Wednesday, September 28, 2016

Three Trends I Missed in 2004
Twelve years ago,  I wrote a book  “The Doctor In America: Inside the Physician Culture.”  The book was never published.   At the time, I was editor of a newsletter Physician Options, was a contributor to,  and had just published a book A Managed Care Memoir,  an account of my personal journey through the highways and by ways of managed care across the U.S.
The book contained 19 chapters, containing commentary on the  physician culture and resistance to change,  new directions for 2005, improving Care in independent practice,   hospitals and physicians interactions ,  revitalizing primary care,physician  interaction with pharma, consumer driven care,  the power  Health Savings Accounts, and the question: “Can physicians adapt to consumerism and patient-centered care?”

In the new directions chapter,  I cited 8 trends.

1.        From a youthful society to an aging society obsessed with looking younger

2.      From inpatient to outpatient care

3.      From prescription drugs as an incidental expense to an intolerable cost burden

4.      From costs absorbed by employers to costs shifted to employees

5.      From national to world concerns about infectious disease

6.      From enough physicians and nurses to shortages of both

7.      From laissez faire medicine to activist programs to prevent and managed disease

8.     From a la carte care to standardized care ti improve quality, consistency, and outcomes

What I failed to see  were the massive movements to hospitalists,  to physician extenders,  and to ObamaCare.

·         Hospitalists -  From its inception in 1996,  the number of specialists called “hospitalists” has grown from a few hundred to 50,000.   The two physicians who first described  “hospitals,”  we have these words, “This new field is substandially larger than any suspeciality in internal medicine (the largest of which is cardiology with22,000 physicians, about the same size as pediatrics (55,000(, and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107.000),  Apr9oximately 75% of U.S. hospitals… now have hospitalists).
  • Nurse as Physician Extenders  -   Thomas Bodenheimer MD and Laurie Bauer, RN, of the Cetner of Excellence in Primary Care (T.B.) and the School of Nursing (L.B.) at th University of California in San Francisco, make these predictions ( “ In the primary care practiced of the future, the physician’s role will increasingly be played by nurse practitioners (NPs).  In addition, the 150 million adults with one or more chronic conditions will receive some of their care from registered nurses (RNs) functioning as care manager.”  This is because of primary care shortages.  The number of primary care entrants is 8000, but the number of primary care physicians  retire each year will reach 8500 by 2020.

  • ObamaCare -   In 2004,  I failed to anticipate  that a national health reform law,  the Patient Protection and Affordable Care Act of March 2010, would be enacted, even though national pressures were building to protect patients against rising costs and medical bankruptcies.   Like everybody else I also failed to see the economic collapse of 2008, which made the election of President Obama inevitable.     We are now more than 6 years into ObamaCare, also commonly referred to as the ACA.   Although it has reduced the number of uninsured by 20 million and lowered the number of uninsured to just above 9%,  the ACA (Accountable Act) has been unpopular from the onset, largely because it has failed to live up to its promises of keeping your doctor and health plan and lowering premiums.   Instead millions of Americans have been forced to switch doctors and health plans, and their premiums have increased by $7500 rather than the promised $2500 reduction.      The fate of ObamaCare will be determined by the 2016 presidential election.                                     


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