Joy of Her Homeland
Since immigrating from Zimbabwe in 1992, Julia Wilson-Hangasmaa, 59, has come to appreciate the freedom Finland affords people to pursue their dreams without worrying about meeting basic needs. A retired teacher, she now runs her own recruitment and consulting agency in Vaaksy, a village northeast of Helsinki.
But she has also watched the rise of anti-immigration sentiment, exacerbated by the 2015 migrant crisis, and worries about the sustainability of the high quality of life in Finland. “If we have attitudes that are ‘Finland is for Finns,’ who will take care of us when we are elderly?” she said, referring to a common right-wing slogan. “Who will drive the truck that delivers the food to the supermarket so that you can go and shop?”
When she returns to her home country, she is struck by the “good energy” that comes not from the satisfaction of sisu but from exuberant joy.
“What I miss the most, I realize when I enter Zimbabwe, are the smiles,” she said, among “those people who don’t have much, compared to Western standards, but who are rich in spirit.”
The Farmer and His Cellist Daughter
Tuomo Puutio, 74, started working at 15 and supported his family for decades as a cattle and dairy farmer. Thanks to Finland’s school system, which includes music education for all children, his daughter Marjukka, 47, was able to pursue her dream of a music career beyond their village. “You get the chance to be a cello player, even if you are a farmer’s daughter,” she said.
Music is a source of well-being for many Finns, many of whom sing in choirs, learn instruments or attend regular concerts, especially during the country’s long, dark winters. But Ms. Puutio worries that these opportunities may not be available to future generations: Finland will hold parliamentary elections on April 2, and the far-right Finns Party, which won the second-highest number of seats in 2019, has promised to cut funding for the arts if it secures a majority coalition this year.
“Music, which I am passionate about, it creates a mind-set where you can face your inner feelings and fears,” Ms. Puutio, who now manages an orchestra, said. “It touches parts of our soul we could otherwise not reach. And that will have a long-term effect on people’s lives, if these experiences are taken away from us.”
The Former Olympian and the Therapist
Many of our subjects cited the abundance of nature as crucial to Finnish happiness: Nearly 75 percent of Finland is covered by forest, and all of it is open to everyone thanks to a law known as “jokamiehen oikeudet,” or “everyman’s right,” that entitles people to roam freely throughout any natural areas, on public or privately owned land.
“I enjoy the peace and movement in nature,” said Helina Marjamaa, 66, a former track athlete who represented the country at the 1980 and 1984 Olympic Games. “That’s where I get strength. Birds are singing, snow is melting, and nature is coming to life. It’s just incredibly beautiful.”
Her daughter Mimmi, a dance teacher and certified sex therapist, recently got engaged to her girlfriend. Mimmi, 36, said she is encouraged by the openness and deeper understanding of gender and sexuality she sees in the next generation.
“A lot of teenagers already show themselves as they are,” she said. As adults, “we need to encourage that.”
The Violinist Who Fears a Warming Planet
Finland’s natural treasures, about one-third of which lie above the Arctic Circle, are particularly vulnerable to the effects of the climate crisis. Like Ms. Puutio, Tuomas Rounakari, 46, a composer best known in Finland as a former member of the folk metal band Korpiklaani, is concerned about the rising popularity of groups like the Finns Party and the anti-climate policies they’ve championed.
Global capitalism is still leading the game. To me, all of this is alarming.
Tuomas Rounakari
“I am worried with this level of ignorance we have toward our own environment,” he said, citing endangered species and climate change. The threat, he said, “still doesn’t seem to shift the political thinking.”
The Badminton Dad and His Children
Reasons for optimism can be personal. For the Hukari family, that reason is badminton.
A sports facility in the rural community of Toholampi has enabled Henna, 16, and Niklas, 13, to compete at a European level, exposing them to new places and players from around the continent. The game has given the teens a fulfilling hobby in a remote area and their parents, Lasse and Marika, optimism about their children’s futures.
Mr. Hukari, 49, hopes that, in time, the children will come to fully grasp the opportunities they have gained from badminton. “Now, maybe they don’t understand what they have, but when they are my age, then I know they will understand,” he said.
