Monday, December 26, 2011

A Look Ahead

Call it an après-holiday reflection, but as I look back at 2011 and anticipate the year ahead it is only natural to ponder what the New Year will bring in of our evolving field of medicine.

What might we expect in the year ahead?

Data Increasingly Becomes King

As the New Year begins, I suspect we will first see more of the same: more market consolidation with larger hospitals eating smaller, financially–strapped hospitals and doctors throwing in the towels of financial independence in favor of corporate employment or retirement. 2011 was the year that cardiologists realized their practice rug was irreversibly pulled out from under them by a 2009 national “stimulus package” whose changes to payments for office based imaging services kicked in on 1 January. Private cardiologists were left with few options to maintain their incomes besides joining with larger hospital systems. It was that same 2009 legislation that provided funds for Electronic Medical Records that gave government-mandated data collection legs.

But the real effects of health care reform have yet to sink in. I expect healthier hospital systems will look for new ways to leverage their current financial largess with national name-brand centers of regulatory excellence to be maintain their public perception as “cutting edge.” With that, the use of data to improve clinical efficiencies while simultaneously using the data to market services will become 2012’s data-driven mantra. Like the fortune-teller’s crystal ball, those centers with the foresight and wherewithal to process and puree the large volume of clinical data spewed forth by today’s caregivers data entry personnel will be richly rewarded as new pressures to the cost curve surface. There will be a distinct competitive advantage to those who can simultaneously compare treatment, demographic, and socioeconomic trends in near real-time with an eye for more financially efficient care.

Privacy Lost

The demand for this data to help to cut costs and maximize profits has already superseded the government’s ability to maintain patient privacy. Oh sure, we’ll still see a handful of large-dollar HiTECH Act and HIPAA violation penalties assessed to make it look like things are under control, but there’s a different reality now: clinical data leaks are worse than ever and not likely to be slowed any time soon. One only has to realize the extent of the mobile-medical movement and the innovations in hand-held devices capable of fully managing patients at a distance to appreciate the futile nature of the government’s ability to enforce the HIPAA/HiTECH acts. After all, despite the government’s heavy-handed wrist-slapping in this regard, I have yet to see a story of how the government recovered any of the data lost or how they rectified damages to those whose medical information has already been compromised. Shouldn’t that be the focus? Sadly, these rules have had another important downside: they put care providers in the impossible catch-22 of trying to maintain data security while health care is provided over larger geographic locations in near real-time, twenty-four hours a day. What do you mean they can’t use their cell phones to send clinical data to each other?

“Repeal and Replace” Has Already Been Replaced

The big news story of 2012 will be the Supreme Court’s ruling on the constitutionality of our new health care law’s mandate to purchase health insurance. Much of the fragmented Republican presidential candidates have vowed to “repeal and replace” the new health care law, but they would be better served to acknowledge that our health care system has already made massive irrevocable changes as far as doctors are concerned. Hence, repealing and replacing the PPACA will not change what has happened to our prior health care delivery mechanism.

Americans should not think for a minute that going back to the days of old doctor’s offices on every corner is possible – it’s become too cumbersome and too expensive to do so. Instead, the local minor care will be by the likes of Rite-Aid, Walmart or Walgreens. For those who want to see a doctor, from now on a nurse might have to do. Appointments for skilled “care providers” will increasingly be made online or via kiosk. If a phone call is desired, large call centers with phone trees with built-in logic and recordings to check for “quality” will be our new reality as disposable administrative health care personnel are increasingly replaced by technology.

Still, some independent doctors’ practices will survive for a while in the more affluent regions of the country. Cash-based practices will flourish thanks to a persistent demand for this care. Their challenge to this model will not be in providing care but rather getting the data to do so. Larger health systems in control of larger laboratory and medical record operations are unlikely to relinquish this data-driven power willingly. Whether these independent physician models will evolve to counteract this reality remains to be seen.

