Nutrition – One of The 7 Keys to Healthy Aging

“If We Could Give Every Individual The Right Amount Of Nourishment And Exercise – Not Too Much And Not Too Little – We Would Have Found The Safest Way To Health,” Hippocrates.

 Two thousand four hundred years ago and it is still the best advice.

Your agenda is health and longevity. This means most of us have to modify our lifestyles. That is the goal. If lifestyles are changed to include appropriate eating patterns and appropriate food intake along with exercise, better sleep, no tobacco and less stress, then health and wellness will follow and persist. This means many fewer chronic illnesses and a longer lifespan. But it is very important to modify lifestyles for the long term, not just a few weeks or months.

A good place to begin is with nutrition and for that a good starting point is to understand and follow the Mediterranean Diet. It consists of extensive fresh vegetables and fruit each day plus regular servings of nuts, seeds and beans along with whole grains such as whole wheat, oats and brown rice, olive oil and fish with a topping of wine but limited meat and very little added sugar. This is widely considered to be a sound, healthy diet. As a general rule it is food prepared “from scratch” in the kitchen, not processed food from the manufacturers nor prepared foods from the corner deli or fast food place.

There are some specifics that should be noted.

Cover your plate with two thirds vegetables and only one third with meat or fish. Make the veggies the major part of the meal. Fresh and local when possible and organic whenever available. Fix them simply such as steaming, stir frying or baking. Fresh vegetables need little seasonings although some herbs are both flavorful and healthy additions. Dark greens should be a frequent part of the meal – spinach, kale, collards, dandelion greens, arugula and Swiss chard are good examples. Spinach, arugula and dandelion make a wonderful salad; toss it with olive oil and balsamic vinegar and perhaps top it with a few slivers of carrot plus some cucumber slices and cherry tomatoes. Consider steaming or stir frying the others.

Fruits are important. Eat a wide variety of types and colors, preferably local and fresh although frozen is fine. Avoid canned fruits as they invariably have added sugar. Berries like strawberries, blueberries, blackberries, raspberries and cherries are high in polyphenols that are valuable for many metabolic processes and especially good for the brain.

Whole grains means just that and not refined white flour as found in most breads, packaged foods such as most cereals, pasta, cakes, pies, cookies, and yes even pizza. Refined white flour has essentially no nutritional value so it is essential to avoid all of these, with perhaps a rare treat or two. It follows that trips to the fast food outlet are verboten. Fats are fine in moderation and indeed are essential. Get them from olive oil, avocados, nuts and seeds and from fin fish. Avoid trans fats. Keep omega 6 fatty acids to a minimum; they are found in many commercially baked goods.

It is critical to avoid sugar. This is difficult since we have been trained to desire sweet tastes and sugar of various types is added to many packaged foods, sodas, yogurts and of course ice cream. The limit per day is 25 grams for women and 37 grams for men. To put this in perspective, a can of soda has the full complement of sugar for a man and is well over that for a woman. One more reason to avoid fast foods. When you buy cheese avoid ones with food colors; real cheese has natural color. Yogurt is very healthy but most brands add fruit, flavoring and a lot of sugar. Look to also see that the cultures are “live;” many are not and essentially all flavored yogurts and those with sugar added have no live cultures.

Fish are high in omega 3 fatty acids – the good fats. You need them and can’t create them in your body so it must come from your foods. Most beef comes from animals that have been placed in small pens for months and fed a diet of grains like corn and soybeans so as to fatten them up. But this fat is mostly omega 6 fatty acids which is pro inflammatory. Unfortunately, the USDA labels the fattest beef as “prime.” Beef from cattle that have been grazed their entire life have minimal omega 6s and do have omega 3 fatty acids but the amount pales compared that found in salmon, mackerel or sardines. Another important point – find meats that do not have additives, either on the range, the feed lots or added after butchering. Antibiotics, growth hormone, nitrites and other additives are likely adverse to your gut health.

Chickens are usually raised in buildings so that they never see the light of day before slaughter but do have antibiotics in their feed and may be stimulated with hormones to grow larger. Look instead for poultry from farms that use no additives and let the chickens fun free. And with all meats avoid these that have added liquid “to retain moisture.” Get real chicken and real beef, lamb or pork, additive free and pasture grazed.

