There have been some great conversations lately on the BOG listserv. I am always amazed by how much we can learn from one another through collaboration and sharing of ideas.

The question was raised if the world of cardiology is going flat, and an example of the number of STEMI programs being higher than the true demand for STEMI care was given. In my opinion, this is driving to the core of the issues we will face in the next several years.

The basis of the "competition" for STEMI and “market share” in general is unregulated fee for service medical care, the business of medicine.  In an environment in which there was "plenty of fee" being paid, the traditional model of care was sufficient. Attempts at capitation and other managed care models were in general frowned upon and in some cases, derided openly.

As more downward reimbursement pressure has been placed on the health care sector in general and hospitals and providers specifically, a "peeling back of the layers" of civility has occurred, with an unfettered drive to garner more service, the goal is simply to acquire more fee, usually with thinly veiled lip service to "quality" or "access." Most systems are poorly organized, each physical plant viewed as a stand-alone institution in which the most common metric is comparative sales. These systems are simply not able to move to a regional model due to the institutional coefficient of inertia.

Five years ago, all of our practices competed for the top trainees, often signing prize recruits 18 months before they finished training. Our training programs bought in, generating board after board, subspecialty after subspecialty, perversely driven by a fifty year old doctrine that “medical care was about the science,” the thinking that founded the National Institutes of Health and was hugely successful in bringing medicine from the barber shop to the bench. Those training programs are not wrong in the scientific sense, but we are no longer discussing that scientific underpinning. We are now, as they say in Texas, "talkin' bidness."

Directly- and indirectly-related problems now abound.  PCP's doing echo on their office desk, PCI programs on every corner, spiraling costs of insurance so insurance companies can be profitable, the unusual situation of over 450 EHR vendors, the lack of jobs for many of our new trainees.

I believe we are seeing the bifurcation of U.S. medicine; the distinction into the scientific complex and that part that delivers care. I sense we are standing at the front door of the most significant change in U.S. healthcare since penicillin. I anticipate we are witness to, and living, the conceptual shift of medicine from a commodity to medicine as a right of citizenship. And with it will come monumental shifts in our lives. Other less advantaged countries made that choice outright. Some had it thrust upon them by world circumstance. We stand at our Rubicon by virtue of bloated cost, of hidden expense, of lack of perceived value to the country.

And we must respond. The question is how.

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