Primary Care Evolves to Specialty Care; Specialists Evolve to Administrators

Want a primary care doctor in 2012? See your specialist. No longer is primary care a visit to the doctor. Need a school physical? See your Walmart nurse. Need a vaccination for overseas travel? See your Rite-Aid pharmacist. Need cholesterol management? See your endocrinologist. You get the point. Primary care doctors (family practice doctors, pediatricians, internists, and even some ob-gyns) will continue their evolution to become managers of fleets of nurse-practitioners or nurse-doctors. The influx of patients and demands on their time will require this. And because data flows to today’s specialists faster than ever, so too will computer-mandated primary health care. In response, specialists will quickly offload these computer-generated demands to their less-skilled counterparts in favor of maintaining new patient appointments more likely to generate their favorite procedural care. But as more and more “procedures” are eyed as ‘expensive,’ proceduralists will increasingly collaborate with hospital administrators as the onus of limiting costs is spread to them. Skilled proceduralists that also carry MBA’s will be viewed by our current cauldren of hospital administrators as 'the bomb.'

Social Media’s Influence On Medicine Grows

Social medicine will continue its parallel track to conventional medicine. People will find support and suggestions from others. Need a good doctor? Ask your friends. Need some information? Ask a friend on line. If they don’t know the answer, they are likely to know someone who they know and trust who will. Think you were gouged on price for a procedure? Ask your friends. The truth will set us free. As patients are presented with more information faster than ever, social media will continue provide a potent concierge service to patients as they negotiate the ever-changing system before them.

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So there you have it. A few of my broad-based pie-in-the-sky projections for 2012. Will they materialize? I can’t be sure. But it's clear the health care cost piñata has burst. Sure there's still a scramble to pick up the few remaining financial health care candies lying around. But the end of our bountiful health care game is fast approaching and what next year's game will become is anybody's guess.



Anonymous said...

Brilliant assessment!

Yes, we physicians were just a pass through so this administration could give money to the Silicon Valley/high tech beneficiaries. Don't worry, though. This money will be recycled in campaign contributions--muliplier effect. Upgrade cycles will ensure that this is the gift that keeps on giving.

The EMR will provide a means to better 'supervise' our practices. Can you say big brother will be watching?

Don't forget the guidelines that have metamorphasized into written in stone commandments? By the way, how did you have so much time to compose this blog entry? Shouldn't you be reviewing the DOJ list of 'fraudulant' ICD implantations for your hospital/employer? More guidelines equals more fraud equals more payment withheld.

Are you following the NCDs for dual chamber pacing? Are you willing to violate the guidelines to do what is right for the patient or should we implant a PPM then explant it 40 days later and replace with an ICD?

I see a criminal in the making. We have ways of dealing with lawbreakers.

Medical Quack said...

As patients and doctors and consumers we are becoming data chasers by all means too:) You are right privacy is dying on the vine sadly.

It's not only "big" data but it's "flawed" data too that worries me. When you add on machine learning to flawed data sources, well the ride is on.

With big business in all areas trying to connect their data sources we have flaws. Even social security has 31k who are alive in the the social security death index. I would have to have to straighten out that mistaken identity being one of those for sure. It's bad enough we have dead doctors who live forever on the web with MD referral pages but to still be alive and have to fight that identity issue, well I feel bad for those folks.

Add on some marketing to some of the data sources, as what was done by Health Grades as they merged with a PR firm..who knows what we will get next, maybe there is a market for "dead doctors":)

Personally I think we should put out an excise tax for those folks selling data and making billions and I think of that every time I have to buy a tire for my car and pay excise tax. I call it the Attack of the Killer Algorithms...sure there's a lot of good out there that makes us smarter and I like all of that however when I read about a small town in Wisconsin where 52 businesses are being foreclosed on who never missed a payment it makes you wonder where risk assessment is going, behavioral foreclosures now too?

One being foreclosed on was a church who was not making a big enough profit? Go figure...I think we need some layers of forgiveness with risk assessments all over and in the payer area of healthcare too.

John Alexander said...

