It would be hard to imagine a more interesting year for health care than 2010. On the other hand, implementation or "refudiation" of health reform could be déjà vu all over again. As we start the 14th year of the Effective Physician, we offer our thoughts on seven hot topics for the coming 12 months.

William E. Golden (left) and Robert H. Hopkins

State Legislation

Frustrated at the federal level, opponents of health care reform are blanketing state legislatures with bills to exclude physicians and patients from mandatory participation in specific health systems. Perhaps the only thing odder than congressional debate about health care will be health care debates at the state level among local politicians. There may not be a consistent plan for many years to come.

Medicaid on the Ropes

Medicaid in many states cannot pay for current obligations, let alone a 20% increase in enrollment in 2014. Many states have reduced their Medicaid staffing by 20%, despite increases in enrollment. It will be hard to maintain reimbursement, sustain physician participation, and protect benefits to the disabled and mentally ill.

Tough Choices

The elimination of coverage for some transplantation procedures in Arizona is just the beginning of the adult conversation needed regarding health technology, public dollars, and effectiveness of care. Case-by-case denials of services make headlines, but the context of increasing taxes to pay for ineffective health services could result in new policy. The health professional community will have to start reviewing care across specialties to ensure that resources are available for effective services for those patients who will benefit. New priorities and mechanisms of identifying those priorities will be inevitable.

Exciting New Drugs

Internal medicine has not really seen new blockbuster medications for many years. The imminent release of thrombin and factor Xa inhibitors to reduce thromboembolism in atrial fibrillation is a long-awaited event. Similarly, the summer of 2011 may see the release of new antiviral agents that could double the cure rate in patients with the most common genotype of hepatitis C and reduce the total number of weeks of interferon therapy needed to achieve this improved outcome. Successful release of these agents could have a huge impact in internal medicine offices next year.

Licensure Heats Up

A dull topic for decades, renewal of licensure may soon require demonstration of continued competency through board recertification or other standardized processes. Meanwhile, the expansion of privileges for nurse practitioners and physician assistants to improve access to primary care will challenge licensure authorities. It seems odd that while everyone advocates greater use of team-based care, we are marching toward siloed licensure authorities for nurses and physicians, which only aggravates fragmentation of care. As clinical care grows more complex and patients’ needs expand, perhaps the best option is to unify nursing, medical, and pharmacy licensure boards into one entity that would credential professionals in accordance with capabilities and the functioning of team-based care. Having separate standard-setting agencies for nurse practitioners and physicians no longer make sense.

Rebooting HIT

The federal government’s stimulus program to support adoption of health information technology in clinical settings will probably hit more than a few potholes as clinical sites struggle to implement meaningful use, software vendors strive to meet uncertain government requirements, and government agencies miss important deadlines. The attempt to integrate software programs with clinical routine to create networks of clinical enterprises will temper the optimism of policy designers and health reformers. There is still a long road ahead.

Uncertainty for U.S. Medical School Grads

The growth of U.S. medical school enrollment, coupled with more competitive international and U.S. offshore medical school graduates, has created a relative shortage of first-year residency positions. Last year – for the first time – unassigned American medical school graduates had difficulty obtaining any residency position in the scramble after Match Day. This trend is projected to worsen in 2011. Moreover, good international and offshore American medical school grads have outperformed weaker U.S. medical grads in residency programs for the past several years. Graduating from an American medical school is no longer a guarantee of postgraduate training for those who struggle to graduate. Finally, the federal budget cutters once again are taking aim at graduate medical education subsidies. Financial support for those who get training positions may be at substantial risk.

In the meantime, we hope that the Effective Physician can continue to offer guidance on evidence-based care for your patients. Clinicians remain on solid ground in applying good clinical science: It is the pathway to professional satisfaction and community support of our daily efforts.

This column, "The Effective Physician," regularly appears in Internal Medicine News, an Elsevier publication. Dr. Golden is professor of medicine and public health and Dr. Hopkins is program director for the internal medicine/pediatrics combined residency program at the University of Arkansas, Little Rock.

Perspective: 7 Hot Topics for 2011