The five things to pay attention to in 2010

The five things to pay attention to in 2010

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There’s no doubt that despite my thoughts that Obama wouldn’t (and shouldn’t) have pushed health reform in 2009, it was a very big year for health care. Death panels, public options et al—one hundred thousand visits to THCB in August don’t lie.

So what should you look for next?

  1. The finish is the start: It looks like some version of the Senate bill will be a done deal by sometime late January. That means that there’s about two years of health care industry players figuring out what it all means. The biggest two questions are; what will the types of plan sold in the exchanges look like? (high deductible with some preventive care thrown in is most likely), and what will the cuts and changes in Medicare payment actually look like in practice? (More of the same or real re-alignment around some kind of bundling). All these changes need reactions from the incumbents to reorganize around the new revenue streams.
  2. The economy and the politics: Sometime around now, the Bush recession is becoming the Obama slump. Despite the Tea Party/Palin/Beck implosion of the Republicans these last 14 months, we’re almost certainly going to see Democratic losses in the Senate and House in 2010. Whether those losses are bad enough to cost Democrats control of Congress depends on whether the end of the recession becomes a weak recovery or Japan in the 1990s.  Given the unremitting support from Republicans for policies any logical business-minded group logically should oppose in health care, and how much the current bill leaves undone in future changes to Medicare and more, the 2010 elections really matter.
  3. Complications and opportunities in the IT rollout. I have great respect for the good folks at ONC who have done wonders in a relatively short time. I also think that the “new” focus on interoperability and patient access to data is a very important part of meaningful use. But it’s clear that we are not going to simply see mass adoption of the mainstream EMR vendors’ products. Instead physician organizations are also going to dip their toe in SaaS based Health 2.0 tools, or remain too confused to actually do anything before 2012 or 2013. Meanwhile, ONC initiatives (like Beacon and Extension Centers) are going to be very important in this transformation. And don’t forget, most private sector health care players aren’t very used to working with the government in the manner of their defense and agriculture counterparts.
  4. Patients will continue to get rowdy. 2009 was the year of patients demanding access to their data and moving from meeting online to actually starting to see (and even exchange) their data. A combination of new “unplatforms” (iSlate?), better data exchange, technologies for social organization (Facebook, Twitter, Foursquare), will continue to force its way into health care. We’ll of course be covering this in Health 2.0 over the year (including in a brand new report coming out this week). But the distance between a patient’s advocate disputing access to their records and appearances on NPR (and in legislation) is getting shorter and shorter all the time. Health care providers and organizations are just starting to wake up to this.
  5. An evolving discussion about quality of care, especially concerning dying. Ten years after To Err is Human argument about quality of care is now public. What’s coming up next is a discussion about who should be in control, and what should happen, with patients who are much closer to death. It’s unclear as to whether throwing many more medical services at very, very ill people does them any good. It’s clear that many many people think that we do too much, not too little. There’s been little discussion in the court of public opinion about this issue. But as more baby boomers see it happen to their parents expect the “automatic” setting in ICUs across the country to be challenged much more.

These are just some of the many issues we’ll be following on THCB. And soon (no promises exactly when) we’ll be doing it in a brand new format. Welcome to 2010. For you health care junkies it’ll be even more fun.

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29 Comments on "The five things to pay attention to in 2010"


Guest
Nate
Jan 4, 2010

I see your no starting the year any less partisan or factless. When it is congress that controls spending and passes all the laws how is it the Bush recession and not that of the Democrat congress that passed all the laws since 2007?
I know the left is loath to take responsibility for their failures but you controlled two houses for 3 years and the white house for 1, own it baby own it!
Having been through many government “reform” exercises it will not be two years of us figuring out what it means. There will be minimum 5-10 years of lawsuits and court cases that tell us that. It’s not the names on the bills or the intent of them we live by, it is the very very poor job regualtion writers do writing them that you need to understand and history has shown only 10 years and billions wasted in court will do that.
You might want to check your current polls or relook up the meaning of the word implosion..you meant explosion in popularity maybe? Palin has almost cost Obama and all three are way past democrats in congress. The only political implosion has been your party.

