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More chronic illnesses, more diseases of old age, consumers demanding more quality and safety, physicians no longer in typical private practice, and high deductible health care polices are each about to cause major changes in the practice of medicine and how it is delivered to patients. Will this come about smoothly or, more likely, with some serious hand wringing?
Health care delivery will change substantially in the coming years. This is not because of reform but rather due to a set of drivers that are exerting a great push and pull to the delivery system. Some of these changes will be quite transformational and some will be very disruptive of the status quo. What are these drivers?
One of the most important is that there will be many more individuals with chronic illness. The Milliken Institute offered a white paper a few years ago on chronic illnesses and noted that nearly one half of Americans had one or more chronic illnesses, most of them preventable and which were costing the economy over $1 trillion per year and rapidly rising.
These are diseases like diabetes with complications, heart failure, cancer, or chronic lung disease. What is apparent is that they are mostly due to adverse lifestyles. Eating a non-nutritious diet -- and too much of it combined with a sedentary existence leads to obesity. One third of Americans are overweight and another one third are frankly obese. Add to this chronic stress and that 20% still smoke and there is an effective recipe to produce chronic illnesses. Chronic illnesses will make up a greater and greater proportion of all medical ailments as time goes on. And of course they are more difficult to manage, generally last a lifetime and are inherently expensive to treat (although there is much that can be done to reduce the costs of care.)
A second driver of change is the aging of the population. The American society is growing older and just like a car: “Old parts wear out.” Aging brings on visual and hearing impairments, mobility difficulties and diseases like osteoarthritis, Alzheimer’s and other chronic illnesses that, as best we know today, are not due to adverse lifestyles but are tied into the aging process.
Another driver is the increasing demand for medical services. Perhaps this is saying the same thing another way. More aging and adverse lifestyles create more disease and the need for care.
Consumerism is becoming – finally – more and more of a driver of change. Patients are coming to want and expect to be treated like a valued customer. Like the movie where he shouted “I can’t take it any more,” now “the patient is no longer willing to be patient any more.” What do the patients want? They want service, good service. They increasingly understand that quality and safety are not ideal so they are looking for and expecting high levels of quality & safety. Perhaps the most important one of all is respect, respect for their person, confidentially, and the quality of their care. But also patients want convenience & responsiveness. They don’t want to have to travel long distances, wait long times in the “waiting room,” nor be put on indefinite telephone hold. They want interaction by email and other electronic methods. And finally, patients increasingly expect to have a closing of the information gap – they expect the playing field between patient and doctor to be much more level in the future.
Professional shortages are also definite drivers of change in the delivery system. There have been shortages of nurse and pharmacists noted for more than a decade. More and more there is a shortage of primary care physicians (PCPs) and also general surgeons. These shortages are more acute in rural areas and urban poor areas.
Combined with shortages are changes in professional aspirations and lifestyles. More and more physicians want and expect to have more time for family and recreation. And they no longer want to run their own private practices. They prefer to be employed with little if any administrative burdens. Indeed the number of PCPs in a typical private practice arrangement has declined precipitously in recent years. And since so many patients coming to the ER today are uninsured, many physicians are no longer willing to take call unless on a contract with the hospital. Most physicians are willing to accept that some patients will be of limited means but they are not wiling to be overwhelmed with non paying patients.
And among many other drivers of change is that patients will have greater requirements toward a direct share of costs. Today we have mostly “prepaid” health care, meaning that our insurance covers most everything, minus a low deductible or co-pay, from routine exams and well baby care all the way to a heart transplant. Among employer sponsored plans, there is an increasing push toward high deductible plans, with deductibles in the $1000-2000 range. Even some Medigap plans have high deductibles corresponding with much lower premiums.
These are but a few of the drivers that will change the delivery of health care in dramatic ways in the years ahead. I discuss them in much more detail in The Future of Health Care Delivery – Why It Must Change and How It Will Affect You with data obtained through over 150 in-depth interviews of medical leaders from across the country. It is fair to expect that physicians, patients, hospitals, insurers and employer/government sponsors will be challenged to adapt.
My next post will examine what these drivers of change will actually cause to happen to the delivery system.