Sunday, January 16, 2011

The End Of Internal Medicine As We Know It – Health Affairs Blog

by Caroline Poplin

Physicians have doubtless been issuing jeremiads since before Jeremiah. We are overworked, underpaid, and underappreciated.

But today, general internists have a real problem. And it is our leaders who do this to us. As summarized in the Annals of Internal Medicine:
To realize the full benefits of the Affordable Care Act, physicians will need to embrace rather than resist change. The economic forces put in motion by the Act are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups. The most successful physicians will be those who collaborate with other providers to improve outcomes, care productivity and patient experience.
In the future envisioned by the health policy community, including the leadership of the Amercian College of Physicians and the American Medical Association, patients who want a personal physician, someone they know and trust, who understands and cares about them as individuals will have to pay extra for “concierge” care. Everyone else will migrate to team care from large “Accountable Care Oranizations” (accountable to whom, one may ask—certainly not the patients). These teams may well improve patients’ blood pressures, glucose control, lipid panels, maybe even weight, and indeed improve the outcomes of patients whose outcomes can be improved. Their care will be efficient: providers (yes, providers) who do not see enough patients, whose patients do not improve adequately, who order too many tests, do not meet the fifteen criteria for meaningful use of EHRs, or do not continuously pursue quality improvement projects, will see their incomes fall.

Perhaps the new organizations will provide better care for some patients and some conditions. Will other patients — those with poor prognoses, bad attitudes, complex or ill-defined diagnoses, multiple complications, cognitive limitations, even just morbid obesity — be lost in the shuffle.

And whether this radical overhaul of the health care delivery system will reduce health care costs overall, ostensibly the point of the exercise, is unknown. The cost of multiple layers of highly paid managers (including multi-million dollar executives) and the extensive information technology infrastructure on which these elaborate systems depend, is not trivial. Indeed, modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions that pay serious attention to suggestions from production workers and those who deal directly with customers. What little evidence we have on cost savings from ACOs is largely anecdotal and equivocal.
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