The Matriarch and Her Granddaughter
Born 17 years after Finland won independence from Russia, Eeva Valtonen has watched her homeland transform: from the devastation of World War II through years of rebuilding to a nation held up as an exemplar to the world.
“My mother used to say, ‘Remember, the blessing in life is in work, and every work you do, do it well,’” Ms. Valtonen, 88, said. “I think Finnish people have been very much the same way. Everybody did everything together and helped each other.”
Her granddaughter Ruut Eerikainen, 29, was surprised to see Finland now ranked as the happiest place on earth. “To be honest, Finns don’t seem that happy,” she said. “It’s really dark outside, and we can be quite gloomy.”
Maybe it isn’t that Finns are so much happier than everyone else. Maybe it’s that their expectations for contentment are more reasonable, and if they aren’t met, in the spirit of sisu, they persevere.
“We don’t whine,” Ms. Eerikainen said. “We just do.”
https://www.nytimes.com/2023/04/01/world/europe/finland-happiness-optimism.html
Assisted-living homes are rejecting Medicaid and evicting seniors
Some residents who drained their nest eggs to cover private-pay rates have been evicted after turning to Medicaid to pay their bills.
by Christopher Rowland - Washington Post - April 8, 2023
Shirley Holtz, 91, used a walker to get around. She had dementia and was enrolled in hospice care. Despite her age and infirmity, Holtz was evicted from the assisted-living facility she called home for four years because she relied on government health insurance for low-income seniors.
Holtz was one of 15 residents told to vacate Emerald Bay Retirement Community near Green Bay, Wis., after the facility stopped accepting payment from a state-sponsored Medicaid program. And Emerald Bay is not alone. A recent spate of evictions has ousted dozens of assisted-living residents in Wisconsin who depended on Medicaid to pay their bills — an increasingly common practice, according to industry representatives.
The evictions highlight the pitfalls of the U.S. long-term care system, which is showing fractures from the pandemic just as a wave of 73 million baby boomers is hitting an age where they are likely to need more day-to-day care. About 4.4 million Americans have some form of long-term care paid for by Medicaid, the state-federal health system for the poor, a patchy safety net that industry representatives say pays facilities too little.
Residents of assisted-living facilities — promoted as a homier, more appealing alternative to nursing homes — face an especially precarious situation. While federal law protects Medicaid beneficiaries in nursing homes from eviction, the law does not protect residents of assisted-living facilities, leaving them with few options when turned out. In Wisconsin, residents who entered facilities on Medicaid, as well as those who drained their private savings after moving in and subsequently enrolled in Medicaid, have been affected.
“It’s a good illustration of how Medicaid assisted-living public policy is still in its Wild West phase, with providers doing what they choose in many cases, even though it’s unfair to consumers,” said Eric Carlson, a lawyer and director of long-term services and support advocacy at the nonprofit group Justice in Aging. “You can’t just flip in and out of these relationships and treat the people as incidental damage.”
The U.S. government does not monitor or regulate assisted-living facilities, and no federal data is available on the frequency of evictions. In Wisconsin, The Washington Post counted at least 50 Medicaid-related evictions since the fall based on statements by operators, as well as nonprofit and government Medicaid agencies.
But evictions have become so common that some states, including New Jersey, have enacted policies to curb them. Nationally, state ombudsman programs for long-term care received 3,265 complaints related to evictions from assisted-living facilities in 2020, the latest data available. That data does not detail the reason for evictions, though ombudsmen said most complaints arose after operators declared that a resident’s needs had become too great to be handled at the facility.
Emerald Bay did not explain why it stopped participating in Medicaid. But advocates, family members and the nonprofit that managed the facility’s Medicaid contract contend the motivation was financial: Medicaid reimbursement is lower than full private pay rates.
Family members said they were upset and angry. Holtz spent her entire savings paying out of pocket with the understanding that she would be permitted to stay once she qualified for low-income insurance, her relatives said. Ann Marra, Holtz’s daughter, said her mother — who worked much of her life as a professional secretary and raised her family in Algoma, a small town on Lake Michigan — deserved better treatment.
Marra feared the eviction would affect her mother’s mental health.
“It’s cruel, heartless and sad,” she said.
