Jack Percelay writes….
No, I haven’t been in a coma unaware of what is probably the most significant change for hospitalists for the decade, it’s just that I’m writing this Sunday morning, March 21st, waiting for the House of Representatives to vote, and thus don’t yet know the results. But I thought I’d use this position of ignorance to comment relatively objectively on the outcome, whatever it may be.
Regardless of whether President Obama signs a bill or not, healthcare reform will remain on the front page and we as hospitalists will be subject to increased scrutiny as a result. If the legislation passes, Republicans and other opponents of “Obamacare” will vigorously monitor healthcare expenditures and policies, trying to identify a system run amok. Warranted or not, as hospitalists directing huge numbers of Medicare dollars spent on inpatient admissions, we will be blamed for excesses within the system as well as loss of patient and physician autonomy in both anecdotal reports and the occasional more systemic analysis. Opponents will say, “See, look at what is happening to our system because of a massive government takeover of healthcare.”
On the other hand, if the legislation fails, Democrats and those in favor of a public option will interpret the same results with the following mantra: “See, look at what is happening without healthcare reform” and will use precisely the same vignettes to point out how the failure to pass legislation has resulted in persistent perverse incentives which result in physicians providing discoordinated, inefficient, wasteful and inequitable care.
Inevitably, the truth will be somewhere in the middle, and the issues more complex than a politician’s soundbite. But we will be front and center, and as a hospital medicine group leader, part of your practice management skillset and job description will be managing these expectations within the microcosm of your local community. (I also encourage you to be politically active within your state, and nationally as well, but that’s for a public policy column.)
What does this mean for us as leaders within our local HMGs? Couple of things. First, regardless of the outcome, we cannot expect that we can now bury our heads in the pure practice of bedside medicine and be free from the political spotlight. We should expect an increased and continued focus on our work. Our response should be to continue to do the best job we can as physicians, and to stay above the fray of the “he saids, she saids” of our political process and media headlines. But be prepared emotionally for this increased scrutiny, and prepare the troops as well.
Second, public reporting of outcomes and other metrics is bound to increase. Hospitalists must expect to generate and track these data. Look for more not less paperwork/e-work. Group leaders should leverage these increased requirements from government and insurers to negotiate with those they contract for a stipend to fully support these non-clinical duties. Hospitals will be subject to even greater scrutiny than we are as physicians. Hospitals will need our active collaboration to make them look good, and we should be able to negotiate “win-win-win” agreements that enable the work we do as hospitalists to benefit the patients we care for, support the financial viability and publicly reported outcomes of the hospital, and ensure that we as hospitalists are appropriately compensated.
Finally, we must view the next several years as an opportunity for us to innovate. Innovate within our own local HMGs, experiment with new systems and models of care. We lack the power, responsibility, and authority to determine how to insure large populations, but we are ideally situated at the bedside, hospital, and hospital system level of healthcare delivery. The regulations haven’t been written yet to monitor the reimbursement systems that will change as a result of Sunday’s vote. We have the creative power as individuals and respect as an organization to influence these pending statutes.
As I wrote at the beginning, both parties will continue to snipe at one another. We are politically exhausted, both as members of the public and as subjects of discourse. It’s the bankers turn to be slammed in the public forum. I expect healthcare reform will likely move from legislators to regulatory bodies like CMS or perhaps to a politically neutral “expert panel;” both of these bodies are relatively receptive to successful demonstration projects. As hospitalists, we can neither rest on our laurels nor claim exhaustion at the end of this marathon. Rather, we get to return to the trenches and do what we do best: care for patients. If the best model of health care is free-enterprise, government free health care delivery, there has got to be a hospital medicine practice out there that can demonstrate these outcomes. If a new system is to be instituted in 5 years as a result of Sunday’s vote, leading edge practices should demonstrate effective models for the rest of us to follow. And if we try a promising model that is not successful, best that unintended consequences or demonstrated in trial projects rather than in one fell stroke “as a government takeover of one-sixth of the GNP.” As Atul Gawande pointed out in a recent colum, such improvement is usually incubated at the local level. That’s our responsibility, and it’s a helluvalot more fun than trying to influence one’s state and federal legislators.