Single Payer? Yes, But. . .

(The referenced point discussion is the article titled "Mental Health Services in a Single Payer System"-Ed.)

Few will deny that the American health care delivery system is flawed. It is considerably less obvious, however, why that insight should lead to the support of a single payer funding system at this time. Rather, such a proposal runs the risk of falling from the frying pan into the fire.

We offer three perspectives to consider: the doctor's, the patient's and the health care policy-maker's.

The Doctors' Lounge

Despite the current dissatisfaction of most physicians, the predominant comments heard in the doctors' lounge concerning a single payer system are about the risk to professional autonomy, the paperwork and the lack of focus on quality of outcome, with resulting further physician demoralization. Physicians pride themselves on their creative, caring and selfless duty to their patients. The irreconcilable intrusion of a third party into the doctor-patient relationship has already created conflicts of interest. When providers find a particular insurance company's meddling intolerable, they can terminate the contract, albeit with some decline in income. Interference with professional decision-making from the sole source of payment would make noncompliance tantamount to professional suicide. "Power corrupts and absolute power corrupts absolutely."

The Thienhaus proposal also fails to address the physician's demand for tort reform. The practitioner would be faced with a third party deciding what is and is not a covered treatment. If a non-covered treatment were thought to be beneficial, would it be malpractice not to provide this service? Will a single payer institutionalize the worst aspects of the current system, i.e., financial penalties and sanctions for perceived overutilization, dissatisfied patients and malpractice suits due to accusations of underutilization? The failure of the Clinton administration to include physicians in their reform discussions should not be repeated. The threat of a malpractice suit is a visceral issue for physicians and a fundamental issue that must be resolved.

In addition, paperwork and the complex regulations in the Medicare and Medicaid systems are far greater than that for private payers. It requires a giant leap of faith to assume that a single payer system would be simpler.

The Patient's Concerns

The American patient is far more consumer-oriented and individualistic than their European or Canadian counterparts. Further, they are more interested in personal health outcomes than social justice. Consumers want the right to sue their HMOs if they do not receive the services they request. Will they be able to sue the single payer?

A consumer economy creates efficiency-that is, the distribution of a product in a market. In the case of health care, the question is how promptly can potential consumers access the kind of service they need. In exploring the answer to this question, it is not necessary to cross any borders to Canada or Europe; substantial segments of the U.S. population are already covered by single payer insurance of some kind. Patients who qualify for state mental health care services, veterans and those in staff-model HMOs are examples. There are no data to indicate that these recipients of single payer health care are more satisfied than their counterparts in more open systems.

The Policy-Maker's View

"If you think health care is expensive now, just wait till it's free." Demand for health care services has proved to grow faster than the rest of our economy (Vincenzino, 1999). Though the proposal suggests that expert panels will decide on a basic benefits package, we believe politics, not science, will decide what is covered.

Vocal activists will demand coverage for their condition or treatment of choice. For example, current research money for HIV far exceeds that allocated for diabetes, even though more people are affected by diabetes (Davidson, 1998). The U.S. Congress will mandate the service. Powerful forces in the pharmaceutical industry will influence the expert panels to favor medications over psychotherapy, despite evidence that psychotherapy is equally effective (e.g., Keller et al., 2000). Practitioners of every philosophy and training will seek the constitutional right to feed at the public trough. The health care global budget will either strain the economy, or the services demanded will be greater than what the global budget can meet.

The Thienhaus proposal perpetuates a system of fee-for-service payment that does not contain any incentive or requirement for quality improvement. The ratio of quality of outcome to the cost of service equals the value of the service. Fee-for-service arrangements focus attention on the tasks of health care and result in the micromanagement techniques of prior authorization, case-by-case utilization review and endless accounting of CPT codes.

A reformed payment system would reward providers for global performance and overall outcomes. Improvement in the overall population health and well-being should be the basis for determining our profession's value to society, not the number of sessions or procedures performed.

In Conclusion

We agree that the American health care delivery system is in need of major structural changes. There is no rational connection between employment and access to health care services. Nor is there any evidence that the forces of supply-and-demand can remedy over utilization or lack of access. One size does not fit all, however. A system for urban youth may not suit rural retirees. Rather than institute wholesale radical changes, pilot projects in small geographic areas could determine feasibility of a variety of models. Specific measures of health outcome, cost, access, patient satisfaction and provider satisfaction could and should be identified. May the best system win.

References:

1. Davidson MB (1998), Diabetes research and diabetes care: where do we stand? Presented at the 58th Annual Meeting of the American Diabetes Association. Chicago; June 13-16.
2. Keller MB, McCullough JP, Klein DN et al. (2000), A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. N Engl J Med 342(20):1462-1470 [see comments].
3. Vincenzino JV (1999), Medical care costs: trends and outlook. Statistical Bulletin-Metropolitan Insurance Companies 80(4):28-33.