The title of this article is intentional, as odd as it may seem. Futures is plural on purpose, and the question about reform is not rhetorical. The political events of the past year created a widespread and misleading impression that a (singular) new future for health care was being created in Washington. In reality, health care in the United States is multidimensional, and it is heading in many different directions simultaneously. Efforts to legislate a “one size fits all” solution are doomed to failure. Consequently, physicians can look to their futures as an expanding realm of possibilities, each with its own implications for reforming a part of a complex system.
Lessons of History
Health care has changed dramatically since the modern era of American medicine began in the mid-1800s. We have travelled an impressive distance from the days when patients had to bite the bullet (literally!) during exploratory surgery or swallow untested nostrums. Today’s state-of-the-art health care is defined far more by research-based scientific advances than by any other factor, including political “reforms” that have done little more than shape the financial processes to pay for it.
Reimbursement has become a Rube Goldberg mechanism that must be changed because it wastes scarce resources, but it does not ultimately define the foundations of appropriate clinical practice. If health care were suddenly redirected along the political lines most recently pursued in Washington (payment overhaul), reform would not have any impact on the exciting discoveries announced every week in medical journals. How doctors should be treating patients is defined not by payment, but by rapid advances in knowledge about health and disease. In particular, medical science is being revolutionized at the level of genes and molecules, creating clinical complexity that exceeds the capabilities of any single physician.
Consequently, the future is something that very few physicians can approach as sole practitioners. The concept of a medical home is founded on the increasingly obvious fact that it takes a team to treat a patient. In the future, physicians will need to choose which care team to join. There will be lots of choices as reimbursement shifts from fee-for-service to bundled payment—a shift to be accelerated, ironically, by the latest failure of legislated health reform.
In addition to choosing a care delivery team in the coming years, physicians will also have the choice of being a player (direct caregiver), a coach (care coordinator), or even a general manager (chief executive) of an integrated health system (accountable care organization). The accelerating development of new practice arrangements will also provide exciting opportunities for entrepreneurially inclined physicians. Some of the most important advances in medical practice over the next 5 to 10 years will be developed by MDs and DOs who see the “big picture,” not patients.
The expanding realm of futures for physicians is also made possible by the medical applications of networked computers and communications technologies (generally abbreviated HIT). Indeed, the exciting growth of medical science would not be possible without ongoing advancements in data collection, storage, and processing. Physicians will need to embrace the digital transformation of medical practice, particularly the adoption of electronic health records, because the information required for good patient care is already exceeding the storage and processing capabilities of the human brain (and physicians are human).
Like physicians, technical experts who design electronic medical records are struggling to cope with the increasing complexities of medical science. However, today’s problems with user-friendliness are not an excuse for staying on the paper trail tomorrow. The real imperatives of reform, finding the least-expensive ways to deliver medical care of acceptable quality, compel development and adoption of HIT that enables state-of-the-art medicine. Consequently, many physicians will find their futures at the interface between clinical practice and information technology—doing more good for health care by designing systems than by treating patients.
Digital transformation will provide additional proof that science and technology have more long-run influence on the future of medical practice than payment mechanisms. Clinical care teams using integrated medical records will be able to evaluate their performance in real-time and apply the proven tools of continuous quality improvement with their own current data, correspondingly reducing the need for quality indicators and other national standards based on historical data. Best processes will replace best practices as more health care delivery systems adopt information systems that promote consistent delivery of effective and efficient health care—doing it right all the time, as inexpensively as possible.* Ultimately, pay-for-performance will become non-payment for non-performance and create new opportunities for physicians who complement their knowledge of clinical practice with skills in information technology and decision sciences.
Diversification of Practice Locations
The transformative power of information and communications technologies is not limited to electronic medical records. Computer scientists and mechanical engineers are developing portable devices and telemedicine tools that allow physicians to see patients in an expanding variety of locations. Physician-patient interaction is no longer confined to the exam room in a hospital or medical office. With telemedicine, the physician and the patient don’t even need to be in the same place, or even to be together virtually at the same time.
Physicians will have more options to practice in non-traditional settings, and patients will not always need to leave home or work to interact with caregivers who build their futures on these technologies. In addition, more delivery organizations are providing medical services in locations that are convenient to patients, such as shopping centers and worksites (factories and office buildings). For more than a few physicians, the future offers the option of working from home and managing the health care needs of their patients located somewhere else.
Prescription for Meaningful Reform
The latest reform efforts in Washington have been remarkably detached from these emerging foundations of medical science and clinical practice for the 21st century. A few elected officials and industry leaders addressed them in early stages of the political process. However, the progressive trends in health care were forgotten as the focus of reform shifted almost exclusively to “overhauling” insurance—that is, seeking to expand the number of insured Americans without seeking to improve insurance’s impact on efficiency and effectiveness of the medical marketplace.
Because health reform is very unlikely to be legislated in the foreseeable future, physicians are still stuck with a problematic status quo. Or are they? Why shouldn’t physicians take full advantage of the diverse opportunities being created by science and technology? The answer is obvious. Physicians who can envision a more effective, efficient, and equitable health system must become actively involved in collective efforts to build it from within, not to wait for elected officials to impose it from outside.
However, physicians cannot accomplish reform alone because hospitals and health systems, private and public payers, and corporate and individual purchasers are also affected by the outcomes. Acceptable reform can only be accomplished by multi-stakeholder partnerships—and physicians can be anything from players to “owners” on these teams. Physicians should not be asking whether to get involved in improving American health care, but how to be involved and how to use medical science and technology to achieve desired improvements in cost, quality, and access.
An increasing number of physicians will determine that their greatest contributions to improving health care will be made as entrepreneurs and executives, not as caregivers. (Indeed, most of the health systems identified as models for reform are led by physicians who no longer treat patients.) Regardless of the role they choose to play, all physicians should think globally and act locally because reform, like health care itself, is ultimately local. It will not come from Washington. It can be led by open-minded, visionary physicians.
Jeff Bauer, Ph.D., a nationally recognized medical economist and health futurist, is a vice president of Affiliated Computer Services (ACS), a Xerox Company. Visit www.jeffbauerphd.com or contact him at firstname.lastname@example.org. His weekly blog is posted at www.thehealthydebate.blogspot.com.
* Bauer, Jeffrey C. and Mark Hagland Paradox and Imperatives in Health Care: How Efficiency, Effectiveness, and E-Transformation Can Conquer Waste and Optimize Quality (New York: Productivity Press, 2008), pp. 51-52.