Long-Term Thinking About Health: Seven Trends That Should Concern Us

July 23, 2008

This country is in a healthcare crisis today — but we’re not thinking enough about tomorrow either. Here are seven trends to watch, starting with the short-term and ending with what may seem more like science-fiction.

The seven trends are: Doctors leaving the public system, a shortfall in primary care, underutilization of medical treatment, “superbugs,” virtual health care, climate change, and radical self-redesign and enhancement.

1. Doctors Leaving the Public System: Medicare dodged a bullet when Congress stopped a substantial pay cut for physicians this month. But doctors continue to leave the Medicare system – in Texas, in Washington State, in Tennessee, and elsewhere. And many doctors already limit the number of Medicaid patients they accept. Shortages will become more acute as SCHIP and other reforms (hopefully) increase the number of Medicare and Medicaid recipients, and they’ll hit lower-income and minority communities first and hardest.

2. Unavailability of Primary Care Doctors: Primary physicians (internists, family practitioners, gerontologists, etc. ) aren’t paid enough. It’s part of a general tendency to under-compensate for “cognitive services” – thinking, talking, and diagnosis. Doctors are economic actors like the rest of us. So the result of this payment bias is a critical lack of ‘cognitive’ physicians who should be the drivers of the medical process. Instead, young doctors are being lured into high-cost specialties. This increases the use of costly (and sometimes unnecessary procedures), according to studies conducted at Dartmouth and elsewhere.

This shortage is already crippling health reform in Massachusetts. The idea of increasing compensation for primary care keeps circling around in health circles, as it is now – along with the concept of a”medical home,” which is a re-articulation of health reform ideas that appear at regular intervals like comets. The thinking is probably correct, but the problem will persist – until there is fundamental reform in the way doctors are educated, compensated, and rewarded with social status. And meaningful reform will be difficult without adequate primary care.

3. Underutilization: Medical policy types are well-versed in the cost problems and health complications that stem from over-utilization of health services. Over-utilization is a central tenet of the McCain health proposals. But, while it occurs – especially in certain specialties – the reverse problem of underutilization is prevalent and growing.

As insurers and employers shift more and more costs to individuals’ pockets people are seeking less and less treatment, as this California survey (warning: pdf file) demonstrates. 38% of respondents said they avoided seeking medical care – either preventive or curative – because of health costs. That’s up from 34% three years ago, and it’s a problem. Failure to seek needed care increases health costs, adds to individual suffering, and can allow untreated contagious conditions to spread. Which gets us to …

4. Superbugs: A study of MRSA “superbug” infections published last year found a dramatic increase in occurrence among Chicago’s urban poor. Crowded living conditions in jails and public housing could be a factor, according to the study’s authors, and illegal tattoos may also be contributing to their spread. Now British hospitals are facing a new superbug called “Steno” that is at least as hard to treat as MRSA.

As new viruses mutate and spread, ready access to preventive and curative medicine becomes more critical. Superbugs would be a concern even if we had a fully functional health system. With the system we’ve got, the impact of new mutated viruses could be serious – and potentially catastrophic.

5. Virtual Health Care: Online healthcare holds great promise for the future – both as a way for people to manage their own health, and as a tool that links doctors and patients in a unified network. But even now, before “Health 2.0” is a reality, we’re seeing a wave of health data losses and thefts. (They’ve become so common that I have a whole blog section devoted to privacy issues.)

The combination of electronic medical records, electronic prescriptions, and other online tools could result in new forms of crime – with scary enough potential results that I’d rather not describe them in public. (Why serve as a think tank for the bad guys?) Virtual health could also cause substantial shifts in the kind of medical care people demand. While that might actually be a thing, failure to plan for it could result in some temporary inconveniences.

6. Climate Change: Global warming could change the way we use medical care – and how much we need. As an Australian study found (and we summarized here), overall hospital admissions went up by 7% during heat waves, while mental health admissions went up by the same percentage – and kidney-related admissions increased 17%. That adds up to a snapshot of medical conditions on a globally-warmed planet. Other changes, like a dramatic increase in the occurrence of mosquito-borne diseases, could also take place.

7. Radical self-redesign: ‘Transhumanism’ – the movement to re-engineer the human body – isn’t a well-known term today. But the process is already underway, and it will gain momentum in the coming decades. Choosing our children’s genetic characteristics … building computer technologies into our bodies … extending our lifespans … all of these will come into being in the coming years. This will raise a series of questions in fields like medical ethics and health financing, as we’ve discussed before.

