| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Perspectives |
1 From the Department of Radiological Sciences, UCI Medical Center, University of California, Irvine, 101 The City Dr, Orange, CA 92868-3298. Received March 16, 1999; accepted May 21. Address reprint requests to the author (e-mail: rmfriede@uci.edu).
Index terms: Perspectives • Radiology and radiologists, socioeconomic issues
What has happened in medicine over the past several years is history. History is recorded, so one must be careful that one's statements relating to the past are accurate. Efforts to anticipate the future are ubiquitous. The predictor must be cautious—the only thing that is certain is that the future will be different from the present. It is fairly safe to predict the changes that will occur in the next 4 or 5 years—history has shown that over a short time, the changes usually will relate to the past, a variation of the previous 5 years. This is not true for predictions about changes 10–20 years in the future. In the science of futurology, one cannot use simple extrapolation for long-term predictions. Therefore, long-term forecasts must be conditional forecasts. For example, if the Democrats control the U.S. Congress for the majority of the next 20 years, the future practice of medicine may be different than that which would occur if the Republicans maintain control of Congress. Future changes, in other words, are conditional upon other events that are themselves difficult to predict.
One nice thing about predicting the future is that nobody can say that you are wrong—and if, in the future, it turns out that you were wrong, by that time nobody remembers what you said.
Joseph Goldstein, MD, chair of the Department of Molecular Genetics at the University of Texas Southwestern Medical Center in Dallas stated that the three major factors that have transformed our lives in the past century are "McDonald's, the microchip, and the discovery of the genetic code" (1). Obviously, he did not consider it from the viewpoint of physicians, who might have included managed health care in the list of factors that transformed our lives.
In this article, which is the first of two parts, I discuss the changes that have occurred in the practice of medicine and attempt to predict what will evolve in the future; in part II, I will discuss the changes that have occurred in the practice of radiology and my outlook for the future. In radiology, we are intermediaries, and as such we are directly affected by what happens to the rest of medicine (2).
The drastic changes that have occurred in medicine over the past 10 years actually started in 1929, 70 years ago, in Elk City, Oklahoma, where the first medical cooperative was established to provide medical care through prepaid insurance. In the 1930s and 1940s, several large managed health care organizations were formed, including the Ross-Loos Medical Clinic (Calif) in 1929, the Kaiser-Permanente Medical Care Program (Calif) in 1939, the Health Insurance Plan of New York in 1947, and the Group Health Cooperative of Puget Sound (Wash) in 1947 (3).
In 1970, a Minneapolis (Minn) physician by the name of Paul Ellwood, Jr, MD, coined the term health maintenance organization, or HMO, as an alternative to the fee-for-service system. You may not have known that, in 1971, President Nixon, in his health message to Congress, embraced the HMO concept and proposed legislation to allow Medicare participants to join such organizations. Congress passed the Health Maintenance Organization Act of 1973, which provided incentive grants for the establishment of HMOs. From 1970 until approximately 1980, enrollment of patients in HMOs increased from 3 million to 13 million participants (4). In 1985, enrollment was approximately 19 million, and, by 1998, enrollment was estimated to be over 150 million.
Three major stimuli for the development of managed health care were, first, the rapid rise in the cost of health care for workers, which had become a large part of industry's budget, and, second, the government's concern about rising health care costs in the United States, which had increased from $250 million in 1980 to about $1 trillion in 1995. Health care was consuming about 14% of the gross national product (5). The third and precipitating factor was the failure of President Clinton's health care proposals in 1993, after which the government backed off from involvement in structuring of the health care system and left the field wide open to business entrepreneurs. By 1995, HMO enrollment in the United States had grown to 56 million participants, and HMOs were now a powerful force in American medicine (4).