Buying organic vegetables and fruits and grass-fed meats are more expensive for sure. But the health benefits outweigh the costs.

Is there anything that you can eat? Yes, dark chocolate, preferably 85% cocoa or more. It is inherently healthy. So is coffee. It is not only OK but healthy to have alcohol in moderation.

You are eating not just for yourself but also for the bacteria in your intestines – the gut microbiota (microbiome.) The 100 trillion of them need nourishment so that they can help maintain your immune system, your intestinal lining cells and so that they can produce various nutrients that your cells in various organs use for energy. Their “food” is the fiber that your intestinal enzymes cannot digest but which the bacteria love. The best sources are in vegetables and fruits. Consume inadequate fiber and the “good” bacteria are starved. If meanwhile, you eat sugar, refined white flour or too much alcohol, you will be feeding the “bad” bacteria with detrimental results. That, of course, is a common combination in the standard American diet but it leads to increased intestinal permeability (“leaky gut”), local and systemic inflammation, passage of toxins into the bloodstream and the induction of a variety of complex chronic illnesses. So, treat those bacteria well. The foods like veggies with their high fiber content that benefit the gut microbiota are called prebiotics. Foods that include bacteria and yeasts that are known to be healthy are called probiotics and are found in many foods like live culture yogurts, live culture Kefir, non-pasteurized sauerkraut, kim chi and other fermented foods. Have some regularly.

To recapitulate – aggressively avoid added sugars; eat lots of veggies of a wide range of colors including dark green leafies; include only whole grains and not too much. You need good fats as found in olive oil, nuts and seed, and lots of fish. Dairy, eggs and poultry are best if it comes from grass fed animals. Same for beef, pork and lamb in limited quantities. Include some wine and plenty of water. Be sure to include plenty of fiber foods and probiotic foods as well. Local, fresh and organic are preferable.

This combination will keep you healthy and keep your intestinal bacteria happy as well. When they are happy, you will be healthier

A final word comes again from Hippocrates; “All disease begins in the gut.” 

Still the best advice only now we begin to understand just why he was correct.

Next post – Keep moving!

A New Way To Improve Primary Care Yet Reduce Total Costs

PCPs in the current reimbursement model are obliged for business reasons to see too many patients per day which of course means less time per patient. PCPs are frustrated and patients are less satisfied. With less time it is hard to build a strong doctor – patient relationship and without it there is less opportunity to build trust. Readers of my posts know that I am a strong advocate for primary care and for granting the PCP added time per patient but doing so with no decrement in income. Here is an innovative experiment by an insurer to incent PCPs to offer more time to those patients with chronic illnesses while enhancing preventive care to all. 

Added time and good care coordination will improve the quality of care for the individual patient with a chronic illness and yet will reduce costs by eliminating excess specialists visits, tests, procedures and, by improving care quality, it will reduce the need for hospitalizations. That was the assumption underlying a program by a large not for profit BlueCross/Blue Shield plan - CareFirst. Fundamentally the plan incents PCPs with opportunities for increased income in return for giving added time and good care coordination to those with chronic illnesses along with enhanced preventive care to all patients. 

The insurer calculated that about 80% of their medical expenditures went towards the care of just 15% of patients. These were patients with complex chronic illnesses. Knowing that primary care physicians receive about 5% of total healthcare expenditures it was hypothesized that they are in a position to strongly impact much of the other 95%. The insurer also wanted to raise awareness of healthy lifestyles to assist all of their enrollees to remain healthy. So the agenda was to create incentives for PCPs to have an impact to reduce the total cost for those with chronic conditions while improving the care and concurrently maintain the health of the remaining enrollees. 

Oversimplified, the new program works like this. PCPs form into actual or virtual groups or panels of 5 to 10 and enter into an agreement with the insurer which then increases their reimbursement by 12% for each visit. The insurer also agrees to pay the physician within one business day, reducing the doctor’s need for working capital.  