After a stressful search, Holtz’s family moved her on March 13 to an assisted-living facility that still honors state Medicaid. Emerald Bay’s operator, Baka Enterprises, did not respond to requests for comment.
Advocates for assisted-living residents worry that pandemic-induced economic conditions are contributing to the problem in pockets of the country. Profits in assisted-living facilities are threatened by a shortage of staff and big spikes in labor costs, inflation that is jacking up the costs of goods, and higher interest rates. Meanwhile, occupancy rates continue to lag behind pre-pandemic peaks.
The industry blames evictions on insufficient Medicaid funding. Reimbursements, made under federal waivers that allow states to spend Medicaid dollars for elderly care outside of nursing homes, are not keeping up with rising costs, industry representatives said.
“Chronic Medicaid underfunding is not sustainable and is limiting participation as well as driving many providers out of the waiver program, reducing access to care options,” said LaShuan Bethea, executive director of the National Center for Assisted Living trade group.
The gap in pay rates between Medicaid and the full amount charged to families paying out of pocket varies among states. While private pay rates are often $5,000 a month or more, Medicaid in many states pays only about $3,000 a month, said Paul Williams, vice president of government relations at Argentum, a trade association representing assisted-living facilities.
Operators “have tried to hold off [canceling Medicaid contracts] as long as they can, hoping the reimbursement will be increased to help them afford inflation factors,” Williams said. “Hope has diminished in some states of that happening, and they’re saying, ‘I cannot do this anymore.’”
In 2020, about 18 percent of 818,000 residents in U.S. assisted-living facilities were supported by Medicaid payments, according to federal data, a ratio that has remained stable for at least a decade.
In Wisconsin, at least four facilities have canceled Medicaid managed-care contracts in recent months. In addition to Emerald Bay’s 15 residents, Cedarhurst of Madison had 28 residents who were Medicaid beneficiaries when it terminated its contract last year. Residents found out they were being evicted after being called to a group meeting in late fall, said one of those told to leave, Elizabeth Burnette.
“Residents were in tears to hear they had to find another place to live,” Burnette, 80, said. “Most of us are incapacitated in some way, with walkers and in wheelchairs or mobile beds.”
Cedarhurst operates the facility, which is owned by a Massachusetts-based real estate investment trust, Diversified Healthcare Trust. Going to 100 percent private pay at the Madison site was a “tough decision” made in conjunction with Diversified Healthcare, Cedarhurst spokeswoman Christie Schrader said.
Cedarhurst became the facility’s operator in November 2021.
“When we took over management, we inherited Medicaid residents with special cases who required advanced care that we do not offer at our communities,” Schrader said. “Therefore, we believed it was in the residents’ best interest to aid them in finding alternative placement which could care for them in the way they deserve.”
The lobbying and trade group in Wisconsin that represents the long-term care industry said assisted-living operators recognize evictions are highly stressful for residents and their families.
“Not only is it traumatic for the resident and the family, it’s also traumatic for the facility. It really is,” said Rick Abrams, president and CEO of the Wisconsin Health Care Association/Wisconsin Center for Assisted Living. “This is the residents’ home. Everyone understands that.”
He said evictions usually occur when an assisted-living facility and one of the state’s nonprofit Medicaid managed-care organizations cannot agree on the monthly rates for care of an elderly person. Written notices given to residents in the recent evictions stated little about the rationale.
HarborChase of Shorewood, outside Milwaukee, had six Medicaid residents when it said it was ending its Medicaid contracts in January, according to managers of the state’s nonprofit Medicaid managed-care organizations.
“With the new year comes necessary changes,” Karin Bateman, chief operating officer of Vero Beach, Fla.-based Harbor Retirement Associates, HarborChase of Shorewood’s parent company, wrote in a three-paragraph letter to residents on Jan. 6 that informed them that the facility would no longer accept Medicaid. “Our 60-day notice of Medicaid termination gives you time to plan accordingly.”
Harbor Retirement Associates did not respond to requests for comment.
The evictions carry an especially harsh sting for residents who enter assisted-living facilities paying full rates out of pocket with the understanding that, once their nest egg has been spent down, they can remain in the facility under Medicaid. Such arrangements are common across the country and are discussed with families by marketing staff, according to elder-law attorneys and industry experts.
