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THE TSUNAMI HAS BEEN used as an apt metaphor to describe the coming impact of changes in American health care. (1) Those of us in health care are walkers on a beach unaware of the danger and destruction that is bearing down upon us. One might well object that most of us are anything but "unaware" about changes in health care these days. but our knowledge is not the same as foresight. Do we really see what dangers lurk on the horizon?

Even the most knowledgeable person can be surprised when cataclysmic events occur suddenly and seemingly without warning. Journalist Hedrick Smith, a long time Moscow correspondent for The New York Times, admitted that he did not foresee the sudden collapse of the USSR, despite his many years of living in and reporting on that country. (2) If such a historical and cultural "tsunami" can catch even the most knowledgeable and astute observer by surprise, how comfortable can we be about our future?

Today's events in medicine suggest that a tsunami-like catastrophe could catch us unaware at any time. Our health care system may be teetering toward the brink of its own implosion; yet who among us is considering this possibility--let alone preparing for it? It is human nature to believe that things will eventually work out for the best; often this is so. But we need to consider the bleaker picture as well. This article will describe some reasons why an apocalypse of American medicine could occur and discuss some actions we might take to prepare for such an event.

Five trends that threaten medicine

Let us consider five readily identifiable trends that threaten American medicine. None of these trends is a secret; they will seem all too familiar. We live with these realities every day, but do we consider their long-term consequences? Any one of them ought to be enough for serious concern, but taken together their meaning may be much more ominous.

The five dangerous trends are:

1. The practice of providing medical care is becoming too complex from both a business and a legal perspective.

2. Less money is being spent on medical care without any corresponding reduction in services provided, creating long-term operating deficits.

3. Investor-owned, for-profit corporations are changing the focus of medicine by putting shareholder concerns ahead of patient care.

4. Employment-linked health care insurance creates a growing uninsured population. adding extra financial stress to our hospitals.

5. Providers are losing faith in their future and are becoming increasingly demoralized about practicing the healing arts.

Let us consider each one of the trends in more detail before thinking about their cumulative impact on our future.

1. Business and legal camplexity

The growth of complexity is insidious. Each day we adjust a little more to living with increasing complexity in doing the business of medicine. Keeping up with the science of medicine ought to be enough, but it Is not. Laws are passed that turn normal referral patterns and innocent billing errors into "crimes" punishable by fines and jail. HMOs and insurance companies develop new and ever more complex rules for the care of their "covered lives," making navigation of any particular health plan difficult even for knowledgeable patients and their doctors. We all grumble about how difficult the practice of medicine has become, but we strive to cope and carry on.

Any given doctor's office, clinic, or hospital will have at least a dozen separate contracts for providing health care services. Each contract has its own special requirements and restrictions. Billing requirements vary, the referral forms for each health plan are unique, and the panel of referral specialists is different for each plan and changes from day to day. Thus, layer upon layer of complexity is added to practicing medicine--this slows us down, needlessly increases overhead, and diverts us from attending to patient needs. We seem to never experience a day when these sources of complexity are reduced, streamlined, or eliminated. Worse, as soon as we learn to play the game. the rules change once again.

If business complexity were the only problem, things would be bad enough, but it gets worse. Practicing medicine is becoming a legally dangerous activity. We have all learned to live with the ever-present threat of a malpractice action, but who among us is ready to face the full fury of the government in a criminal case?

The Health Care Financing Administration tries to reassure us that it only wants to catch the "bad apples." but who believes this? HCFA's new emphasis on documented medical services (i.e.. E & M bullet points) and aggressive discovery of what the agency considers "fraud and abuse" now includes a request for deputizing private contractors to investigate individual doctors. Moreover, HCFA specifically wants these agents-for-hire to have blanket permission to issue search warrants, make arrests, and carry firearms. (3) How will it play in your office or clinic when the C-men arrive with guns and warrants to search your patient records for fraud and abuse? Why are we not reassured?

# posted by Medical Information : 3:42 AM