My Top 5 List of Impactful Health Care Trends

Years back, when I was first getting my start as a hospital administrator, I was told that the future was managed care, that fee-for-service would be a thing of the past. That prediction has largely not been realized. On the other hand, I was employed in a health system that was working to accumulate market share through the acquisition of primary care physician practices and to ensure future viability through preferred provider arrangements with health plans. I feel that we were early adopters of the trend toward vertical integration. Philadelphia was then home to six medical schools and over 30 hospitals; today, it is dominated by just three major health systems.

Health care change moves at a glacial pace, unlike many industries such as entertainment, airlines, or banking. Just think of it – 20 years ago, we were still shopping at Blockbuster for DVDs. In that time, we have gone from DVDs and cable to a seemingly endless choice of streaming services. Entertainment, when you want it, delivered to your fingertips. In contrast, health care feels largely the same as it did 20 years ago, yet we can see it begin to change in profound ways.

Some of what I observe in this column may be evident to you, other topics may reflect my unique perspective. I will not address certain trends, such as deteriorating Medicare payment, the impact of the No Surprises Act, and the expanding role of nurse anesthetists and other advanced practice nurses, since those are so evident to us all.

One of my favorite books and movies is “High Fidelity,” by Nick Hornby. In the movie, starring John Cusack, the lead character seeks to capture the defining moments of his life in top 5 lists – lists of breakups, favorite partners, music, and others. So… here is my top 5 for changes impacting anesthesiology.

For-profit and investor interests in health care are nothing new. What is new is the emergence of health care entities such as hospitals and group practices as financial assets, in and of themselves. Private equity is often cited, though academic researchers such as Lawton R. Burns have noted that the market behavior of private equity is really no different than other major investors. If anything, financialization is just one enabler of vertical and horizontal integration. Mega mergers and acquisitions are very much evident in the nonprofit sector as well, including the recently reported acquisition of Geisinger Health by Kaiser Permanente that will form the core of a new system, Risant Health.

My general observation is that size matters, and scale is necessary. It is important in negotiation and contracting and for supporting the information infrastructure and staff necessary to meet compliance requirements, maintain sophisticated billing systems, and compete. Having said this, we see this scale also achieved through development of regional systems, often through mergers or alliances of local practices.

For several years, at ASA and before, I had the privilege of being a board member and officer of the National Health Council, an umbrella organization of chronic disease-related patient advocacy organizations such as the American Diabetes Association and American Heart Association. From this vantage point, I watched as patient advocates became more active in a wide variety of roles, from drug development, to clinical effectiveness research, to creation of clinical standards, development of patient-reported outcomes, and service on national professional certifying boards.

At ASA, the patient voice plays an essential role in the development of practice parameters as well as resources for the Perioperative Surgical Home and Perioperative Brain Health Initiative. Indeed, patients and consumers are regularly polled in the development of our advocacy positions. In the clinical setting, physicians now routinely engage patients in shared decision-making. With the amount of available information, consumers, especially younger ones, can be expected to take a more active role in their health care decision-making.

Closely related is the very real impact of health disparities that affect minority populations, including underserved urban and rural communities. In Chicago, where I live, there is a 30-year lifespan difference between my community in River North and those neighborhoods just a couple miles west. These disparities, particularly in maternal care, are increasingly a focus of policymakers and are strongly considered in the development of ASA quality measures.

Retail medicine has become an all-encompassing term that describes emerging and untraditional formations between insurers, technology, and retail outlets. Recent examples include the development of Uber Health, the combination of CVS and Aetna, and Amazon’s acquisition of One Medical.

Traditional health care says to the patient, “come to us.” Health systems have been largely organized around the convenience of physicians. The new ventures seek to go to where the consumer is. Many individuals do not have a primary care physician, so for some, these “retail” centers will be a convenient and consistent point of contact. These centers will own the patient referral, amass the data that goes with it, and eventually serve to challenge hospitals and health systems as the center of gravity in the health system.

We are experiencing unprecedented undersupply of physicians, nurse anesthetists, nurses, and other professionals. The pandemic and its aftermath certainly accelerated this trend, but it was under way even before. An aging population is contributing to increased demand. For anesthesiology, the growth in ORs, ambulatory surgery centers, and non-OR locations is a contributor. The stressed supply of professionals is also attributed to an increasing pace of retirements as well as career options in insurance and industry that may detour physicians from clinical careers. Many physicians and other professionals are opting to move to independent contractor status, working as part of companies or individually to provide locum tenens services. Solutions to these challenges are under way through initiatives launched by the ASA Anesthesia Workforce Summit in June 2022, as well as larger efforts being explored by federal policymakers.

There are also generational shifts happening. Medical school classes are increasingly diverse and bring new views and aspirations. Young people entering the profession are reported to be concerned about work-life balance, but I see something else – a sense of calling that often transcends the job to encompass social and environmental concerns about the patients and communities they serve.

Another aspect of emerging generations of physicians, however, is that they do increasingly see themselves as employees. Unionization is becoming more common in residency programs and of increasing interest to practicing physicians.

Technology is transforming the practice of medicine and the delivery of health care. Two are most relevant: 1) artificial intelligence (AI) and machine learning and 2) telemedicine and remote monitoring.

According to an April 29 Wall Street Journal article by Nidhi Subbaraman, “In California and Wisconsin, Open AI’s ‘GPT’ generative artificial intelligence is reading patient messages and drafting responses from their doctors. The operation is part of a pilot program in which three health systems test if the AI will cut the time that medical staff spend replying to patients’ online inquiries” (asamonitor.pub/42TFgOw).

Computing power has long been predicted to influence the future of medicine. A March 30 article in NEJM spoke to this history and cited a paper by William B. Schwartz from 1970: “He predicted by the year 2000, computers would have an entirely new role in medicine, acting as a powerful extension of the physician’s intellect” (N Engl J Med 2023;388:1201-8). It has taken much longer, but the increasing role of AI can be seen throughout medicine in a wide range of tasks, including image recognition and decision support. A review article by Hashimoto et al. published in Anesthesiology in February 2020 summarized current literature and cited uses in managing depth of sedation, adverse event/complication prediction, and management of OR logistics (Anesthesiology 2020;132:379-94). It is doubtful that AI will replace anesthesiologists, but rather potentially support and strengthen their roles.

Several simultaneous trends are pointing to the future of remote care. These include the use of telemedicine and remote monitoring coupled with the acceleration of ambulatory surgery and at-home recovery. Telemedicine grew in use during the pandemic and is now becoming more common in medical care. For anesthesiology, its potential in preop assessment and follow-up care appears clear. For a baby boomer looking at both my routine medical care and potential surgery, the possibility of recovery at home is viewed as more comfortable and cost-effective.

These trends and more are a great challenge, but also a great opportunity for the specialty. I hold abundant optimism for anesthesiology. Having worked in health systems and in other medical specialties, I see anesthesiologists as uniquely qualified to lead in these turbulent times. Indeed, leadership is already evident in the range of skills (quality and safety, systems thinking, diplomacy) that anesthesiologists bring to their work every day, the numbers of members who have assumed leadership positions, and the number of issues that, collectively, this specialty has been called upon to lead.