Annual medical society meetings are often a place for bold statements about the future of medicine. But the tone at the Society of Critical Care Medicine's Annual Congress in San Francisco in January arguably was more forceful than usual.
Incoming president J. Christopher Farmer, MD, FACP, chair of the critical care department at the Mayo Clinic in Scottsdale, Ariz., spoke of the field as being “in crisis” and at an “inflection point,” due to patient demand outstripping the supply of intensivists (see story, page 25). But the real Sturm und Drang came from Charles Hobson, MD, a surgical intensivist with the North Florida/South Georgia Veterans Health System in Gainesville, Fla.
Dr. Hobson referred to the gap between intensivist supply and patient demand as a “perfect storm” that will only intensify with time, during a talk about the potential effects of the Patient Protection and Affordable Care Act, or ACA, on critical care.
The ACA's push toward treating patients outside the hospital means the patients who are eventually admitted will be sicker, he noted. “ICU beds will make up an increasing percentage of the beds, and the existing shortage of intensivists will only worsen,” Dr. Hobson said.
As well, the act's emphasis on cost containment and care efficiency will be felt most acutely in the ICU, he predicted. “We live in the locus where the pressures to control costs and limit lengths of stay are highest and will continue to grow. When things go wrong in the place where we work, the costs skyrocket,” Dr. Hobson said.
Intensivists also will be under greater pressure to rationalize the structures within which they practice, he said. For example, they will need to defend their use of open or closed ICUs or specialized versus multidisciplinary ICUs. New data related to how practice structure affects outcomes will be closely scrutinized, he added.
Physician extenders and telemedicine increasingly will be used to help meet demand, he predicted. “The drive for efficiency will be relentless. People are not going to care how tired we are or how many hours we work,” Dr. Hobson said.
The longer-term effects of the ACA on critical care practice will depend on how the health care system responds to initial effects and changes, he said. For example, if bundled payments for acute care become the norm, there will be a higher demand for the quality of care provided by intensivists, he said.
“If quality reporting and outcomes mandates show that intensivists provide more cost-effective care, the demand for intensivists will increase,” Dr. Hobson said.
Echoing a phrase used by several at the conference, Dr. Hobson said that critical care is increasingly viewed as “primary care for the critically ill,” due to intensivists' role in coordinating care among disciplines. Perhaps, then, “we can leverage some of the support for primary care medicine in the [ACA] toward federal support for improving the intensivist workforce and, more importantly, ensuring intensivists have control over ICU resources,” he said.
The current and near-future situation may constitute a storm, but it also provides an opportunity for significant, positive change in the field, Dr. Hobson said. Now is the time for intensivists to consider whether to re-explore a multidisciplinary, unified fellowship for critical care that includes internists, pulmonologists, surgeons, anesthetists and emergency medicine clinicians, rather than continuing with separate training programs, he added.
Alternatively, he urged his colleagues to ponder whether they should push for separate departments of critical care medicine at their facilities, instead of the discipline being a division of anesthesia, surgery or medicine. Doing so could provide more control over resources, he noted.
“I would ask, can we leverage the power of this storm to make structural changes in critical care that will attract new entrants to our field and provide them the resources to do what must be done?” Dr. Hobson said. “Such questions are likely to continue in the near future.”