Memo From The Editor

Our fearless forecast: Sunshine—but some rumbles, too

By Jeff Forster, Editor

When you get right down to it, we really want to know justtwo things about the future: What will there be more of? And lessof? We all hope for more gain and less pain, more relief and lessgrief. We won't always get what we hope for—but without hope,we'll have nothing.

Wiser heads than mine have surveyed the landscape of medicalpractice, and this is what they see on the near horizon. I couldn'tresist the temptation to stir a couple of my own thoughts intothe pot.

More clinical staff in doctors' offices. "The demand forhealth services created by our aging population will require doctorsto focus on the things that only doctors can do, and to delegateor supervise the rest," predicts Geoffrey T. Anders, presidentof The Health Care Group in Plymouth Meeting, PA. "Officeclinical staff will grow, perhaps dramatically, particularly theuse of limited-license or alternative medicine practitioners."

Dorothy R. Sweeney, vice president of the same firm, adds:"Whether it's triage nurses or RN patient educators, thehigher-level, well-trained person will be in very great demand.Practices will also need to add more 'semi-trained' medical assistants,or just bright people, to move patients in and out of the office.The salaries for these employees must rise; many practices nowpay the same as—or less than—McDonald's does for such individuals.You get what you pay for."

Less clerical staff. If the Aging Revolution increases demandfor clinical staff, Geoff Anders' corollary is that the InformationRevolution will reduce demand for nonclinical staff. "Theexplosion of new information technology, including e-commerce,will allow medical practices to become much more efficient—fromverifying eligibility to scheduling appointments to ordering suppliesto handling accounts payable and receivable," he says. "Officeclerical staff will shrink, perhaps dramatically."

Dot Sweeney isn't sure about the "dramatically" partof that forecast, but she feels strongly that "technologywill transform the very nature of clerical jobs in the doctor'soffice. People will need to be skilled in managing electronicmedical records, billing, and scheduling." She also seesanother type of "clerical" job evolving: patient advocate/patientrep. That job—communicating with patients when the doctor doesn'thave time, troubleshooting problems with insurers, dealing with"customer satisfaction" issues—will require more experienceand sophistication.

More Webs to spin. Those more sophisticated employees willneed to be Web-savvy. "Physicians' offices will increasinglyuse the Internet to exchange information with insurance carriers,"notes David C. Scroggins, a consultant with Cincinnati-based ClaytonL. Scroggins Associates. "A lot of big players have cometogether on this in the past year. Both insurance carriers andproviders want a more convenient way of accessing subscriber informationand verifying preauthorization."

Less PPM entanglement. The pendulum has swung with a vengeance,and doctors are moving away from practices owned by "others":hospitals, physician practice management companies, etc. One signof the times: A nine-doctor group in Denver held an "independenceday" party to celebrate being cut loose from a 400-doctororganization. That trend of separation "will be increasinglyevident over the next 24 months and will probably continue throughthe next five years," predicts David Scroggins.

Any of those newly freed doctors who need advice can checkout "Undoing the damage: How to reclaim the practice yousold," which appeared July 12, 1999, and is also availableon www. memag.com.

More lawsuits against HMOs. Okay, so that prediction is a no-brainer,especially if Congress opens the door to health plan liability.To be sure, many lawsuits, like the recent spate of class-actionsuits against managed care organizations, may be tossed out ofcourt. But that won't stop the attorneys from banging on the door.Suddenly, everyone in pinstripes has awakened to the thought thatHMOs just might place more emphasis on saving money thanon ensuring quality of care.

Less confidence in the system. Disenchantment with HMOs is spreading, but doctors themselves are not unscathed. A survey of households, conducted by National Research Corp., found that the proportion who had a "very high" level of confidence in their physicians dropped from 26.8 percent in 1998 to 18.3 percent in 1999. Financial incentives that health plans offer to physicians are bound to come under increasing scrutiny and criticism—as are the physicians themselves (see "Invitation to a lawsuit: Financial incentives to limit care," Nov. 22, 1999, also available at www.memag.com).

More power to patients. Dwindling public confidence becomesan even bigger issue in light of a prediction that consumerismwill be the next big market force in health care. Lots of people—includingPaul Ellwood, the daddy of HMOs—are taking that view. It's notjust that people can turn on their TVs and see ads for Viagraand Propecia. They also can turn on their computers and find detailedinformation on the most occult disorders. The need for patienteducation will increase, not decrease, as patients download—andoverload on—all that health care information.

More alternative medicine. This will be one of the manifestationsof consumerism. "The American public wants access to alternativetherapies," says Philip L. Beard, president of the ProStatResource Group in Overland Park, KS. "Many of these therapieswill become a standard component of treatment plans, and the resultantpublic pressure will force other payers to include some benefitcoverage. But Medicare will move very slowly, if at all, towardcoverage of such therapies."

More government intervention. Steven I. Kern, a health attorney in Bridgewater, NJ, believes the government has only begun to rev up its anti-fraud efforts. "Medicare, Medicaid, and third-party payers, in conjunction with the government, will seek to turn every miscode, every omitted chart entry, every misstep into a criminal matter, or at a minimum a civil case with huge punitive damages." Bottom line: Steel yourself with a good compliance program (see "The search for Medicare fraud: Don't let billing mistakes make you a target," June 21, 1999, available at www.memag.com).

Kern also thinks that acts of medical negligence will be subjectedincreasingly to criminal investigation and indictment.

No question about it, there's a lot on the immediate horizon—muchof it challenging and encouraging, some of it a wee bit scary.Our challenge will be to give you more help, and more specificdirection, than ever. We'll do so in a number of ways:

This issue's cover story launches a year-long series on "re-engineering"your practice to make it more satisfying for your patients, moreefficient for your staff—and more rewarding for you.

• Another series, to begin in March, will explore the ways in which the Internet is transforming the practice of medicine.
• A new column, Computer Consult, will debut in February. It will feature real doctors doing real things with information technology.
• A special section in March will examine the implications of adding nurse practitioners, physician assistants, and other professionals to your practice.

May there be more of the good stuff and less of the bad inall that lies ahead for you. And may you always find a helpfulhand and a sympathetic ear at Medical Economics. Feel freeto contact me at any time by phone (201-358-7340), fax (201-722-2688),or e-mail (jeff.forster@medec.com).

Jeff Forster. Our fearless forecast: Sunshine--but some rumbles, too. Medical Economics 2000;2:8.