Is Obamacare Good For Innovation?- It’s All in What You're Asking For

In a recent Forbes article (http://www.forbes.com/sites/robertpearl/2014/03/06/malcolm-gladwell-on-american-health-care-an-interview/)  Malcolm Gladwell sat down with Robert Pearl to discuss healthcare.  Although not thought of as an expert in this area, I’ve also found Gladwell to be one of the most creative minds in America.   One of Gladwell’s books on innovation (Tipping Point) is something of a roadmap for a new paradigm, showing how the crowd can be delivered to solve problems; it also outlines a role as an accelerator for the individual.  I’ve written (pleaded) about this call to action (http://alanpittmd.blogspot.com/2012/12/why-i-use-linkedin-and-hope-you-do_20.htm). In the interview Gladwell asks where Obamacare is good for innovation, and how to “nudge” the system forward.  For me, innovation responds to a problem.  Obamacare has redefined the ask for innovators.

Since the last great change in healthcare (Medicare/Medicaid in 1965), America embraced something of a losing battle, a war on death.  Like every country, our healthcare reflects our traditions, We value the trailblazer over the settler, the surgeon over the internist, heroic care over chronic care.  We’ve paid for ever increasing breakthroughs at the margins (end of life) while largely ignoring less costly, and less sexy gains in quality of life.  This has left us with the most expensive system in the world with limited success for the average citizen.  We don't live longer than other developed countries.  And one could argue whether a country that ruins their citizen's fiscal health when they get sick is not very civil. 

Obamacare is a required shift.  The current system, something of a snowball of stakeholders, is not sustainable.  We are moving from volume (fee for service) to value based care, from heroic to chronic care management.  As with many transitions we are now moving through the 5 stages of Kubler Ross's scale, caught somewhere between anger and depression.

In terms of innovation, it's all in what you ask for.  This is one of the most chaotic times in American Healthcare.  However, in chaos there is opportunity.  We are seeing the beginnings of innovative strategies focused on new forms of care delivery.  Both large and small opportunities are nudging their way forward.  Americans are the world's greatest innovators.  Fear not Mr. Gladwell.  We are processing the new rules of the game.

Dear Doctor, Which one are you?- Patient, Physician, or Specialist?

We are all patients at some point.  Rich or poor, when sick we are worried and vulnerable. We’d all like a cure but at a minimum we want care, reassurance that all can be done, is being done.  Ideally we’d like to have confidence in the person watching over us. This can be a tall order.  As a senior physician, I remember the feeling of helplessness when my mother became a quadriplegic.  I became an increasingly passive participate as she went from hyper-acute ICU care, to inpatient care, to chronic care in a nursing home to home (http://alanpittmd.blogspot.com/2012/08/the-apex-of-care-i-am-successful.html).  Each step “forward” felt like a step back as her care became increasingly fragmented.

For some, healthcare experiences become a calling to serve.  They elect to become a physician, nurse or other healthcare professional.  Having interviewed many potential medical students, many have a naive, idealized view of the profession.  Now in mid life, with longer hours and a much less certain financial future than when I started, I had a somewhat jaded view until recently when my daughter Taylor elected to go into medicine. We had many discussions about a her choice.  Finally, she turned to me and asked what I recommended she pursue in these chaotic times- business, law, research? As a physician she was pursuing a worthy profession.  I couldn’t disagree.

After medical school most physicians specialize. In part, this is financial.  American specialists tend to make more than generalists.  However, this is also a result of the Darwinian selection process. Successful medical school candidates tend to be type “A.”  They want to be right.  Specialists train to know more about less (occasionally to the obscured) than their generalists counterparts.  However, over time, specialists are socialized to think of themselves as specialist first, then physician and then as a patient.  Some forget they were ever young doctors with calling.

The Accountable Care Act (aka..Obamacare) has come as a surprised.   Several provisions ask for coordinated care and a team approach, in essence asking for a cultural change for healthcare providers.  With a loss of income and control, many specialists are understandably frustrated, anxious and angry.   Although I don’t expected sympathy from many American’s for the plight of the specialist, earning less every year for the same (or more) work is never easy.  Although most in healthcare recognize the need for change, each group hoped the change would come from someone else’s piece of the pie. 

For many in my profession, Obamacare has become a rallying cry, representing of all that is bad with big government.   However, if you were President, what would you do?  The bills for decades of over utilization are coming due.  Although it remains to be seen whether care will improve for the average American, the current system is simply not sustainable.  Decisions have to be made in the best interest of the patient and the population, not the profession.   My daughter's choice has been a bit of a pause for me.  It has helped remind me healthcare is a noble pursuit, and that specialty care is a by-product of the business but not the purpose of the medicine.  Ultimately, we are all patients first.