An actuarial analysis of the PCP group’s patients is done using claims data from the prior year to create an anticipated “global budget” for the coming year.  The 15% or so of patients that need chronic illness care coordination are “flagged.” The PCP’s obligation is to give those patients whatever added time is needed per visit, to create a complete care plan and to post it in an electronic medical record (for which the PCP gets an additional $200). This serves as automatic preauthorization; no further calls will be needed for tests, procedures, etc. – a major time saver for the PCP and the office staff. The concept also anticipated that with extra time per patient, the PCP would be able to handle most issues including those of patients with complex chronic illnesses, reducing the need for specialist referrals. Finally, the insurer makes available a nurse “care coordinator” at its expense  to call the patient as often as necessary to check on medication use, medication side effects, weight gain or whatever else the PCP has built into the care plan. The expectation starting out was that this approach of incentives for giving the patient with a chronic illness the intensive primary care and the care coordination needed would enhance quality yet reduce the overall expenditures for that patient.  

If, at the end of the year, the PCP groups’ total claims came in under the projected global budget, the members of the virtual group would get back a portion of the savings. With these incentives, it was anticipated that the PCP would be sure to carefully coordinate care so that there were no excess specialist visits, no unneeded tests or procedures and, with better care overall, less ER visits and less hospitalizations. The end result, it was hoped from the start, would be higher quality care, lower total expenditures for that care, enhanced income for the PCPs and a more satisfying practice. It could be a win for everyone. Now three years in, the plan seems to be working. The physicians are pleased with the added income and the insurer is pleased that total costs have dropped. 

The whole concept was to coordinate the care that the patient receives with the expectation that the patient will be better served, the providers will be more satisfied and the total costs will be reduced. It is a transformational change in how the PCP functions. It is an equally huge transformational change for the insurer –a change that accepts that extensive primary care with care coordination costs extra money but recognizes that the end result is better quality at a lower total cost.  

After two years, it was reported that it saved $136 million with the 297 panels of 3,600 PCPs that had joined the program caring for about one million individuals. All of the PCPs enjoyed the added income in their reimbursements and two thirds received end of year incentive payments as a result of the savings. Overall the average PCP in the program received about 29% more than they otherwise would have under the standard fee schedule.  

At the end of three years and with enough data to be actuarially credible, there have been quite definite improvements in ten measures such as costs per member per month, number of emergency visits, admissions per 1000 members, length of stay, cost per admission, and readmissions within 30 days after discharge, etc. while maintaining or improving quality measures. Not all panels of PCPs were as successful as others and those that were tended to be successful in each of the three years in the program. At the end of the third year, about 60% of the panels were granted an incentive award for beating their projected global budget. The successful panels tended to be those in small private practices and, interestingly, had sicker patients under care yet they maintained higher quality scores. Another important finding was that some specialists tended to much higher utilization (and therefore costs) than others despite similar patient problems. PCPs who tended to refer to high utilization specialists were much less likely to achieve an end of year incentive payment. 

Of course, there are some questions to raise. If the PCP is spending more time with these patients but still has the same total size practice, then where is the time coming from? Does it mean less time for other patients? PCPs have now learned which specialists expend more dollars per patient than others. Will their referrals gravitate to these specialists regardless of known or perceived quality? Patients will likely in the future be offered incentives for choosing the PCPs that are most effective with this program; is that appropriate? And what about those PCPs who have converted their practices to direct primary care? They are actually saving the insurer considerably, probably much more than the incented PCPs in this program. The insurer should consider paying all or part of the DPC fee for their insureds since the insurer is benefiting substantially yet at no cost to itself. 

Perhaps the most important outcome, from my perspective, is the recognition by a major insurer that it is possible to create a new incentive-based approach to reimbursement – in this case within the old fee-for-service model – which actually costs more for primary care (up from about 5% of total costs to about 7-8% of total costs) yet significantly reduced those total costs of care while improving quality. 

Note: I talked to CareFirst's CEO, the former chairman of the board and a vice president about the program but I have no financial relationship; this program is used for illustrative purposes only and is not meant to be an endorsement.

 

 

A “Grand Bargain” To Improve Quality and Decrease Medicare Costs

There are just a few key reasons why Medicare has become inordinately expensive. There is no end in sight for cost escalation. But there are some obvious solutions and they all begin with chronic illnesses.

Chronic illness – diabetes, heart failure, cancer, chronic lung disease, etc. – are increasing at exponential rates; are caused largely by lifestyle behaviors; and consume 70-85% of all claims paid. Medicare enrollees tend to have chronic illnesses; 85% have at least one and 50% have three or more and many are taking 5-7 prescription medications. Any attempt to control costs must begin with chronic illnesses. 

