Evolving Frontiers in Medical Specialties
THE DOC WHISPERER “It’s Change I Don’t Like” Jack Lewin, MD I didn’t realize that my career would move toward this special skill—of helping panicked, angry, confused,
sometimes loud-barking physicians of all specialties achieve greater life and career satisfaction in today’s rapidly transitioning environment. But this is something I am now apparently called to do. Hospital and medical group leaders increasingly are asking for assistance for large contingents of their doctor colleagues to help them better cope, survive, or—better—thrive in the world of change that is upon us. More than half of American physicians are now employed, and many of them thus think they are insulated from the changes afoot. They’re not—and their employers (often hospitals) will be helping them understand reality as health reforms progress. Many of those in private practice—even in larger medical groups—are freaking out because of the uncertainties ahead. But at least 50 percent of U.S. physicians (and U.S. hospitals) are already engaged in payment reform and are moving away from fee-for-service (FFS) payment to bundles or capitation or salary in organizations that are themselves taking risk or capitation. I consult with an innovative home health company that is moving in this direction as well. I predict that half of those remaining doctors in FFS payment models will convert to something else within five years, because they will hear the whispers that their bottom line will be better if they move toward being rewarded for better outcomes, patient satisfaction, and efficiency. So I see a group of probably 25 percent of physician colleagues who will remain in FFS and just try to ride out the changes until they retire. A few doctors who provide discretionary or very episodic care, such as plastic surgeons, may be able to remain in FFS indefinitely. But the world is changing, and doctors are experiencing stresses keeping up with it. The future is not grim. It will be better. Science is accelerating, and we can do more amazing things to help people than ever before. But not in the same old way we used to practice. . . . So, as of right now, what should we expect to see coming from the “political” world? More cuts are coming in health care! Doctors, hospitals, home health, drug and device companies: This means you. We need to be ready very soon to propose how to seek additional savings in Medicare and Medicaid entitlements of (I’d suggest) $500 billion to $1 trillion over ten years to be sure these programs do not continue to rise faster than the GDP—and to prevent other blunt-edged cuts such as we have seen in sequestration. We can find ways to do that without hurting patient care by promoting payment reform, delivery system innovation, mobile and telehealth innovation, patient 12 13
San Francisco Medicine april 2013
activation in shared decision making, and anything that ferrets out waste and/or promotes value (better outcomes at lower costs). The fact that health costs have recently slowed is likely to be temporary. But the nation can no longer afford to have health costs rise faster than the GDP (our ability to pay for them). Sacred-cow tax deductions are likely to be reduced or capped in solutions to the budget, deficit, and debt ceiling issues. Don’t be surprised if this happens. But if these offset health care cuts, are they perhaps not worth it? I’d rather see deficit reduction with a carbon tax, and perhaps a value added tax (a VAT, or modified sales tax) that excludes food, health care, and energy; but fat chance of that happening. The physician “doc fix,” or SGR formula (SGRrrr expressed as a growl), is not likely to be included in these deliberations, even though the Senate plan proposes that. It’s still a lot of money (less than $200 billion), even when the cost for eliminating it is less than it will ever be right now. But, unless a lot of hell is raised pretty fast around here, it could easily be dropped from the table and just kicked down the road again. Patients should be aware that publicly funded care (Medicare and Medicaid) is significantly at risk of being transformed in ways that put beneficiaries at greater future financial risk through the deliberations ahead. Better pay attention. In closing, as Mark Twain is alleged to have said, “I support progress and innovation; it’s change I don’t like.” Jack Lewin, MD, is chairman, National Coalition on Health Care, and founder, Lewin and Associates LLC. He is former chief executive of the American College of Cardiology, the California Medical Association, and the State of Hawaii’s Department of Health and its public hospital systems.
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