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On the horizon in hospital medicine

January 2011

2011 has rolled in! Making predictions is hard and risky but always tempting. No matter what your politics are with respect to health care reform, it’s clear that medicine in the U.S. is going to be shaken up. In fact, reform or no reform, this process is underway.

Here’s a look at my crystal ball on hospital medicine this year and beyond.

More with less
Tighten your seat belts, folks, and get ready to ride the demographic wave of new Medicare recipients. A big shout out to the baby boomers, who are turning 65. According to recent media accounts, this wave means we should expect a new influx of between 7,000 and 10,000 boomers in the Medicare fold–every day.

It’s shocking but true: Health care, just like any other resource–oil, lithium, arable land–is limited. We don’t need a rocket scientist to figure out that managing limited health care resources is going to be key. It’s a simple supply-demand equation, with demand increasing while supply stays limited and is unlikely to keep pace.

That means that “more with less” is going to take on new meaning. Boomers are coming with predefined expectations of a health care system that’s creaking under the weight of escalating costs, where primary care is scarce and specialty care plentiful. Both are equally scarce in rural areas.

We’ll need to figure out how to manage those expectations. When they clash with reality, we can expect shock, disappointment and anger–especially if we, as stewards of this precious resource, do not take a proactive approach.

Spreading out
As this aging demographic keeps growing, American creativity and innovation will need to step up. One, we’ll absolutely need to extend physician reach by employing an increasing number of midlevel providers. Two, we’ll need to use technology such as tele-health, both at a micro level–within a health care system to do tele-rounding, tele consulting, etc.–and on a macro level, with larger systems providing specialty support to smaller, more geographically isolated hospitals.

Tele-health is poised to be the “next big thing.” Already, the technological pieces are falling into place with ubiquitous high-bandwidth connections, wifi, iPad-like devices, software with smarter algorithms, expanded point-of-care laboratory devices and, of course, the rapid spread of EMRs. Couple these advances with a nudge from both the CMS and private insurers, and tele-health coverage will be deemed legitimate care and paid for accordingly.

That will be just about as disruptive a force as any we’ve experienced. And the maturing tele-health Web will inevitably lead to the next step, perhaps in the next decade, when we will witness the birth of home hospitals–hospitals that come to your home.

Hospital medicine will no longer be just hospital-based medicine but will be acute care medicine, location appropriate and governed by the nature and stage of the patient’s illness and patient wishes. Acute care medicine will also encompass skilled nursing facility care. Due to advancing technology and the pressure to bend the cost curve, some–if not most–SNFs will provide a certain level of acute care.

We’ll also have to deal with this looming and powerful variable in health care delivery: the confluence of electronic personal (as in owned by the consumer) health records, ubiquitous smart phones, health care-related apps (for the smart phones) and Web-based social networks. Innovations that will enable us to harness these forces are limited only by our imagination.

Extending the reach!
As I mentioned, midlevel providers will play an ever-growing role in hospital/acute care medicine. Many institutions are already struggling with how best to utilize midlevels as part of a well-oiled, cohesive team.

By and large, midlevels are being trained on the job. As a result, there is a great deal of variability in their skill levels and no standardization beyond their initial schooling. Aspiring PAs now receive 26 months of training, and NPs can train in office medicine or acute care. In my experience, even NPs coming right out of acute care training need additional training and close supervision on the job before they can be considered seasoned inpatient medicine providers. The same is true for PAs.

Clearly, we’re struggling with a dearth of institutions to train midlevel providers to become confident and astute hospital medicine clinicians. Even with experienced midlevels, it can be a challenge to figure out how to use their skill sets in a way that frees up physicians to care for complex or critically ill patients without onerous supervision or self-defeating finances. We still need to find the sweet spot between extending the physician reach and providing quality care to more patients without over-extending.

Skill up!
Hospital medicine administrators are looking at midlevels, usually in addition to existing MDs. Could we at some point see midlevel providers replacing some physicians?

A lot of the answer to that question depends on market dynamics, but I certainly think it’s a possibility. Even if midlevels don’t outright displace existing MDs, some expanding programs in the future may consider: “Should we hire one physician or two midlevels?” or some similar permutation. This is already in play.

If you are a hospital medicine physician and you do not relish critical care, shun procedures and find solace in the non-ICU wards, you should be worried. An appropriately trained midlevel provider could very well do your job. One could also conjure a downward pressure on hospital medicine physician income if doctors’ practicing skill set is not measurably commensurate to their education.

The most obvious antidote is to upgrade your skills, either clinical (procedures, active ICU care, palliative care, transplant medicine, etc.) or nonclinical, such as those that come from being actively involved in committee work, teaching, quality improvement, health care IT, etc. Because I now run the risk of seeming to be partisan toward the physician cohort, let me state that I see midlevel providers as respected colleagues–and I personally know several who I would prefer to have as my own acute care provider.

The above is just a snapshot of how I see some of the chips falling in the foreseeable future. There are many other potential game changers that are out there, such as advances in genetics and many different perspectives on how the future could unfold.

What other variables or developing phenomena do you see affecting hospital medicine this year and in the near future? Let us hear about them!