No Repeal. No Replace. How About We Agree to Amend?

No Repeal. No Replace. How About We Agree to Amend?


Dea Robinson, FACMPE
Independent Healthcare Consultant
Doctoral Student
Colorado State University
Organizational Learning, Performance & Change


Either way, “Obamacare” will most likely change in the near future and while there have been speakers, debates and numerous articles on what could happen, there are other factors that are being neglected.  To this point, let’s just go with what the last speaker, T.R. Reid said at the last Denver Medical Study Group meeting.  T.R. predicted that the US healthcare industry will end up with a single payer system.  And, to my point, regardless of what the system is from a leadership and administrative lens for healthcare, business as usual is, well, business.

Healthcare is personal, and healthcare is a business and this is where we have a rub.  Some forget that choosing a plan to offer employees affects the person making the recommendation and choice and must balance the decision within the parameters of an accountable budget to owners or a board of directors.  One fiscal reality is as healthcare expenditure continues to rise, we see employees who ‘work for benefits’.  So, instead of working for a paycheck, workers are working for healthcare coverage.  Just imagine if workers did not work for benefits, and instead worked because they wanted to and healthcare coverage was just as normal as having a latte on Monday morning.  A recent Health Affairs  blog provides a good overview of Obamacare and the differences between the two plans, but let’s suspend some of the unknowns for some knowns  We know the Baby Boomer generation and Generation X will continue to consume more healthcare services as they age, and the next generation (Millennials) will continue to push the healthcare consumer needle into places we haven’t been before that will require healthcare leaders to consider different staffing, utilization, and reimbursement models.  As we continue with our suspended unknown mindset, let’s discuss what we know.

Generational forces.  In a recent MGMA Stat poll of 1,487 respondents that asked the question regarding telehealth services, 74% of medical practice administrators respondents reported their personal physicians did not provide this type of service, but were willing to use the service (49%) if offered.  Of note, the MGMA data provided earlier was not stratified so we could not soft test respondent demographics in the respondent sample, but this is the kind of information needed for forward thinking healthcare leaders need to consider.  The next generation of healthcare consumers are the Millennial generation, a cohort birthed when the internet was implemented (born between 1981 -1995).  This group of individuals defines their generation by technology use (Hershatter & Epstein, 2010).  It is possible that the demand for telehealth services has not matured in practice because the patients most comfortable with this practice do not constitute most of healthcare patients -yet.

How to get paid and for what.  A shift in technology-driven healthcare requires a shift in mental models for healthcare system leaders to let go of old payment models for physicians and staff leading to more knowledge work.  The payment models in place today are still predominantly based on a per patient or RVU model combined with hours spent in an office.  We may always have a bricks-and-mortar place for patients to go and I think this is a good thing, but here is the challenge.  Could we starting to think creatively on how to use RVU’s and hours worked as part of reimbursement instead of the only metrics of production?  I have had numerous private discussions with colleagues over the ‘value’ issue in healthcare.  Typically, the conversation ends with submission to what HHS will decide what value will be, or what the hospital decides it will be, and so on.  What is value in your healthcare system?  What do your patients value and are you rewarding the right people or teams?  Typically, the answer is, yes, but if you can’t measure it, it doesn’t exist.  I get it and my response is look to ‘patient experience’ for some ideas and your internal medical staff for the other half of value.  Are you rewarding poor behavior because RVU’s are high but no one wants to work as a team because of the culture in your organization?  Let’s also not forget that patients typically file malpractice claims based on how they were treated by the physician, not the medical outcome.  What is value for your patients, employees, physicians, and staff?

Patient record disconnectedness.  Given the mobility telehealth delivery provides, services can be delivered from any global location and this trend will challenge tightly held ways of working for providers.  Are you ready to manage people you don’t see?  Are you ready to pay people you don’t see when healthcare services happen in a cloud?  And, are you ready to assess effectiveness and outcomes of virtual medical teams?  Baby Boomers have done some great things for healthcare delivery.  They insist on living longer and doing more as they age and their lifestyles reflect expectations of their health.  A few years ago, I heard Atul Gawande, MD talk about healthcare complexity and one of the takeaways from his talk was about the challenges of systems.  He claimed one of the biggest challenges to healthcare is the complexity of systems to ‘talk’ to one another.  While some of the biggest advances have been in technology; alternatively, some of the biggest obstacles to care and customer service are also the result of technology.

I recently observed an orthopedic surgeon dictate into his Dragon dictation system and it was one of the most painful displays of human-technology interaction I have experienced in a long time. (Full disclosure:  I was a medical transcriber for many years to put myself through college and it is a struggle not to grab the keyboard and just type the words.)  He had great coping skills, however, as administration had provided a little stuffed animal to squeeze and throw in the air when his ‘Dragon’ didn’t work.  And then, when the dictation system started to transcribe his words, his computer shut down to restart and install new software.  Sound farfetched?  This is the kind of ground-level, front line frustrations that can prevent us from moving forward to providing the right care, at the right time.

Obamacare will morph and change, but we have things we can address now in a proactive way to move the healthcare needle on our own.

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