Managing a physician practice, hospital, academic institution, health insurance company, or any other health sector business is going to be tougher in some ways than perhaps ever in history over the next decade. Why? Because health care of necessity will undergo unprecedented change, and much of how it will shake out is uncertain. The ongoing explosive increase in knowledge and science is itself a blessing and unprecedented challenge. But it’s the economics and financing of health care that generates the most uncertainty in terms of how to position for success and excellence.

Who can guess what the Supreme Court will do when they (most certainly) review the constitutionality of the Affordable Care Act? It is uncertain. How will the solution to the debt ceiling affect health care funding? It is uncertain. But, because the “bullish forces” which underlie health care reform -- pressures to reduce costs; improve consistency of quality; move away from volume-based fee-for-service reimbursement; focus on population-based health improvement; greatly promote integration/mergers of physicians, hospitals and insurers; and get more uninsured people into coverage -- are unrelenting, major shifts in financing, payment systems and delivery models are inevitable. To what extent will changes manifest, how fast, and in what directions? Who knows? There is a lot of uncertainty!

For example:

• Shifts in amount and type of reimbursement: What will happen with reimbursement and payment reform? How much average funding will be available per person? McKinsey & Company believe millions more people will be covered with more overall dollars added to the system in five years, but that the per capita funding -- across public and private payers -- will drop, regardless of the ACA.  How does that affect practice? It ain’t positive, gang. New forms of reimbursement are already developing -- to what extent will these developments plus regulatory change affect the viability of private practices?
  
  
• Changes to Medicare (and Medicaid): Federal budget pressures could produce unexpected crises in funding. The debt ceiling discussions could create some really big nightmares if drastic cuts are enacted or created through poor public policy. How do we plan for the future -- will private practice survive if massive cuts occur? Can payment reforms head off draconian changes that may be imminent?
  
  
• The future of integration: Will accountable care organizations work and become a common phenomenon? Will hospitals or physicians or insurers dominate them?
  
  
• The future of CV technology and imaging and innovation: CV technology and imaging has been under financial assault for a decade as its use and contribution of costs has increased dramatically -- largely due to new diagnostic and therapeutic benefits conferred. But will these economic assaults continue, or will new scientific evidence actually promote increased investment in and appropriate use of imaging and new technology? Will these technologies now spread hugely across the developing world, versus primary prevention -- or will both things occur?

Managing in uncertainty will require that we depart from traditional strategic planning to instead develop an array of scenarios of possible developments and have action plans to apply to the various scenarios that we could face. That’s not how most of us are approaching the uncertainties of the next 5-10 years. There will be spectacular winners and big losers in this era. But, we cannot approach this future with a status quo, ‘business as usual’ philosophy, folks.

I was fortunate to get some consultant folks to visit Heart House from McKinsey this week to talk with ACC senior staff about the importance of starting to model scenarios around the many uncertain variables we face in cardiology and CV care -- to be ready for likely discontinuities and/or crises -- and to take advantage of possible opportunities for members and the patients they care for.  It was fascinating. It made me aware of how important it is to get this kind of management and leadership education to our board and other physician leaders as well. In fact, all of medicine needs to begin to think about how to prepare to be nimbly able to respond to the irony of certain change in the face of uncertainty.