OR WAIT null SECS
Advances in care delivery and technology are taking root now that could significantly change the way care is delivered in the future. Healthcare’s innovative thinkers and practitioners give us their predictions for the future.
It’s 2025. Do you know what your profession looks like?
Try to imagine how the practice of medicine will transform in the next 10 to 20 years - not an easy exercise considering recent healthcare reform efforts and scientific discoveries make even a six-month view into the crystal ball a little cloudy.
Will there be high-tech full body scans, an iPad in the hand of every practitioner, and hologram versions of yourself being beamed into the homes of your patients?
Not likely, but rising costs and increasing demands on the healthcare system will surely force a transformation in the role of today’s physician. More than just universal EHR adoption or smartphone use, the practice of the future is likely to reinvent the care-delivery model, rethink reimbursement, and retool technology.
Here, some of healthcare’s innovative thinkers and practitioners aim to reimagine the doctor of the future, as signaled by some of the innovations taking root today.
A new way to deliver care
The traditional, one-size-fits-all, office visit model of medicine has reigned for decades. Physicians are locked into a system that requires they see patients in their office every 15 minutes, and alternatives like e-mail consultations have been slow to catch on.
Healthcare has been stuck here because of the payment structure, says David Moen, a physician and medical director of care model innovation at Minneapolis-based Fairview Health Services. Moen’s job is to rethink the traditional model and find ways to make the alternatives work. The current financial structure limits this innovation, he says, and fails to take into account patient engagement and drive efficiencies.
But at Fairview, they are initiating care reform, Moen says, which will in turn inform payment reform. Moen says the future of care includes different delivery models (think phone, Internet, and group visits), a greater focus on patients’ behavior, and a far more team-oriented approach.
“This is probably the most opportune time in decades for physicians to provide leadership to the change taking place,” he says.
Moen’s colleague, Eric Christianson, an emergency department physician at Fairview, has been trying his hand at what some believe will become a new tier for healthcare delivery: online visits.
As part of a pilot program with BlueCross BlueShield of Minnesota, Christianson has started seeing some patients via the Internet, using a Web cam and a telephone. Already, after only about 40 visits, Christianson says he can see how this method would make him more efficient, and give him some flexibility in his schedule.
“It seems to me to be a very common sense, logical step,” he says. “The technology is out there. There are still things that need to be worked on, but as it’s being developed and being refined, it’s clear to me that it could be utilized for betterment of patient and physician experience.”
Not only will the online care model extend healthcare access to people in rural or underserved areas, but it can offer the physician a unique way to control her schedule. Imagine spending half of the day in the office seeing patients, then returning to work - perhaps from the comfort of your home - in the evening after your child’s softball game or dinner with the family. Any down time between patients, such as a last-minute cancellation, can be filled with another appointment.
A patient can go online to find out which physicians are available for an online visit, says Roy Schoenberg, CEO of American Well, which provides the online system.
The physician can review records, communicate, and write a prescription - and actually get paid (albeit less than for an office visit).
Minnesota is one of only a few areas using the online care model, but Schoenberg envisions the system evolving to allow for other disciplines to participate and for physicians to consult with each other.
Christianson also sees the mode taking off. “There’s no question that online care is something that is going to grow,” he says. “This is just another layer we can utilize and help with the efficiencies of the whole system.”
Perhaps the ultimate move toward more efficiency would be seeing more than one patient at a time. Imagine if you could corral a half-dozen of your patients with similar conditions into a single visit, allowing you or your staff to give the information and guidance once. For some physicians, this is already a reality, and many see group visits as a new model for the practice of the future.
Although group visits have been around for several years, the concept is gaining in popularity, and more payers are beginning to reimburse for them.
The concept started around patients with a similar condition, such congestive heart failure, who are in a rehab program, says Erica Drazen, managing director for the emerging practices division of CSC Healthcare Group, a planning and performance improvement consulting firm in Waltham, Mass. In a group visit, there may be a facilitated discussion about diet or exercise, after a nurse or physician has evaluated each patient individually.
“Patients listen to what is going on with every patient, as well as talk amongst themselves,” Drazen says, which provides them with greater insights into their condition and builds support among the group.
“As you hear questions and answers, you learn a lot about yourself,” she says. “Patients love the visit experience.”
Surprisingly, privacy concerns don’t seem to be a barrier to such visits, Drazen says, and of course any exam is done in a separate room.
This can allow the physician to be more efficient, and it also gives her some insight into the condition she might not otherwise get in one-on-one visits.
Group visits tend to be limited to organized systems of care, such as an HMO or large clinic that allows for reimbursement, Drazen says, but “where they are introduced, they spread pretty quickly.”
