MD 2.0: Physician Leadership for the Information Age. Grace Emerson Terrell MD
time is now. We are at the beginning of what we expect will be the single fastest transformation of any industry in U.S. history. In this tidal wave of change demographic and socioeconomic forces colliding with the status quo will radically alter the landscape of the health care delivery system in ways that were inconceivable a decade ago.2 Our nation is addressing a number of critical issues, including recovery from the Great Recession with its housing and mortgage crisis and the near-collapse of the world’s financial system, a polarized political leadership, rapid demographic changes brought on by the aging of the population and immigration, terrorism, and health care financial reform. Among these competing national priorities, no individual issue in America has posed as pressing of a concern and heightened importance for the public as those that directly impact their personal well-being and health. The election of President Barack Obama in 2008 brought landmark reform efforts for our nation’s health care system, while the subsequent national elections of 2010 brought to office a new set of legislators who ran their campaigns on the promise to repeal this legislation. While political debate continues on the funding, necessity, and timing of many aspects of the Patient Protection and Affordable Care Act of 2010 (Affordable Care Act), it is currently the law of the land, and the underlying focus on the rapidly accelerating health care costs in the current fee-for-service system will continue to drive the health care market to more cost-efficient delivery models regardless of the partisan political debate in Washington.
In 1960, U.S. federal government spending for education as a percentage of gross domestic product (GDP) was 3.7%; for defense it was 10.1%, and for health care it was 0.3%. In 2008, federal government education spending as a percentage of GDP increased to 4.6%, defense spending had decreased 5.1%, and health care spending had increased to 4.6%.3 Since 1960 the federal, state, and private expenditures for health care services and goods in the U.S. haves accelerated from 5.2% in 1960 to 17.6% in 2009 (Figure 1, below). Factoring in the impact of the Affordable Care Act, national health expenditures (NHE) as a percentage of GDP are expected to reach 19.6% by 2019.4
While the uninsured segment of the American population stood at 49.7 million in 2010 and the projected impact of insurance market reform will bring this number down to 24.4 million by 2019,5 this population segment will continue to challenge health care providers when their lack of access to basic health care services inevitably leads them to the emergency departments of our overburdened hospitals.
More than a decade has passed since the release of the Institute of Medicine’s (IOM) landmark report, To Err Is Human6 in 1999 that cited the high number of medical errors occurring throughout our health system. Even today with significant resources having been dedicated by health care organizations, government agencies, not-for-profit organizations, and physician practices across the country to launch and conduct major quality improvement initiatives, our nation’s health system still faces significant challenges with eliminating medical errors.7
The economic incentives of a fee-for-service health care system drives overutilization of profitable services by health care providers, which the private payers respond to through managed care, and the governmental payers respond to through regulation. These counter measures to overutilization lead to increasing frustration on the part of physicians and other health care providers, who perceive less freedom to practice medicine unfiltered by externally imposed constraints. Along with the anxieties provoked in providers by the current punitive tort-based malpractice system, physicians face very low professional morale. The current self-reported professional morale among physicians is dismal, with only 23.1% reporting professional satisfaction in the current practice environment.8 Regardless of professional morale, demographic and socioeconomic changes will continue to drive the health care delivery system reform an serves as justification for continued innovation and our need for strong, diplomatic and collaborative leaders among physicians to improve the health of our current and future patients.
The Impact of a Generation
No generation has made such a significant impact on the focus of medicine in America as the baby boomers. In 2011, the first wave of baby began to start hitting age 65 and become eligible for Medicare benefits at a rate of 7,000 per day. As the 80 million boomers continue to age and consume greater portions of health care, American society will focus its attention on the needs of the boomers at this stage of their lives, as we have necessarily focused on this portion of our population since their disproportionate demographic impact began in the post-war births in 1946.
The baby boomers are growing old. When this population segment was in the 1950s and 1960s, America was focused on the “youth culture.” In the 1970s-2000s, the culture has been focused on the socioeconomic issues of marriage, child rearing, and work-life productivity. In 2011 the tides turned again as the largest segment of American society began to grapple with the issues of retirement and physical decline. We should not expect the baby boomers to “go gently into that still night” any more than we should have expected them to acquiesce to the draft during the Vietnam War. This portion of the American population, with demographic strength in numbers, coupled with buying power and political strength, will be reaching that point in their life cycle with increasing health care needs.
The aging of the baby boomers will lead to inevitable health care reform. One could argue that the Clinton health care reform attempt of the early 1990s failed because the baby boomers were too young, healthy, and productive at that point in their lives for health care to rise to the top of federal political policy concerns. Boomers were far more concerned in 1990 with competing for good jobs and having a thriving economy than health care concerns, as long as the cost of health care did not interfere with more pressing economic concerns.
However, as this population segment moves into its golden years, the 40 million generation X workers cannot replace the 80 million boomers in the workforce without radical structural changes or liberal immigration policy. Although it became apparent decades ago that inefficiencies in the health care system would make a daunting challenge to meet the health care needs for this group, it was not until the boomers approached the years in which their Medicare entitlements kicked in that we began experiencing intensified focus on wellness and longevity research, changes in political agendas, renewed efforts in innovation across the gamut of care delivery, new technologies, and most importantly, transitions in our approach to payment models away from the volume-driven care delivery system that emerged with the managed care era (when the boomers were productively employed and the problems associated with health care costs were thus focused upon employee benefits) toward one that is working toward being more focused through delivery of high-value and high-quality services.
The Medical Profession in America
The earliest archeological evidence reveals that humankind has always worked through cultural evolution to change the environment in ways perceived to meet our needs. Whether through the development of rudimentary stone tools, transformation from hunter-gatherer methods of food acquisition to agricultural methods, the development of densely populated settlements, or the development of modern technology and scientific methodology, humankind has sought to improve our lives by changing our physical and social environment. However, the consequences of our actions also lead to unanticipated adverse environmental changes. With the advent of animal domestication and the rise of dense populations of relatively sedentary groups of people, disease patterns changed as rich niches for rodents, parasites, and insects developed. Exposure to new bacteria, molds, and toxins occurred with the new dependence on a grain-based diet subject to putrefaction due to the need for storage. The more narrowed nutritional spectrum of the agriculturally-derived grain-based diet also led to nutritional deficiencies in vitamins, proteins, and minerals, and in times of poor crop yield, starvation.9 Whereas evidence of treatment of trauma has been found in the earliest Paleolithic records, the advent of cities over the past five thousand years has furthered the spread of epidemic infectious diseases derived from viruses, bacteria, and parasites. In the modern era, civilization has wrought exposures to chemical and industrial toxins, radiation, alcohol and drug addiction, and an increase in the prevalence of other lifestyle-influenced diseases such as diabetes, cardiovascular disease, and cancer.
As long as