The popular conception in healthcare is that (1) a new law was passed, (2) it changed everything, and (3) in a bad way. Over time, however, it should get clearer that, while there was a law passed, the law alone is not driving changes to our healthcare system: it’s our own demographics and behavior. Most of the tax dollars currently fueling our healthcare system (and arguably our economy) are tied to an aging Boomer population that are soon to drop off the income producing cliff into the Medicare population. Bye bye income earners; hello ridiculous public healthcare expenditures. Though it is true that the timing for expanding public spending on healthcare (with the federal mandates aimed at employers and Medicaid eligibility expansion) could not be more poorly timed, the situation is more of a “Perfect Storm” than a surgical strike.
The financial stress of our changing population and of a historic utilization based healthcare system is causing our healthcare system to morph in every way. “Health insurance,” with increasing cost, copays and deductibles and reduced benefits, is quickly ceasing to look like your father’s 80/20 major medical plan and starting to look more like catastrophic coverage. Fee for service compensation is fast becoming “spoken” out of existence. There are more “pay for performance,” “case rate” and other outcome and risk based compensation models than you can shake a stick at. The simple truths are: payers have to deliver more with less; and patients have to bear more and more of their healthcare expenses.
The question of “how” is the number one question. And oddly, unlike the historic patient physician dynamic, the answer may not lie as much with physicians as with the expanded (and essential) role of patients. Patients have traditionally expected physicians to bear the entire burden for wellness, but that may have to change. How much of our healthcare ills do we patients control? How much of our expenditures are lifestyle issues? The irony, however, as one physician with a large healthcare system recently stated “We don’t know anything about wellness. All of our training and work day is spent helping when things go wrong.”
Patients arguably have a significant contribution to make towards improving the “healthcare system,” and yet there seems to be little incentive for them to get more involved. Where is the reward for healthy choices (aside from better health!) and the disincentive for unhealthy ones? Employers may ironically be in the best situation to reward healthy patient decisions by increasing contributions for good “markers” like BMI and such. Physicians, however, seem to lack such leverage. How can a physician reward healthy patient decisions and implement consequences for bad ones? Physicians that figure that out stand to gain the most in a performance or outcome based system.
Years ago, when it became financially unattractive to take hospital call, enterprising physicians developed a new niche, “hospitalists.” Will they again develop another niche, “preventionists.” As they become more invested in an outcome based system, will providers of all kinds find ways to stimulate healthy patient behavior, and can providers develop an economic model that drives that? Will patients see the benefit of taking up the slack by becoming a player?
What “insurance” (commercial and governmental) will become is anyone’s guess, but it clearly seems to be morphing. In fact, with “health insurance” looking less and less like “health insurance,” it looks as though a “two tiered” type system is emerging. With health insurance looking more like catastrophic coverage and outcome based payment gaining momentum, will providers be able to enlist patients into a wellness and prevention model of care? The future of our country’s ability to pay for any kind of healthcare may require the physician patient dynamic to shift to a far more collaborative model than we are used to. And that may be best for all concerned!