What should we be allowed to do to ourselves and our children? Which changes should be paid for as a social right, and which are a personal choice? Will we create a ‘two-tiered’ race of human beings? These science-fiction questions will become increasingly concrete as we consider the health care reform issues of the coming century.
(image Creative Commons, courtesy Leo Reynolds)


9 Responses to “Long-Term Thinking About Health: Seven Trends That Should Concern Us”

  1. MA Health reform watcher Says:

    Whoaa. To say the primary care shortage “is already crippling health reform in Massachusetts” is way overstating it.

    Here’s the data: The number of people who said they “Did not get needed care in past year because of trouble finding a doctor or other provider who would see them or trouble getting an appointment” went up from 3.5% to 4.8%. Is that “crippling?”

    Yes, there’s a shortage of primary care in MA, same as many other places. As more people get insurance, the problem is more noticeable. But which is better: expanded coverage with primary care delays, or being uninsured?

    The state is taking steps in this area. They approved drugstore clinics, over the objections of the medical establishment and the mayor of Boston. Today, insurers announced they will cover the visits, with lower copays. A bill waiting final passage sets up loan forgiveness for primary care, increases the number of PAs a doc is allowed to supervise, and does some other things.

    Health reform is doing what it was intended to do: expand coverage to the uninsured. There’s a lot more to do. But hold off on the obituaries.

  2. reskow Says:

    Per the WSJ article I linked to, which is well-researched:

    Her experience stands to be common among the 550,000 people whom Massachusetts hopes to rescue from the ranks of the uninsured. They will be seeking care in a state with a “critical shortage” of primary-care physicians, according to a study by the Massachusetts Medical Society released yesterday, which found that 49% of internists aren’t accepting new patients. Boston’s top three teaching hospitals say that 95% of their 270 doctors in general practice have halted enrollment.

    For those residents who can get an appointment with their primary-care doctor, the average wait is more than seven weeks, according to the medical society, a 57% leap from last year’s survey.

    The dearth of primary-care providers threatens to undermine the Massachusetts health-care initiative, which passed amid much fanfare last year.

    You didn’t provide a link or citation for your survey info, and I can’t respond to it either way with so little context provided.

  3. […] An article from The Sentinel Effect last week addressed seven health care trends that should concern us all.  All seven were good points, but lack of primary care providers caught my attention.  I think that we could do a lot to solve this problem with a restructuring of our health care system.  Doctors become doctors for a myriad of reasons.  They want to help people.  They want a challenging profession.  They want to be well-respected.  They want to be financially secure.  The list goes on and on, but money has to play a part in it.  Unless they’re permanent volunteers for Doctors Without Borders, they’re probably doing pretty well financially.  The median salary for a primary care doc is just over $153,000.  Not bad at all, unless you compare it with the median salary for a Cardiologist, who can expect to make nearly twice that amount.  Now, Cardiologists play a vital role in health care, just like every specialist.  But so do family practice doctors.  Why would someone want to toil away for years as a slave-labor resident to become an FP when specialization would yield a much more lucrative career and help pay off all those student loans?  I’m not saying that all doctors should receive exactly the same compensation – I realize it takes more training and skill to do brain surgery than it does to diagnose the flu.  But by forcing primary care doctors to squeeze as many patients as possible into a day in order to command a salary that is still only half of what a specialist can make, we’re essentially steering doctors in other directions. […]

  4. […] Long-Term Thinking About Health: Seven Trends That Should Concern Us […]

  5. […] primary-care providers threatens to undermine the Massachusetts health-care initiative”) and key bloggers (”This shortage is already crippling health reform in Massachusetts.”). Even I’m […]

  6. Lynn M Says:

    Great article. Underutilization of medical services is always going to be a problem in difficult economic times. With healthcare tied to employment and unemployment rising, many people will not seek medical treatment until they absolutely have to, leading to problems (as mentioned in your article) like superbugs. But another problem is that uninsured people will be cramming into emergency rooms with the cost getting passed on to the rest of us. The health care industry is one of the few industries still hiring in this country because medical care is needed by all (not to mention that our population is getting older and people are living longer). But with uninsured people seeking medical treatment and people electing NOT to seek medical attention to save money, the industry faces quite a bit of trouble.

  7. […] Introducing the transhuman. Luckily he’s not on the scene yet. (See trend #7). Sentinel Effect. […]

  8. The recent debate around how to best control health insurance and the cost, has pushed the issue of prevention to the front. It should be at the headline of every newspaper in America. Shifting the focus on what is really important in health insurance. It is important that we are more pro-active and prevention-oriented; we can make a major impact on common and costly chronic diseases such as diabetes and obesity. This can help to secure stability in health insurance.

  9. Anonymous Says:

    Hmm..this made me think. I am a college student looking for differetn med articles to do a paper over. This one is in my top two.

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