As I write this article, the health care reform debate is ongoing. The final outcome has not yet been decided. Even if this legislation passes, most measures will not take effect until three to four years from now. There are some trends that can be commented on.
I tried my best to find positive trends and convey some optimism. I wanted to write an upbeat article but I see difficulties ahead. First, there is the growing shortage of primary care physicians. The amount of paperwork, phone calls, referrals and increasing office overhead has made primary care a difficult specialty. Medical students are simply not going into primary care. Pay per performance and quality measures dont sound like less hassles to me. The simple fact is that unless reimbursement goes up and/or hassles go down the shortage in primary care will not improve. Even if fixed today it will take years to catch up to the numbers needed.
Unfortunately there is no market based, supply and demand response to changes in health care. Prices are fixed by Medicare and managed care has tagged their reimbursement to Medicare. Therefore when a procedure or evaluation is inappropriately paid for, there is no way for the provider of that service to obtain a more appropriate reimbursement. This leaves no option other than continuing to provide the service unhappily or to stop providing the service. Both options are of concern, because you either have a stressed out unhappy physician or a service that is not being provided.
This explains some of our emergency on call problems. The hospitals are being forced to step in and subsidize the failing system. The malpractice problem is an added negative along with the high number of uninsured. The ever smaller number of physicians taking emergency room call is burning out at a faster pace.
Then there is the STAT problem. Everything is STAT. To cover the malpractice risk there are time limits to see consults, to call back, to start a protocol, to sign your orders, to document your plan and on and on. There is stress in the office and there is stress in the hospital and it is becoming almost impossible to handle both. After years of coping with the stress, physicians are adopting like following Darwins theory of evolution. To pick one example, you have surgeons that are not doing vascular work or limiting their practice to breast only, or hernias only, or bariatric surgery. I recently saw a patient who needed to be transferred from a large hospital because there was no surgeon wanting to perform a whipple resection. How difficult is it to find an ENT for a nose bleed in the emergency room or a central line placement. Now they call the poor radiologist to place the CVP line and STAT.
Lets add the new idea of penalizing the hospital and physicians for complications and re-admissions. Whos going to want to treat complicated patients? This trend to find a happy niche and avoid the complicated patient is going on in all specialties. This evolution in practice patterns seems to be going to wherever he or she feels to be more in control of their own professional life. The trend seems to indicate that there will be hospital based physicians and outpatient based physicians or large groups that can supply both.
The question looking forward is who will set the pace. Will hospitals and physicians working together be able to point out and fix some of the significant errors in the hospital based practice; will physicians be able to reduce the hassles of office practice? Do things need to get worse and a crisis to occur? Is that the only way to bring change?
Patients can detect the stressful hospital with lack of teamwork between the medical staff and the administration. They tell me on an almost daily basis. Their insight is remarkable. Stressful hospitals will lose elective surgeries and admissions without a doubt. Successful hospitals will need to form good partnerships with their medical staffs. Obviously hospitals with better payor mixes and in better financial shape will be able to do this easier.
Patients can also detect the stressful office; they look for organized smooth running practices.
I feel bad for our patients; mostly they have no idea of the complex situation around them. They just want a good honest doctor and a good caring hospital. I wish we could get rid of all the other characters that get in the way.
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