Tuesday, April 29, 2014

SHM 2014: scientific assembly or rally?

Being a clinician, as I sat in the plenary sessions of our 2014 national meeting I started to wonder. Was I in the right place? There was some clinical content at the conference (I'll blog a bit of that later) but, unless you paid extra to attend a precourse, it was largely relegated to the breakout and poster sessions.

I attended the plenary sessions in hopes I'd get a better idea of the vision of our leaders and where they are taking the field of hospital medicine. It wasn't encouraging. The highlights below centered around Ian Morrison's talk and some elaboration in a panel discussion.

Consolidation and increased centrality of care

Morrison said:

Doctors discretion in selection of specific technologies and clinical protocols
will be increasingly constrained by large motivated health systems that employ

He might as well have said “prepare for the decimation of evidence based medicine.” I'll explain. EBM takes the external evidence and applies it to the individual patient's attributes, preferences and values, as directed by the judgment and expertise of the individual clinician. It's incompatible with medicine by central control. That point seems widely misunderstood about EBM but it was taught by the founders and still applies today.

The transitions of care

Morrison said:

Care coordination of transitions will be at a premium.

The hospitalist model is a deliberate disruption in the continuum of care. Hospitalists created these artificial transitions and have been trying, with little success, to undo the consequences ever since. Don't expect them to suddenly fix it now.

Renewed focus on primary care

What will that mean for patients? It will mean limited choice and limited access to specialists. We've been there before. With heavy managed care in the 90s patients found it very difficult to access specialty care. It backfired. It was a patient satisfaction disaster. Are we going to try again?

The second curve

By that he means, broadly, the future demands of the economic and regulatory environment of health care.

Components of the second curve, according to Morrison, include the following:

A shift toward population health.

As important as that is, what do hospitalists have to do with it?

A shift from volume to value as the compensation incentive .

Value based purchasing is the latest term for P4P, based on performance surrogates that do not equate to real quality and to date have had no proven beneficial impact. [1] [2] The principal effect of the incentive has been to drive elaborate charting and coding games to create the appearance of delivering quality care to very sick patients. It's difficult for me to see how any of that can be good.

Morrison ended with some remarks about how hospitalists can “lead the redesign of acute care” to achieve the triple aim. If inpatient medicine's place in health care is about to diminish precipitously (see Bob Wachter's post here and if you're still skeptical about the incredible shrinking hospital see here) why, of all people, would hospitalists emerge to be the reformers? We would do that by “reaching out beyond the walls” of the hospital according to Morrison. In other words we wouldn't be hospitalists anymore.

So Morrison is predicting the demise of EBM and the demise of the hospitalist model, at least as originally conceived. I'm not criticizing him. He's a health care futurist and is just the messenger. The disturbing thing is that the leadership of SHM doesn't seem to mind.

1 comment:

james gaulte said...

In spite of better meds,better testing modalities,more knowledge,more information available to the patient, the trends you discuss will make the future a much worse time and place to be old and sick.