But facilities may have strict limits on the number of beds they designate as Medicaid-eligible, or they can back out of state Medicaid contracts completely. Such caveats may be buried in the fine print of resident agreements or are not addressed at all in the contracts, according to contract provisions in the Wisconsin cases reviewed by The Post. Families often sign such contracts in a time of stress, as they are seeking a safe place for a parent who can no longer remain in their own home.
“This is how people are getting screwed, by promises that the place will take [Wisconsin Medicaid] if they stay for two years. Then they either sell to another company, or change their minds and opt out of the program entirely, which you really can’t stop them from doing. At that point, the family has used up their funds,” said Carol Wessels, an attorney specializing in elder law in Mequon, Wis.
Family members are often left feeling betrayed.
“It’s appalling to say the least,” said Megan Brillault, whose mother, Nancy Brillault, was evicted from HarborChase of Shorewood after spending most of her $120,000 savings. “They said, ‘Here, let us take your money, all your life savings, and you can live here forever,’ and 10 months later they’re saying, ‘We miscalculated, and we are no longer taking Medicaid beds.’”
Megan Brillault provided an email to The Post in which a HarborChase representative said Nancy could transition to Medicaid after paying private-pay rates for one year. The residency contract did not address the issue, said Brillault, a lawyer.
Medicaid pays for nursing home care directly. It’s an entitlement — if a low-income person qualifies, the state must fund a nursing home bed. Medicaid pays all costs in nursing homes, including room and board, as well as care.
Assisted living is different. At those facilities, Medicaid money can be used to reimburse only the cost of care, such as bathing and dressing, and not room and board, although some states offer supplemental payments to help with rent and food.
With the overwhelming majority of residents paying privately, the median operating profit for U.S. assisted-living facilities in 2019 was 29 percent before deductions for interest and rent payments, according to the National Investment Center for Seniors Housing & Care.
Kate McEvoy, executive director of the National Association of Medicaid Directors, said states want to give elderly people options outside of nursing homes but are squeezed between restrictions on how Medicaid money can be used and the high costs of assisted living.
“This has been a challenge in what has primarily been a proprietary, market-driven model,” she said.
In the eviction notice emailed to Holtz’s family in Wisconsin, Baka Enterprises, Emerald Bay’s operator, said it had decided to terminate its contracts with the state’s Medicaid program that covers services for the elderly. It did not provide a reason, but cited a provision of its contract with residents that allowed it to discharge them if they could not afford private-pay rates and the facility did not have designated Medicaid beds.
Kris Holtz, Shirley Holtz’s son, said he was not aware of the provision when he moved his mother into Emerald Bay. Shirley Holtz paid private rates for 26 months before qualifying for Medicaid. She lived at Emerald Bay for another two years at the Medicaid rate before receiving the eviction notice, he said.
The Emerald Bay Medicaid contract was managed by a nonprofit called Lakeland Care. “In the end, Emerald Bay asked us to pay the full private-pay rate for these members, which we are unable to do as a Medicaid-funded agency,” Lakeland Care’s chief executive officer, Sara Muhlbauer, said in a written statement to The Post.
Experts say moving elderly people out of familiar surroundings can induce a condition called “transfer trauma” that accelerates decline. Shirley Holtz’s relatives detected rapid changes after the eviction, said Marra, her daughter. Her mother lost 15 pounds, she said, and quickly stopped using her walker.
On Monday, three weeks after moving out of Emerald Bay and into the new facility, Shirley Holtz died. “The move was a huge factor in her decline,” Marra said in a text.
Even as she mourned, Marra texted an expletive to describe the U.S. long-term care system, punctuated by a red-faced frown emoji. “Kinda angry right now,” she said.
https://www.washingtonpost.com/business/2023/04/06/seniors-assisted-living-medicaid-eviction/
Editor's Note -
The preceding clipping about the eviction of seniors from long-term facilities in the USA is a nice counterpoint to the the preceding clipping about life in Finland.
- SPC
Doctors are drowning in paperwork. Some companies claim AI can help
by Geoff Brumfiel - NPR - April 5, 2023
When Dereck Paul was training as a doctor at the University of California San Francisco, he couldn't believe how outdated the hospital's records-keeping was. The computer systems looked like they'd time-traveled from the 1990s, and many of the medical records were still kept on paper.
