Take your PICK, of ANY of them, my friend. They are ALL absolutely BREATHTAKING! "SEA WORLD" is FABULOUS, but, – personally, – I preferred the Animal Kingdom

I own a medical practice, and have grappled with questions like this.

Let's look at how things REALLY work. A large portion of our revenues come from governmental payers such as Medicare, Medicaid, State Employees Health Plan, and Tricare.

These payers have fee schedules where they pay a certain amount for a certain service. For example, a payer might pay $70 for CPT 99213. These fee schedules are generally not negotiable. Try negotiating with Medicare. It ain't gonna happen. In fact, I question whether their payment systems can even handle paying differing amounts to differing providers for the same service. (Each "service" is defined by a CPT or HCSPCS code.

Let's look at private insurers such as Blue Cross, CIGNA, and United Healthcare. Yes, these payers do negotiate to some extent. However, there isn't a whole lot of negotiation going on. They have a lot of leverage. Let's say that the provider threatens to stop being in network with that payer. So what? Ain't no skin off their back. So it annoys the policy holder? Does the provider relations department really give a darn? Not generally. Usually, the patient just complains to the medical practice because they're easier to communicate with. They are the ones who are told that they're the bad guys. If the policy holders go to the trouble of speaking with someone at the insurance company, it's generally some clerk who can't do anything.

The willingness of insurance companies to negotiate is typically not related to the quality of medical care. They have no way to know who gives better medical care. It might be related to fees in the general geographic area, and I suppose that the provider might have a LITTLE more leverage if it was -say- the only endocrinology practice in the region. However, we're in a similar situation, and it hasn't done much for us.

Now let me give my thoughts on the "single payer" system.

Okay, it's a nice idea. Here's the problem. A payer system is just that. It's a system for payment. Granted, it would be less of a headache to deal with one payer rather than dozens. Also, I see the point that this would be a monopsony (like a monopoly, but one purchaser rather than one seller). The playing field is already not very level, and this makes that inequity worse.

What we need is a healthcare system, not a payer system. We have all these small businesses, when we really need one large interconnected organization. I think that we need something more like the public schools where the government employs the physicians, builds the buildings, and supplies the information systems to make it all work. The problem with the "payer" system is that we still have all that administrative overhead dealing with getting paid. If restaurants worked this way, you'd have five billers for every waiter. If public schools worked this way, you'd have teachers spending their time coding their bills: "Hmm, I gave Billy one lecture, and supervised him at recess for thirty minutes, and gave him ten minutes of one-on-one." Absurd, eh? That's what medical practices do.

Many physicians would probably oppose my vision. However, that's based on ego and not logical thought. This would actually INCREASE their ability to negotiate their salaries because as employees, they can unionize and go on strike. Under the present system, this is prohibited under Robinson-Patman Federal Antitrust laws. It would be illegal collusion (AKA price fixing).

Thanks for listening.