The future of health care delivery

• Technology. New technologies have made health care delivery much more nimble by embedding tools into smartphones, allowing providers to access information wirelessly, or miniaturizing equipment. Hand-held ultrasound is now available at a price that a single physician can afford. For hospitals, on the other hand, the cost of new technologies like MRIs, CT scanners, and equipment for radiation therapy is so high that in order to stay abreast of trends, hospitals need substantial hard-to-raise capital.

• Costs. The costs of care are rising with no end in sight, and none of the current reforms and other proposals offered thus far will effectively curb the increases. This is because most approaches offered by government and insurers do not address the real problems. Patients, in the meantime, are facing greater requirements from employers to share the cost of care. Among employer-sponsored plans, there is an increasing push toward high-deductible-plans, with deductibles in the $1,000-$2,000 range.

The most glaring problem in American health care, however – and the largest driver of change – is the limited time that primary care physicians actually spend with their patients. Most primary care physicians in the United State, including many ob.gyns., are trapped in a business model that forces them to see at least 24-25 patients per day (a total patient load of 2,000-plus). The model typically allows for about 12 minutes of face time with each patient and leaves no time for careful listening, for care coordination, for talking with specialists, or for thinking deeply about diagnostic dilemmas.

When patients have a slightly complex case that cannot be solved in 12 minutes or less, physicians are left no option but to refer these patients to a specialist, which dramatically increases the cost of care delivery.

The changes ahead

There are many pilot programs embedded in the Patient Protection and Affordable Health Care Act that attempt to address health care delivery cost and quality, and perhaps some will bear value in coming years. Overall, however, reform in Washington is largely about medical care financing and insurance coverage.

Accountable care organizations and medical homes are good alternatives to traditional care models and could provide outstanding care, but these options will not succeed unless productivity standards are lowered such that the generalist physician truly has the time to listen, think, prevent, and coordinate. Similarly, capitation (payment of a fixed sum for all care for one patient for 1 year) will succeed only if the rate per patient is sufficient enough so that the physician can sustain a practice while seeing fewer patients and hence spend enough time with each one. Thus far, this has rarely been the case.

In the absence of major changes on the horizon from the government or insurers that put incentives and funding in the right places, health care delivery can only transform in fits and starts in response to the major drivers of change. Although some changes to the current system will be truly transformational, many will only be incremental.

Among the transformative – and one could say disruptive – changes will be change in our hospitals. Certainly more and more can be accomplished in the outpatient setting, but as more people survive longer and have more chronic illnesses, there will be a need for more hospital beds, ICUs, operating rooms, and high technology – the reverse of the mantra of recent decades which proclaimed that we had "too many hospitals and too many beds." Hospitals also will need capital for renovations, new wings, and all the needed technology. With credit tight, smaller hospitals will merge into larger systems, and there will be few stand-alone community hospitals in the coming years.

To compensate for the shortage of nonspecialists and to allow generalists to do what is needed and what they are best at doing, there will be greater use of nurse practitioners, physician assistants, nutritionists, exercise physiologists, and other nonphysician professionals. Physicians will increasingly need to embrace, rather than marginalize, the work of adjunct providers in providing quality interaction with patients, augmenting preventive programs, and enhancing care coordination.

Ob.gyns. will likely find such team-building helpful as they strengthen their efforts to provide preventive care and promote healthy behaviors for women of all ages. The model of a health care team also can help ob.gyns. as they strive to deliver more preconception care and to work with women before and during pregnancy to create optimal intrauterine environments that will lead to healthier offspring. Like family physicians and internists, ob.gyns need time to spend with each patient to learn about her family and the environment in which she lives.