In recent years, there has been the increased recognition that the US healthcare system has become a hodge-podge of both private and public coverage options for patients, as well as a billing and reimbursement nightmare for many providers. As a candidate in the 2016 presidential election, Senator Bernie Sanders of Vermont promoted the concept of “Medicare for All” which proposed to offer the general citizenry roughly the same coverage currently available to older Americans.

Since then, others have taken up the banner for some sort of single-payer health care plan, with options ranging from keeping policyholders’ current plans for those who like their insurance while offering a “public option”  to the more draconian measure of eliminating insurance companies from the picture altogether.

As with many complex social issues, there are no easy answers, no “one-size-fits-all” solutions. In this blog, we’ll take a look at two of the options under discussion and their implications for patients and providers.

Single Payer Plan, also known as “Medicare for All”

Initially proposed by Senator Sanders, “Medicare for All” would entail just that: basic coverage for essential services, such as physical exams, necessary surgeries, chronic condition treatment and pallliative care would be covered. As with current Medicare plans for the elderly, additional non-covered services such as dental, vision and prescription drugs, would possibly become add-ons available through separate policies similar to Medicare Advantage or other supplemental plans, and administered by various insurance companies.

Canada is one example of single-payer type coverage, with many Canadians opting to buy supplemental insurance to cover non-eligible services. The US government would be the payer with this plan, as with Canada, and would likely be organized in ways similar to Canada’s healthcare.

Other Forms of Single Payer Coverage

Yet another proposal similar to Medicare for All would see all citizens receiving more comprehensive forms of coverage, as has been proposed by Senator Elizabeth Warren, along with some other legislators and some physician groups. These latest plans have the goal of eliminating insurance “middlemen” altogether, and so help further drive costs down.  Single payer may impose less financial hardship on individuals, especially in lower-income brackets as coverage is available regardless of ability to pay.

Universal Coverage

While the goal of both types of plans is to expand coverage to more individuals, universal health care provides access for everyone to healthcare services including emergency types of care. According to Deborah Ng writing for Pfizer, this type of coverage could become more expensive for individuals, but also provide a better level of choices, as it would not be limited to what government could afford to pay, but be funded through a number of entities, such as pools of insurance companies, a special payroll or incomes taxes.

This brings us to perhaps one of the biggest obstacles to the implementation of any kind of mass health coverage plan: people are enthusiastic about the prospect of universal/ single payer coverage until they learn that their taxes are likely to go up to help pay for it.

The Affordable Care Act’s (“Obamacare”) limitations

The Affordable Care Act (ACA) sought to expand healthcare coverage to at least 30 million people by requiring the purchase of insurance policies (partially subsidized though government payments) as well as expand Medicaid. However, the realities are thus:

• Insurers continue to pare down policies, with restrictive networks, limit and deny care, while increasing co-pays, deductibles and other patient out-of-pocket costs. 
• 30 million people remain uninsured, with many more under-insured. The ACA preserves the fragmented system of financing care, making it all but impossible to ever truly control costs.
• The law also continues to place a disproportional burden on middle class and lower-income Americans as well as those dealing with chronic or acute illnesses.

Implications for Physicians and Administrators

Not surprisingly, most doctors and other healthcare professionals are cautiously optimistic about the prospect of simplified billing and revenue management by not having to deal with the confusing jumble of policies, regulations and contracts through dozens of insurance carriers, but instead could focus on what they do best: practice medicine, with more autonomy while providing care for all who need it, regardless of income.

More administrators and other healthcare executives¸ such as Kim Hollon, chief executive of Signature Healthcare, the parent company of Brockton Hospital, are coming around to the idea of expanding coverage to make it more affordable for more individuals. According to Hollon, single payer could ease the administrative workloads caused by adhering to multiple insurers’ requirements while leveling the vastly differing prices charged by hospitals for the same services.

Speaking from a Canadian viewpoint, Dr. Michael Apkon, now Tufts Medical Center chief executive and who formerly ran a Canadian hospital, reports that Canada’s health care quality is “every bit as good as what I’ve experienced here.”

Sorting it Out with the Help of Practice Management Services

We may well be on the road to national single payer coverage but there is still a long way to go. One thing seems pretty certain: insurance companies aren’t going away any time soon, nor are the medical bills and other claims that need to be paid. With Medicare, for example, there is a constant flow of regulatory changes and updates that providers and their billing staff need to be aware of for compliance and full reimbursement.

If single payer eventually becomes the law of the land, it’s very likely that insurance companies (or whichever entity takes their places) will be around to process exempt services, much as dental, vision and similar services currently not covered in basic Medicare.  Specialty practices will still be in need of guidance and reimbursement assistance. Since 2002, M-Scribe has helped dozens of medical practices with their billing needs and revenue cycle management concerns.  Contact M-Scribe at 770-666-0470 or email for a complimentary consultation and more information about our array of billing and practice management services.