Sunday, February 9, 2014

Movings and dislocations in life and medicine

A little over a month ago, my family of five moved to a more spacious and modern house in the same neighborhood. I'm slowly getting adjusted to our new place - the locations of the light switches, how to operate the refrigerator's automatic ice maker, which cycle to choose among the dozen different options displayed on our high-end washing machine. It still takes me a few minutes longer to get ready in the morning, while groping through unfamiliar dresser drawers in novel locations. (We purchased a new bedroom set after we moved in.)

There are undeniable advantages to our new home, including central air conditioning, larger appliances, and energy-efficient windows that don't require covering with plastic when the outside temperature plummets. But it may be a while before I can think of it as home, and overcome my automatic instinct to take the turn that leads to our old house when returning from work. I know in my heart that this move is forward progress, but now it feels more like a dislocation.

Our country's health care system is experiencing a similar sort of dislocation, driven not only by the error-plagued implementation of the Affordable Care Act, but trends that have been in motion for decades. Soaring medical technology costs and physician subspecialization have bloated health care spending to nearly one-fifth of the U.S. economy. An employment-based health insurance system that made sense when many people worked for a single company for their entire adult lives is gradually collapsing under its own weight. The ACA's requirement that insurers pay for a minimum set of "essential health benefits" and remove lifetime coverage limits has driven up premiums and shrunk provider networks for millions of people, even as state Medicaid expansions have made millions of others eligible for health insurance for the first time in their adult lives.

Based on the number of new patients I'm seeing in my office because "my new insurance plan won't cover visits to my old doctor," I would not be surprised if more Americans end up changing doctors this year than in any year before. But will they then settle comfortably into permanent patient-centered medical homes? Will newly formed alliances of clinicians and hospitals succeed in organizing themselves to provide accountable care that improves population health outcomes? In other words, is this seemingly inexorable movement toward a brave new health system forward progress, or a temporary dislocation?