← Becker’s Healthcare Podcast
Loading summary
Transcript1 lines
- [00:00]
A
This is Scott Becker with the Becker Healthcare Podcast. Today's discussion is eight issues that we're watching in health care and we'll talk a little bit about the Triple Aim, supply, demand challenges, technology, the payers health systems, and a little bit more. And hopefully people enjoy this. I would encourage you at any time, feel, feel free to text Scott Becker, 773-766-53221. I'd love to get your comments and thoughts, sound quality thoughts, anything you like, whether you agree with the substance or not. Second, if you're the first person to text Scott Becker at 773-766-5322, we'll send you a $100Amazon gift certificate just as a thank you for listening and for jumping in. So here's seven or eight issues that we're watching in healthcare. First, we talk about the Triple Aim is trying to lower cost, improve quality and improve access. It seems like currently that we're moving largely in the wrong direction on all three of these points of the Triple Aim. Healthcare inflation is on the rise. I know we're now at more than $30,000 a year for a family of four for insurance through commercial insurers. We're at a spot where most families in the country make less than 75,000 or $80,000 a year. So those are numbers that just don't work. As we run into tremendous shortages of physicians in specialties and subspecialties and across the board, it becomes harder and harder to have the access that we want to have for our population. And then if you can't have access to, you can't have quality. And even on the quality side, the United States health system does some things remarkably right and it's remarkably challenging. But it's very hard to have the kind of quality you want to have when the bench in many specialties is getting lighter and whiter. So we look at this and say on the Triple Aim, we're ultimately moving in the wrong direction. We've got to figure out a way to fix this. It does strike me, as we talk about this, that Washington, D.C. on the right and the left is somewhat broken and not focused on solving the real problems, but focused more on political sloganeering on both sides of the table. Second, we talk often about supply demand, and I often think that supply demand is the fundamental problem in healthcare. We're at about 1 million1 physicians versus a population of 350 million people. We're increasingly running into shortages of specialties. In many specialties. You're also in a spot where in subspecialties. And I remember the situation with a very close friend who died of a melanoma of the eye and cancers the last year or so. You know how once you got past the first two specialists in that particular cancer, there was nobody else left. And whenever one of those doctors was on vacation and this wasn't at one place, this was in the entire country, he couldn't get help or couldn't get access. The shortage of specialists and subspecialist is becoming incredibly acute. And I think people are starting to see that very much. You need to know somebody to get somebody. You need to know somebody to get to the right specialist. And that's also a horrible thing. The supply and demand challenge for health equity as well. Third, in terms of primary care, where arguably hundreds of thousands of primary care doctors short already, if we really wanted to have the traditional model where you were seen by a primary care physician and stay with that primary care physician for a lot of your life, that seems to be moving towards an age of the past and being filled in by pas nurses, advanced practitioners, and that's okay, that's not a bad thing. But. But that's what's happening because we're so short on primary care. Currently we produce about 25,000 doctors a year. About 10 to 12,000 doctors retire a year. A huge percentage also go part time by the time they're 40 to 45 or so. And we've got challenges on medical education that we'll talk about that in a second. But at the end of the day, the numbers just don't work. We're producing about 20,000, 25,000 doctors a year. We're losing about 10 to 12,000 doctors a year. Thank God that we have immigrant doctors to help fill some of those gaps. Some of the very best doctors in many of our communities from other countries, and thank God for them. Another thing I'll note, medical education. Medical education in the country was largely developed prior to the Internet. You've still got four years of college, four years of med school, three to four years of residency, often a fellowship. So doctors aren't getting out till 30, 31, 32, and again, many are part time by 40, 45, 50, the number just doesn't work. And we have to shorten medical education, get rid of year of med school, get rid of a year of residency. You know, in other countries they produce doctors that we rely on here that are some of our best doctors. By the time they're 27, 28, we're at 30, 31, 32. And you contrast that against an aging, growing population and more cancers, more heart disease, more everything than ever before. We've got to figure out a way to manage that. Just as an example, more and more situations where you end up in these discussions, I was on a podcast with a dermatologist. She's the 1 dermatologist for 500,000 people in Northern Minnesota. Similarly, neurology, same problem, was on a podcast with a neurologist, one neurologist for 500,000 people in Texas. And this is in an area of Texas. And this is at a time when, of course, dementia, Alzheimer's, et cetera, is all on the rise. People are aging and staying alive longer, but they're not sick. Few other things. Nurse education has improved dramatically the last few years. People may complain about it, but we're getting nurses out of training quicker than before. We're producing about 175,000, 180,000 nurses a year. That's a huge move in the right direction. We talked about this already. The era of the core primary care physician, where you had the same primary care physician for life, may be very much coming to an end. And it's more transactional and filling in the gaps and PAs and everything else. The PAs are largely terrific. So it's not a knock on PAs, but it's a different model that we're moving towards. Finally, ER wait times are another example where we're at supply and demand. Just 10 years ago, systems were advertising they can get in and out of the ER in 30 minutes. Now you're lucky to get in and out in two and a half to four hours. It just has changed dramatically over a 10 year period. There's just no place for patients to go. Third, I'll mention rural health care. Rural health care is in a vicious cycle. Lower population can't attract doctors, systems close down labor and delivery, and it becomes a very much a vicious cycle because you can't get people to come to areas and live in areas if there's not enough health care. And health care professionals won't go there, there's not enough population. So the whole thing has gotten to be a real challenge in a vicious negative cycle. Russell In a spot where doctors today, other than a generation ago, largely want to go to the top 30 to 50 metro areas, a physician and her husband, a physician and his wife or whoever, largely want to go to the top 30, 50 metro areas. And that's very different than a generation ago where many went to