Sunday, April 27, 2008

Medical trends - The American Doctor Story: Reflections on Ten Trends

I’ve been reading The American Story: The Age of Exploration and the Age of the Atom (Channel Press, 1956) – a series of essays by historians on transforming events and individuals. The common theme is American exceptionalism - molded by our frontier mentality, individualism, distrust of authority, the U.S. Constitution, dissatisfaction with the status quo, and determination to better things. These same traits apply to American doctors today.

1) American Doctors Seek Reform

A survey of 2193 doctors published in the April 1 Archives of Internal Medicine indicates 59% of doctors favor universal coverage. This survey is misleading for 2 reasons. It polls only a small number of doctors polled. And it doesn’t distinguish between single payer and incremental reform. It’s no secret American doctors are dissatisfied with the status quo, and it’s known most favor “incremental reform.” Doctors have a bad taste in their mouth over Medicare, and an even greater distaste for managed care... A truly national survey, such as the one now being conducted by Physicians Foundation for Health System Excellence, an organization representing doctors in state medical societies, will likely show what sort of reform doctors have in mind.

2) Convenience Care Will Be Wave of Future

Craving for convenience is driving health care reform. There is even a Convenient Care Association ( Thirst for convenience takes multiple forms - nurse-run retail clinics, doctor-managed retail clinics, worksite clinics, urgicenters, free-standing emergency rooms, surgicenters, and multispecialty ambulatory centers. Cash-only clinics, retainer practices, doctors making house calls, work calls, and hotel calls, and non-office based doctors bearing laptops and making e-visits are variations. All sorts of facilities are springing up in suburbs. A central theme is: go to where the patients are rather than waiting for them to come to you. Patients want convenience – nearby locations, longer hours, shorter waiting times, easy payments, and doctor’s practice who delivers convenience will grow.

3) High Tech, High Touch Will Prevail

In his 1982 book, Megatrends, John Naisbitt, after studying American newspapers for 10 years, concluded for every high tech health care development, Americans sought a high touch counterpart. For every coldly scientific specialist, Americans seek a warm generalist. For every major cancer center, there is a holistic component. Americans frequent the offices of alternative practitioners twice as often as they visit regular doctors. The trick for doctors is to find the right balance between alternative medicine and traditional medicine. Dr. Neil Baum, a medical marketing expert, says the best way to strike a balance is to ask patients about alternative therapies, show neutrality and understanding, and form and develop referral relations with legitimate alternative practitioners. Health plans cover 40% of acupuncture procedures and 80% of chiropractic care. American doctors will learn to live with alternative medicine. It’s here to stay.

4) Achieving Quality and Performance Goals Unlikely

Today the rage is to measure quality and performance of doctors through use of data. Indeed, these measurements and data accumulations have become the raison d’etre for health plans and regulatory agencies. Yet data documentation and analysis has yet to make much of a difference in efficiency and costs. Indeed, over the last 14 years studies by the Agency of Healthcare Research and Quality have shown little linkage between costs and quality. The reasons may be simple: it’s easy to measure costs, but quality resides in the eyes of beholders. Health quality doesn’t yield itself to metrics; it’s based on human relationships, expectations, and outcomes. And it’s difficult to judge physicians’ impacts on outcomes because most outcomes depend on what patients do outside of hospitals and doctors’ offices and on their socioeconomic status. Doctors have no control over how income interacts with race, gender, and education, yet these principle factors that influence health and longevity.

5) Ideas That Lower Costs Are Scarce

Experts say 70% of high health costs are due to new technologies. This may be, so the search is on for technologies that lower costs. These technologies are rare, and most focus on IT technologies – aggregating costs to identify costs of total system encounters of a given disease, data channeling patients to low cost providers; predictive modeling to show most effective intervention strategies, instant nanotechnology testing at the site of care, use of e-visits to avoid office visits, and websites, such as, showing patients what providers offer the best value for the buck. Other ideas include: doctors dropping all health plans and dealing with patients directly, cash-only practices with low overheads, preventive wellness programs cutting high cost chronic diseases in the bud, and high-deductible plans making patients more conscious and responsible for spending their own money

