The impact of single-payer health care on physician income in Canada, 1850-2005

Optimizing Physician Payment for a Single-Payer Healthcare System

Current forms of payment of independent physicians in U.S. health care may incentivize more care (fee-for-service) or less care (capitation), be inequitable across specialties (resource-based relative value scale [RBRVS]), and distract from clinical care (value-based payments [VBP]). Alternative systems should be considered as part of health care financing reform. We propose a "Fee-for-Time" approach that would pay independent physicians using an hourly rate based on years of necessary training applied to time for service delivery and documentation. RBRVS overvalues procedures and undervalues cognitive services. VBP shifts insurance risk onto physicians, introducing incentives to game performance metrics and to avoid potentially expensive patients. The administrative requirements of current payment methods introduce large administrative costs and undermine physician motivation and morale. We describe a Fee-for-Time payment scenario. A combination of single-payer financing and payment of independent physicians using the Fee-for-Time proposal would be simpler, more objective, incentive-neutral, fairer, less easily gamed, and less expensive to administer than any system with physician payment based on fee-for-service using RBRVS and VBP.

Single-payer Health Care: Financial Implications for a Physician

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.

Facial Transplantation in a Nationalized Health System: The Canadian Experience

Facial transplantation (FT) is recognized as the ultimate reconstruction for severely disfigured patients. The substantial cost of these procedures in a nationalized health system has not been extensively published. The first Canadian FT performed in May 2018 was a great opportunity to address this subject and evaluate the viability of such a program.

The salary of physicians in Chinese public tertiary hospitals: a national cross-sectional and follow-up study

Background

Salary is perceived as a key factor affecting job satisfaction, employment, and the retention or migration of physicians within and across countries. This study aimed to describe physicians’ salary and workload and to examine the factors determining the salary of physicians in China.

Methods

We conducted a self-administered, smartphone-based national survey in 136 tertiary hospitals across 31 provinces. A total of 17,615 physicians self-reported their salaries after tax and their characteristics, practice settings, and work efforts in 2015. Then, 2498 of the physicians were followed up for the second-round survey in 2016. Univariate analysis and general estimate equations were applied to evaluate the factors associated with salary.

Result

In 2015, the average annual salary of the physicians was US$13,764. Physicians in eastern China earned more than those in central (p < 0.001) and western China (p = 0.002) after adjustment for locality expenditure per capita. The salary for men in 2015 was US$14,832, which was more than that for women (US$12,912; p < 0.001). Of the respondents, 76.3% worked more than 40 h per week. The physicians dealt with 40 patients per day on average. Consequently, 67.2% physicians spent no more than 10 min with each outpatient. After adjustments for age and management position, salary was associated with years in practice, education background, and specialty, but not with weekly work hours and gender.

Conclusions

The physicians’ salaries were relatively low, and the majority of the respondents worked more than 40 h per week. Years in practice, education background, specialty, and region were associated with salary, while weekly work hours and gender were not. To better remunerate Chinese physicians, more resources are demanded, and a workload-based salary scheme should be adopted.

Doctors as Stewards of medicare, or not: CAMSI, MRG, CDM, DRHC and the thin alphabet soup of physician support

Physicians are deeply involved in Canadian medicare because it is through medicare that they are paid. However, from its origins to the present physicians -as a profession - have not been strong supporters of medicare. Fearing loss of income and individual autonomy, they have frequently opposed it with criticisms, strikes, threatened job action and lawsuits. Some opponents are unaware that medicare was a boon to physician income, and many fail to connect medicare with responsibility for improving the health status of the country. This paper will trace physician involvement, support and opposition to medicare from its inception to the present, with special attention to small physician organizations that have supported medicare. It will close with a proposal for how doctors could display greater stewardship.

What can the Canadians and Americans learn from each other's health care systems?

Numerous papers have been written comparing the Canadian and US healthcare systems, and a number of health policy experts have recommended that the Americans implement their single-payer system to save 12-20% of its healthcare expenditures. This paper is different in that it assumes that neither country will undertake a significant philosophic or structural change in their healthcare system, but there are lessons to be learned that are inherent in one that could be a major breakthrough for the other. Following the model in Canada and in Western Europe, the USA could implement universal health insurance so that the 32.0 million (2015) Americans still uninsured would have at least minimal coverage when incurring medical expenditures. Also, the USA could use smart cards to evaluate eligibility and to process health insurance claims; these changes resulting in an estimated 15% reduction in US health expenditures without adversely effecting access or quality of care. Such a strategy would result in the eventual loss of 2.5 million white-collar jobs at hospitals, physician offices and insurance companies, a long-term economic gain. Only a few would agree with the statement that Canada already functions with a multi-payer reimbursement system as evidenced by (1) a federal-provincial, tax-supported plan, administered by each of the provinces, providing universal coverage for hospital and physician services and (2) roughly 60% of its residents receiving employer-paid health insurance benefits, underwritten primarily by investor-owned plans, that are less than effective to reimburse for pharmaceuticals, dental and other healthcare services. What could be learned from the USA and particularly from Western European countries is possibly implementing an approach, whereby at least upper-income Canadians could opt out of their federal-provincial plan and purchase private insurance coverage - being eligible for far more comprehensive "private" benefits for hospital, physician, pharmaceutical, dental and other healthcare services. Aside from generating billions of additional needed revenues from the private sector, it could (1) help eliminate long waits for non-emergent physicians' care by appointing newly minted specialists to their medical staffs; (2) offer prompt admissions for elective cases to "private" wings of hospitals; (3) increase available funding for what is currently an undercapitalized system; (4) enhance the system's sluggish operations; and (5) encourage more competition among various providers. Although such a two-tier approach, such as available in the USA and elsewhere, is politically dead on arrival in Canada today, private insurance being already legal and commonly available there. Interestingly, this recommended solution is utilized in most western European countries where there is a higher percentage than in Canada of public (versus private) funding of their total health expenditures. Because of various vested interests, attempts to implement any of the aforementioned proposals will undoubtedly result in considerable political rancor. There is greater likelihood, however, that the Canadians because their need to be more effective and efficient in their delivery of care, and their overall long-term fiscal outlook will agree to the further privatization of their healthcare system before the Americans will mandate universal access, use the smart card to process insurance eligibility and claims or will impose price controls on high-tech services and on pharmaceuticals. Copyright © 2016 John Wiley & Sons, Ltd.

Why Oncologists Should Support Single-Payer National Health Insurance

The authors support the establishment of a single-payer national health insurance plan and encourage ASCO to put its advocacy behind such a program.

Public payments to physicians in Ontario adjusted for overhead costs

We used data collected in the 2010 National Physician Survey and public payment data published in the Institute for Clinical and Evaluative Sciences report Payments to Ontario Physicians from Ministry of Health and Long-Term Care Sources 1992/93 to 2009/10 to estimate 2009/2010 net physician income from public payments for Ontario physicians by specialty. Incorporating overhead substantially affects estimates of physician income and changes relative position. For example, ophthalmologists were ranked second when only public payments were considered but eighth when overhead was included. Conversely, hospital-based specialties such as anaesthesia, radiation oncology and emergency medicine rank significantly higher after overhead is included.