I feel that I have been spending way too much time as a “chronicler of the decline,” to use von Mises’ phrase. The secular trend in health care (literally spanning the last 100 years) is one of increasing centralization, consolidation, and reduced choice. Nevertheless, there are some promising developments that give me hope for a better future.
Here are five notable trends, in no particular order:
1. Direct patient care. Direct care encompasses all models of health care where physicians and patients have said goodbye in part or in toto to the third-party payer. Those include the booming direct primary care models, concierge practices, and specialty outpatient surgical centers. Other arrangements will undoubtedly emerge. Doctors in increasing numbers are “opting out” of the insurance system to try to regain professional autonomy and satisfaction.
There is no question that these models, limited in scope as they are for now, are providing perfectly good care and, in many cases, much lower prices as well. Anyone unfamiliar with this trend, or anyone with doubts about its benefits, should check out the work of Dr. Keith Smith at the Oklahoma Surgery Center, listen to this podcast interview of Dr. Josh Umbehr at the AtlasMD clinic, read the Direct Primary Care online journal, or follow the #directprimarycare hashtag.
2. Cost sharing ministries. Health care cost sharing ministries are a type of mutual aid society where members pledge to help pay one another’s medical bills. Belonging to a cost sharing ministry fulfills Obamacare’s individual mandate, but the monthly contributions members make are not for health insurance. Instead, these go to pay a member’s previously paid medical expenses and to cover the administrative overhead of the organization.
Prototypical ministries have been Christian organizations, but newer organizations, though still religious in character, only require a more general statement of faith and a pledge to abide by certain values and lifestyles, such as not smoking, not abusing alcohol, not engaging in extra-marital sex, and committing to good health habits.
These organizations have been around for approximately 15 years (though Amish mutual aid societies have been around for decades). So far, about 500,000 Americans are participating and their numbers is growing.
The monthly contributions are markedly lower than the monthly premiums one would otherwise make to an insurance plan. Yet, because of the inherent self-restraint built into the arrangement, the ministries have managed to pay several hundred million dollars annually and remain solvent. There have been cases of ministries successfully helping individual patients pay medical bills of several hundred thousand dollars.
Some legislation has recently been introduced to allow further growth for this market.
3. Medical tourism. When the system gets so expensive and congested at home, patients may find it to their advantage to go abroad and obtain medical care. Medical tourism is a worldwide phenomenon that allows patients around the globe to circumvent the limitations of their own health care systems.
As the demand for international medical care booms, trade organizations have emerged to promote standards of quality and serve as knowledge brokers between the various parties involved. One of these is the medical tourism association. A look at their website will make you realize this is a vibrant industry and that medical tourism provides increasingly sophisticated care at a quality that is comparable — or possibly superior — to that offered at the average U.S. hospital.
4. The maintenance of certification (MOC) rebellion. The open rebellion against the American Board of Internal Medicine (ABIM) and the American Board of Medical Specialties (ABMS) is an extraordinary and unforeseen development against establishment medicine and the status quo.
If new board certifying organizations, such as the NBPAS, can succeed at breaking the monopoly of ABIM and ABMS, that alone would be a huge victory, as competition among credentialing organizations would likely bring costs down and could improve the educational relevance of certification. We have already seen some positive effects of these efforts, as the ABIM has backtracked from some of its expansionist plans.
More important, the MOC rebellion is generating much needed discussion on the topic of accreditation, licensing, and who’s best qualified to judge the worth of a doctor. Our health care system owes its origins to certain assumptions about the objective value of medical care. Any re-examination of these assumptions is a welcome development.
5. Health care social media. As trite as this may sound, I will add my voice to the many which have hailed the emergence of social media and its adoption by physicians and health professionals. I have been on Twitter for barely six months, yet the impact on my professional life has been tremendous.
Besides being enriched by meeting new colleagues from around the globe, I find myself much better informed about professional stories of interest than I ever thought possible. Goodbye, flipping through the TOC’s of the handful of journals landing on my desk!
— Rich Duszak, MD (@RichDuszak) October 8, 2015
Social media are also leveling the playing field between practicing doctors and the academic and regulatory ivory towers. Many of us are finding ways of communicating our opinions (and dissent) in a way never before possible. Although much of the time chaotic, the online conversation can alter the discourse in a positive way, be it on health policy, public health, or medical science per se.
All in this together
Not one of these five trends alone will solve our daunting problems or overturn the strong centralizing forces that are dominating health care today. Taken together, however, these are certainly hopeful developments that we should all support.
That said, to the extent that we believe in shared professional values, we should also encourage one another in whatever practice model we find ourselves. Patients need the new choices that these emerging trends open up, but patients also need and can still find heroic defenders of good medical care within the system. We should support anyone doing the right thing, whatever the circumstances.
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