The top news headline on the computer screen for Aug. 26, 2016, is hard to comprehend, but there it is.
"Healthcare costs on the rise."
Some of the more pessimistic pundits have been warning about such an unthinkable development since early 2014 (touch date and keyword costs for three stories, MH-OnLine 2014). But that doesn't make it any less difficult to acknowledge that the old nemesis of the past three decades of the 20th century is back.
The nation's employers, governments and general public likely will blame each other for letting a good thing slip away, just as they argued two decades ago about who was at fault for rampant medical inflation. But what it all comes down to is, they're spoiled.
They're used to the unbroken string of productivity gains and cost decreases they've enjoyed ever since a long-promised devotion to routine medical management finally came together in the year 2000.
Faced with market pressures to reduce costs and a political reaction against reductions in care choices, the healthcare industry went through a period of turmoil never before seen.
But out of that pressure-cooker came a commitment to scrutinize every ordinary act of healthcare delivery through the power of information technology and its main product: current data packaged for action.
The power was turned loose on one medical process after another, gathering continual evidence of what was working and what wasn't. Healthcare networks developed feedback loops enabling them to manage patients hour by hour instead of day by day.
The computerized routine peeled off layers of unnecessary or counterproductive care, netting big gains in such high-cost areas as cardiovascular medicine, critical care, antibiotics use and staffing.
Over the years, the scrutiny burrowed into ever deeper layers of medical routine, and the inevitable payoffs fed expectations among purchasers of health coverage that next year's premiums would be lower without sacrificing workers' health status.
But according to the industry observers quoted in today's on-line report (touch on-line for photos, interview summaries) the health-management specialists are finally running out of places to work their wizardry. And in the giddiness that enveloped healthcare during years of productive re-engineering, some ticking time bombs have been ignored.
The days before efficiency. No matter what cost pressures loom in the coming months, they can't compare with the crush on the industry from all sides at the turn of the century.
That's when the now-prevalent principle of provable value for the health dollar was being formed in the face of unchecked increases in health costs borne by government and businesses.
But although providers held the keys to cultivating that principle, the impetus came from payers, who got the value concept off to a rocky and contentious start. Payers championed a strategy of cost control by herding and prodding providers into discounting their services and by challenging what had been unlimited latitude to rack up specialist and test expenses.
Popularizing what was known then as "managed care" through their health-benefit dollar, large employers sought to rein in healthcare's penchant for spending by requiring HMOs and providers to meet agreed-upon health needs of insured workers in return for fixed payments.
But those were the days without advanced information technology to guide daily healthcare management.
Rather than draw on complete histories and computer-aided diagnosis, as is the current routine, clinicians relied on sketchy memories of patients to help hatch hunches about possible problems. HMOs took the route of least upfront cost, even though precise data often would have exposed it as less effective in the long run. It was like flying without instruments.
Nowadays a patient with certain symptoms might be whisked to a specialist for expert diagnosis in the typical tight-knit healthcare superstructure. The specialist would identify the appropriate computerized critical path for a generalist to follow, while instructing where to check in the computer database for more guidance compiled from peer-reviewed current medical findings.
But back in the late 1990s, HMOs without such management capabilities tried to limit access to specialists and diagnostic testing while expecting primary-care doctors to catch or prevent every imaginable illness in patients whose pasts were largely a mystery.
HMOs enlisted the help of so-called "integrated delivery networks" that sought to care more efficiently for enrollees by managing a continuum of treatment options, from walk-in clinics to hospitals to home care and nursing units. But most of them were networks in name only because their primitive information systems were unable to capture the benefits of trading and coordinating patient data throughout a diverse collection of care sites.
Even without the precision of computer assistance, the so-called "gatekeeper" doctors who were instructed to catch problems early ended up doing their job all too well. They initiated a flood of treatment to cover a backlog of aches, pains and conditions that never had been attended to because of patient cost and access barriers or just plain penny-pinching by HMOs.
The unexpected load alarmed investors of publicly traded HMOs who saw quarterly earnings drop through the floor. With only administrative expenses and dollar volume of treatment to draw on for cost-cutting, HMOs began to reduce customer service and develop ever more restrictive policies on choice of doctor, covered treatments and referrals to specialists.
Caught between a consumer rebellion against eroding service and an investor rebellion against eroding profits, HMOs and provider networks turned inward to find other ways to corral costs without curbing care.
Trimming fat an ounce at a time. The solution didn't come at once, but rather in thousands of unspectacular increments. The process merely used tons of data on cost-effective medicine that had been pumped out for years in medical journals and staff memos but had never been converted to action.
A quantum leap in computer software in the 1990s transformed information systems from processing drones to powerful engines for taking in, analyzing and acting on data.