smaller towns, smaller communities. There's lots of efforts to try and Change this but. But it's very hard. Fourth issue I'll note is the payers continue to have massive power. The government essentially through Medicare and managed care, Medicare and Medicaid has turned over a huge amount of the federal fisc to the major payers. Four of the major payers are amongst the four largest companies in America. That's UnitedHealthcare, CVS, Aetna, Elevance, Cigna. You've got a situation where those payers have dramatic power compared to large health systems and practices. And also the entire payer complex has become too complicated for many small practices and huge resources are used by it, on it, by even large health systems and just really a waste of money and time. Medic loss ratios were down to 80, 82% a few years ago and the payer industry cheered over this. But it's really a disaster because that means we're spending 18% on administrative cost as those medical cost ratios have come up to 80, 89%. We're still spending a tremendous amount on administration of healthcare versus actually delivering healthcare in sort of a debacle. When I talk about the payers and watch the political theater in Washington, you have congressmen, Congresswoman questioning and berating the insurance executives. But it's really very circular because the problem that has developed is largely because the United States federal government has turned over in state governments, have turned over so much money to the big payers to run Medicare Advantage, to run Medicaid managed care plans. And they've done so with the intent that those big payers would, would say no, would cut cost because there's no other way to get where you want to get to, which is lower cost without some rationing. I'm not a fan but this is what's happened. So you've got exactly what the federal government has paid for happening with payers denying care or making pre authorization very hard and it's really challenging. But it's led to gigantic payers. It's led to the government criticizing the payers but the government's one has turned over the money to the payers. Fifth, we'll talk about AI and technology. What we're seeing throughout healthcare is cascading use cases. Great, great movement on the enterprise and on the side of administrative side moving and making progress on the clinical side. Still a long way to go. I'm a big believer that our problems will be solved through a mix of technology and people. That we don't want to fully rely on technology and not put in more residency spots for specialists. I believe that we need both great technology and more residency programs. It can't be one or the other or will end up in a horrible situation. Sort of a trust plus verify. Yes, technology will take us a long way, but we better increase the number of residencies, the number of specialists we have as well, to take care of our aging and growing population. The sixth issue I'll talk about is large health systems. Large health Systems, you're about 60% of health systems have some margin. About 40% don't. By and large, health systems are very busy, they're quite full. People criticize health systems for their business model, but at the end of the day, health systems have huge bricks and mortar. They've got huge labor needs. I don't know a way around that. And I think health systems are doing a pretty good job of managing with the situation they have. And what has been proven over the years is we very much need our hospitals and health systems and they're often pretty much the backbone of the safety net in our country. So very much need it. The larger, doing better, smaller, independent ones are struggling, rural ones are struggling. What I say to hospitals talking about strategy is that they need often a clear purpose. Here is what they're going to be great at, something that they're going to be great at. The seventh thing I'll talk about is the tiering of health care. So we're going through a period of time where economically you're seeing a whole different level of tiering of health care. And I'll go through this. Compared to the old days, commercial insurance versus Medicare versus Medicaid versus indigent care, on the commercial side, you had better access, perhaps better quality. On the Medicare side, okay? On the Medicaid side, more challenging, the injured side, more challenging. Now, what you've seen in the commercial side break down into a whole nother tier. We've got a concierge tier. So you've got concierge where people are paying access fees for primary care. Recently, a cardiology practice in our area, dermatology practice in our area, have added in administrative fees and essentially concierge freeze. You got to pay those to have access to the practice. What this leads to is a whole different level of health equity concerns, tiering of healthcare concerns that essentially the very wealthy, the top 10%, can afford this concierge stuff that the rest of people, commercial, Medicare, Medicaid can have less access. I don't for one blame the doctors, specialists, the primary care, the duty and concierge at all, but it does point to the Absolute need for more supply and demand. Those primary care doctors going concierge were overwhelmed under the old system. Can make a nice living under a concierge system. I don't blame them one bit. But somehow or another we've got to come back to how do we solve this issue of supply and demand. So there's not so much incentive to go to concierge and so much lack of access for the rest of us that aren't unconciered. The eighth point I'll talk about in terms of healthcare and I'll just mention it shortly. I had a chance to visit with a graduate class in health systems management. Brilliant group, brilliant. Absolutely brilliant. And when they ask for advice on what they should look at, what I think about is to really focus on what you're seeing, what your common sense shows you. If you see a three hour wait in the yard, why is that happening? What's the shortage? What's the problem? Why is it happening? If you see in your inpatient services and people can't get access to on an oncologist, why is it happening? What's going on? And to see what you see and then to advocate for it and at the same time, of course do the best job you can. It's really based on quality of care, quality of service. Probably the best leader in the country that I hear constantly talk about the core mission is the CEO Janice Spizo of UCLA Health, who constantly talks about it's all about are we doing great quality for our patients, great patient care, we're really taking care of patients and counseling, coming back to that. But, but as a graduate health student, you know, master's in health administration. Use your view, your, your perspective on it, yours is as important as anybody else's as to what's going wrong, what's going right, and then advocate for what's needed. I want to thank you as always for listening to the Beckers Healthcare podcast. This is Scott Becker, publisher, founder, Becker's Healthcare. As I said earlier, I'd love your comments, I'd love your thoughts. I know I've only covered a handful of issues Today I'm at 773-766-5322. Send me your comments, send me your thoughts. We'll send the first person who does so a $100Amazon gift card. Thank you so much for listening.