Imagine it's 2022. What is it like to walk into your doctor's office? Maybe you make an appointment through an app on your tablet and walk through the door just a few hours later. Then, when you're done, you might use that same device to hand over your copay. Perhaps you don't see a doctor, but instead join a group of fellow patients to get tips from a dietitian.
Or maybe you don't even walk in the office, but get your blood test results through an Internet portal and then exchange a series of questions and answers with your doctor over secure email.
Meanwhile, the medical office you go to is more likely than ever to be part of a hospital or large group practice, and your insurance plan is more likely to limit where you can seek care.
Those are some suggestions from Central Massachusetts doctors and medical experts about what their industry could look like in a decade. Whether these kinds of predictions come to pass is far from clear. For one thing, there are major political developments afoot that could shape the health care industry in major ways. For another, it's always dangerous to make definitive statements about future technology — and health care is supremely dependent on technical developments. But current trends make the adoption of practices like these reasonably likely.
The office of Robert Q. Terrill, a Worcester shoulder and hand specialist, stands at the intersection of old and new ways of practicing medicine. He works at the Saint Vincent Hospital building, but he's a sole practitioner, renting his space.
The practice is a family operation, like many solo practices historically have been. The office manager is Dr. Terrill's son, James. The younger Terrill said he has a background in medical technology, and the office has been an early adopter of things like electronic medical records. Terrill has also been able to set up things like a system that lets customers pay the office through their iPhones and electronic signatures to make paperwork easier to organize. He said new x-ray technology means they no longer have to send patients to the hospital to check for a broken bone. Instead, the doctor can see a patient, do an on-site x-ray, put a cast on if necessary and get them out the door.
"From a patient standpoint, that's awesome," Terrill said.
But the technology is both very expensive and very complex for a small office to deal with. Terrill said when they decided to connect different internal IT systems, it meant hiring a single programmer who took a year to complete the job.
"That's difficult, that you need to know so far in advance what you need to do," he said.
The obvious solution to these kinds of problems is to become part of a larger organization that can provide technological solutions more economically. Many hospitals are happy to buy physicians' practices. A survey by the American Hospital Association found that community hospitals nationwide employed 160,000 doctors in 2000. By 2010, the number was up to 212,000, or about 20 percent of all practicing physicians. That doesn't include the consolidation of solo practices and small partnerships into large group practices, which many say anecdotally also appears to be a major trend.
"It's something that I know a lot of other doctors have done here at Saint Vincent," Terrill said. "The hard thing is that, in doing that, you lose your autonomy."
He said that's especially difficult for older doctors like his father, who are used to setting their own schedules and deciding how and when to see patients.
It's not just in individual practices that more technology means more complications. Jack Dutzar, president and CEO of Reliant Medical Group — the area's major multispecialty medical group — started practicing medicine four decades ago, before the advent of laparoscopic procedures, robot-assisted surgery or precise imaging technology like CT scans and MRIs.
"Of course we had x-rays," he said. "I'm not that old."
Dutzar said technology has so far not fulfilled the promise of simplifying medicine — the Star Trek vision of a universal device that a doctor could wave over a patient to diagnose his or her precise condition. Instead, advanced procedures like genetic testing can only suggest that a patient might be vulnerable to a particular cancer, leading to more rounds of expensive testing and observation.
With all that added expense comes a societal consensus that someone needs to make sure health care dollars are being put to their best use, and insurance companies and government agencies have stepped in to do that.
"People want to know where the money's going and what your decisions are like," Dutzar said. "I think it's a very good thing. I think it's critically important, although often clumsily and awkwardly implemented."
Right now, many insurance plans limit the hospitals that members can choose or make them share the extra cost of going to an expensive medical center. Various organizations also publicize the cost of care in different places along with quality scores and patient satisfaction levels to help patients choose the best-value option.
A more comprehensive way of changing how health care expense works is the much-discussed combination of globalized payments and accountable care organizations. Essentially, a health care entity — perhaps a hospital and a bunch of affiliated doctors' offices or a large multispecialty physicians' group like Reliant — is paid a set amount for each member in exchange for ensuring they get whatever care they need. It's similar to capitation systems that were tried and discarded in the 1990s, but advocates say current electronic records technology can improve outcomes by holding the accountable care organizations responsible for quality as well as cost.
Daniel Lasser, chairman of the Department of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester, said the consolidation of doctors into large groups won't happen overnight, in part because older doctors don't want the hassle of switching to a whole new way of doing things. But he said a tightly organized system could make care much more efficient.
"I think the ideal practice — and this is probably a pipe dream — but if you're going to build it from scratch, you'd have a hub-and-spoke kind of arrangement," he said.
Primary care would be available all over the place, and specialists like optometrists or physical therapists would cycle among the local sites. Patients would visit a hospital only for serious situations — and except in extreme cases — they'd go to a community medical center, not a large teaching hospital. It's something the UMass Memorial Health Care system is already starting to address, Lasser said, shifting less critical care to the community hospitals it owns and away from UMass Medical Center.
Lasser said globalized payment systems will also allow for much more creativity in how care is provided. In the currently dominant fee-for-service system, he said, a health care provider gets paid for a doctor's visit, but not for an email exchange, and not as much for a visit with a nurse or dietitian. If an organization were being paid simply to manage a member's health, it could run a group visit in which 10 diabetics struggling with controlling their blood sugar would meet with a dietitian for an extended time instead of having short individual appointments with a doctor.
"Who do you think is going to do a better job?" Lasser said. "I'm willing to concede the dietitian is probably going to do a better job than I can."
Lasser said global payments would also encourage doctors to communicate with patients remotely for things like routine test results. "If I'm booked to see 25 patients tomorrow, probably 15 of them could be handled over the phone or asynchronously (though email or an online portal), and 10 of them really need to be seen," he said.
Getting rid of the 15 unnecessary appointments would allow a doctor to meet with patients for much longer when necessary, Lasser said, when they have to give someone a new diagnosis, for example.
He said doctors' offices will probably book appointments on shorter notice and stay open longer so that at least some locations within a system are available to patients on weekends and evenings.
"You can go shopping on Sunday now and you can do practically anything around the clock, but it's a lot harder to get in and see your doctor," he said. "We are hearing from the marketplace that there's a demand for this."
Richard Aghababian, president of the Massachusetts Medical Society and founding chair of the Department of Emergency Medicine at UMass Medical School, said improved, efficient health care will come with less choice for consumers. Accountable care organizations or insurance companies will direct patients to particular providers.
"You will have less opportunity to shop around," he said. "It will be clear which hospital you use."
But Aghababian said the information systems that are now in place will make sure patients don't lose out on quality of care. That's an important point, he said — people shouldn't forget how much better modern health care has made people's lives.
"Yes we've become expensive," he said. "But in the end, we're living better and the quality of our life is better than it was." n
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