First and foremost—cost

Rapidly risings costs, changing patient demographics, and provider changes form an almost “perfect storm” of factors that will require change from the current model. First and foremost, the cost of our current methods is not sustainable and often unaffordable for patients, providers, and payers. According to the Centers for Medicare and Medicaid Services National Health Expenditure Projections 2012-2022, “Health spending is projected to grow at an average rate of 5.8 percent,” which is 1% faster “than expected average growth in the gross domestic product (GDP).” While the slow economic recovery held this increase to 4.0%, “improving economic conditions, Affordable Care Act coverage expansions, and the aging of the population” has already driven an increase in the 2014 rate to >6%. At the current pace, by 2020, US health care cost will reach >20% of gross domestic product, despite the changes in the Affordable Care Act. Given that approximately 40% (16% Medicaid, 14% Medicare, and 8% government employed) of Americans are insured by a federal or state government health care plan, this rising burden of health care costs is a significant contributor to unsustainable federal deficits. In fact, Harvard economist and health care policy specialist, David Cutler, has stated that “the United States does not have a deficit problem—it has a health care problem.” The Congressional Budget Office projects that, between 2015 and 2024, the annual budget shortfalls will rise substantially from a low of $469 billion (2015) to approximately $1 trillion (2022-2024) based mainly on the aging population, rising health care costs, expansion of federal subsidies for health insurance, and growing interest payments on federal debt. Furthermore, US businesses, which already are struggling to remain competitive in a global economy, are further challenged by continued inflation in health care costs. According to the Kaiser Family Foundation, the average annual premium for family coverage has risen from $5845 in 1999 to $16,715 in 2013.

Although the rate of increase has slowed somewhat, the costs still have risen 29% since 2008. The cost of high deductible plans are approximately $1000 less for a family plan, but the average worker still paid $999 for single coverage and $4565 for a family plan.

This competitive disadvantage is magnified by the fact that other developed countries have either contained costs to levels <50% of American standards or transferred the cost of health coverage to government-run systems. According to the Organization for Economic Cooperation and Development (OECD), in 2012, the United States spent 2.5 times the average OECD country for health care. In dollar terms, the United States spends $8233/person compared with $3268/person in the OECD countries.

Several market forces already may have begun the process of reducing the steady rise of health care costs such as the overall downturn in consumer spending, the increase of high deductible plans, increased transparency in quality and costs, and health care exchanges. First, the great recession of 2008 reduced family income for elective procedures/care that resulted in reduced usage. Companies and insurers responded to the increased costs by introducing more high deductible plans, which transfer a greater proportion of costs to patients. With consumers being more directly exposed to the out of pocket costs, the public has demanded increased transparency, and patients want to be empowered with improved cost data when making their health care decisions.

The US public has always believed that they enjoyed some of the finest health care in the world, and in many areas they have. The United States leads the world in health care research and in cancer care and survival. The United States has the highest survival rates for colorectal and breast cancer. Despite these successes, the US health care system consistently scores poorly on measures of “quality, efficiency, access to care, equity, and the ability to lead long, healthy and productive lives.” The Commonwealth Fund ranked the US health care system last among 7 industrialized countries for the measures. As a result of these poor rankings, many patients and their politicians are questioning whether they are getting a good value for their investment in health care. As a result of these increasing costs, questionable value for the population, and demographic changes that predict increased usage, both government and business leaders are demanding changes to the health care delivery system and the removal of an estimated $750 billion in medical care waste.

Demographic changes

Several demographic factors (such as aging, obesity, and increased population diversity) are likely to increase the demand for health care services. The most significant demographic change to affect health care is the aging of the population. According to the US Census, in 1970, there were 20,065,502 (9.8%) individuals >65 years of age in the United States. This number had risen to 40,228,712 (16.1%) by 2010 and is projected to grow to 54,804,470 by 2020. This increased older population is due to an increased life expectancy and due to the maturing of the baby-boomer population. As baby-boomers reach Medicare ages, the rates of gynecologic conditions such as menopausal issues, pelvic organ prolapse, urinary and fecal incontinence, and cancer will increase.

Actuarial data show that elderly patients require several times the amount of health care resources compared with their younger counterparts. By age 80 years, they require nearly 12 times the inpatient charges as 40-year-old patients. This will lead to increased inpatient use at an increasing rate until 2020-2022, when the yearly increase will plateau at 0.89%. In addition, outpatient services will also likely increase.

The aging of the population is not related just to a Medicare population. Societal changes have led to an increasing number of obstetrics patients with advance maternal age. The average age of first birth in the United States increased from 21.4 years in 1970 to 25.0 years in 2006. Although women in their 20s continue to make up the largest number of deliveries, the rate of birth is falling in this age group. Over the same time period, deliveries in women >35 years old have increased 8-fold, which makes them the most rapidly increasing proportion of delivers by age group. In gynecologic care and all of medicine, our own success at preventing and treating infections, cancers, and long-term medical disorders in younger ages has increased the life expectancy for US women from 75.6 years in 1970 to 80.8 years in 2007 and produced the rise of “the age of chronic conditions” such as congestive heart failure, diabetes mellitus, hypertension, and hyperlipidemia in proportions never seen in human existence.

