Monday, July 22, 2013

Great Healthcare Migrations
Migration promises going to a better place, and moving from a bad place
Electronic aids, particularly domestic computers, will help the inner migration, the opting out of reality. Reality is no longer going to be the stuff out there, but the stuff insider your head.
J.G. Ballard (1930-2009), English novelist
The story of America is a  story of migrations – from Europe to America,  from crowded East to Western frontiers, from black South to white North,  from old North to new South and new West,  from Mexico to America, from cities to suburbs.  It is movement from brown pastures in search of green pastures.
In healthcare, the story is a search for cost containment.  It is a search for less costly, more convenient, more accessible, more effective, freer,  greater choice,  more personal, and, if possible, more entitled care.  On a national scale, it is constantly moving.  On a regional and individual level,  its component parts are in motion too.
It is part reality, part fantasy.  With the internet and mobile devices and apps,  people can find and rate the good places, but the Net is full of hype and unsubstantiated claims, unsupported by double-blind unbiased studies.  Still, on the whole, the Internet world is a place of infinite connections.  It is filled with fellow sufferers who share your pain and who can tell you what works for them.
Besides this computer-driven inward migration, there are two great migrations taking place out there.
One is centripetal; the irresistible drawing-in of caregivers into large integrated corporations, including government.  These entities offer comprehensive services employing all, or most, providers. In a 1988 book, I called this migration “the corporate transformation of medicine.” It is more than that.   It is huge, and in my opinion, irreversible, as well as irresistible, for the public trusts large pluralistic organizations to be socially responsible, more so than scattered individual practices and independent free-standing entities.
Its most powerful and visible form is government-directed care from Washington. This type of care is popular, particularly among recipients of federal entitlements,  but it is proving to unsustainable in Europe, other Western democracies, as well as in America.  Broad scale social welfare programs, statism,  no longer works in down economic times.  In aging populations with low birth rates, demand invariably outruns state resources and punishes the young.   Government becomes overwhelming bureaucratic. It has no choice. It must account for every  penny. It becomes a government of forms and paperwork.  To control fraud and abuse, it spends 90% of its time controlling 10% of abusers.
The other migration is centrifugal,  the spinning out of care from large organizations and government to decentralized sites – retail clinics in drugstores,  walk-in clinics everywhere,  urgent care centers in malls, concierge and cash-only medical practices, and, last not least, to patients’ homes and to patients themselves.  Mobile wireless devices,  data-sensitive implants, Skype-like communication systems, in the hands , under the skin, and inside the bodies of patients and hooked up to doctors and hospitals, drive this scope and power of this centrifugal movement, which is still in its infancy.
Thus far,  for U.S, patients,  these great migrations have not moved on a significant scale outside the United States – to India, Canada, the Caribbean, Mexico, and beyond, but that too is stirring, as the observers and promoters of “medical tourism” remind us.
Tweet:  Health care migrations are centripetal, into large organizations, and centrifugal, decentralized care away from these organizations.

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