Is there a good solution to the Medicare cost rise issue? Are there approaches that could be instituted now that would have an immediate impact on improving quality of care and thereby reduce costs? There are and could be the basis of a “grand bargain.” Here are five workable suggestions. 

1) The first recommendation is to recognize that one is never too old to benefit from sound preventive measures. Most chronic illnesses are related to excess calorie consumption, lack of exercise, chronic stress and tobacco. And aging leads to impaired mobility, vision, hearing, dentition and cognition. So Medicare should strengthen the wellness, health and preventive programs with specific funding to PCPs to engage in detailed, in depth preventive care. The new annual preventative care session built into the Affordable Care Act (ACA/Obamacare) is a good start in this direction but it must be augmented since a single yearly session is not sufficient to deal with the serious lifestyle issues leading to and exacerbating these chronic illnesses. This will improve health now and substantially bring down costs in the longer term.

2) The second recommendation is to recognize that older individuals with multiple chronic illnesses on multiple prescription medications who may have visual, hearing, mobility and cognitive impairments cannot be effectively diagnosed and treated in short time periods. There must be time – to listen, think, prevent and treat. This means adequate reimbursement per visit to spend the time required. And it means Medicare must pay the PCP sufficiently and specifically to provide chronic illness care coordination. This must be done in a way that is a quid pro quo – higher reimbursements but only in return for the care the patient needs and deserves. This will markedly improve quality, substantially reduce costs and do so immediately. It means the PCP must substantially reduce his or her case load from today’s 2000 plus to no more than 1000 (and preferably substantially less) so as to have the time required for each patient. (Many believe that it best to convert from a fee for service to a fixed reimbursement system, capitation system or a salaried approach. That is probably a good idea but only if the system grants the PCP the critical needed time per patient, i.e., assignment of a limited number of patients or a large enough payment per year per patient so as to keep the total number of patients under care low enough to give the time needed.)

3) The third recommendation is that Medicare should reconsider its approach to hospital care alternatives. For example, today a patient becomes eligible for nursing home care only if he has been hospitalized for three or more days. Costs could be dramatically reduced if a patient could be sent directly to a well-qualified nursing home by his PCP who certifies in writing as to appropriateness. Similar consideration should be given to home antibiotic administration and other home care alternatives which mean better quality and lesser costs. 

4) The fourth recommendation, somewhat of an alternative of the second, begins with the realization that primary care is generally not expensive. Indeed when Medicare originated, it was the patient’s responsibility to pay for primary care and should be again. Medicare should institute high deductibles with the opportunity for a health savings account (HSA) to pay for primary care with tax advantaged dollars. Patients begin to ask questions and challenge recommendations when they are paying for primary care directly. They can request more time per visit and pay for it through their HSA. Both have the result that the care quality goes up and the overall cost to Medicare goes way down because the patient gets the time needed by the PCP to give good care, avoid excess testing and avoid the reflex to refer to the specialist unless really appropriate. The patient-doctor relationship is corrected to being a direct contractual relationship leading to better care at much lower cost. Most studies suggest that the deductible needs to be high enough to be meaningful, often about $1000 or more. This could be reduced for those of lesser means. Given the importance of preventive care, that might be excluded and continued to be paid for by Medicare. High deductibles will be politically difficult. But high deductibles are available thought the private plans for Medigap and for the Part D prescription drug policies so the precedent is there. This would lead to a much more responsible use of the entire system with better care and much reduced costs.  

Meanwhile, many PCPs are switching to a direct pay system where they no longer accept Medicare and either expect to be paid per visit by the patient or be paid a flat annual amount (retainer). Medicare is losing these physicians now who are providing better care but at a cost to the patient. Better that Medicare reexamines its policies and adapts now. 

5) The fifth recommendation relates to end of life care. Americans believe in individualism and the right to whatever care is available, damn the expenses. And physicians are trained to treat death as an obstacle to be surmounted rather than to be accepted as ultimately inevitable. This plays out eventually towards the end of life where “one last” drug, procedure, etc. is proposed or requested or both. Generally this occurs because the physician has not engaged in a constructive, honest and empathetic conversation with the patient well ahead of time and ongoing. This is fundamentally irresponsible use of the medical care system by both patient and doctor. Much better is reasoned, empathetic discussion between patient (and family) and the doctor followed by humane, compassionate active support and emotional care – in other words, death with dignity. End of life discussions are not only logical but humane. And it must be stressed that this recommendation has nothing to do with so called “death panels” or some nefarious means of rationing care. 