Furthermore, the women we treat have different and more complex disorders. Dietary and activity changes have led to skyrocketing rates of obesity, which impacts rates of women’s medical issues like abnormal uterine bleeding, stress urinary incontinence, or complications that arise from more difficult operative procedures. Our current practices will influence future care. For example, the effects of an increased cesarean rate have led to a tremendous increase in placental complications and more difficult gynecologic surgeries. On the positive side, we may see less cervical dysplasia from beneficial therapies such as human papillomavirus vaccination. Unfortunately, we will be facing an increasingly higher risk and more complex population at a time when cost containment is most critical. In addition, we cannot expect relief from medical legal pressures or patient demand for services.

The United States has become more diverse over the last 30 years, and there is no evidence that this trend is slowing. Kotkin wrote that “the United States of 2050 will look different from that of today: whites will no longer be in the majority. The US minority population, currently 30 percent, is expected to exceed 50 percent before 2050. No other advanced, populous country will see such diversity.” This increased diversity of the population will result in changes in the prevalence of certain diseases in a geographic region; therefore, the need to understand the unique needs and susceptibilities of this diverse patient base will increase.

New types of caregivers/practice pattern changes

To complicate plans to care for this growing and aging population, experts also predict a coming “doctor shortage” in primary care and targeted specialties. Even though more providers are being trained today than ever before, the Association of American Medical Colleges (AAMC) has suggested that “the United States faces a shortage of more than 91,500 physicians by 2020-a number that is expected to grow to more than 130,600 by 2025.” This physician shortage is due to the increasing number of patients and the retirement of the baby-boomer physicians. One report states that one-half of the current physician workforce is over the age of 55 years, with approximately 250,000 physicians likely to retire by 2020. Prediction of the precise number of providers that will be needed is a difficult task, and previous predictions sometimes have been incorrect. The final numbers needed will be determined by a number of factors that will be difficult to elucidate until the roles of the provider and the new methods of providing care for patients has been determined.

These potential physician shortages are exacerbated by generational, gender, and regulatory factors. The baby-boomer obstetricians/gynecologists were trained in an environment that included long work hours, sleep deprivation, and an emphasis on independent practice. This training environment resulted in obstetricians/gynecologists who practiced in a similar fashion during their career and who were more likely to prioritize work-related activities over home life. They are being replaced rapidly by the millennial generation physicians who were trained in an environment that was more focused on adherence to guidelines, a team approach to medicine, and the risks of sleep deprivation. They expect more from their job, are more focused on family life, and are more likely to switch jobs frequently. The specialty has increasing numbers of women graduating from residencies. According to the American College of Obstetricians and Gynecologists, “women represent 80% of all residents in obstetrics and gynecology (and) approximately 50% of all active ob-gyns.” Despite this increasing role for women in the obstetrician/gynecologist workforce, most women remain the primary caregiver for their children, which results in surveys consistently suggesting that women expect more work-life balance than their male predecessors. The net effect of these generational and gender changes is a workforce that works fewer hours per week and will require greater numbers and/or improved efficiency.

This effect is being augmented by the recent changes to residency training that place strict limits on work hours. Although studies are still forthcoming on their full impact, the changes to residency training, which were meant to reduce errors because of fatigue, possibly have led to increases in other types of errors and residents graduating with less valuable surgical/clinical experience. With a growing body of literature on the negative consequences of sleep deprivation and the increasing number of obstetricians/gynecologists who were trained in an environment devoid of sleep deprivation, we believe that it is only a matter of time before work-hour restrictions are introduced to the practicing workforce. Combined with an increasing workload, these changes will create a significant physician shortage in our field and will require expansion of residency slots, increased use of physician extenders, a greater emphasis on team medicine, and/or redesigned roles. Although the AAMC obviously is biased by their organizational goals, the AAMC has a clear message: “Primary care is the foundation for a high-performing health system, giving millions of Americans a way to manage chronic conditions and prevent the progression of others,” said Atul Grover, MD, PhD, chief public policy officer at the AAMC. “In addition, the shortage of specialists could prevent the burgeoning population of older Americans from getting the care they need to treat cancer, diabetes mellitus, strokes, and other ailments with a higher frequency among the elderly population. Taken together, both pose a significant problem for the future of health care delivery in the United States.”

There is a critical need, in addition to the clinical roles, for an active physician participation in medical staff functions, administrative duties, and quality improvement efforts. Lomas et al demonstrated that improvement, in their case-lowering cesarean delivery rates, required strong physician opinion leaders to augment education and protocol changes successfully. Others have outlined the critical role medical leadership shows and the need for effective interventions to improve quality of care and control costs.