"I was just totally shocked by how analog things were," Paul recalls.
The experience inspired Paul to found a small San Francisco-based startup called Glass Health. Glass Health is now among a handful of companies who are hoping to use artificial intelligence chatbots to offer services to doctors. These firms maintain that their programs could dramatically reduce the paperwork burden physicians face in their daily lives, and dramatically improve the patient-doctor relationship.
"We need these folks not in burnt-out states, trying to complete documentation," Paul says. "Patients need more than 10 minutes with their doctors."
But some independent researchers fear a rush to incorporate the latest AI technology into medicine could lead to errors and biased outcomes that might harm patients.
"I think it's very exciting, but I'm also super skeptical and super cautious," says Pearse Keane, a professor of artificial medical intelligence at University College London in the United Kingdom. "Anything that involves decision-making about a patient's care is something that has to be treated with extreme caution for the time being."
A powerful engine for medicine
Paul co-founded Glass Health in 2021 with Graham Ramsey, an entrepreneur who had previously started several healthcare tech companies. The company began by offering an electronic system for keeping medical notes. When ChatGPT appeared on the scene last year, Paul says, he didn't pay much attention to it.
"I looked at it and I thought, 'Man, this is going to write some bad blog posts. Who cares?'" he recalls.
But Paul kept getting pinged from younger doctors and medical students. They were using ChatGPT, and saying it was pretty good at answering clinical questions. Then the users of his software started asking about it.
In general, doctors should not be using ChatGPT by itself to practice medicine, warns Marc Succi, a doctor at Massachusetts General Hospital who has conducted evaluations of how the chatbot performs at diagnosing patients. When presented with hypothetical cases, he says, ChatGPT could produce a correct diagnosis accurately at close to the level of a third- or fourth-year medical student. Still, he adds, the program can also hallucinate findings and fabricate sources.
"I would express considerable caution using this in a clinical scenario for any reason, at the current stage," he says.
But Paul believed the underlying technology can be turned into a powerful engine for medicine. Paul and his colleagues have created a program called "Glass AI" based off of ChatGPT. A doctor tells the Glass AI chatbot about a patient, and it can suggest a list of possible diagnoses and a treatment plan. Rather than working from the raw ChatGPT information base, the Glass AI system uses a virtual medical textbook written by humans as its main source of facts – something Paul says makes the system safer and more reliable.
"We're working on doctors being able to put in a one-liner, a patient summary, and for us to be able to generate the first draft of a clinical plan for that doctor," he says. "So what tests they would order and what treatments they would order."
Paul believes Glass AI helps with a huge need for efficiency in medicine. Doctors are stretched everywhere, and he says paperwork is slowing them down.
"The physician quality of life is really, really rough. The documentation burden is massive," he says. "Patients don't feel like their doctors have enough time to spend with them."
Bots at the bedside
In truth, AI has already arrived in medicine, according to Keane. Keane also works as an ophthalmologist at Moorfields Eye Hospital in London and says that his field was among the first to see AI algorithms put to work. In 2018, the Food and Drug Administration (FDA) approved an AI system that could read a scan of a patient's eyes to screen for diabetic retinopathy, a condition that can lead to blindness.
That technology is based on an AI precursor to the current chatbot systems. If it identifies a possible case of retinopathy, it then refers the patient to a specialist. Keane says the technology could potentially streamline work at his hospital, where patients are lining up out the door to see experts.
"If we can have an AI system that is in that pathway somewhere that flags the people with the sight-threatening disease and gets them in front of a retina specialist, then that's likely to lead to much better outcomes for our patients," he says.
Other similar AI programs have been approved for specialties like radiology and cardiology. But these new chatbots can potentially be used by all kinds of doctors treating a wide variety of patients.
Alexandre Lebrun is CEO of a French startup called Nabla. He says the goal of his company's program is to cut down on the hours doctors spend writing up their notes.
"We are trying to completely automate all this wasted time with AI," he says.
Lebrun is open about the fact that chatbots have some problems. They can make up sources, get things wrong and behave erratically. In fact, his team's early experiments with ChatGPT produced some weird results.
