A dozen years into the 21st century, trend lines are beginning to reveal the future of our health care system. As we begin the 15th year of this column, we offer some thoughts and predictions for physicians and their patients in the years ahead.
P Financial reality trumps tradition. As state governments cut Medicaid programs, they’re concurrently planning for their greatest expansion ever in 2014 with the implementation of the Affordable Care Act. The Federal government has yet to come to grips with its own future austerity requirements, but that day is coming soon. Hospital administrators understand the need to reduce health care costs, but are terrified to acknowledge that fewer bed days are a core driver of efficiency. Patient expectations, technology adoption, and traditional economic models will be upended. Medical practice in specialty silos will become increasingly difficult. The profession will either work together as innovative stewards or become recipients of administrative fiats.
P Defining efficiency. Much will be written about achieving efficiency in health care. Unfortunately, these articles will be long on concepts and short on models. The efficient use of resources in the pursuit of a quality health outcome is not easy to measure quantitatively, especially in the face of the clinical complexity of patients with comorbid conditions. Algorithms are in development, but they lack validity and prospective validation. Future systems will rely on complex mathematical formulations that obscure their clinical logic, which may lead practicing professionals to avoid them. Accurate efficiency software has become the new holy grail of insurance companies and government programs. Meanwhile, local providers will pursue clinical effectiveness through evidence-based protocols that are aimed at achieving better outcomes at lower cost.
P Ashes of primary care. Bromides about the value of primary care finally will be abandoned. There simply is not enough money available to make primary care attractive or economically feasible in a small-practice environment, unless it is provided in a concierge setting. The rush to embrace paraprofessionals as viable, satisfying alternatives to the primary care physician will further undermine student/trainee interest in the field. Office-based clinicians who depend on a high-volume, quick-visit practice with minimal chronic-disease management will find their niche increasingly unsustainable.
P Primary care phoenix. Although primary care practice (as we now know it) will fade away, a new framework will emerge as the physician takes on a consultant role to the paraprofessional staff. There will be a need to assess office protocols, review practice patterns, examine difficult cases, and revise information technology templates. These skills will require a greater facility with clinical literature assessment, the implementation of quality improvement initiatives, people management skills, and a population-based approach to delivering health care. The primary care physician of the future will spend less time seeing routine patients, so this model will appeal to a person who is different from those who enjoy talking to patients one on one. Unfortunately, education for this model rarely exists today in a graduate training system that has been slow to change over the last 30 years.
P Speed bump for hospitalists. Hospitalist medicine has captured a large share of internal medicine graduates who seek to avoid the complexities and financial challenges of office-based practice, opting instead for the structured and better-compensated employment of inpatient medicine. Bundled payments and penalties for readmissions could pose a challenge to the field’s economic appeal in the near future. Will bundled payments for inpatient care enhance or reduce the role of hospitalists? Will such payments sustain the economic salaries of the field in the context of other inpatient providers? How will the difficult problem of 30-day readmissions be factored into economic incentives for hospitalists? These challenges will cause some tinkering, but not a wholesale revision of this core field of internal medicine.
P Human factors. As health information technology becomes the norm of clinical practice, attention will increasingly focus on the limitations of human interaction with computer systems. Administrators and programs continue to add features and requirements for the proper documentation of every clinical interaction to meet regulatory and billing requirements, in addition to the complete description of the event. In our own outpatient practice, the number of clicks and menus to navigate for a level 3 or 4 follow-up visit poses challenges. A step or two may be eliminated from this process as we integrate the patient’s presentation, revise the treatment plan, and input multiple aspects of the visit into templates for a 15-minute encounter. Patient safety, accuracy, and professional efficiency will require revisiting emerging health-information technology expectations.