I believe that, in the late 1980s and early 1990s, we physicians made a fundamental mistake. We were so busy trying to protect the fee-for-service system that we were not major players in the establishment of managed health care policy. We forgot that our prime purpose should be as advocates for patients, and, as such, we should have had a major say in the methods of managed health care. Instead, we became recipients of the rules established by the entrepreneurs, which, in many cases, were slanted more toward profit than patient care. Managed health care became too much involved with management and too little involved with the problems of patient care. Profit-oriented chief executive officers drove down costs, often sacrificing quality in the process. In California, we have experienced the growth of managed health care to the point where unrestricted fee for service is almost extinct. In California, approximately 25% of the population is uninsured. Of the remaining 75%, 49% are participants in HMOs; 22%, in preferred provider organizations (PPOs); 5%, in point-of-service plans, (an HMO hybrid); 21%, in Medicare/Medi-Cal; and approximately 3%, in indemnity fee-for-service plans (6).
Managed health care is deeply rooted in California, which in many ways was the birthplace of modern managed health care. In California, HMOs became the prevalent form of managed health care. Outside of California, PPO plans, which are, in effect, controlled fee-for-service plans, are more popular than the more restrictive HMO plans. To cope with patient demands and physician complaints, HMOs were forced to expand their services, which increased their costs. In 1993 and 1994, approximately 90% of HMOs reported a profit or surplus (4). In 1995, that number declined to 60% and today is probably less than 50%. Stock prices of managed care companies have decreased dramatically over the past 3 years. In 1996 alone, HMO stocks as a group decreased by 22%. The answer for HMOs was to raise rates. Kaiser-Permanente last year increased its rates by up to 14%; increases of 8%–10% were common, and further increases will probably occur this year.
The main base of HMO support is corporate America, because of the lower insurance costs. However, even this may change if there is further public discontent with the restrictions imposed by HMOs. Recently, new Medicare legislation has allowed Medicare beneficiaries to enroll in PPOs, as well as HMOs, and this may stimulate additional PPO growth.
It is interesting to note that when Medicare and Medicaid were created in 1965, politicians were concerned about health care, not costs. In 1965, the budget office projected that the cost in 1990 of Medicare Part A (the hospital insurance portion of Medicare) would be $9 billion. The actual amount in 1990 was $66.9 billion, which shows the difficulty in projecting ahead (7). The percentage of gross national product accounted for by health care costs was 5.1% in 1960 and 13.6% in 1990; in 2030, these percentages are projected to be 37% with indemnity health care and 14% with managed health care (7). The indemnity costs are obviously overinflated, and the managed health care costs are underestimated. Such overinflated estimates have stimulated support for managed health care.
Richard Lamm, former governor of Colorado, recently described the clash of ethics between the medical profession and public policy makers (8). This is the clash between those who are patient advocates and believe in a 1:1 ratio between physician and patient and those who believe that the new medicine is related to the overall public interest, which is referred to as the "1:n ratio." Changes in the perception of health care can be summarized as follows: From 1940 to 1960, the main concern was with whether the physician was nice and caring, and the physician-to-patient ratio was 1:1; from 1960 to 1990, the concern was with the physician's use of the latest technology, and the ratio was still 1:1; in 2000 and beyond, the concern will be with health care as measured with population-based methods, and the ratio will be 1:n.
I believe physicians will find it difficult to abandon the concept of the 1:1 relationship. For those of us who have been practicing medicine for 15 years or longer, the concept of sacrificing the individual patient's welfare for the greater good of the community seems like heresy. Unfortunately, Governor Lamm is correct. The time when we would do whatever is necessary to diagnose disease and to treat the individual patient has disappeared. Whether we like it or not, "spare no cost" medicine is gone. No society can continue to fund an open-ended system. As Governor Lamm pointed out, the health care system can no more do everything beneficial for the individual patient than the educational system can do everything beneficial for the individual student. In the future, tax money and corporate payments will be to benefit the health of the people as a whole, while individuals with problems beyond the standards will have to use their own funds. If society does not want health care distributed in this manner, it should not make health care a responsibility of public policy.
