Yesterday, Today and Tomorrow

Abstract

When the managing editor of Inquiry, Ronny Frishman, learned that would be retiring as CEO of The Lifetime Healthcare Companies and Excellus BlueCross BlueShield at the end of 2012, she invited me to write a retrospective commenting on industry changes during my 40-year career. She also invited me to play seer offering a forecast of the future. Why thought. always fancied myself as somewhat of an industry observer. So with some trepidation about self-embarrassment, offer this commentary. welcome responses, which should be directed to my email address below. Said simply, from my vantage point there are parts of our industry that have been immune to change and others that have undergone profound metamorphosis. But before delving into my observations, it is appropriate to comment on the status of our health today versus 40 years ago. Life expectancy and quality of life are much better than they were at the start of my career. More disease is curable, and if not curable it is often effectively managed as a chronic condition, usually extending a high-quality life. Consider cancer as an example. Back in the 1970s, oncologists could mostly measure a tumor and then predict when death would occur; today's treatments are now more humane and tolerable. More interventions are noninvasive or minimally invasive. Drugs have fewer side effects and increasingly are able to target just the cells causing disease. Bionic implants are used to remedy musculoskeletal, circulatory and nervous disorders. The improvements obviously came at a cost. Forty years ago health care was 7% of gross domestic product (GDP); today it is 17%. Elements of Care Delivery and Financing Remaining Largely Unchanged Concern about Affordability It seems the country has forever had a concern about the ability to pay for health care. Historians actually report some level of anxiety back to 1912, when Teddy Roosevelt proposed national health insurance as part of his progressive Bull Moose Party platform. What has been particularly worrisome over the years, whether coming from private or government sources, is whether adequate funding will be available to deliver the same level of health care access, quality, and service to the poor and near-poor as others receive. Perhaps a more current worry is whether the middle class, now facing higher levels of benefit cost-sharing, will be beset by the same access to care anxiety suffered by the poor and near-poor. There is already evidence of delayed diagnostic workups and increased therapeutic non-compliance for patients with high-deductible health plans. There has been a near-constant argument that the country is approaching the limit of what it is able to spend on health and medical care. Some suggest it won't be long before cost explicitly becomes part of medical policy decision-making, as exists in other countries (for example, the United Kingdom). The refusal by some doctors to participate in Medicare and Medicaid and the successful introduction of concierge medicine all suggest that accessing higher levels of service and quality may be tied to ability to pay. Faith in Doctors and Evidence-Based Medicine There is, appropriately, a reverence accorded physicians for the role they play. You still hear broadly, I have faith in my doctor. Surely, some progress has been made establishing evidence-based medicine, but so much of what is done to patients falls into the category of art, perhaps buoyed with a dose of underlying science and logic. For patients, truly knowing who is a good doctor versus who is not remains largely elusive; clearly, this involves a dimension of faith. Whether this will ever change is an interesting question. There are so many diseases and relatively few patients. Beyond the first 50 most prevalent diseases, will there be enough fully risk-adjusted observations to support use of the scientific method--that is, to have a control and test group approach to learn what works versus what does not? …