What I Saw in 2019

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

It’s kind of bleak in Maine in late January, and Chronos Time Travel was having a sale on senior citizen trips to the year 2019. My wife does about all the farm work and my neighbor said he’d plow us out if we got snowed in, so I plunked down the money and away I went. Here’s what I saw when I got there.

Just about all the docs, PAs, Nurse Practitioners, and even some dentists, if you can believe that, worked for a hospital or health care system. Most of the hospitals were in some sort of hub-and-spokes regional system. I heard there were a few states where that pattern hadn’t become dominant, but they were exceptions.

Some of the factors leading to the development were a little unexpected. Now, in 2013, there are a couple dozen certified vendors of “health information technology” software. Several of them couldn’t make the next level of federal certification and disappeared. That was a terrible blow to group practices and hospitals that had years invested in their “orphan” systems. It pushed some small groups and hospitals into larger regional systems where they didn’t have to manage their own information technology.

Another issue was medical liability/malpractice. The word got around that systems that were self insuring, that is, setting aside money to cover their own risk, and buying a policy to cover losses larger than they could stand, were spending far less than what the insurance companies were charging them. You had to be in a sizable system with a few hundred clinicians and close to a thousand hospital beds to spread the risk enough for it to work, but it was working.

The main driver behind formation of those regional systems, though, was the need of all the docs and hospitals to be a part of an “Accountable Care Organization” (ACO) if they were going to get patients and get paid. Think of an ACO as a health care department store that has just about everything you need, in which your records are accessible to whichever clinicians need them, and in which the quality of the care is being monitored and used as a basis for the organization getting paid. Working people’s health insurance typically authorized them to get care from one ACO. They could negotiate to change ACOs, but rarely could they get care from more than one.

It was different if you were going to have something major done, like a hip replacement, or if there was a problem. Then your employer health plan’s purchasing officer would sit down with you and go over things like how many cases various ACOs had done, how many infections they have and the costs for the places you might get your care.

Most employers were providing their employees health insurance, but it was a little different than now.

Most of those of any size were self-insuring with “stop loss” policies to pay the bills for cases that cost over $100,000. Some smaller employers had formed groups like the State Truckers Association to get their numbers of employees up to 500 or so to make the self-insurance approach work. Most plans had their employees meeting some of the initial costs out of their own “health savings accounts,” so they would exercise some constraint in how much care they used.

The ACOs, including their small rural hospital members, were self-insuring for health care and generally keeping their employees within their own systems.

Some full-service ACOs were sidestepping the insurance companies to contract directly with employers and even individual patients. If the patient and the provider were bound to each other, and either the entity paying the bill or the one providing the care were big enough to carry risk, then the insurance company brought no value to the transaction.

The country was down to three health insurance companies. People were having trouble seeing why those three should be collecting hundreds of billions of dollars more in premiums than they were paying out for care.

I only had time to visit a few small rural hospitals. They were the community units for their ACOs. They were doing all the outpatient clinic stuff you’d need to make the ACO commitments work, some of which used local clinicians, some itinerant docs and some telemediated consultations.

There was a bunch of services I was not familiar with that used the video connection. For example there were autism support, Alzheimer’s support, juvenile diabetes support, and colostomy support groups, and probably other groups with not many folks in each hospital but with four or five hospitals on the line. There were the usual prenatal classes and even a short series of classes for people planning to get pregnant.

There were morning get-togethers that doubled as exercise classes for the elderly folks with diabetes, hypertension, chronic lung disease and/or depression. After the exercises they’d talk about healthy cooking recipes. Those sessions went out on local cable TV to the housebound.

As far as I could tell, these hospitals were doing about all the things in 2019 they are doing now, plus more mental health and a lot more health promotion. Second, they had some way of finding out what the local folks wanted and responding to those wants. Finally, they weren’t the poor whiney dependents of their ACOs, but were supporting the high cost referral parts of their systems.

It was a good trip.

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine.

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


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