Tuesday, July 16, 2013

Shifting Healthcare Landscape

A Three-Way Conversation About the Shifting Healthcare Landscape
A good conversationalist is not one who remembers what was said but says  someone who  says what one wants to remember.
John Mason Brown (1900-1969), American drama critic,  Esquire, 1960
I am just back from a  conversation over lunch with two eminent gentlemen – a former administrator of a large academic hospital and the former chairman of the board of that hospital.  For an hour and a half, we exchanged views on  the changing healthcare landscape.
As we spoke , I thought of Edward de Bono, MD, an English physician who founded a thinking institute on Malta( Letters to Thinkers, 1987).   de Bono said the healthcare landscape was composed of a series of vertical holes, which hospitals, academic centers, and specialists inhabited.  At the bottom of each vertical hole resided  a collection of world class experts.
Loosely connecting the vertical holes, on the horizontal plains  surrounding the vertical holes, were generalists-  family physicians, general practitioners, pediatricians, internists, psychiatrists, and  primary care doctors of every ilk.
The only problem, said de Bono, was  that the vertical holes ddin't nterconnect with each other or generalists strewn across the landscape. 

Obamacare aims to connect the holes and doctors around the holes.  How? Through comprehensive reform and a series of steps:  forming Accountable Care Organizations (ACOs) where hospitals, primary care physicians, and specialists, working in tandem, prevent disease, promote wellness, coordinate care of chronic disease  for a define Medicare population, and thereby save Medicare money, hence the alternative name for ACOS “Accountable  Savings Organizations.” The ACOs or ASOs will do this through govenment  command, control, and communication structures which will standardize and homogenize hospitals, physicians, and health plans through protocols, guidelines, and data-driven outcome analysis..
So far, the results of this ACO effort have been mixed (“Mixed Results in Health Pilot Plan,” WSJ. July 16, 2013.  Of the 32 Pioneer ACOs selected bb CMS because they were large integrated systems likely to succeed, 18 saved money, 13 enough to save money for Medicare. Two hospitals lost money, seven told CMS they wanted to move to another plan, and two said they wanted out of the plan. Meanwhile,  250 hospitals are in the process of setting up ACOs,  and commercial insurers have developed ACO contracts with hospital systems.
But I digress.  Back to the conversation.  
When asked if Obamacare would succeed,  I said I doubted  it would. It went unsaid, but I sensed my companions, being from a Deep Blue, Obama-friendly state, one of 16 to develop their own health exchange,  thought otherwise – that Obamacare was irreversible and inevitable.

My reasoning was that because of delays , imissed deadlines,lsoaring costs,  and  a 65% unpopularity among the citizenry,  it would surely falter.   Furthermore, its comprehensive integrated programs, depend on its central pillars working together. The pillars,  were  crumbling one by one because of ailed promises, underfunding,  digital unpreparedness, and Republican opposition.
When I observed that I thought hospitals were in the catbird seat because of their administrative, technological, and marketing skills,  one of them said, “Do you really think so?”  I sensed disbelief, so, out of politeness, we dropped that line of conversation.
My fellow conversationalists agreed that exchange signups among the young “invincibles” and undereducated minority groups would be a tough sell  because of sharp premiums hikes among the young and language barriers among minorities .   I noted that Blue Cross & Blue Shield in a trial run among 500 Hispanics had only 4 questionnaires returned.
We touched upon prevention and wellness programs,  and we all thought changing behavior outside hospital and office settings was a  dicey proposition, given life-long habits, socioeconomic conditions, and individualism in the American culture.
We discussed how rampant  physician employment by hospitals,  ubiquitous presence of hospitalists, and encroachment of electronic health records impacted physicians.  The consensus was that although physicians liked the security of hospital employment,  and that could stay in their offices generating revenues rather than having their day disrupted by hospital rounds was welcomed. 

On the other hand,  physicians resented giving up autonomy by becoming employees,  and many missed the hospital staff camaraderie, the intellectual stimuli of interns and residents, and the dull routines of being trapped in the office doing physicals, rectals,  pelvic, and routine procedures.   

Many physicians,  particularly those over 50, were having a hard time getting accustomed to  the rigors and restraints of data entry and  loss of productivity induced by entering data on electronic health records.
We  dealt briefly on the mysteries and the process of writing well.  All of us had read Stephen King’s book On Writing.  All of us had written books, and all of us wanted to know the tricks of the trade in marketing them,  especially in the E-book era, which had dealt such a staggering blog to the publishing industry.  They were intrigued how I had managed to turn out a daily blog over the course of seven years.   Nothing to it, I thought, all it takes is a compulsion to write,  having something to say, and a a talent for verbiage.
Tweet: Today’s blog concerns a conversation between 3 seasoned healthcare veterans discussing shifts in the healthcare landscape.

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