Guest
Jan 4, 2010

You are spot on with #4. Yes, patients (and patient advocates) will continue get rowdy.
2010 is the year that patients will be heard. Especially if Regina Holliday’s efforts are any indication.

Guest
Alexandra Albin
Jan 4, 2010

There is not enough to said about the need for interoperability standards of EMRs. I have seen this be the demise of large business initiatives in other industries and is often driven by proprietary software models, and everyone’s desire for a piece of the pie and the fear that if they share/expose themselves they will loose. Other businesses failure do not necessarily result in life and death. Heath care is too critical for standards to not happen. Without standards EMRs are doomed to fail or not achieve the hope (as depicted in the pict above). So, I really hope that we rise above the bottom line and get it right. 2- Medical record accessibility is a pet peeve of mine. And, one would hope there would be legislation that would prevent medical institutions from the large variations of policies and pricing for our personal property. For pete’s sake, one would think that those records are paid for by our extraordinary medical costs.

Guest
Jan 4, 2010

The health care bill will dominate 2010 just as it dominated the last half of 2009. Whether it will be meaningful reform or not, who knows.

Guest

Agree with Nate re they hyperpartisanship of the present and yet to come. This is not really just about health care, but a fight for political control and government extension. I suspect that the divisivess will become more acute, particularly as taxes will rise in the near term, while the ‘reform’ measures are years away. I expect that the financial costs will be higher than we have been told and that the benefits will be less than promised. The 2010 election will be a reenactment of the gladiators of Ancient Rome. http://www.MDWhistleblower.blogspot.com

Guest
Michael Millenson
Jan 4, 2010

Uh, Nate. How about the fact that the regulatory policies are the responsibility of the executive branch? And Ben Bernanke, appointed by Bush, blames lax regulation for the recession? Not to mention the control of Congress by the Republicans in the years before the recession, which began before any laws passed in 2007 would have even taken effect.
Seems to me that the one who’s hyper-partisan is you.

Guest

Matt, you have addressed what we should look for in 2010. Let me add the dramatic changes that we can expect in the next five to fifteen years.
Some of the principal drivers of change:
There will be a very large growth in demand for medical services, driven, at least, by a growth in the population, an aging of the population and a shift from acute to chronic diseases as those most prevalent.
Consumerism is beginning to have an impact that will spread rapidly and increase exponentially with resultant patient expectations changing.
The costs of medical care are high and rising and ultimately this will lead increased to efforts to reign in the rate of rise.
Despite the drivers of change and the strength of effort behind those drivers, there are at least as many barriers to prevent change, slow change or modify it. Many are financial barriers. Other barriers are professional shortages and changed professional work expectations. A lack of important standards inhibits advances – interoperability is needed for the interaction of devices such as monitors in the intensive care unit [ICU], equipment in the operating room [OR] and among various electronic medical record products.
As a result we shall see:
Hospitalized patients will be more in number, older and sicker with complex, chronic diseases. Levels of care in the hospital will intensify and there will be a consolidation of advanced care into tertiary centers. Hospital care will increasingly utilize technologies and hospitalists will do most inpatient care, yet, more and more care will be performed at less intense sites, including home.
Hospital beds will increase in number, intensity and format. More hospital beds will be constructed to serve the added needs of an aging, growing population with complex, chronic diseases. There will be multiple approaches to connect specialists & technology. The eICU [electronic ICU] will become commonplace with the specialist present physically some of the time and virtually all of the time to both improve care and reduce costs.
All medical information will be digitized – once the two key barriers [interoperability and effective physician documentation] are overcome. All data will be in a digital format; the patient will “own” their data and control its access which will be easily accessed, transmitted, and secure. The electronic medical record [EMR] will be designed around physician work flow so that it will enhance productivity. ePrescriptions and drug order entry with alerts and knowledge built into the algorithms will become the norm. These advances will have a fundamental impact on medical care, care quality and safety, costs, and will open opportunities for effective research with data mining.
A major shift is occurring in how medicine advances with more and more related to advances in engineering and computer science. Basic science is and still will be critically important but technology advances will take its place as an equal. With the rapidly rising cost of healthcare, technology, when properly deployed, although usually a major driver of increasing costs, will instead serve as a means to reduce the rising costs of health care by reducing workload, improving productivity, accounting for the shortage of professionals, and making hospital care more affordable. This is one of the critical challenges for developers, manufacturers and end users of technologies.
To summarize, and as explained more fully in The Future of Medicine – Megatrends in Healthcare, the result of all of these advances will be 1] custom-tailored medicine, 2] a much greater focus on prevention, 3] vastly improved ability to repair, restore or replace organs and tissues, 4] readily accessible and manageable medical information leading to new knowledge and 5] much improved quality and safety. It is less clear 6] that the current healthcare reform legislation will create the needed incentives to maximize useful approaches designed to reduce the costs of care.

