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Thursday, August 11, 2011

The upside of being unsatisfied

Earlier this year I went to a patient safety conference sponsored by the IHI conference. It was a very interesting conference. In contrast to the usual medical conferences I attend, the population of attendees was very heterogeneous, made up of a small fraction of physicians and an admixture of nurses, PAs, NPs, PhDs., administrators, counselors, health techs, and a host of others involved in some form in the delivery of health care services. The focus was mostly on primary care s opposed to specialty care, although it was interesting that it appeared to require many different specialists to delivery primary care (although not MD specialists). Common to all of these participants in the delivery of primary care was the recognition that their future was completely linked to the need to change. No one I met was at all married to keeping the present delivery system.

Here I was in what could be best described as a supercharged atmosphere literally where it was a given that everything would change and everyone thought... "Bring it on!". Ditch the fee for service payment system... what are you waiting for? So what if we have been operating using a particular set of models before. They don't work for us or our patients.

It was such a stark contrast to the crowds that I generally run with who are as a rule vested in as little change as possible. Why such a contrast? The major reason is that primary care providers are not at all happy with their current lot. What they generally do to bring value to patients is arbitrarily not valued as much financially as what many other medical specialty activities. In contrast, those involved in specialty care, particularly those who are proceduralists who are highly paid, like their practices just the way they have been.

Outside of the internal struggles within medicine as to who is valued or not, there is a larger process which will likely satisfy those who want change for the simple reason that change is inevitable. When the super committee appointed by Congress gets back to work, they will look at the task ahead of them. Whatever their partisan bent, champions of expensive health care will not likely find many allies. They will be charged with one major task... cut spending. On the Democrat side of the aisle, there will be huge pressures to "save" Medicare and Medicaid as we know it. On the Republican side of the aisle, the goal might be different in that there will be huge pressures to re-conceive how Medicare and Medicaid are structured, moving perhaps to more market based principles. However, both parties will measure a key element of success with one common metric; spending less money and curbing the rate of growth of health care spending.

When the revenue streams are cut with the prospects of further cuts into the indefinite future, this will turn everything upside down.  Expensive hospital based medicine will be a business no one will want to be in. Present profit centers will become cost centers and top billers in the present  will be viewed as consumers of expensive resources. Everything will be turned on its ear, if you remain in the world where your income sources are strictly linked to third party payers, particularly ones whose mandates will be to spend less because they are broke. Fee for service might not be dead, but lucrative fee for service paid for by government entitlement programs will be a thing of the past. The drive to cut costs will overwhelm all other priorities. 

Remember that happiness = results - expectations. Those who expectations are the continuation of an unsustainable payment system which rewards them arbitrarily but handsomely will be disappointed. Those who expectations have already been dashed,  this sea of change and disruption of the present system is viewed with great glee. It is the upside of not being happy with their present circumstances. Whether they will fare any better in the future is an open question. We can hope that we will be left with a health care delivery system that serves patients better for less money. That is the real measure of success.

1 comment:

  1. It will be interesting to see how the enthusiasts in primary care who favor tearing down the current delivery system respond to the only realistic alternative, that being a more market based system of reimbursement for health care. As has been pointed out in this column on many occasions, when people receive some form of subsidized care their consumption goes up. The corollary to that of course is that when they are paying out of pocket their utilization will go down including for necessary care not just the quarterly blood pressure check and labs because they are on a statin. I have an almost exclusively market based practice and my annual income fluctuates radically from year to year and notably with the state of the economy. Just how enthusiastic are those in primary care going to be when their schedule is not full two weeks in advance with those routine blood pressure and cholesterol labs from which they generate significant and steady income. And have they considered that patients who are not constrained to seeing an in-network PCP before consulting a specialist are going to balance the marginal cost of a specialist with the higher probability of a correct diagnosis and more expert treatment and forgo their family doc. Most critically, are they really prepared to confront, as I do in my practice where patients are paying out of pocket, the oft asked question "Is this really necessary?" This would be good for medicine generally, and health care economics particularly, but the revolutionaries out there should be careful of what they wish for never having actually had to compete in the marketplace.