I must be getting old.

Sitting in a meeting recently where three health system executives (read: Hospital) were talking with bated breath about the coming changes in healthcare, specifically ACOs and the integration of hospitals and physicians (read:  We’re going to employ you), I had a strange sense of the familiar.

• ‘Working in partnership with our physicians’
• ‘Keeping people well instead of fixing them when they get sick’
• ‘Have to change the way we think about our work’
• ‘Primary care has to be the driving force, not the hospital and the proceduralists’
• ‘Catching the second curve’
• ‘Getting paid for quality, not just volume’

These were the phrases that offered peeks at the vision. 

Don’t get me wrong.  I am not a curmudgeon.  I agree with the vision, agree that we have to figure out how to change this entire industry.  And if you are a regular reader of these posts, you have discerned that I am more than a bit cynical that policy makers are the source of our salvation.  I believe the answers will come from the market, from people like the leaders on this panel out there getting their hands dirty trying to really get this figured out.

And there was not one of the magic phrases that pointed to where we need to go with which I disagreed.

But something was really bugging me.

I knew a large part of my angst was because the entire conversation was just way too hospital-centric.  And that lead to my succumbing to temptation and heading to the microphone to ask a question of the panel.

On a side note, a few years ago, my father pointed out to my sharp witted and sarcastic old son that sometimes he should just keep his funny comments to himself and privately enjoy the chuckle.  Maybe I should have heeded the advice.

My turn at the mic…

‘For those of us old enough to know this is not our first rodeo with this issue, there is a great sense of déjà vu in the air.  What will be different this time around compared to the early 90s? Why will this work now when we said exactly the same things 20 years ago?  And specifically, should I launch a consulting business helping hospitals divest the physician practices they are now acquiring?’

Just kidding on that last one, though I am keeping the business plan in my desk drawer.

The panelists gave a couple of good answers, along with some canned pabulum that comes in that type of setting.

But I’ve been thinking about how I would answer my own question. 

There really are some things that are different; forces that are big, maybe big enough to make this happen.  Here are three that matter.

First, and maybe sufficient all by itself, is the overall economic picture.  When President Clinton made a run at comprehensive healthcare reform, we were on the front end of one of the greatest periods of wealth creation in the history of our country.  People were feeling good, so it was hard to get 300 million mobilized about anything scary.   A few wonks were waving charts claiming we were headed off a cliff in terms of future healthcare costs, but we were all fascinated with this rapidly expanding coffee company from Seattle that had persuaded us that we couldn’t be cool if we just drank old fashioned Folgers.   Sure, healthcare costs were rising.  But not as fast as the appreciation on my house, so who cares? Clinton and Clinton had no shot.  Life was just too good for anyone to care. 

Now, everything about that broad economic backdrop is so different that it just might be enough motivation for us to fight through the petty issues that derailed the last vision of the ‘integrated delivery system.’  Even people outside the industry know something is broken.

Second, the physician half of this grand integration plan is in a very different place than it was then, and that, too, might be a big enough force alone to get this done. 

One of the healthcare specific things that was part of the great economic boom in the 90s was the explosion of physician-owned ancillaries.  When specialists could get a whopping return on their investment in an ASC or an MRI, why tolerate the silliness that came with dealing with the hospital? 

Another thing that has changed in the physician world is the cumulative effect of years of flat to declining reimbursement.  Last time, a practice might be complaining that their commercial rates had declined from 220% to 180% of Medicare.  Sure, that was aggravating, but was hardly enough justification to muster any real emotion.  Now?  How about being stuck at 110% or lower for over a decade?  Or worse, how about being in a specialty that Pete Stark has put in his cross hairs, ratcheting down reimbursement at every turn?

Docs are simply in a different place financially.  Many are worn out from the fight and more willing to talk about working with the hospital if it can shield them from further downward slides.

There is also a generational change among physicians.  It used to be that if you went into medicine you also, implicitly, chose to be an entrepreneur.  Maybe you did not think of it specifically in those terms, but practically that is how it worked. Med school lead to private practice, which led to become a partner, which meant you lived and died on the entrepreneur’s comp plan.

 No more.  The new crop of young physicians is not just willing to consider employment models, but many will only look at those arrangements.  They don’t want the hassle of ownership, and given the financial picture for many independent practices, can you blame them?  Why own a business if there is no shot of an upside?  For this group, the realities of being a physician in a hospital-centric integrated delivery system is not a bitter pill to swallow, but exactly what they envisioned when they took their MCAT. 

The third thing that is different is the information technology.  Let’s set the historical context.  It was in the fall of 1994 that the Clinton health plan was declared dead.  About a year later, in August of 1995, Netscape went public, the event that most cite as the beginning of the Internet era.  Think about that for just a second.  We were going to coordinate care across populations, manage health instead of sickness, and hold providers accountable for both cost and quality using nothing but a fax machine.

There is just no way it could have happened in the 90s without the technology.  The sheer magnitude of manual processing required to support the ACO concept would have collapsed under its own weight.

Looking back on it, we were nuts.  We were going to do all of those grand population management things back then before we knew what a browser was?

In the past 15 years, we have made a lot of progress in healthcare IT. We have invested billions and are continuing to invest billions paving the healthcare information super highway as fast as we can.  Though there is much work left to do, we’ve come a really long way toward having the underlying information infrastructure that is necessary to make this vision a reality.

The economy and healthcare’s heavy price tag; older physicians in a very different place and younger physicians with a very different frame of mind; and information technology that is getting close to actually enabling all of this - Is this enough, or will this be another failed attempt to fundamentally transform our industry?

Time will tell, but that brings us to Lawdie.

Lawdie’s friend Bobby was watching a movie about a snake charmer from India. The snake charmer reminded Bobby of his friend.  ‘That yogi walks like Lawdie Berra,’ said Bobby.  From then on, Larry Berra was Larry no more, but forever Yogi.

That same Yogi Berra who observed, ‘It’s déjà vu all over again.’

Is this the 1990s all over again? 

Maybe not.  These reasons are pretty compelling.  This time, we might actually make it happen.

But maybe so.  Our next time here we’ll explore the other side and look at a few things that suggest we may not have learned the right lessons last time. 

Maybe I’ll keep the divesture business plan close for a while.