Rather than being uncomfortable for patients with chronic illnesses, group visits can be empowering, says David Ehrenberger, a family-practice physician at Bloomfield Family Practice, which has conducted group visits and is participating in a patient-centered medical home pilot project.
“That group dynamic is extremely powerful,” he says.
For some physicians, the answer to declining reimbursements has been a migration to so-called concierge medicine, in which patients pay a retainer fee for highly personalized care and greater access. The benefits for physicians are clear - no more payer headaches and more time to care for patients. Many, however, reject the idea of asking patients to pay even more for care and dropping those who can’t afford it.
But like other models of care delivery, the concierge model is sure to evolve, and Susan Wilder thinks she has tapped into the future of concierge.
Wilder, a primary-care physician at LifeScape Medical Associates in suburban Phoenix and a well-known advocate for patient-centered healthcare, practices what she calls hybrid concierge. Only those patients who want to pay for the extra access (usually about 5 percent) do so, allowing the physician to continue to see the other patients as well. As medicine adapts to be more patient-centric, Wilder says, this hybrid concierge model can be one solution.
Wilder likens the model to the airline business: customers who want to pay first-class rates for additional services can do so, but you’re not going to kick the coach passengers off the plane.
“We hold the keys to our own shackles,” Wilder says, adding that physicians are responsible for allowing the rising overhead and declining reimbursements. Physicians have accepted the current payer-centric system, and it’s time to take control of the practice and try something different, she argues.
Wilder says she was ready to abandon medicine entirely, as she found she was unable to devote the appropriate time and energy to her patients. The hybrid model gives her flexibility without locking her into one model that might not be sustainable in the future. Her practice isn’t based solely on concierge patients (who may opt out of the model if it becomes too costly), or on insurance plans, whose reimbursement rates are declining.
“We really tried to think ahead, and we really are patient centered,” she says.
Many healthcare practitioners and observers predict a major shift in the role of the traditional solo or small practice primary-care physician as the main provider. The primary-care doc won’t go away, but instead take the helm as the care organizer, coordinating care increasingly provided by midlevel providers such as nurse practitioners and physician assistants, a model already being explored in the patient-centered medical home pilots.
“The physician plays a central role, as a team leader, not as the central provider,” says Harry Jacobson, who served as vice chancellor of health affairs at Vanderbilt University and director of Vanderbilt University Medical Center. “Medicine is a team sport, and we need to find a way to learn how to train people as teams.”
This shift will be predicated by the increase in demand for primary care and the shortage of primary-care physicians. As the healthcare system begins to reward outcomes and focus on prevention, a care coordinator will emerge. That coordinator will come up with the plan and delegate how it’s executed.
“That person needs to be a physician, because the medical care of patients will be more complex,” says Aaron Michelfelder, a family practice doctor and head of curriculum development for Loyola University Chicago Stritch School of Medicine.
The entire healthcare workforce will evolve, mainly because technology will expand the capabilities of midlevel professionals and prompt physicians to take on new roles, says Jason Hwang, a primary-care physician and executive director of healthcare at the Innosight Institute, a nonprofit think tank focused on healthcare and innovation.
Hwang predicts that technology will enable this shift in duties via a process the business world calls “disruptive innovation” through “commoditization of the work or the experience.” New technologies commoditize skill by making the job more easily taught and performed, Hwang says. This is true in any industry: As new tools are developed, lower-level professionals can perform a skill once relegated to the more highly trained.
In healthcare, “what was done by specialists will be done by generalists, and what is done by generalists will be done by nonphysicians,” he says.
Of course, some primary-care physicians will be more interested in taking on the position of the care coordinator, as seen already in patient-centered medical home pilots, rather than the duties of the specialist. But Hwang issues a warning about that path. “If technology can help physicians coordinate care better, you could imagine it wouldn’t take long for that same piece of software technology [to] help a nurse practitioner coordinate care. If you are progressing down that path, and you’re placing all your eggs in the primary-care basket, it’s time-limited.”
Tech tools of the future
The root of physicians’ transforming role is technology, for both diagnosis and for organizing the exponentially growing amount of patient information.
“The physician of the future is going to be faced with making decisions with so many data points that they cannot make the best decisions without computer-assisted support,” says Jacobson.
You think there’s pressure to adopt EHRs, e-prescribing, and patient registries now? In the next decade or two, healthcare information technology promises to become even more advanced - and necessary. The burgeoning field of personalized medicine that is using patients’ genetic information to better tailor treatments and protocols to each individual patient will continue to grow, meaning even more information.
