Three Big Questions on Health Care for Matthew Holt
1) It’s an old bromide that ‘the more things change, the more they stay the same’. One of the repeated statements we hear from members is ACOs are just HMOs all over again. Do you think that’s true?
Is an Accountable Care Organization (ACO) an HMO all over again? Or is it a PHO? Or a different TLA? So far according to Eliot Fisher (who basically came up with the concept) the ACOs don’t appear to be accountable, organized, or much care. 
We also mustn’t forget that while the ACOs are coming in 2012--that's pretty soon--we don’t yet know exactly what they're getting paid for and which populations they're covering. Nor is it exactly clear which entities qualify to be ACOs. The idea is that Medicare will pay for improved outcomes for a defined population and that private insurers will follow suit. What is clear is that the political fight about how these rules are set is on in earnest.
So what if anything is different now compared to the 1990s? Then it was immediately clear that most providers who were "integrating" quickly used that horizontal integration to face down health plans and employers. The “jobless recovery” of the mid-2000s did not include an increase in the total number covered by private insurance; Medicaid sucked up the difference, but when the economic music stopped in 2008-9, uninsurance went up to 52 million. And that was the background for the Affordable Care Act, which, while it was largely about expanding coverage, also contained a few time-bombs about new ways of paying for care.
As Herb Stein said, if something is unsustainable in the long run, it will end. Payments for procedures lead to more expensive and worse medical care; that evidence is in and it's essentially irrefutable. It's pretty clear that after the 2008-9 recession, government is out of money, voters don't want to pay more taxes, and employers are pretty fed up. So you may not believe the hype, but maybe we have reached the point where we can't sustain our health care system any longer and we have to try something different.
By the way, a TLA is a three letter acronym (if you're still wondering from that first paragraph)
2) Many of the changes needed in order to achieve the ‘triple aim’ [lower costs, improved care, better patient experience] are not clinical, but are cultural and societal, such as education, literacy, food policy, attitudes about death and aging, the built environment. What role do physicians have in calling attention to these factors?
If I were to pick two topics that physicians can easily do something about, I'd suggest food and end of life care. These are two areas where technology and education--combined with a few nudges from the system--can make a big difference. Here are two specific things that physicians can do tomorrow when seeing patients.
First, we are programming kids for a life of struggling with obesity in how we feed babies. Most start on white rice cereal--we might as well start them on a spoon of white sugar. Instead the Whiteout campaign, led by pediatrician Alan Greene, MD, suggests that first solid food should be real food. An avocado, mashed carrot, even brown rice. It's an easy suggestion to tell your patients. After all most of them are parents or grandparents (or will be someday) and they only have the best interest of their kids at heart. http://www.facebook.com/whiteoutnow
Second, it's no secret that we deal horribly with end of life care. And despite your state’s progress on physician-assisted end of life, I'd wager Oregon isn't much better. Do your patients have a living will? Do they know what they'd want at the end-of-life? Do they know who would advocate for them? Engage with Grace is a movement that asks people to discuss five simple questions with their family. Ask your patients: have they had the conversation? http://www.engagewithgrace.org/
3) Some think health care will be less and less in the clinic and more in the home, using remote health monitoring, and so on. Do you agree? Will that help with the health care workforce crunch?
Taking blood pressure every three months in the doctor's office is probably useless, and relying on the memory of the patient and the doctor for who took what pill is probably worse than useless. Technology is available to take care of this, and it'll be part of the fabric of the home and the clinic in 15 years.
What isn't so clear is how we get from here to there on the services side. We'll be uploading gigs of data from those patients to the cloud. We're also developing systems to figure out when there's an exception and when we need to intervene. Who gets those alerts and who intervenes? Almost no primary care practice is set up for that now, but in 15 years time the successful primary care physician will be seeing 3-4 patients for 30 or 60 minutes at a time, and spending the rest of their time managing a team--which may not be in their office or their organization--that's caring for those patients remotely. And that team may have almost no clinical qualifications, but the successful ones will care a great deal for their patients and make a big difference in their patients' lives.
So technology and people can solve the primary care crisis. But we know what won’t: we cannot train enough primary care docs to do what primary care docs do now, and the rest of the world is getting pretty unhappy at the number of primary care docs we're stealing from them. So let's get real about not heading further down that route; primary care’s transformation is inevitable.
Matthew Holt is a health care futurist (and new father) and founder of Health 2.0, and writer at TheHealthCareBlog.com. He spoke at the OMA Annual Meeting in April.