Hope and change


Robert M. Wachter, MD, MHM, has given the last plenary address at every SHM annual meeting since 2007. The talks are peppered with his one-of-a-kind take on the confluence of medicine, politics, and policy. Then there was the time when he broke into an Elton John parody.

Where does that point of view come from? Well, as the dean of hospital medicine says in his ever-popular Twitter bio, he is “what happens when a poli-sci major becomes an academic physician.”

That’s a needed perspective this year, as the level of political upheaval in the United States has added to the tumult in the health care field. Questions surrounding the implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the continued struggles that doctors face when using electronic health records (EHRs) are among the topics that he will address in his this final discussion.

Dr. Robert Wachter

“While [President Donald] Trump brings massive uncertainly, the shift to value and the increasing importance of building a strong culture, a method to continuously improve, and a way to use the EHR to make things better is unlikely to go away,” said Dr. Wachter, whose address is titled, “Mergers, MACRA, and Mission-Creep: Can Hospitalists Thrive in the New World of Healthcare?”

Dr. Wachter, chair of the department of medicine at the University of California, San Francisco, said that the Trump administration is a once-in-a-lifetime anomaly that understandably has made both physicians and patients nervous – particularly at a time when health care reform appeared to be stabilizing.

The new president “adds an amazing wild card, at every level,” he said. “If it weren’t for his administration, I think we’d be on a fairly stable, predictable path. Not that that path doesn’t include a ton of change, but at least it had a predictable path.”

The defeat of Republicans’ plan to replace the Affordable Care Act (ACA) with the American Health Care Act (AHCA) showed that the divide over health care extends even to intraparty discussions.

“The implosion of the AHCA shows how difficult health reform is and how quickly the ACA became the de facto standard,” Dr. Wachter said. “It is now that status quo that is so difficult to change.”

Dr. Wachter, who famously helped coined the term “hospitalist” in the 1996 New England Journal of Medicine paper that propelled the nascent specialty, said that one big challenge to HM is determining the future of how hospitals get paid – and how they pay their workers (335[7]:514-7).

“The business model for hospitals will be massively challenged, and it could get worse if a lot of your patients lose insurance or [if] their payments go way down,” he predicted.

What that means for the daily schedules of hospitalists remains to be seen, but Dr. Wachter doesn’t expect much in the short term.

“The job will be the same,” he said. “Take care of patients well, make them happy, satisfy your bosses and colleagues, and do it for less money. The biggest shift is likely to be that more and more people/systems – doing the same thing – will find that they don’t need as many hospital days, which means that we’ll have fewer patients and fewer hospitals. But we knew that.”

Dr. Wachter is more interested to see what will happen in postacute and other nonhospital facilities, how quickly technology continues to disrupt, and who hospitalists will work for (be it staffing companies, medical groups, or “something new”).

The veteran physician in him says not to get too distracted “by all of the zigs and zags,” he noted, while the political idealist in him says not to ever forget that the “core values and imperatives remain.”

If the past decade of wise words ending SHM’s annual meeting are any indication, Dr. Wachter’s message of trepidation and concern will end on a high note for attendees.

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