Each of these recommendations incorporates a balancing of rights and responsibilities. The first offers the enrollee added wellness and preventive services but it must come with the responsibility to use them effectively. The second grants the PCP added revenue per patient but only for the commitment to take the needed time with patients and of offering extensive preventive services and chronic illness care coordination. This of course means limiting the total number of patients under care per PCP. The third grants a new approach to paying for alternative care but only provided that it is certified as appropriate. The fourth places the responsibility for first dollar coverage on the patient/enrollee but with it must come a right to a better doctor-patient contractual relationship – one that the patient can void if the response is not adequate for the dollars expended. And the fifth recommendation places a responsibility on patient and doctor alike to have in depth and rational discussions regarding end of life options and needs while expecting Medicare to pay not only for the discussion time but also for the option selected. 

These five recommendations could have a major impact on Medicare expenditures, beginning immediately. The real benefit of course is that these recommendations will improve health care quality while leading to more satisfaction by patient and doctor alike. It would be a valuable “Grand Bargain.”

 

 

Medicare and the Continuing Loss of Primary Care Physicians

Primary care physicians (PCPs) have been marginalized by Medicare for decades with low reimbursement rates for routine office visits which has led to the 15-20 minute office visit with 10-12 minutes of actual “face time” and a panel of patients that well exceeds 2000.  

Is there a good solution to the Medicare cost and quality issues? Setting aside either the Democrats’ approach to basically enact price controls by ratcheting down reimbursements or the Republican’s plan to re-structure Medicare to a defined contribution plan, albeit not for ten years, are there approaches that could be instituted now that would have an immediate impact on improving quality of care and thereby reducing costs? There are, but in this Part 6 of my Medicare series, we first need to understand one of the major issues facing Medicare today – the crisis in primary care.  

A 10-12 minute interaction means no time for the PCP to truly listen, no time to prevent, no time to coordinate and no time to just think. This has in turn meant that whenever a patient has a slightly more complex issue, one that is not easily recognized in a short time frame, then the PCP is quick to refer to a specialist. It is this very act that dramatically drives up expenditures with added tests, imaging and procedures along with the specialist’s fees. Medicare has been exceptionally short sighted in this regard and as a result is the prime culprit in the rapidly rising costs of care.  

Further, this lack of time being reimbursed means that two critical quality care needs area left largely unattended. The first is offering extensive preventive care and the second is coordinating the care of the patient with chronic illness. Recall that 85% of Medicare enrollees have at least one chronic illness and 50% have three or more. These are mostly the result of years of adverse behavior patterns but it is never too late to begin preventive care so time spent here is valuable for better health quality and ultimately reduced costs. And those with a chronic illness need to have their team of caregivers coordinated – every team needs a quarterback and the PCP is the obvious choice. But Medicare does not reimburse for this critical function which when done correctly means less reliance on specialists, tests, procedures and prescriptions. The result of this low reimbursement for routine visits and lack of reimbursement for either extensive preventive care or chronic care coordination over the years is a PCP shortage, many current PCPs no longer accepting Medicare, and the remaining PCPs trying to see 24 to 25 patients or more per day, each for 15 minutes despite the patient’s complex problem list. And this means less than stellar patient care in many instances. 

The result is a real problem facing Medicare right now - the rapid loss of primary care physicians (PCPs) who will no longer accept Medicare. In 2009 there were 3700 physicians that opted out of Medicare; the number rose to 9500 in 2012 according to CMS in a Wall Street Journal article; this on top of the shortage of PCPs across the country, with no end in sight. The ACA does include an extra 10% increase to primary care providers but this will probably be too little, too late. And if the mandated 27% across the board physician cut in reimbursement is ever implemented by Congress (it probably never will be but Congress refuses to clarify itself) then it is reasonable to expect that there will be a mass exodus from accepting Medicare reimbursements by all physicians, not just PCPs. 

