Wayne Myers, MD, Look What's Coming columnistby Wayne Myers

The monumental health insurance reform bill that passed last month is only the beginning. Within the evolving regulations and, perhaps, legislation, I think we’ll see several of the following trends.

One important idea is “bundled payments.” The policy objective is to reduce incentives for doctors and hospitals to do so many tests and procedures. Bundling of payments, paying a single, predetermined lump sum to care for an entire episode of illness from diagnosis through hospitalization to recovery regardless of how often tests are repeated, will save startling amounts of money. It will be widely adopted in spite of frantic lobbying by imaging and related interests.

For rural communities, bundled payments will accelerate movement toward the development of community health systems in which the docs, the hospital, the rehabilitation facility and home care join in a single organization. This will also increase pressure for rural hospitals and community health centers to develop an organizational framework under which they can join and prosper.

Such community-wide organizations can almost certainly do a better job of taking care of patients than our current fragmented arrangements. This deserves repeating. Coordinated care is not only cheaper. It’s better.

Kaiser Health News on January 26th, 2010 ran a compelling article on the good work being done by the Southcentral Foundation in Anchorage, Alaska. The Foundation, a consumer-controlled quasi-tribal organization, is doing a remarkable job taking care of complicated patients with multi-system problems by coordinating their care and doing what the customers need to have done instead of what clinics are accustomed to doing.

A few rural communities already own and operate their health care systems. The most completely evolved that I know of are the tribal Alaska Regional Health Corporations. They typically operate a hospital, several rural community clinics, and mental health, dental and EMS facilities. They draw contract funds from the Alaska Area Native Health Service, an element of the Indian Health Service, but they also collect from private insurers, Medicare, Medicaid, and state and federal grant and contract funds. The coverage area for such an organization in rural America would correspond to a trade area for other purposes.

Where will the docs come from to staff such organizations? The United States has more physicians than England and Canada, but significantly fewer than most countries of Western Europe. Our problem is that over 70 percent of our physicians are in referral specialties instead of primary care. The shortage of primary care physicians has gotten appropriate attention. If we start paying physicians for the care we need through mechanisms such as bundled payments I believe we’ll have a surplus of referral docs. What should happen to them? During the Clinton efforts at reform there was a cartoon of a physician with white coat, stethoscope and sign that said “will practice cardiology for lots and lots of money.”

Can a $390,000 per year radiologist be retrained to earn $170,000 per year as a family doc? I know of no data on that question. There are issues of adjustment, cognition and temperament. I’m being a bit facetious but there are very real competency issues involved when referral docs try to do primary care. Internal medicine sub-specialists can probably relearn a lot of their general internal medicine. Family practice is the only primary care specialty taught as a primary care specialty. The coordination of the care of multiple disorders is difficult and has infinite numbers of permutations. Picking referral docs for retraining would be tough.

Nurse practitioners and physician assistants can handle much of primary care, and many other specialties for that matter, but it is a serious mistake to think that ends the story. People who write on the subject seem to have no idea of the complex outpatient and inpatient work rural general internists, family docs and pediatricians do. Maggie Mahar’s recent blog on the subject (“Hey Nursie!” The Battle over Letting Nurse Practitioners Provide Primary Care) is excellent but misses the rural angle.

Other predictions: Incomes of primary care docs will increase a bit over the next 15 years, but not as much as referral physician incomes will fall relative to the overall economy. Institutional support patterns (big town/ middle town/ little town) will become more fixed as referral relationships become formalized and ready to work on a moment’s notice. Telemedicine, a solution in search of a problem for 40 years, will become more useful, as health care develops regional systems. Smaller hospitals with lower intensity capability will decrease in relative importance as inpatient facilities.

The local hospital, though, with the right leadership, may take on a new role as the health hub of the community, fostering health promotion from before conception through grief, mourning and resolution. Expect change. Create it.

Wayne Myers, a pediatrician, founded the University of Kentucky Center for Rural Health and served as its director. He also served as director of the Office of Rural Health Policy in the Department of Health and Human Services’ Health Resources and Services Administration. He is a past president of the National Rural Health Association.

Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Spring 2010 Issue