Myles Riner, MD, FACEP
The nice folks at Perspectives on the Acute Care Continuum asked The Fickle Finger to take another shot at gazing into the crystal ball of healthcare trends and events for 2014. Looking back at last year's effort, I think these predictions were reasonably accurate, except perhaps for this one: Obama will use his Constitutional authority to raise the debt ceiling without Congressional approval. Never happened, because Republicans in Congress eventually chickened out.
I think my predictions specific to emergency medicine (EM) were nearly spot-on:
- There will be more emergency department (ED) visits in 2013 than in prior years.
- Emergency physicians will make less money in 2013 than in prior years.
- More ED patients (and sicker ones) will be treated by nurse practitioners (NPs) in the ED.
- Commercial and government payers will push back on emergency physicians (EPs) even harder in 2013 through RAC and commercial claims audits and recoupment demands.
- Single ED groups will continue to be swallowed up by hospitals and larger ED groups.
- The popularity of EM residencies, relative to other specialty training programs, will begin to peak in 2013.
- ED boarding of admitted patients will continue to plague the practice of EM.
Not surprisingly, most politicians won't give a damn.
I can't prove #2, but I still think it is true, in part because EPs are working fewer hours per month, but EP incomes may have been (temporarily) sustained by significantly rising charges throughout the industry.
In any case, here is The Fickle Finger's set of predictions for 2014. I am trying not to be too pessimistic, but this last year was dismal, except for the stock market; and this year will likely be just as bad, except for the stock market.
Obamacare. What can be said about this program that hasn't already been said by far too many, every day, ad infinitum? Surely, whatever you think about the basic premise (everyone, including young invincibles, must be insured, excepting of course, lots of poor, ineligible and undocumented people across the country); the botched roll-out of HealthCare.gov, the hit or miss expansion of Medicaid, and the trash-it vs. fix-it Congressional brouhaha all have to leave you with a sense of frustration, if not hopelessness.
The Fickle Finger predicts that even as the HealthCare.gov website steadily improves; the complexity of this revamped insurance market, the machinations of the health insurance industry (especially the narrow networks that will come between patients and their chosen providers), the constant drumbeat of criticism from Republicans and the lack of a serious tax consequence for "going bare" will continue to plague Obama not just in 2014 but throughout his entire presidency. Biggest mistake, in The Fickle Finger's opinion: no preferential role for not-for-profit healthcare insurance plans.
Recently, HHS announced that something like 360 ACOs have been approved. ACOs are penetrating both the Medicare and commercial markets, and they are operating mostly on the shared savings incentives approach. Balancing utilization reduction (i.e. rationing) against performance on so-called quality measures ("so-called" because no one is really sure if performance on these metrics actually translates into quality of care) is the equivalent of squeezing blood from a stone, especially in the face of increasing patient expectations and ever-expanding scientific advances in diagnostics and treatment modalities.
The Fickle Finger predicts that some ACOs will be able to squeeze a bit of waste out of the system, but that ultimately the success of any cost-effective care ventures in this country will have to wait for transformational changes in the several cultures we have in the US, especially in how we look on the art of death with dignity. Don't hold your breath.
Many years ago, healthcare was mostly a private affair between doctors and patients, but now the media has taken a prominent role in forming and shaping our opinions and expectations about healthcare. It is a mixed bag. Transparency is probably a good thing overall, but the tendency of the media to hype everything, to contract a complicated story into a headline, to tug at heartstrings and fan the flames of outrage, has created far more heat than light. The most recent story of the brain dead child on a ventilator in Oakland is yet another example. Social media (and political partisanship) has only compounded this dilemma, and the question becomes: how can physicians educate the public on the real benefits and limitations of healthcare in the face of such a constant barrage of misinformation and half-truths?
The Fickle Finger predicts that the physician-patient relationship will continue to suffer at the hands of the media and electioneering, as evidenced by ever more "compelling" stories about the latest scientific miracles of genetic engineering, and the latest tragic accounts of medical failures, frustrations with Obamacare gone awry, Medicare fraud, physician shortages, narrow networks, death panels and the like.
Use of cholesterol-lowering drugs is expanding, as drug companies and their physician marketeers continue to stretch the indications for these drugs to cover just about everyone and their sister and even their pets. Almost overlooked was the recent notice that the FDA will be requiring the addition of a box warning about the memory loss side effects of these agents.
The Fickle Finger predicts that as statin prescribing becomes ever more popular, it will suddenly dawn on us that the push to lower cholesterol levels is creating a massive increase in the number of people with early onset, often subtle but significant and possibly irreversible, cognitive and memory deficits and other nervous system-related side effects. Huge class action suits will follow.