6) Doctors Need New Capital Partners

In the health care marketplace, the hard truths are it takes money to compete, to market, to save money and to make money. Every doctor’s health care bright new idea requires start-up capital to test its validity and marketability; every doctor organization needs capital to recruit doctor believers, to integrate, and to lay down infrastructure to establish its creditability; and every physician and every physician group must interdigitate in some way with other health care players. These are some of the reasons why doctors are partnering or being acquired by hospitals; why physician entrepreneurs are seeking out venture capitalists; why corporations are turning to doctors to help them cut down on health costs; why health plans have decided that low pay for less care doesn’t work, and more pay for coordinated care or bonuses for measurable outcomes for certain diseases might be the answer. The search for capital will create new bedfellows.

7) “Cottage Industry” to Transform

The one-on-one relationship of patients with doctors is a tested, time honored, and honorable tradition and it will continue. But it will surely change in the face of cost pressures and search for more productivity, greater convenience, and lower costs. Decentralization outside of hospitals and traditional doctors’ office is already well underway. The idea of hanging out a shingle and waiting for patients to come to you is under stress. In the future, it is likely doctors in “medical homes” and other settings will oversee teams of nurses so more patient care can be supervised; patients with chronic conditions will be handled routinely in their homes or at work through telemedicine and home visits; many patients known to the doctors will be treated through telemonitoring and audiovisual communication; and those patients who do come in for evaluation will come bearing their personal health records or computer-generate histories based on their complaints, symptoms, age, and gender.

8) More Minimal Invasiveness and Robotic Surgeries

In the quest to minimize pain, avoid complications, shorten recovery time, achieve standardization, and lower costs, minimally invasive techniques are currently in vogue and will grow in use. The most common gateway to most of these techniques is clearly either through either the vascular system – stents, catheters, ablation procedures, and implanted devices – or through laparoscopic approaches featuring small incisions, remote manipulation, visual manipulation, and things like gastric bands. Other examples are “virtual” examinations of the bronchial tree, GI tract, biliary tract, or genitourinary system. . Finally, there is robotic surgery, most commonly performed in major academic centers and large hospitals using the De Vinci system, performed on over 40,000 patients last year..

9) Problems of Managed Care

It is not an overstatement to say doctors consider themselves at war with managed care organizations that have appointed themselves as remote guardians and overseers of care. More and more doctors and their organizations are suing health plans for underpayment, delaying and rejecting claims, unwarranted bundling and lowering of fees, eliminating patients for pre-existing illnesses, canceling policies for costly patients, underpaying for out-of-network care, or so simply steering patients to lowest-cost providers, and in general, basing physician performance on a cost-basis. To doctors, the problems of dealing with health plans go even deeper and raise these questions: Who is health plans to judge what went on at the patient encounter when the plans were not there? Doesn’t what health plans do constitute the practice of medicine? Isn’t doctor time devoted to paperwork a sheer waste of training and talent? And isn’t the physician skyrocketing overhead, due largely to hiring staff to handle claims, an unreasonable health care cost?

10) IT Will Fall Short of Promises

Finally for physicians, there are the over-hyped promises of IT as the panacea for better care, lower costs, higher quality, and greater safety. So far studies have shown only marginal or no benefits of “paperless” practices. The siren songs of EMRs, PHRs, clinical protocols, evidence-based care sound too good to be true, and they ignore expenses of installation and management, lost productivity, low returns on investment, and difficulties of convincing partners and staff of value. What is needed are lower cost systems that talk to each other, portable easy-to-use entry devices, user-friendly systems adapted to practical clinical use, studies showing a positive return on investment, less harassment and pressure from those who have never been in practice, financial incentives to use the systems, systems that address the true needs of patients and doctors at the point of care.

1 comment:

Unknown said...

Richard - wonderful post as usual. I would only add that the globalization of healthcare is not something to be ignored. While I do some work in the area of medical tourism I was nonetheless surprised by Fast Company's medical tourism article this month that states that cardiology and orthopedics are specialties that could truly be impacted in the U.S. by people traveling overseas. Up until now whatever pain has been caused by medical tourism has been pretty much directed at hospitals. Take care, Anthony