Four  Health Care Trends:  Top Dogs and Underdogs, Or, Inside-Out,  Downside-Up

Every dog has his day.

Cervantes, Don Quixote

Until recently,  government and hospitals  have been top dogs in the health reform fight.   They have had the authority,  the political clout, the money,  the structure, and the power to impose their will.   Consumers and physicians have been the underdogs.

But times, they are a 'changing.

Now,  the underdogs,  consumers and physicians, are beginning to have their day.  They are barking their complaints, and the top dogs are listening because health reform  isn’t working well.  Government and hospitals need the help of the underdogs to help them make  dysfunctional  health reform function better, to reduce  soaring premiums and deductibles , to expand, narrowing provider networks,   to make health reform  work in favor of those who deliver and receive care, and to win the hearts and minds of “constituents, “ i.e., voters in the next election.

Every dog has his day.  The underdogs, patients and doctors, are becoming top dogs, as evidenced by these trends,  which are about transitioning from inpatient to outpatient care (inside-out) and responding to consumers and  physicians by ending cumbersome regulations  (downside-up).

One,  hospitals are shifting emphasis from the inpatient side  to the outpatient arena to survive.  This is occurring because  technology advances make possible  better outpatient care,  because patients worry about hospital infections and other hospital hazards;  because patients  prefer to be treated at home and in convenient outpatient  locations ;  because  urgent care clinics,  independent emergency facilities, and conveniently located  diagnostic and treatment centers with adequate  parking are growing fast, and eroding hospital market share,;  and because costs and regulations  are lower in outpatient setting.   In a word,  outpatient settings are where the future lies and what the action is.

Two, hospitals are employing doctors at a record pace,  and most acquired doctor practices are located outside the hospital.   For hospitals it makes sense to keep those practices outside the hospital.  Furthermore, because of federal rules,  hospitals have been able to  charge more for hospital-owned  facilities.   Because of something called the “Facility Fee,” a previously obscure Medicare arrangement, hospitals have tacked on fees of hundreds of dollars when the hospitals “owns” the facility.  When patients visit some doctors' offices and urgent-care clinics, they're  running into something unexpected: extra feels as though they had gone to a hospital. These fees. which often  amount to hundreds of dollars, occur when hospitals own physician practices, urgent-care centers and other operations. Consumers around the country are complaining about separate, unexpected facility fees, based on hospital ownership of previously independent physician owned practices.   In November, 2015,  Obama signed a bill lowering  facility fee” on hospital-owned practices located outside the hospital,  a victory for consumer underdogs.

Three,   older patients prefer to be treated at home and to spend their post-hospital days and  last days at home.      Hence,  the booming businesses of home care, of companions for the elderly,  and of home and hospice  visits by nurses and doctors.  Home is where the heart is, and Medicare is punishing hospitals for premature  readmissions to the hospital, which may occur because of patient misunderstandings and poor health care at home.  Consequently,  hospitals find themselves in the home care business and are sending nurses, doctors, and other caregivers to home to prevent readmissions.

Four,   CMS is finally beginning to listen to doctors about what’s dysfunctional and unworkable in health reform.   What’s wrong includes such commonsensical things are electronic medical records that inflate costs and take time away from patients,  burdensome credentialing processes that make hospital privileges difficult to obtain for locum tenens physicians and others,  and bureaucratic pre-authorization requirements  designed to cut costs but more often results in time-consuming hassles with phycians and their staffs.    Too often well-intentioned interventions drive up costs and reduce clinical efficiency.   Bureaucrats and insurers too far removed from patient-physician relationships are learning consumers and physicians know what they are talking about how to make practices work, and they are learning physicians  must modify and individualize care in the real world, recognize a variety of clinical presentations and multiple coexisting conditions, the variability of human biology, the effects of social and cultural contexts, the diversity of  patients’ preferences regarding risks and benefits,  all of which defy rigid protocols (P. Hartzband and J. Groopman,  “Medical Taylorism,” NEJM, January 14, 2014).

The moral of this blog?  You government officials  and hospital administrators, out there,  Listen to consumers and doctors.  They are telling you what works best in the real world.  They are telling you when protocol is folderol.  Make them an integral part of the health care conversation, and you and health reform will benefit.