Outlook for 2006
As Yogi Berra once said, making predictions is difficult, especially about the future. The older I get, the less certain I am of many things, especially the future. History is punctuated by unforeseen major or catastrophic events that change what most of us expect to happen. So, with that in mind, I’ll offer some thoughts about what we in San Diego medicine might have to look forward to in 2006.
Reimbursement
First the bad news. There can be little doubt that physicians will face decreased or at best flat reimbursement in 2006. Government, through Medicare and Medicaid, pays for more than 40% of all healthcare, and we all know the state of government funding today. The federal government faces unprecedented deficits, and the Iraq War and Hurricane Katrina guarantee a continuation of the problem. Cuts in public funding for most everything — and healthcare is the government’s biggest target — are inevitable. The Medicare reductions of sustainable growth rate (SGR) policies and our governor’s recent precipitous 5 percent cut in Medi-Cal are clear examples. Despite organized medicine’s valiant efforts, some cuts will occur. We can thank our medical societies for fighting to make these cuts as small as possible. Living off government funding has never looked bleaker, and revenue projections from other payers are not much better.
Probably the only way to maintain sustainable government and health insurance plan funding will be through success in pay-for-performance (P4P) programs. These will force physicians to improve care for certain conditions at the risk of staying in business. This is more like changing with a gun to our heads than acting for the good of society. Being part of a health system that knows how to play in the P4P ballpark will be increasingly important for all physicians who depend on third-party reimbursement, which is just about all of us.
Staying independent in a private practice may only be possible with patients paying directly for care. This is becoming more common as more people lack health insurance or move toward high-deductible health plans and health savings accounts. Monthly fees for concierge primary care and negotiated direct payment for specialty care are growing in popularity and are a déjà vu experience for physicians who have been in practice for 30 years. Patients paying directly for medical care, what a novelty!
More Computers
2006 is the second year in the “decade of health information technology,” as declared by the Feds in July 2004. Compared with the “noise” of reimbursement problems, this is the real historical change going on in medicine. Most of the large medical groups and health systems in San Diego are underway with conversion to electronic health records. The San Diego Medicine Information Network Exchange (SD Mine) project, led by Steve Carson and the SDCMS Foundation, is working to ensure that San Diego is a leader in the interoperability of all these electronic records.
The transition to electronic health records is expensive, and no one is stepping up to pay for these other than physicians or their employers, even though most of the financial benefit is enjoyed by others, such as the health insurance plans. Having a computerized health record is likely to be mandatory soon in order to do the reporting necessary for participating in P4P programs, which as stated above may make the difference in practice survival.
Still to come and likely to be launched in 2006 for many physicians is greater computerized clinical decision support and secure online communication with patients and other physicians. The online platforms of service, now well established in other industries such as banking and travel, are likely to become much more visible in healthcare in 2006. The mega-search engines of Google and Yahoo are changing how all of us find information instantly. Whoever dreamed we would be using these tools in the exam room with patients in order to answer their questions?
Genetic Testing
Clinical applications from the Human Genome Project are likely to become more visible in 2006. With time and new technology, we will all know our genetic maps much like we now know our lipid profile. If technology can provide us with more information, it will do so. What we have to figure out is how to use it. What will knowing our patients’ inherent strengths and vulnerabilities do to clinical practice? Will we usher in a new era of predetermination? Already we have introduced new labels of “pre-disease” such as prehypertension and pre-diabetes. Knowing all our risks probably has value, but how will we handle the downside of too much information? Will fortune tellers replace the crystal ball with genetic profiles? Who will be the last well person?
Imaging Rules
As I write this I am a few days away from getting my colonography, also known as virtual colonoscopy, and a colonoscopy as part of a research study comparing the two at UCSD. At 55 I am finally getting my colon cancer screening with a double whammy. The advances in imaging since the first CT scans are truly amazing and promise to continue in 2006. What I wonder is what radiologists will do when the machines analyze the data and print detailed reports, much like our EKG machines do.
Enough of my musings for 2006. I invite all SDCMS members and other readers to share their thoughts about the current and future state of medicine. We want San Diego Physician to be a reflection of the state of mind of San Diego medicine. Our personal and practice financial picture might not be rosy, but the San Diego County Medical Society begins the year in great financial shape after the sale of our building and a growing membership. Contrary to a popular pessimistic expression, I still encourage my children and other young people to consider a career in medicine. Regardless of the twists and turns of time, we will always be needed and valued.