The Silent Healthcare Revolution

AmbulanceThe presidential campaign is far enough along to confidently conclude that the health delivery revolution will not be televised. Instead, it will continue its quiet progress, remaking nearly a fifth of the economy without political, media or public awareness. Such is the course of American revolutions.

When the issue surfaces in the campaign, peripheral questions are raised. All agree prices for some drugs are unconscionable. The GOP vows to finally succeed in its efforts to repeal the Affordable Care Act and replace it with something better they have yet to come up with. Bernie Sanders promises Medicare for all where everyone can get all the care they want without worrying about costs, which will be paid by some of his new taxes on the rich. In fact, none of these things is going to happen in the next Congress regardless of the election results.

To put it nakedly, what we’re witnessing is a big move toward the industrialization of medical care—figuring out what strategy works best to deal with a specific problem, coming up with an efficient way of implementing that strategy, informing providers about what works best and providing them with incentives to follow the recommended path. That doesn’t remove the art from medicine, but does shift practice more toward science, with inevitable uncomfortable changes for practitioners who have long enjoyed extraordinary autonomy.

It all starts with the move toward more evidence-based medicine, a trend accelerated by the Affordable Care Act. In the years ahead, there will be best practice guidelines for a growing variety of ailments. The spread of electronic medical records, simultaneously pushed by the government and the ACA as well as the growth of larger physician practices where patients are shared, will first provide provide added data on what works and subsequently make it easier to identify those who deviate from preferred protocols.

Meanwhile, physicians are increasingly becoming members of large groups that are paid for results rather than specific care delivered. More than half America’s physicians now work for someone else. A quarter of them work for groups at least partially owned by hospitals, which are often paid a flat fee for a given diagnosis, as Medicare has long done. The ACA’s creation of Accountable Care Organizations that are compensated for keeping people healthy accelerates the trend toward paying for results.

Together these changes reverse the old reimbursement system where providers who did more are paid more. The system is starting to tilt toward those who can do the job adequately for less.
It is important to acknowledge that this trend is bipartisan. Republicans tend to favor capitated plans, like Medicare Advantage, where the government makes flat payments to care for an individual without regard to the specifics of the care delivered. The liberal single payer group in the Democratic Party advocate a plan where the government decides what types of treatment are worth paying for. One might say that conservatives favor a buffet while liberals want to define what will be offered on an a la carte menu. Each approach is a move toward standardization or industrialization. Some of us would even term it rationalization.

Gil Scott-Heron’s 1970 prediction that The Revolution Will Not Be Televised has been challenged by street activity staged by groups ranging from Occupy Wall Street to Black Lives Matter, but when it comes to American medicine, he certainly got it right.

For 16 years, Jim Jaffe worked for House Democrats who served on the Ways and Means Committee, apprenticing with Representatives Green, Gibbons and Gephardt before working for Chairman Dan Rostenkowski.

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