Guest
Jan 4, 2010

The problem is health care delivery is about money, power, ego, and control and has nothing to do with patient care.
The people who believe it is their destiny to control other human beings who they know nothing about don’t know a myocardial infarction from passing gas, and wouldn’t see uropsesis if it jumped up and beat them over the head with a 2 X 4 until they were bloodied.
Once the entire process is political, personal care of people will be a nostaglic memory. I saw an insurance company ad on televsion. It was a sad drama about a poor child with a subdural. The narrator said “We are so thankful because our Insurance Company (I didn’t quote a name for fear of litigation) “let” (and I emphasize the word ‘let’) us go to the best doctors.”
Really? The guru CEO of the company who makes 50 million bucks a year ‘let’ you go to a good doctor? If he didn’t like you would he send you to a bad one? My goodness, this is sad. And to think they have enough money to put this on televison. I guess the insurance company belives in this, but to me it reeks of pure arrogance.
As an old rank and file primary care doc I find this to be utter hypocrisy. When I was in practice for myself (I finally gave up) we ran out of money after 3 1/2 weeks every month, and took almost no time off. We couldn’t keep the doors open because we carried a lot of poor people and no young people ever came close to wanting to take on such a mission.
God help us in this brave new world.
Dr. B
drtombibey.wordpress.com

Guest
MD as HELL
Jan 4, 2010

Mayo Clinic just dropped Medicare in Arizona! There is a bellweather for your hoax and chains.

Guest
jd
Jan 4, 2010

Tom B:
I work for an insurer in a mid-level capacity and was sitting at home passing gas, pleased with my ability to distinguish this from a heart attack, so thought I might be qualified to offer a few words of criticism.
The $50 million CEO salary you refer to didn’t exist in 2009, or 2008, or 2007. But that’s not the important point. The important point is that even if it did, it wouldn’t explain the problems you found yourself in, or the problems your patients and the nation faces in affording the cost of health care.
Here are the actual incomes of the top execs of the seven largest for-profit companies (pretty much all the big ones). If you add them up, you get nearly $68 million dollars in 2008. If you add up the revenues of those same companies in 2008, you get $248 billion and change.
Two things to note about this:
First, the total revenue of the seven largest for-profit insurers is about one-tenth of the total money spent on health care in the United States in 2008. How much of our total mess could for-profit insurance really explain or be responsible for if it only ever controls about one-tenth of the dollars? (and even then they passed most of it through to providers)
Second, the percent of total revenue for these for-profit insurers that went to CEO pay was on average 0.027%. In other words, less than one-third of one-tenth of a percent. And when you look at their pay in light of the total cost of health care, it is one-tenth of one-tenth of one-third percent. Now, I’m only looking at CEOs of the seven biggest for-profits, but obviously the picture isn’t going to change that much when we add the rest in.
I think we can all agree that this pay makes no perceptible difference in the cost of health care. And for comparison, take a look at this list, which is the first list I found using a Google search for non-profit CEO pay outside healthcare. The average is around 0.4% of revenue. Naturally, the huge amount of revenue in health care plays a major factor here in getting the percentage lower.
As we’ve been through many times before on this blog, when you look at insurer profits the situation is similar. Here, the total is about 3% of premium and 1% of total health care expenditures. With administrative costs, you get about 12% and 4%, respectively.
Even if insurer executive pay, profit and admin cost are all too high (and in aggregate I agree they are), these are but small parts of the problem.
Until you understand that the incentives in the system are the problem, you don’t really understand anything about what caused our mess. We treat too much in some cases because it pays, focus on the wrong interventions in others because it pays, do too little preventive care because that doesn’t pay, and coordinate too little and too haphazardly because that doesn’t pay either. And neither physicians nor insurers nor (especially) hospitals and pharma have the right incentives to help people stop from getting sick in the first place.
Your mission was noble, but the fact that your enterprise failed as a business tells me that this is not something insurers could have remedied, because if they took up non-paying customers like you did they would have gone out of business as well. This is a problem that the state must remedy, because only it has the funding mechanism (taxes) to make subsidizing the poor work on a large scale.

