Volume 61, Number 3 - Summer 2010

 

By Kirk Pappas, MD

My son Nick is 14. Of my three children, he is the most likely to pursue a career in medicine. In 14 years, when he finishes his Physical Medicine and Rehabilitation residency, the way he practices, receives, finances and experiences health care will be far different from today. However, the changes will be just beginning. These changes, which began this year with the new health reform legislation, will take two generations to be woven into the fabric of our culture. 

The passage of health care reform is a permanent and historic inflection point. While we have yet to experience the effects of the reforms, they are coming. 

For me, access to health care is a moral issue. From that perspective, the process of health reform resembles the Civil Rights movement of the 20th century for African Americans. It is a graded step-wise process in the grand tradition of change in our country. 

Barack Obama was not even born when the Supreme Court declared segregation unconstitutional in Brown vs. the Board of Education. He was just three years old when The Civil Rights Act of 1964 permanently changed the landscape of rights for African Americans. 

Without these changes, President Barack Obama would not have been possible. The changes, however, took more than 40 years to come into full effect. 

Where will we be in 40 years with health care reform and the delivery of health care? Will we look like Canada, the UK, Germany, or perhaps a Third World nation? When my son is 54, what will practicing medicine be like? 

When the health reform legislation is fully enacted in 2014, more than 95% of Americans will have access to health coverage. As the bill stand now, the undocumented will still be left out, but I imagine that by 2014, steps will be taken to include everyone. 

Next year, extension of coverage will add millions of children to Medicaid-type programs from Alaska to Maine. Parents may well be in one plan and kids likely in another as parents drop dependents off their employer-based coverage. 

By 2013, Medicaid payments will match Medicare payments, with specific emphasis on primary care reimbursement. As we argue about SGR and GIPC, the playing field of reimbursement will be changed. What will stop the commercial payers from changing? 

Payment and insurance changes will lead to changes within utilization and reimbursement as market forces take hold of the “business of medicine.” There will be an expansion of new entrants to the market, from pervasive concierge care for the rich, to perhaps more of a virtual world for advice. Which groups of doctors and hospitals will be able to take care of the newly insured 40 to 50 million people in this country?

Pay for performance, pay for quality, integration, prevention, and electronic medical records will be as common as the stethoscope, the reflex hammer, and the history and physical. 

The details for all of the above have yet to be legislated, and I doubt they will be. They are more likely to be part of a process, either at the state or federal level. The differential utilization of resources will be evaluated, and pilot projects will look at outcomes. Do people in McAllen, Texas, really need more resources than those in El Paso? 

Atul Gawande, in his famous New Yorker article of 2009, challenged the “assumption that more medicine has to be better.” I am guessing that payment for more utilization will die away and that payment for outcomes will be the next buzzword. Payments are easily regulated, but outcomes are a different story. 

When Thurgood Marshall, the great-grandson of a slave, argued Brown vs. the Board of Education at the Supreme Court in 1954, he may not have imagined that he would be serving on that same court 13 years later. To Marshall in 1954, the idea of President Barack Obama may have been as foreign as the possibility of a man walking on the moon. Yet, two years after Marshall became a Supreme Court Justice, a man did walk on the moon.

I hope you enjoy this issue, discuss it with your family and colleagues, and then look at it again in 40 years. Imagine where we will be by then. 

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