The past six years of change in the American medical scene has left most of us shell-shocked. Every participant in the system, from physicians to payers to patients, has experienced ups and downs related to the shifts in the way medicine is perceived, paid for and practiced. The result is frustration and confusion, with concern by many that we have lost our way on this road to reform.
Where does medical care go now, after the advent of managed care? Does it continue to be a battleground for politicians and special interests? Is physician autonomy a thing of the past? Are we doomed to "legislation by body part," while costs rise and more Americans join the ranks of the uninsured? Or are we actually on the threshold of an expansion of physician influence on the delivery of medical care, with the chance to dramatically improve the health of the average American?
These scenarios would seem to be in direct conflict, yet they are occurring on the same continuum. Managed care is part of an evolutionary process, one that may well take 30 years to complete. The current framework of managed care should be seen not as a finished product but rather as an intermediary step. The question then becomes: What is the next stage beyond managed care, and how do we reach it?
There are two elements that will be critical to moving to the next, more sophisticated plane of medical delivery. Physicians, in order to claim a spot at the heart of the delivery system, with the autonomy and control that that implies, must be prepared to create value in addition to providing good medical care. Although many would say this has always been the objective of medicine, it has not yet been realized. The failure to bring value--in the form of real health--to medical care has directly resulted in the recent upheaval.
What is value? We understand its meaning in our daily lives; we constantly make assessments and decisions based on value. Consider the choice to buy a car, a house, a vacation: We balance the benefits, costs, and attributes of each to decide if it is worth it to spend X amount of money or five times X.
In medicine, this thinking traditionally has not been present. We have assumed that all care is valuable and good, even when the benefit may be minimal. This is no longer a tenable approach. The truly successful practitioner will be the one who can justify the interventions prescribed, both from the standpoint of the resources required and the results expected. Such a strategy introduces the concept of accountability for outcomes, another piece of the puzzle that often has been neglected in medicine. In addition, the needs of the consumer, be it the patient or the employer or society, must be recognized and addressed. We can picture this as a "value equation" that relates the required components of care and demonstrates how to generate value.
One such equation might be: Quality plus access plus reasonable cost equals value--the presence of all three is necessary for value to exist.
The goal of this exercise is to answer the question of what needs to be monitored and improved to provide value as perceived by the customer, a major paradigm shift in medicine. It also shows us which practices are unsuccessful: Care may be available, but too expensive. It may be low cost, but of poor quality. It may be good care but access to it is restricted by geography, hours of operation, etc.
The entities (hospitals, group practices, insurers, employers and so on) that are able to restructure care to augment the perception of value will be the winners in the next stage of managed care. Just as we do not tolerate an absence of value in other sectors of the economy (e.g., where are Eastern Airlines and Studebaker?), we rapidly are approaching the time when we as a society can no longer accept a medical system that delivers marginal benefit but no value.
Notice that I have used the term "medical," not "health," when referring to the delivery system. The two are not equivalent. Health was defined many years ago by the World Health Organization as "a state of complete physical, mental and social well being." Hence, it is not just the absence of disease. In the United States we usually portray health as a series of negatives: no illness, no injury, no suffering.
But true health is a status that extends well beyond this limited view. Using a collection of negatives to describe health gives us minimal insight into what we can do to improve quality of life, not just avoid serious illness or death. The public health successes of the early 1900s probably have done far more to increase life span than all the complicated technology we use today. The challenge is to realize that we now deliver medical care, important as that is to the individual, but have yet to learn how to deliver health care.
The greatest contribution the 21st century physician can make is to design and implement a system to accomplish this. It is not a pipe dream. We already understand many of the components of producing health, including prevention, education, early diagnosis, and the impact of social and economic factors. Many initiatives to address these issues already have been launched, such as the new emphasis on gender-specific medicine, dealing with violence and domestic abuse, and improving access to child care and early education.
What meaningful role can physicians play in identifying and dealing with these issues? That question presents a tremendous opportunity for farsighted medical professionals who want to become health professionals.
Much of this may seem like pie-in-the-sky. Perhaps, but the obstacles to keeping physicians relevant in an era of high technology and the Internet are formidable. Yet there still is a place for those who accept the challenge of delivering value-added services that are focused on improving the health of the community. The payers, consumers and government will be comfortable extending significant autonomy and control to these providers. It's a task that, by definition, will demand out-of-the-box thinking:
- Designing care patterns that reach beyond those populations that usually are insured, such as women, minorities and people who live in rural areas;
- Emphasizing evidence-based medicine by using guidelines and best practices to leverage changes in physician behavior and help provider organizations build credibility;
- Promoting "low tech-high touch" care by emphasizing the patient- physician relationship over the more usual focus on expensive, often invasive, hands-off technology;
- Balancing the cost of interventions with the outcomes that can reasonably be expected; investments in technology and state-of-the-art facilities must be justified by the improvements in health they will bring;
- Managing resources to meet the most pressing needs of the most people by identifying which populations have medical conditions that generate high costs and significant morbidity, yet are amenable to being treated expeditiously;
- Understanding that traditional medical care must be melded with a broader perspective, the recognition that the fundamental question before us all is how can we best make all our citizens healthier, not simply treat individuals.
As we move beyond managed care, the leadership roles will go to those who understand this history and are prepared to tackle the job of building value and health into the framework of the system to come.
Derek van Amerongen, M.D., is national medical director of Anthem Blue Cross and Blue Shield in Mason, Ohio. In addition to his medical training, he holds a master's degree in health administration.