What is the fix? As long as fee for service predominates in the payment system, Medicare needs to increase its reimbursement of PCPs in a manner that ensures that they will offer the patient more time per visit. Time to listen, to prevent, to coordinate and to think. And in a capitated system, Medicare (or its agent) needs to pay enough per patient per month/year to insure that each PCP does not have more than a maximum of 1000 patients (even fewer if the practice is largely geriatric) so that there can be adequate time per patient encounter. 

The next post will highlight some specific recommendations for Medicare to enact that would improve quality and reduce costs.

 

 

“Why Are Medicare Costs Rising So Fast? – It’s Actually Not Complicated”

My last post was the beginning of a primer on Medicare. Medicare covers about 50 million older Americans for general health care and covers about 75% of covered services or 50% of total health care costs of these seniors. Medicare, as the largest single insurer, sets the standard for reimbursement rates across all insurers. It tends to pay slightly less than costs, leading hospitals and doctors to cost shift or charge others a higher rate. Medicare costs are increasing at about 4% per year and will reach $1 trillion by 2022, an unsustainable cost to the government (tax payer). 

There are multiple “parts” to Medicare. Part A is principally for hospital care; Part B is for largely for physician costs and Part D is the prescription drug benefit. Part C or Medicare Advantage is a private insurer managed care alternative to Part A which incorporates Part B and often Part D into one plan. 

Each of us and our employer pays 1.45% (total of 2.9% combined or for a self-employed worker) of earned income into the Medicare Trust Fund each year for Part A. Beginning in 2013, the tax is 3.8% on earned and unearned (i.e., salary or wages plus interest, dividends and capital gains excluding interest on municipal bonds) income above $200,000 for a single person and $250,000 for a married couple. The money paid in is not invested and set aside for use when the individual reaches 65. Mostly it goes to pay for the hospitalization costs of today’s beneficiaries – it is a generation transfer tax. As the population continues to age and continues to live longer, there will a relatively smaller working population to pay the annual bills. It is estimated that the current 50 million enrollees will expand to 80 million by 2030 and the ratio of workers to enrollees will drop from 3.7/1 to 2.4 /1. So the combination of rising healthcare costs, more beneficiaries living for longer times and a relative shrinking of the taxable base means that the Trust Fund will ultimately become insolvent.  

Medicare enrollees tend to have chronic illnesses; 85% have at least one and 50% have three or more. Aging brings on chronic impairments (“old parts wear out”) such as impaired vision, hearing, mobility, dentition, bone strength and cognition. Additionally, enrollees also suffer from the chronic illnesses largely but not entirely the result of life styles. These include obesity, hypertension, heart disease, diabetes, chronic lung disease, cancer and many others.  Chronic diseases are inherently difficult to manage, will last a lifetime (some cancers excepted) and are expensive to treat. Chronic illness results in over 70-85% of claims paid. 

But these chronic illnesses consume more than they need to for a few very clear reasons.  First has been a lack of quality preventive care and attention to wellness. Second has been the lack of careful care coordination. These patients need a full multi-disciplinary team of providers to assure complete care (e.g., the diabetic patient will need an endocrinologist, nutritionist, exercise physiologist, podiatrist, ophthalmologist and others over time). But any good team needs a quarterback and the logical choice, the primary care physician, has been marginalized by Medicare for years. The result is that PCPs only allot about 15 to 20 minutes per patient visit (which translates into about 10-12 minutes of actual face time) – not nearly enough time to deal with multiple chronic issues, multiple prescriptions let alone take the time to call a specialist to explain the rationale for a referral and seek a prompt appointment for the patient. 

These are the basics of Medicare and the major reasons for continuing cost escalations. The increasing costs mean that it makes little sense to promise “Medicare as we know it” to persist in its current state into the future. Change is mandatory. The question is not whether there will be change but how to make changes in a manner that protects the medical and the financial health of the beneficiaries both today and into the future while keeping the benefits affordable. The Democrats and the Republicans both agree that change is mandatory but they offer widely divergent approaches to cost containment.  

The next post will evaluate the actual costs of Medicare for the average retired couple.

 

 

The Coming Disruptive and Transformational Changes in Health Care Delivery

There will be some very disruptive and some transformational changes in the way health care is delivered, not as a result of reform, but as a result of the drivers of change described previously. They included an aging population, an obese society, shortages of doctors, and emerging consumerism, among others.                       