The synthesis of computer power and medical intelligence gave providers and HMOs a way to inject detailed data into the ongoing delivery of care and use it to revise, redirect and standardize care along precisely defined lines that were proven to work in most cases.
Then the results of daily operations could be gathered up and fed back into the computer systems for evaluations of how the process was working.
Some tricky technical feats allowed the clinical data to be merged with then-separate financial and administrative computer systems. That way, medical practices achieving similar results could be compared on costs and narrowed down to the most cost-effective options.
All that remained after that would be to keep feeding the loop a steady diet of information.
Some early applications of this process that had gone mainly unrecognized during years of frenzied consolidation in the healthcare industry suddenly found an audience.
For example, in 1996 a hospital in Salt Lake City reported trimming a million-dollar annual expense for antibiotics nearly in half (in inflation-adjusted dollars) during a seven-year period in which computers combined with continual feedback to and from physicians. The system weighed detailed data on patients, matched it with clinical data and guided the use of antibiotics throughout the facility.
The tightly targeted process allowed the hospital to increase the number of patients treated with antibiotics while using fewer doses overall, decreasing death rates and curbing complications.
In other health networks, computer minds tuned up hardware and software performance like Penske mechanics pushing an Indy car's limits.
Once loaded and mastered, the computerized investigation and feedback process could be used on hundreds of other procedures, treatment regimens and internal staffing challenges.
Networks that had put the computer pieces into place now had a way to use them. Networks and HMOs that had lagged behind scrambled to catch up.
The quality juggernaut. The beginning of the 21st century lobbed one more financial hit at healthcare. Networks stocked up on richer and richer systems of information presentation and "intelligent" computer programs that helped physicians draw conclusions based on complex scenarios of symptoms and responses.
Meanwhile, HMOs and health networks fought over the allocation of risk in managing the backlog of early interventions, which still remained from healthcare's transition to treating illness in its preliminary stages.
But once capital investments cooled and the climb in enrollee medical complaints tailed off, the data-fueled practice of healthcare began paying off.
As the reliance on a sophisticated foundation of information delivery grew more important, it melted a lingering resistance among some physicians to the large-scale reorganization of healthcare.
As more outcomes of medical retooling became known, and the payoff in capturing and using medical data became apparent, a persistent resistance among physicians to entering that data themselves gave way to enthusiasm. Doctors couldn't get the information entered fast enough to suit them.
The resulting frustration over the data bottleneck spurred advances in information entry by voice, handwriting recognition, digital scanning techniques and other technologies that had been slow to mature and undercapitalized for years.
By the middle of the 21st century's first decade, the shift to healthcare competition based on the fruits of re-engineering was complete. Well-oiled healthcare enterprises bid HMO contracts lower and lower each year as internal efforts ran their course and yielded the expected efficiencies.
The elation behind this adrenalin-producing progress was that it constituted "found money" for executives who had long thought there was no place else to find it. Previous efforts had centered on the fringes of healthcare-administrative expenses, reimbursement gimmicks and annoying nitpicking over use of resources.
Suddenly there were so many places to aim the improvement process that healthcare strategy came to revolve around setting priorities on where to aim it.
HMOs made decisions based not only on how much lower the bids were compared with the previous year but also on which processes within the networks were being improved the most. They matched the priorities of their provider partners with the prevailing makeup of their enrollee populations.
The end of the run. After more than a decade of downward pressure on healthcare costs, however, some evidence began to surface a few years ago that the healthcare industry was running out of ways to meet the annual expectation of lower premiums.
The crowing over new inroads in cost-effective care took on a restrained quality, and cost-reduction figures in HMO bids began to taper (touch for MH-OnLine, Dec. 18, 2015, 8: 02 a.m.).
A recent analysis for one big network, leaked to the press and detailed in today's on-line report, concluded that the seemingly bottomless opportunity for cost management in healthcare delivery is about to bottom out.
And festering for years behind that juggernaut are cost pressures beyond the immediate control of the healthcare industry:
The aging of a post World War II "baby boom" generation that didn't benefit from today's devotion to health management until many of their infirmities already had set in.
An imminent epidemic of smoking-related complications involving the "millennium generation," which stampeded to tobacco as a social identifier and badge of rebellion despite financial and other sanctions.
A crushing cost of chronic care for AIDS patients, caused in part by new classes of drugs that did not eradicate the HIV virus but did help stop its progress. That reduced the threat of certain death among high-risk groups and led to a lapse into the risky behaviors that spread the virus.
Public-health efforts to reduce the social causes of health problems had gained ground in the late 1990s and into the decade of 2000. But years of progress in caring for insured participants in the healthcare transformation had blunted the attention to those simmering problems, the industry observers said.