Well said. But the vantage point implies that the change that stimulates the angst is all bad. While I lament the facts as they play out for me personally as an MD I do think that the net/net from a patient perspective is for the better. A simple but I think instructive example from my practice is captured in the following example. I am a cardiac surgeon; in the long pass I was referred patients who presented essentially with the following complaint, "My doctor said something was wrong with my heart". Coronary problems? Your heart valve? Which valve? The patient really did not know. They presented me with an EKG or maybe a cath film or an echo report but no real complete collection of test results. There was no doubt that both the patient and the referring MD were making all best efforts but the truth was that the data I needed to make an informed judgement was not in hand and it took me and my staff a while to assemble the data before I could offer an opinion. The EMR that I have worked with over that past 5 + years has dramatically improved my ability to make better more timely decisions about patient care than ever before. I would not want to go back. The simple facts that surround hospital notes makes this very clear. Handwritten notes readable by the author-sometimes- but essentially illegible to any one else have been replaced by granted a lot of cut and paste at least you can read them. There is no question that the charts now are more useful to patients from an outcome standpoint and doctors alike. The issues of data privacy are real but the value of the EMR far exceeds the risks by the improvement in care. The changes to the "old patterns" doctors are lamenting are way overdue.

John Alexander

Tim Hulsey, MD said...

John Alexander said, " While I lament the facts as they play out for me personally as an MD I do think that the net/net from a patient perspective is for the better. "
But the net/net for the doctor is still 28 hours worth of work to do in a 24 hour day. I don't type as fast as I can write, and MY writing is legible to all. When the government confesses that privacy really isn't a priority, you will then begin to see the unintended consequences unfold. One problem with an EMR (and there are many) is that there is TO MUCH information. I have to spend time I can't afford to sift through to find what little I need. If EMR was such a great alternative, why did the government have to force its adoption? Trust me when I tell you that the EMR is the cause celebre of the government because it gives them access to information they can use to control health care in this country and fashion it the way the MPPs and MPHs think it ought to be. Politicians just want COVERAGE for everyone. Just remember, coverage doesn't equal treatment. THe MPPs and MPHs want to mandate medicine by Public Health principles. I don't know about you, but I don't see patients in groups. I see them one at a time, the way medicine was meant be practiced and the way it is taught. Everyone gets to put their 2 cents in except for practicing physicians. Why not physicians? Because we are the patient's advocate and put their well-being ahead of all those things the government wants to do– not good if you're trying to streamline the system.
If you think that the government has the best interest of the patient in mind and that everything will be OK, you're naïve. If you're a big government guy, don't forget that, under socialism, all patients will get the same care WHETHER IT IS APPROPRIATE OR NOT!!!

gobostonredsox2004 said...

Some top notch posts recently. Thanks for your insights.
Best wishes for 2012 and lets speak in the new year,

Tim Hulsey, MD said...

Speaking of Privacy Lost,
1) "Hacker collective Anonymous has just dumped 200 GB of names, email addresses and passwords for around 860,000 Stratfor users. Anonymous also exposed credit card numbers for 75,000 paying customers of Stratfor."

2) When money was kept in vaults in banks or other institutions, the amounts a bank robber could abscond with were mostly limited. Even if they stole your checks, you could just close that account and move your funds. No one ever robbed Fort Knox. Now, your money is a piece of data in an insecure system and can be obtained from anywhere in the world and taken to anywhere in the world.

Electronic theft has surpassed physical theft. Not only is electronic data storage making your medical information widely available, it is making all your personal and business information available for mischief, fraud, or just a good Sunday afternoon read for anyone with a computer-saavy child. In general, I think this conforms to Big Government's wish to know EVERYTHING about you, not just your health information. It allows them to find every little drop of your assets they can lay claim to and to come up with new ways to ding you and share your wealth more accurately. It allows them to use your information to coerce you conform to their plan. Medical and financial information can be used and manipulated to shape political outcomes, as well as almost any other aspect of society.

In this electronic age, privacy will become non-existent!

Didn't someone write about that?