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:
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.
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.
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?
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.
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.
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.
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.
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: