More Insight

Thursday, July 24, 2008

Future Health

[stolen directly from Smirking Chimp]

By RJ Eskow

This country is in a healthcare crisis today -- but we're not thinking enough about tomorrow either. Here are seven trends to watch, starting with the short-term and ending with what may seem more like science-fiction.

The seven trends are: Doctors leaving the public system, a shortfall in primary care, underutilization of medical treatment, "superbugs," virtual health care, climate change, and radical self-redesign and enhancement.

1. Doctors Leaving the Public System: Medicare dodged a bullet when Congress stopped a substantial pay cut for physicians this month. But doctors continue to leave the Medicare system -- in Texas, in Washington State, in Tennessee, and elsewhere. And many doctors already limit the number of Medicaid patients they accept. Shortages will become more acute as SCHIP and other reforms (hopefully) increase the number of Medicare and Medicaid recipients, and they'll hit lower-income and minority communities first and hardest.

2. Unavailability of Primary Care Doctors: Primary physicians (internists, family practitioners, gerontologists, etc. ) aren't paid enough. It's part of a general tendency to under-compensate for "cognitive services" -- thinking, talking, and diagnosis. Doctors are economic actors like the rest of us. So the result of this payment bias is a critical lack of "cognitive" physicians who should be the drivers of the medical process. Instead, young doctors are being lured into high-cost specialties. This increases the use of costly (and sometimes unnecessary procedures), according to studies conducted at Dartmouth and elsewhere.

This shortage is already crippling health reform in Massachusetts. The idea of increasing compensation for primary care keeps circling around in health circles, as it is now -- along with the concept of a "medical home," which is a re-articulation of health reform ideas that appear at regular intervals like comets. The thinking is probably correct, but the problem will persist -- until there is fundamental reform in the way doctors are educated, compensated, and rewarded with social status. And meaningful reform will be difficult without adequate primary care.

3. Underutilization: Medical policy types are well-versed in the cost problems and health complications that stem from over-utilization of health services. Over-utilization is a central tenet of the McCain health proposals. But, while it occurs -- especially in certain specialties -- the reverse problem of under-utilization is prevalent and growing.

As insurers and employers shift more and more costs to individuals' pockets people are seeking less and less treatment, as this California survey (warning: pdf file) demonstrates. 38% of respondents said they avoided seeking medical care -- either preventive or curative -- because of health costs. That's up from 34% three years ago, and it's a problem. Failure to seek needed care increases health costs, adds to individual suffering, and can allow untreated contagious conditions to spread. Which gets us to...

4. Superbugs: A study of MRSA "superbug" infections published last year found a dramatic increase in occurrence among Chicago's urban poor. Crowded living conditions in jails and public housing could be a factor, according to the study's authors, and illegal tattoos may also be contributing to their spread. Now British hospitals are facing a new superbug called "Steno" that is at least as hard to treat as MRSA.

As new viruses mutate and spread, ready access to preventive and curative medicine becomes more critical. Superbugs would be a concern even if we had a fully functional health system. With the system we've got, the impact of new mutated pathogens could be serious -- and potentially catastrophic.

5. Virtual Health Care: Online healthcare holds great promise for the future - both as a way for people to manage their own health, and as a tool that links doctors and patients in a unified network. But even now, before "Health 2.0" is a reality, we're seeing a wave of health data losses and thefts. (They've become so common that I have a whole blog section devoted to privacy issues.)

The combination of electronic medical records, electronic prescriptions, and other online tools could result in new forms of crime -- with scary enough potential results that I'd rather not describe them in public. (Why serve as a think tank for the bad guys?) Virtual health could also cause substantial shifts in the kind of medical care people demand. While that might actually be a good thing, failure to plan for it could result in some temporary inconveniences.

6. Climate Change: Global warming could change the way we use medical care - and how much we need. As an Australian study found (and we summarized here), overall hospital admissions went up by 7% during heat waves, while mental health admissions went up by the same percentage -- and kidney-related admissions increased 17%. That adds up to a snapshot of medical conditions on a globally-warmed planet. Other changes, like a dramatic increase in the occurrence of mosquito-borne diseases, could also take place.

7. Radical self-redesign: 'Transhumanism' -- the movement to re-engineer the human body -- isn't a well-known term today. But the process is already underway, and it will gain momentum in the coming decades. Choosing our children's genetic characteristics, building computer technologies into our bodies, extending our lifespans, all of these will come into being in the coming years. This will raise a series of questions in fields like medical ethics and health financing, as we've discussed before.

What should we be allowed to do to ourselves and our children? Which changes should be paid for as a social right, and which are a personal choice? Will we create a 'two-tiered' race of human beings? These science-fiction questions will become increasingly concrete as we consider the health care reform issues of the coming century.


Mass Health Reform Watcher said...

Whoaa. To say the primary care shortage “is already crippling health reform in Massachusetts” is way overstating it.

Here’s the data: The number of people who said they “Did not get needed care in past year because of trouble finding a doctor or other provider who would see them or trouble getting an appointment” went up from 3.5% to 4.8%. Is that “crippling?”

Yes, there’s a shortage of primary care in MA, same as many other places. As more people get insurance, the problem is more noticeable. But which is better: expanded coverage with primary care delays, or being uninsured?

The state is taking steps in this area. They approved drugstore clinics, over the objections of the medical establishment and the mayor of Boston. Today, insurers announced they will cover the visits, with lower copays. A bill waiting final passage sets up loan forgiveness for primary care, increases the number of PAs a doc is allowed to supervise, and does some other things.

MA Health reform is doing what it was intended to do: expand coverage to the uninsured. There’s a lot more to do. But hold off on the obituaries.

DifferentiAtlas said...

Reform Watcher,

Thank you for the comment. First off, I did not write the phrase "crippling health reform," but did find RJ Eskow's article worthy of posting.

I am by no means a health care policy expert, let alone an authority on the Commonwealth's healthcare reform. You are certainly right that the 4.8% does not indicate any crippling. Perhaps he just used hyperbole to emphasize his point.

The Wall Street Journal article linked to, however, uses some slightly different data to make the point. Granted, the article is from a year ago, when the new MA plan was still in its infancy, and some of the data cited in the article is from 2005 and earlier.

But it emphasizes the PCP shortage in how few are accepting new patients, and the increase in waiting time for an appointment. So while less than 5% didn't get needed care, others are waiting longer as the pool of new PCP dries up.

One of my mentors works at Codman Square community clinic in Dorchestor, and says since the new law took effect, they have been extremely overwhelmed with patients, and even more underfunded than ever.

I certainly hope that new bill passes to attract more young doctors into primary care, not just in Mass., but everywhere.

Thank you again for the comment, and I look forward to seeing how the MA model for health insurance reform plays out in the coming years as more data come in.