Historically, physicians have been reticent to involve themselves in politics. However, this is a dangerous position to take in today's world. As the government and health insurance corporations look for new ways to extract "value" from an over burdened system, physicians and students must be an active stakeholder in the process both in terms of patient as well as physician well being.

For FY 2009, the Federal Budget calls for spending $420 billion for Medicare, and $224 billion for Medicaid (including SCHIP). This accounts for 21.5% of the TOTAL Federal Budget, and does not include possible "fixes" to the sustainable growth rate (SGR) and physician reimbursement. Additionally, insurance companies negotiate their reimbursement rates based on a percent of Medicare, adding even greater importance to government participation in health care. As our health care system evolves, it is incumbent on physicians and students to help guide the direction of this progression.

A number of issues will shape the delivery of health care in the future. This includes such "value" plans as pay for performance, technology, use of the sustainable growth rate to set physician reimbursement, and an aging population.

The issue with pay for performance is not should it be done, but how should it be implemented. For example, when a primary care physician treats a diabetic patient, Medicare (henceforth referred to as Centers for Medicare and Medicaid Service - CMS) only accepts that a diabetic patient has had their eye exam if there is a letter in the primary care physician's chart from the examining eye doctor. The fact that the primary care physician recommended the exam, scheduled the referral and notified the patient is irrelevant in the eyes of CMS. Thus, to practice quality from the CMS mindset, the primary care physician must follow up and not only make sure the patient receives the exam, but make sure that the eye doctor actually sends them a letter for documentation. Logically, the primary care physician has no control over the behaviors of both the patient and the eye doctor. Therefore, to make sure that they receive a "mark of quality" from CMS, the primary care must hire staff to not only perform this service, but similar services associated with other quality markers. As such, the full amount of responsibility falls on the primary care physician. Neither the patient nor the referred to eye doctor have responsibility. These inequities, as is often the case, will likely lead to unintended consequences. Those unintended consequences will be primary care physicians discharging non-compliant patients from their practice leaving them with poor access to follow-up. The primary care physician should be evaluated on their practice of medicine (recommendation of an eye exam and completion of the referral), not the baby-sitting function that comes with it.

Technology, despite being touted by many in Washington as they way to reign in costs, is considered by many to be the leading driver of these costs. The incremental advances in technology in some areas (such as MRI 3.1 up from MRI 3.0) add little value for the significant amount of cost the new technology commands. As such we are in the midst of a technologic arms race as each hospital system tries to out do the other resulting in duplication of many services.

One should also be wary of the hype surrounding the use of health information technology and electronic health records as a pathway to savings. Most electronic health records cost $20,000 - $50,000 per physician to install, plus the need for routine maintenance. In today's environment, that is unaffordable for many physician practices. Secondly, there are numerous electronic health records and health information technology platforms on the market, but they are not conversable resulting in only incremental access to past health data when compared to paper charts. Therefore, any such "savings" is theoretical, and one could argue not likely without significant changes.

The sustainable growth rate (SGR) is the amount of money CMS can spend on health care without the need to borrow funds. It is at the center of the physician reimbursement debate. Currently, with the SGR in place, as consumers utilize more health care the price tag goes up, which means that physician reimbursement goes down. Given the aging population and the amount of chronic disease in the United States, the cost of delivering health care will always go up from a consumption point meaning that physician reimbursement will always be scheduled to go down unless congress intervenes. Cuts in physician reimbursement typically leads to restricted access for patients as physicians limit their exposure to Medicare patients and poorer service as staff cut backs occur and new equipment is not purchased. Both congress and CMS agree that the SGR is not appropriate, but neither will act to "fix" the problem.

The aging population will contribute significantly to the evolution of health care delivery in the United States. People are living longer, with more chronic disease, and with increasing health care cost. It is incumbent upon the house of medicine to develop mechanisms which attenuate such disease processes in their early stages with the goal of preventing or decreasing progression to more serious disease. Failure to so is not optional, but as of yet, the political will to implement meaningful change does not exist.

The issues discussed here are just a few of many. Health care delivery in the United States faces significant, but not insurmountable challenges. As health care continues to garner ever increasing shares of GNP, physicians must work to ensure that any changes in the delivery system do not negatively impact patients, and the patient-physician relationship.