Health System Change: A Nightmare or a Dream Come True?

Some health care observers are asking the health care leadership what issues are keeping them awake at night.  While it is true that the system is facing major challenges ranging from new models of care, changing payment methods, mergers and acquisitions, and the shifting of financial and clinical risk closer to actual patient care, is this a nightmare or a dream come true? 

It depends on who you ask.  There are at least four different preliminary answers depending on which group you ask.  Patients might say “finally you (health system) are getting it right.”  “I am getting an annual wellness visit where, at least once during the year, I can review my health status with my doctor”.  “I am now getting more than just “sick visits” when something is wrong.  Additionally, needed preventative measures are more readily available at a reasonable cost”.  “I am even getting phone calls from time to time from my primary physician about follow up, missed appointments and medication refills”.  “I have a nurse case manager helping me along the way to get the care I need to prevent any new problems and to provide closer monitoring for ongoing problems.  Furthermore, when I need to be seen, the office is more available keeping me out of the noisy, chaotic, and expensive emergency room”.  The patients will usually say this is a good dream.

On the other hand,  many hospital CEOs are waking up in the middle of the night in a cold sweat.  Admissions are down because doctors are doing better keeping folks out of the emergency room.  Additionally, CMS is penalizing hospitals for readmissions and staff doctors are being measured on emergency room utilization, unnecessary admissions, and readmissions.  Now that doctors are increasingly at financial risk in the community ACOs, the pressure is even more intense to keep their patients out of the expensive hospital. Furthermore, CMS wants to pay the same for outpatient visits regardless of location causing hospitals to lose that advantage.  Hospitals used to be the center of the healthcare universe; however, doctors and patients are increasingly occupying this space.  

There is hope for hospitals as their leadership become enlightened and understand that the facility is a cost center in the scope of the community health care system.  Even as hospital systems are getting bigger in an attempt to manage the flow of inpatient utilization, doctors that are employed by hospitals are still under the same scrutiny to reduce admissions and readmissions as they manage the care of the patient.  There is hope for the future as hospital leaders develop a balanced view of their role in the community.  This is a balance between facility and service with a firm eye on efficiency and quality.   

Physicians have mixed nighttime emotions about the changes in the healthcare delivery system.  There is a forward-thinking group that celebrates the change where they are finally being paid for real patient management.  Their dreams are coming true. Most providers know that care extends beyond the professional interaction at the bedside or the exam table.  It is natural for physicians to want their patients to do well, so an opportunity to make that happen more regularly is professionally satisfying.  There are some specialists that miss the power of the specialists-hospital complex; however, most have a good sense of the new reality and what is best for the patient.  There are others that still chafe under the idea of having to better communicate with the primary physician, but are practical-minded enough to see the advantages of the changes.  On the other hand, some physicians believe that they are living in a nightmare with increased governmental control, electronic medical records, and quality standards that will be the “death of medicine” as they know it.  In fact, they are correct.

Government at all levels have a special interest in the health and well being of their citizens.  Since the federal government already pays for about 60 percent of all health care costs, they have an intense interest in introducing efficient changes that result in better care, lower cost, and a more satisfied patient/beneficiary.  We know that as the triple aim, an idea introduced by the Institute of Medicine years ago.  Unfortunately, the current savings generated by the ACO initiative would only pay for a few days of the current health care expenses shouldered by the government.  With the national debt climbing to over $22 Trillion thoughtful thinkers know that this is not sustainable.  Furthermore, behind all of the economic and financial reasons to change the system is the fact that we are spending more money on health care and not getting the best result as compared to other developed nations.  The simple fact is that we are not getting our money’s worth.

Is there a cure for this national sleep disorder?  Yes, if our leaders learn from other’s mistakes and keep the government’s involvement in the consumer-driven role of an enlightened buyer rather than as an owner-controller.  There must be a balance between an incentive-driven payment system and outcome-driven quality metrics.  The government should maintain the role of casting the vision and not micromanaging.  High performing physicians should be rewarded and encouraged to continue the process of continuous performance improvement. This change should be supported by education and discipline at the local level keeping a professional eye on a national goal and vision.  It is all about making data-led decisions knowing that with continuous improvement there is no comfort zone.  Sleep well.

Craigan Gray

About the Author

Craigan Gray, MD, MBA, JD

Dr. Craigan Gray, Salient Healthcare’s Chief Medical Officer, brings rich experience from private practice, hospital leadership, and governmental health-benefit programs. Prior to joining Salient, Dr. Gray was director of North Carolina’s $12 billion Medicaid program. His time as VPMA at Bon Secours Our Lady of Bellefonte Hospital in Kentucky was distinguished by moving the facility into the top-quality performance tier for Health Grades and CMS health quality indicators. Dr. Gray is a Stanford University trained Obstetrician/Gynecologist. In addition to an MD degree, Dr. Gray holds an MBA degree and a JD degree. He is a Certified Physician Executive and is published in various medical journals.

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