The solution to the problems as described by Governor Lamm is not easy. Although health care is heavily influenced by social problems such as provision of food, sanitation, shelter, work, family, and attention to other problems such as smoking, when and if we solve these problems health care costs will not necessarily be reduced. More individuals will attain an older age, but other illnesses will then consume the dollars saved by preventive medicine in the early years. In fact, as we solve problems that allow individuals to attain an older age, we may well be increasing health care costs over the long run.
Physician mores have changed. Physicians are beginning to be much more selective in the diagnostic work-up and treatment of their patients. They realize the benefits of a public policy that is directed at preventive medicine. They are shocked by the knowledge that there are 40 million or more people without health insurance. But decisions to solve such problems are policy decisions, which have become very politicized. Physicians are not the ones who should decide that every patient over 75 years of age with metastatic carcinoma or every newborn with a serious congenital abnormality should not be treated. These are decisions for public policy makers and they cannot make these decisions without consultation with older patients and parents—this is why such decisions are politically very difficult.
Within the next 10 years, clinicians will have to collaborate with a variety of independent and semiindependent practitioners loosely categorized as nonphysician clinicians (9) (Table 1). Most nonphysician clinicians have 4–6 years of training after high school. The responsibility for regulation of nonphysician clinicians resides with the individual state. Most states permit nurse practitioners and physicians' assistants to perform physical examinations and conduct diagnostic examinations within their area of expertise, and many states allow them to prescribe drugs (Table 2). There may be a requirement for the involvement of a supervising physician, but this is frequently intermittent and at a distance. The Balanced Budget Act of 1997 expanded Medicare reimbursement directly to nurse practitioners and physicians' assistants and removed requirements for physician involvement. Since their reimbursement rates are substantially less than those of physicians, the use of nonphysician clinicians becomes an attractive means of cost control.
|
|
Chapman (11), from Leeds, England, wrote that a shortage of radiologists in many radiology departments has encouraged the development of a trend of radiographers performing as nonphysician clinicians. This started with ultrasonography, where it soon became evident that the skill of the radiographer frequently surpassed that of the supervising physician. First, the radiographer dictated provisional reports, supervised by the physician. These reports were considered to be comparable to those of the physician, so the radiographer then dictated final reports directly. Next, radiographers started to perform gastrointestinal fluoroscopy; to inject contrast material; to report results of intravenous pyelography, computed tomography, and magnetic resonance imaging with loose physician supervision; and, finally, to report results of emergency room examinations. Results of a survey (11) in one London (England) hospital that involved 12,000 emergency room reports by nonphysician clinicians showed that trained radiographers had a sensitivity of 96% and a specificity of 99%. Again, this is a substantial cost saving and may lead to a new category of nonphysician clinician in radiology.
What do I think will happen to the practice of medicine over the next 10 years? Much of this will depend on how our political establishment deals with current problems.
1. I believe that managed care will continue to mutate in response to both physician and patient demands. Although these demands will raise costs, politicians will accede to them. Managed health care will have to establish a more patient-centered rather than profit-centered profile. The public will insist on this.
2. I believe that the needs of approximately 42 million uninsured individuals, with an increase of about 1 million per year, must and will be addressed, because this has become a major political problem.
3. I believe that alternative medicine will be encouraged by public policy planners and will continue to grow over the next several years.
4. I do not believe that we will have universal health insurance, but I believe that, in response to public demand, we will have a layered insurance scheme more expensive than today's managed health care system but less costly than our previous fee-for-service system. Layered insurance will allow the patient to select the depth of coverage desired within the managed care program—for a price. This will, in effect, remove the distinctions between the various types of managed health care organizations such as HMOs and PPOs.
a) For those individuals who are currently uninsured and those using Medicaid, the government will subsidize HMO care under a basic health care plan. The government will attempt to ensure that private HMOs accept these patients, but this will be difficult, and the government may be forced to establish its own HMO, which, in effect, will be an extension of Medicaid. The responsibility for administration of this may be at the state level. I believe there will be enough physicians available to staff such a plan.
b) Those individuals who work for corporate America will have access to multitiered HMO and PPO plans. These might be termed "focused care," where the individual selects the desired level of care. Options would include pharmacy, second opinions, ability to see a health care professional outside of the plan, and so forth. There will be copayment for coverage available to those who opt for more sophisticated plans. The cost to corporations to provide even the basic plan will be higher than it is today. I believe that the majority of these patients will select PPO plans.
c) For the more affluent, there will be restricted fee for service. Patients will be able to have a wide choice of physicians who will accept a predetermined fee. There will be a small group of consultants who will not accept any plan and will require private payment of a larger fee.
