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Monday, November 22, 2010

Where will change in health care come from?

It has been a long time coming and it will likely be still a while before change fully plays out in the health care arena. There is a consensus that our economy cannot accommodate sustained growth of the health care economy which is well above both the growth rate of the overall economy and greater than inflation. The possible scenarios for the end game are too numerous to count and can range from enlightened change and adaption to a Mad Max post apocalyptic hell. I suggest that something entirely different will happen.

Our medical model is based upon a training and credentialing model which may not be the best fit for a rapidly changing world. It is increasingly incapable of change. Rather than provide improved and more efficient approaches to training a health care workforce which can re-invent themselves on a recurring basis and better serve the public, it is better suited to protect itself. Undesirable outcomes trumpeted in the press serve as justifications to reinforce a regulatory framework which does more to serve the interests of those regulated than serve the public at large. No better examples of regulatory capture can be found in health care than anyone else. Whether one deals with state licensing, hospital credentialing, or residency oversight, each additional layer of regulatory hoops creates barriers to entry and brakes on innovation. While the initial motivation and justifications are to protect the public, the ultimate winners are the regulated.

No lesser developed country can afford to duplicate such a wasteful  and dysfunctional system. Much the same as when the US military found it could train highly skilled corpsman to deal with complicated health issues during the Vietnam war and this spawned the development of the PA profession, new models of health care delivery will come from developing countries. It is only a matter of time before rules based management and electronic decision support tools will allow for better and less costly management of the vast majority of common conditions. While resistance to these changes will be difficult barriers to deployment in the US and other western countries, I suspect that this will not be the case elsewhere.

Over time, data will become available which will demonstrate whether more expensive models retained in places like the US are actually superior in outcomes over less restrictive approaches that will be deployed elsewhere. I suspect it will be like any other model in history where high cost activities move offshore to find lower cost alternatives. There might be some modest quality decrement but the cost differences will dwarf any quality loss. The guilds will put a valiant fight but like the Luddites who fought mechanical looms, they will be relegated to the category of a curiosity of history.




  1. This is fantasy land. Shipping medical services "off-shore," please explain. Perhaps one field in medicine, radiology, will be at risk of this type of pressure but, come on, procedure driven fields like surgery, no way. I foresee a future in medicine whereby consumers have catastrophic coverage (covering major medical expenses) but a forced to pay for routine services (visits to the family physician, other specialists). Physician salaries represent only a modest 6 to 7% of the Medicare budget and we are not the problem. I believe hard-working physicians should be able to make a handsome living.

  2. Most health care services will not be shipped off shore although some high end procedures may be done cheaper, even accounting for the cost of a first class ticket and substantial offshore rehab.

    The lower cost alternatives which will develop elsewhere will be training pathways which will train people in shorter times and less expense. While they won't be imported immediately, the advantages of delegating tasks to less expensive workers will ultimately displace higher paid personnel trained through pathways which bring little or no additional value to patients.

    What physicians do will morph over time since what requires their expertise now can be delegated to someone with less training at a later time point. This will include proceduralists. Many of the technical tasks done by MDs in the US will be delegated to technicians when they are deployed in the developing world. This is a trend which benefits the public over time since it makes services less expensive and allows the benefits to be more widely disseminated.

    Hard working physicians should be able to make a handsome living if they deliver something of value to patients. This means re-inventing themselves on a regular basis.