Choosing Wisely, the campaign to get physicians and patients to talk about whether selected tests and treatments are really necessary or useful before these services are ordered, is a reasonable idea, and some of the medical societies that contributed strategies to the campaign are investing in ways to help providers adopt these strategies. I hope ACEP will do the same, but so far, I am not optimistic. I had to chuckle at the American College of Radiologists' approach: most of their strategies are aimed at telling other physicians how to practice instead of advising radiologists how they themselves can contribute to reducing the cost of care. The other thing I found disappointing was that many of the strategies identified in the campaign are not targeted to decisions that actually could save the most money.
The Fickle Finger predicts that few physicians will systematically adopt Choosing Wisely strategies to reduce the cost of care in their practices, unless they are incentivized by shared savings or capitation payments. ACEP, like most specialty societies participating in Choosing Wisely, will pump out some more strategies over time, and perhaps put on a CME course or two on the subject; but few EDs will be able to translate this into a game-changing, cost-effective care program.
Microliter blood testing, on the other hand, is shaping up to be a game changer for medicine, and a welcome one, for the most part. Point-of-care testing on tiny blood samples in the ED and the primary care physician's office could improve throughput and speed diagnostic evaluation in time-critical conditions. It is also more respectful of everyone's time and patience. Unfortunately, it could also lead to higher costs and more unnecessary testing.
The Fickle Finger predicts that the benefits of point-of-care blood testing on microliter samples in the ED will overcome hospital lab and pathologist resistance and become the standard of practice in many hospitals in 2014 and beyond. The number of blood tests that can be performed in this way will expand exponentially.
Between the practice of many health plans in culling their networks of physicians and hospitals, excluding those the plans believe may be too "expensive", and the practice of many physicians who are unwilling to participate in plan networks (especially exchange plan networks) that offer contract rates that are far below traditional commercial and even Medicaid rates: the quality of care provided by these networks is likely to erode. Efforts to shore up quality of care with performance and quality metrics will succumb to the profit-driven economic incentives that drive these plans and will encourage them to obfuscate the quality issue.
The Fickle Finger predicts that in 2014, the culling of physicians and hospitals that have excellent reputations and great outcomes from plans seeking to contract only with doctors and hospitals that are willing to accept deeply discounted reimbursements will become a recognized and hotly debated impediment to the success of healthcare reform; a cause celeb for politicians seeking to play up the empty "you can keep your doctor" pledge; and add further stimulus to the development of a multi-tier healthcare system that is not just about affordability and economic class, but increasingly about quality of care. It used to be that real estate prices were driven by good schools, but soon these prices will be driven by the availability of good healthcare.
Lastly, The Fickle Finger looks at emergency medicine in 2014 (and beyond). This year is likely to be a pivotal year for EDs and emergency physicians, though changes are likely to occur in fits and starts, based on geography, state politics, regional health plan competitiveness and the usual urban vs. rural dichotomy.
The Fickle Finger predicts that:
- There will be more ED visits in 2014 than in prior years, fueled by a rise in Medicaid enrollees, the aging population, early physician retirement, the incentive on primary care physicians to transfer attribution of expensive testing to EPs, climate change and everything else that takes advantage of an open door, take-all-comers medical practice.
- Emergency physicians will be tasked with the responsibility for closing the gaps in care management that no one wants to pay for, and they won't get paid for it.
- Greater demand for nurse practitioners will undermine the ability of many ED groups with an NP-heavy business model survive.
- EPs and hospitals will push back on RAC and commercial claims audits and recoupment demands, with some success.
- Single ED groups will continue to be swallowed up by hospitals and larger ED groups.
- EP productivity will continue to fall as more EM groups cave in to hospital pressure to adopt poorly designed and inefficient EMRs.
- ED boarding of admitted patients will continue to plague the practice of EM, despite efforts by CMS and JCAHO to incent improvements in this metric.
- And lastly, the conflict between check-boxed, cut-and-paste cloned, coding-driven EMRs in the ED and government- and commercial-payer-driven anti-fraud initiatives to data-mine for statistical outliers will flare up into an all-out war, and of course only the lawyers will win.
This post originally appeared on The Fickle Finger blog on December 31, 2013.
Myles Riner, MD, FACEP, was a Partner with CEP America for nearly 30 years, where he served as director of provider relations and on the board of directors. Dr. Riner was also a staff physician at Marin General Hospital in Greenbrae, California, until retiring from clinical practice in 2009. He served as president of the California Chapter of ACEP from 2006-2007, and in 2010, he received both the ACEP Collin Rorie Award for Excellence in Health Policy and CEP America's highest honor, the Myron Wacholder Legacy Award. Dr. Riner is a physician consultant, the author of the healthcare blog The Fickle Finger (www.ficklefinger.net/blog/) and a regular contributor at KevinMD.com. Follow him on Twitter at @MylesRiner.