We should realize that whatever happens to the management of health care will not rid society of medical care problems. There will be continuing flux between managers, patients, and physicians, which will continue to modify the organization and administration of health care. My predictions are based on a moderate continuation of economic growth, with a political balance between liberals and conservatives. Extremes of prosperity or depressed earnings or total control by liberals (advocates of universal health care) or conservatives (advocates of market-driven health care) may affect the balance.
How will physicians be reimbursed? Reimbursement will continue as it does today—capitation, regulated fee for service, or salary. If, in the future, Congress has a liberal orientation, compensation may primarily be through salary and capitation. I believe that it is more likely that regulated fee for service, similar to the PPO structure of today, will be the major form of compensation for most physicians. Small practice groups will disappear—the practice of medicine will be dominated by large group practices affiliated with managed health care organizations. The tendency will be to reimburse support physicians (formerly hospital-based physicians) by means of capitation or salary. Most radiologists will fall into this category. The total income of physicians will continue to decrease over time, as it has in California, although physicians as a group will still earn a reasonable income.
As physicians become more frustrated with the loss of control with regard to patients, reduced fees, and an increased "hassle factor," unions will see an opportunity to organize physicians. The Service Employees International Union has pledged to spend $1 million per year to recruit physicians (12). Currently, about 6% of doctors are already union members, and the number is increasing. Organizers have said they will first concentrate on California, Florida, and Washington, where unions already have strength. Although the American Medical Association has stated that strikes are contrary to physicians' ethical codes, the unions would not rule out the possibility of strikes. If physician unhappiness in managed health care continues, we may see substantial union activity in the next few years.
There is a separate and serious problem for academic institutions. Because their costs are higher, HMOs do not readily send patients to teaching hospitals. To attract HMO patients, academic centers must match the fees paid to private groups. This means that academic centers must have other means of support to maintain their programs. In 1994, a bill was introduced in Congress to create an academic health center trust fund (7). This was to be financed by a 1.5% tax on health care premiums with an additional 0.25% tax added on for research support. It was calculated that over $17 billion would be collected over 5 years. Unfortunately, the bill did not pass Congress. Senator Moynihan introduced a similar bill in 1997 to establish a medical education trust fund that would have received about $13.5 billion from general funds over 6 years (7). This bill never reached the Senate floor. There is no question that outside support will be needed if we are to maintain the quality of our academic institutions. If an added tax bill does not generate support, I believe that Congress may appropriate $2–3 billion per year from general funds and that this money will be channeled to academic institutions.
As a postscript, in my next Perspective I will present my views on the future of the practice of radiology. Many readers will have different views concerning the future of medicine and radiology. I invite you to send your views to me.
References
This article has been cited by other articles:
|
|
 |
|
  R. M. Friedenberg The Underinsured: A Problem That Must Be Solved Radiology, June 1, 2001; 219(3): 591 - 593. [Full Text] [PDF]
|
|
|
|
|
|
R. M. Friedenberg Managed Care and Social Justice Radiology, October 1, 2000; 217(1): 11 - 13. [Full Text]
|
|
|
|
|
|
R. M. Friedenberg The Role of the Supertechnologist Radiology, June 1, 2000; 215(3): 630 - 633. [Full Text]
|
|
|
|
|
|
R. M. Friedenberg The Future of Medicine and Radiology: Part II Radiology, October 1, 1999; 213(1): 3 - 5. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