Having an EHR that collects and presents that information for the physician is just half the battle, Jacobson says. Then the information will need to be better organized in a way that is useful for decision support.
Most experts envision the current push for EHR adoption and integration to continue. The CDC’s National Center for Health Statistics says that about 44 percent of doctors are using full or partial EHRs, up from about 41 percent in 2008. But only 6.3 percent were using systems described as “fully functional.”
With the federal government’s initiative aimed at encouraging all practices to achieve so-called “meaningful use” of EHRs, that number may rise steadily over the next several years, but there is still a long way to go. So if you’re imaging a future of physician holograms beaming in for exams, think again. More likely, the next 10 or 15 years mean more EHRs and more integration of systems so they can better share data.
“Right now our EMR cannot talk across healthcare institutions,” says Loyola’s Michelfelder. “The first thing is that it’s going to be a lot easier for us to take care of patients because we are going to have better access to records.”
Emerging technologies will also expand the options for where patients are seen. Doctors will be less tethered to the hospital and able to perform more procedures in the office, making care more convenient and accessible, Hwang says. For example, MRI machines, portable ultrasounds, and EKG machines can be brought out of the hospital and into the doctor’s office.
Similarly, online visits, like those already being tested by Christianson in Minnesota, will free up physicians to see patients and consult with other physicians regardless of their location.
Finally, technology will enable patients to take a more active role in their care, says Fran Turisco, a research principal for CSC’s Emerging Practices group. More patients will have access to home-monitoring technologies that allow them to be more proactive in their own care.
“We are finding that there are things like the iPhone with an unbelievable number of applications on it to help [patients] adhere to medication schedules,” Turisco says.
But those applications will only be useful if you connect all the dots, Turisco says, making sure the patient and the entire healthcare team is tapped into the same software to coordinate care.
So what happens to the smaller practices that are resisting the adoption of technology or who don’t envision a day when they will communicate online with their patients or other providers?
“Their days are numbered,” Hwang says, noting that around the corner there will be another business model - say, a retail clinic or larger integrated health system - that is connected and moving light years ahead of the old model.
Trying to predict when all these changes will happen really becomes a study in physician reimbursement. Perhaps unsurprisingly, for any new care-delivery model or technology to take hold, there will have to be a change in the current reimbursement structure.
“The primary constraint of change is not necessarily technology, but how the financing mechanism for primary care reimbursement will be evaluated and modified going forward,” says Alex Hunter, president of EthosPartners, a healthcare and management consulting firm in Suwanee, Ga.
And it’s going to take more than federal EHR incentives, Hunter says. It will take real reimbursement reform.
So what will it look like?
“There are 544 people in the House and Senate who are debating that today,” Hunter says, adding that ultimately, the reimbursement system will focus on qualitative management of patients’ health and outcomes.
Already payers are starting to reimburse for less traditional models of care, such as e-mail consultations and group visits.
Several experts predict an even greater increase in the number of physicians opting for hospital employment. Integrated health systems like Kaiser Permanente will dominate the employment landscape, as physicians seek refuge in steady salaries, and younger physicians reject the private practice path for more stability.
These integrated health systems can also more easily bear the heavy load of financing the technology, and support full integration of the electronic systems, he says.
What’s clear is the fee-for-service model’s days are likely numbered. Another option could be more of a lump-sum, per-capita model.
“I definitely see the piecemeal system going by the wayside,” Hwang says. “Ordering a McDonald’s hamburger or your typical retail purchase - that’s the only instance where a piecemeal rate really works.”
In the future, the private-practice physician will be operating a truly independent business free from insurers. Or there won’t be any private practices; instead virtually all physicians will work as employees in hospitals or health systems. The role of the primary-care physician will evolve into that of team leader - the hub of the care management team, coordinating with a number of midlevels and specialists for each patient. Or the primary care physician will go the way of the dodo.
Depends on whom you ask.
But what’s clear is that change is coming. The current landscape is starting to transform, and the future promises a continued acceleration and utilization of technology and a greater focus on patient outcomes.
As a physician who has embraced the less traditional model of care known as hybrid concierge, Wilder suggests all physicians start planning for the future by deciding their true values and goals. Talk with family and friends, or hold focus groups to find out what your patients value, she says.
“Then,” she says, “think creatively about how you can come up with a model practice.”
*(Check out the related podcast with Michael Howe, former CEO of CVS MinuteClinic, who discusses the future of care-delivery models.)
Sara Michael is senior editor at Physicians Practice. She can be reached at firstname.lastname@example.org.
This article originally appeared in the April 2010 issue of Physicians Practice.