For example, when a fake patient told the chatbot it was depressed, the AI suggested "recycling electronics" as a way to cheer up.
Despite this dismal consultation, Lebrun thinks there are narrow, limited tasks where a chatbot can make a real difference. Nabla, which he co-founded, is now testing a system that can, in real time, listen to a conversation between a doctor and a patient and provide a summary of what the two said to one another. Doctors inform their patients that the system is being used in advance, and as a privacy measure, it doesn't actually record the conversation.
"It shows a report, and then the doctor will validate with one click, and 99% of the time it's right and it works," he says.
The summary can be uploaded to a hospital records system, saving the doctor valuable time.
Other companies are pursuing a similar approach. In late March, Nuance Communications, a subsidiary of Microsoft, announced that it would be rolling out its own AI service designed to streamline note-taking using the latest version of ChatGPT, GPT-4. The company says it will showcase its software later this month.
AI reflects human biases
But even if AI can get it right, that doesn't mean it will work for every patient, says Marzyeh Ghassemi, a computer scientist studying AI in healthcare at MIT. Her research shows that AI can be biased.
"When you take state-of-the-art machine learning methods and systems and then evaluate them on different patient groups, they do not perform equally," she says.
That's because these systems are trained on vast amounts of data made by humans. And whether that data is from the Internet, or a medical study, it contains all the human biases that already exist in our society.
The problem, she says, is often these programs will reflect those biases back to the doctor using them. For example, her team asked an AI chatbot trained on scientific papers and medical notes to complete a sentence from a patient's medical record.
"When we said 'White or Caucasian patient was belligerent or violent,' the model filled in the blank [with] 'Patient was sent to hospital,'" she says. "If we said 'Black, African American, or African patient was belligerent or violent,' the model completed the note [with] 'Patient was sent to prison.'"
Ghassemi says many other studies have turned up similar results. She worries that medical chatbots will parrot biases and bad decisions back to doctors, and they'll just go along with it.
"It has the sheen of objectivity: 'ChatGPT says you shouldn't have this medication. It's not me – a model, an algorithm made this choice,'" she says.
And it's not just a question of how individual doctors use these new tools, adds Sonoo Thadaney Israni, a researcher at Stanford University who co-chaired a recent National Academy of Medicine study on AI.
"I don't know whether the tools that are being developed are being developed to reduce the burden on the doctor, or to really increase the throughput in the system," she says. The intent will have a huge effect on how the new technology affects patients.
Regulators are racing to keep up with a flood of applications for new AI programs. The FDA, which oversees such systems as "medical devices," said in a statement to NPR that it was working to ensure that any new AI software meets its standards.
"The agency is working closely with stakeholders and following the science to make sure that Americans will benefit from new technologies as they further develop, while ensuring the safety and effectiveness of medical devices," spokesperson Jim McKinney said in an email.
But it is not entirely clear where chatbots specifically fall in the FDA's rubric, since, strictly speaking, their job is to synthesize information from elsewhere. Lebrun of Nabla says his company will seek FDA certification for their software, though he says in its simplest form, the Nabla note-taking system doesn't require it. Dereck Paul says Glass Health is not currently planning on seeking FDA certification for Glass AI.
Doctors give chatbots a chance
Both Lebrun and Paul say they are well aware of the problems of bias. And both know that chatbots can sometimes fabricate answers out of thin air. Paul says doctors who use his company's AI system need to check it.
"You have to supervise it, the way we supervise medical students and residents, which means that you can't be lazy about it," he says.
Both companies also say they are working to reduce the risk of errors and bias. Glass Health's human-curated textbook is written by a team of 30 clinicians and clinicians in training. The AI relies on it to write diagnoses and treatment plans, which Paul claims should make it safe and reliable.
At Nabla, Lebrun says he's training the software to simply condense and summarize the conversation, without providing any additional interpretation. He believes that strict rule will help reduce the chance of errors. The team is also working with a diverse set of doctors located around the world to weed out bias from their software.
Regardless of the possible risks, doctors seem interested. Paul says in December, his company had around 500 users. But after they introduced their chatbot, those numbers jumped.
"We finished January with 2,000 monthly active users, and in February we had 4,800," Paul says. Thousands more signed up in March, as overworked doctors line up to give AI a try.
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