Guest
jd
Jan 4, 2010

Matt,
About your predictions 4 and 5: I’m not sure that we are really at the inflection points in those trend lines yet. Also, when it comes to engagement of the individual not just as a “patient” but as a “consumer” and “agent,” I think that you may be neglecting another trend: wellness.
Unlike patient control over end-of-life care, wellness is a more positive, optimistic subject. Americans don’t like to think about death, at least, they don’t like their public discourse to be sober and reasonable about death. It will be easier for media and corporations to focus on wellness as a way to engage people in activities to circumvent the current sick-care system and reduce costs, rather than focus on end-of-life care.
This is not to say that I think you’re wrong about 4 and 5, just that I’m not sure we’ll see more than a gradual upward slope of interest and activity here in 2010. I expect a similar or sharper jump of interest and activity in wellness, especially as it becomes clearer that risk selection is on the way out, community rating is becoming universal, and insurers have more incentive to keep people healthy than previously.

Guest
Jan 4, 2010

JD, I agree on Wellness. I’m just thankful that Nate started out 2010 with such a brief comment

Guest
Peter
Jan 5, 2010

jd, I read Tom B’s reference to insurance execs salary/bonus as going beyond blaming the amount as a reason for healthcare woes as it likens more to Nero’s fiddling while Rome burned. Would we get different results from insurance if compensation were half or double – I don’t think so because it is the culture not the pay (even though the pay is disgusting). To me the numbers say that insurance companies and their execs make a good living while doing NOTHING to solve any healthcare problem, be it access, cost or quality. Even Nate points to his value added services and lower compensation as a TPA compared against that of insurance companies to say they don’t live up to their compensation.
“Until you understand that the incentives in the system are the problem” is exactly right but until this country eliminates the bulk of private insurance companies controlling the collection and disbursment of healthcare dollars while they scim the top, we will never solve this mess because they are quite happy getting their “small” percentage of the volume. And you echo my continuing call that the first step in managing the system better in saying, “This is a problem that the state must remedy…”, either through single-pay or at least mandated cost controls which insurance companies will be forced to administer. But the bulk of premium payers/patients aren’t hurting enough yet for the start of a real solution, or at least they can hide behind someone else paying the bills as a reason for keeping the status quo.

Guest
Nate
Jan 5, 2010

Michael who passes regualtions? Executive branch appointees enforce what congress inacts. It was not an executive appointee who decided poor people should get prefential loans.
New Years resolutions hoping to keep it up until atleast Feb

Guest
Nate
Jan 5, 2010

Peter everyone in the country has the ability to buy low cost Nate TPA instead of high cost insurance company. It is against everything America stands for to tell people you can’t spend your money “stupidly” you must buy Nate. As much as I would love the additional business that is not the country I live in nor is it one I want to live in.