I interviewed in depth about 150 medical leaders from across the United States to collect information and then distilled it down to a few key observations for my book “The Future of Health Care Delivery - Why It Must change And How It Will Affect You.”. 

As a result of those previously discussed drivers of change, here is some what we can expect to occur in the coming years. 

First, there will be many more patients needing substantial levels of medical care. These won’t be just any patients but two specific groups that are growing rapidly. Americans are aging. “Old parts wear out” and there are impairments in vision, hearing, mobility, bone strength, dentition and cognition that become more prevalent with age. And of course our society has many adverse lifestyles such as consuming too much of a non-nutritious diet, being sedentary, being chronically stressed and 20% still smoke. These all lead to chronic illnesses like diabetes type II, heart failure, cancer, chronic lung and kidney disease, etc. So there will many more individuals with chronic illnesses. The especially sad thing is that many of these individuals will be moderately young as a result of obesity since one third are overweight and another one third are frankly obese. (And now that the AMA has specifically listed obesity as a disease rather than just a predisposer to disease, then the number of Americans with chronic illnesses jumps dramatically.) This increase in chronic diseases and the impairments of aging will have huge impacts on care delivery.           

Of course, more and more care is and can be done out of hospital. But with many more patients in need of care for serious chronic illnesses, there will be a need for more high tech hospital beds, ICUs, ORs, and interventional radiology. This is different than the mantra of recent decades which proclaimed that there are too many hospitals and too many beds. Now it is the just the reverse. This too is a big change. 

But building new hospitals or new wings or renovations costs a lot of money. So does technology such as the electronic medical record, new CT or MRI scanners, and the needed technology for the operating rooms or radiation therapy equipment. To garner the required money, hospitals will need to access the capital markets. What will smaller hospitals do that have less ability to enter the credit markets? Merge with larger systems to get access to capital. So there will be more and more smaller hospitals merging into larger systems. Indeed there will be few stand alone community hospitals in the coming years. This is quite a disruptive change. 

There is already a shortage of primary care physicians and this will undoubted accelerate since few are entering primary care today after medical school and training.  In part to compensate, there will be greater use of NPs and PAs, especially in primary care. Notwithstanding the debate as to whether NPs can serve as well as MDs in primary care, they can be very effective and allow the MD to do what he or she is best at doing. Together they can create an excellent team.  

Primary care doctors are caught in a catch 22. They are in a non sustainable business model. Reimbursements from insurers have stayed level for years but office and other expenses have gone up each year. So in order to keep their personal income at least flat, they need to “make it up in volume” by seeing more patients. This means no longer visiting their patients in the hospital and in the ER. Instead they wait for the hospitalist or the ER doctor to call with reports. And they shorten the time with each patient so they can see 24 to 25 patients or even more each day.  

But seeing this many patients means they cannot give comprehensive preventive care  and cannot adequately coordinate the care of their patients with chronic illnesses – two of the key things a PCP should be doing for optimum quality care. It is the absence of time – time to listen, time to prevent, time to coordinate and time to just think – that is the critical issue. 

There are at least two approaches PCPs are taking to counter this dilemma. One is to no longer accept insurance and rather expect patients to pay a reasonable fee at each visit. Pay at the door. It cuts out a lot of haggling with the insurer and means they can spend more time with the patient. Importantly, it recreates a normal, typical professional-client relationship since the patient, not the insurer, is paying the doctor directly.  But this is certainly a disruptive change to not accept your insurance! It is like going back a few decades.   

Another approach gaining rapid popularity is to switch to retainer based practices, sometimes called concierge or boutique practices. The basic concept is to limit one’s practice to 500 patients rather than the typical 2000 or more. This means more time per patient. So in return for a fixed fee of about $1500-2000 per year the PCP agrees to be available by cell phone 24/7 and by email. He or she will see you in the office within 24 hours of a call. You get as much time as needed for the problem at hand. And the PCP will visit you in the hospital, the ER or the nursing home – maybe even do a house call.

The result is better quality. But there is more. Since the doctor now has the time – the patient now gets much more preventive care attention. And if a patient has a chronic illness, the PCP will take the very real time needed to coordinate that care. This will mean much better care from the specialists and will avoid unnecessary tests, scans and procedures. Better care at less expense.  – One more very disruptive and I would say transformational change occurring in medical care delivery.