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Future_of_Healthcare.pptxThe Future of Health Care
Learning Objectives
To identify the major forces of future change and how they will affect health care delivery
To assess the future of the Affordable Care Act and health care reform in the United States
To discuss the components necessary to build a delivery infrastructure for the future
To understand the special skills needed by future nurses, physicians, and other health care workers
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Learning Objectives
To evaluate the future of long-term care
To appreciate the role of international cooperation in dealing with global threats
To obtain an overview of new frontiers in clinical technology
To survey the future of evidence-based health care based on comparative effectiveness research and patient-oriented outcomes research
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Introduction
Future direction of health care is governed by:
Current developments, e.g., the ACA has already triggered changes, but its full effects will not be known for some time to come
Forces external to health care delivery, e.g., demographic change, the economy, family incomes, etc.
Historical precedents, e.g., private infrastructure and societal values, state-based health reform, etc.
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8 Forces of Future Change
Social and demographic
Economic
Political
Technological
Informational
Ecological
Global
Anthro-cultural
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Implications of External Forces
The nature of change in health care depends on complex interactions between these forces and the way opportunities are garnered or foregone
Implications for cost (affordability), access, and power balancing
Free market forces do not drive US health care – the government has been a major player that wields legal and regulatory powers. Yet, the government needs the power sector. Tension and power balancing between the two sectors will continue.
Delivery of health care is closely tied to the nation’s economic health
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Social and Demographic Forces
The US is becoming bigger, older, and ethnically diverse
Effects on the need for health care and how the needs will be met
The nation’s ability to afford health care; growing populations of the elderly, disabled, and Medicaid beneficiaries:
Expanding government programs are on an unsustainable financial path
Implications for supply of health professionals
Cultural factors will create ongoing challenges
Uninsured illegal immigrants tap into resources
Personal lifestyle choices cannot be fully incentivized
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Economic Forces
National debt – spending cuts, tax increases, and economic growth will be needed
Economic growth – growth has been slow; growing dependency on government handouts does not bode well
Employment and household income: incomes has fallen
National health expenditures are expected to consume almost 20% of GDP in 2022
A golden prospect: The US is now the world’s largest energy producers – but, much will depend on future energy policy
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The ACA and the Economy
Effect on employment and incomes is uncertain
Some evidence that employers are delaying or cutting hiring, and reducing worker hours to skirt the law’s mandate
Part-time workers could get government subsidies to buy health insurance through the exchanges
However, the affordability of exchange-based plans is unclear
Political Forces
Education and immigration policies the number and qualifications of health care workforce
Americans remain divided on major policy issues, including health care
Politics also has an effect on the economy and taxes
So far, raising the debt ceiling rather than reducing spending has occupied US politicians
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Technological Forces
Technology will continue to revolutionize health care, but cost increases will create challenges
Technologies that increase self-reliance and cost efficiency will receive much attention
Utilization control measures could also receive attention
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Informational Forces
Garnering IT’s potential for health care delivery and management of health care organizations will continue well into the future
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Ecological Forces
Major implications for public health
New diseases
Natural disasters
Bioterrorism
World population growth will intensify human-animal-ecosystems interface engendering new diseases
Technology will find new applications in public health and safety
Dealing with public health threats also divert resources from routine health care
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Global Forces
Globalization intensifies cross-national cultural, economic, political, social, and technological interactions – health and health care will be affected in diverse ways through multiple pathways
Example: cross cultural factors affect the effectiveness of professionals that are part of “brain drains” or “brain gains”
Some signs of increasing globalization:
Drugs manufactured in Asia are exported to western nations
Medical tourism
Cross-border telemedicine
Desire of foreign hospitals and clinics to move into the US
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Anthro-Cultural Factors
Beliefs, values, ethos, and traditions espoused primarily by the middle class
Historically, these have acted as a strong deterrent to radical changes in health care
Disapproval of the ACA has increased among Americans
The American public could end up deciding the ACA’s final fate
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The Future of Health Reform
Will the US have a single-payer system in the future?
Much will depend on the ACA’s successes and failures and how the forces discussed earlier play out in the future
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Lessons from Massachusetts
With some caution, lessons can be drawn about the ACA
The Massachusetts plan has achieved some successes, but cost remains the main issue
Remarkable increase in insurance coverage
62% have employer-based coverage
In the Connector (exchange), premium increases surpass inflation; the state had to set limits on the rise in premiums
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Lessons from Massachusetts
The Massachusetts plan has achieved some successes, but cost remains the main issue
Some mixed results on ability to meet health care needs
Emergency department use has continued to rise
Over 50% of the public is satisfied with care, except for cost and waiting times
Income tax hikes are proposed
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Likely Experiences under the ACA
Caution: One state does not represent the ethos of the entire country
High level of dissatisfaction among physicians
⅓ of MDs not accepting Medicaid patients
Low reimbursement is a primary concern
Views among MDs about the ACA are mixed
The general public and MDs may hold the key to ACA’s future
Likely Experiences under the ACA
Under the ACA there will be
Decreased uninsurance among vulnerable populations
25 to 30 million uninsured will still exist
Shortage of PCPs will be a major barrier to access
Massachusetts’ experience suggests stifling regulations, lower reimbursement, higher costs, and higher taxes
Small businesses expect negative effects
Pervasive negative sentiments could lead to a repeal of the ACA’s major provisions
What If?
The seeds for health care reform have already been sown
Any future reforms will build on the ACA, but some mandates would be relaxed
HDHPs could play a significant role because of their promise to reduce health care spending
Regardless, overall cost control will remain a nagging issue
Universal Coverage and Access
Without a reformed health care infrastructure, universal access would be hard to achieve
To achieve this, Americans will have to give up the dream of universal care for any ailment freely available on demand
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An Ideal System
A philosophy based on value in health care will be needed
Individual responsibility for one’s own health
Self-management support
Patient activation
Preventive services and health education
Public-private collaboration to create strong incentives to help build an infrastructure based on primary care
A combination of HDHPs, regular health insurance, employer contributions, reformed Medicaid and Medicare, and charity care can all play a role in bringing about near-universal coverage
Single-Payer System
Many developed nations have been able to provide basic care to nearly all citizens, with supply-side rationing and higher taxes
A government-run single-payer system does not achieve universal access
In the US, such a system is not feasible in the near future
Rationing and higher taxes will be resisted by most Americans and physicians
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Delivery Infrastructure of the Future
The health care infrastructure will continue to evolve by incorporating
High-value health care
Lowered costs and improved quality
Patient engagement
One model will not suffice to meet a variety of needs
Emphasis on evidence-based care
Cost-saving technology
Targeted programs to the needs of patients in the community
Training of practitioners for a wellness-oriented model
Remote monitoring and virtual consulations
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Implementing the Medical Home Model
Mechanisms for qualifying medical homes: four main pillars are accessibility, continuity, coordination, and comprehensiveness
Mechanisms for matching patients to homes: transparency, fairness, matching of clinical needs, predictable revenues for physicians
Information exchange outside the medical home
Reimbursement that captures critical nonclinical activities, such as care coordination
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Implementing Community-Oriented Primary Care (COPC)
High-impact, high-opportunity areas of focus
Social and behavioral sciences should supplement the biomedical model
Primary care should include primary, secondary, and tertiary prevention
Public health functions must be strengthened as an adjunct to clinical interventions
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Lessons from the Vermont Blueprint
Integration of medical home and COPC models
Community health teams responsible for a defined population
Reduced emergency department use and hospitalizations are necessary for financial viability
The Role of Patient Activation
Requires more informed and engaged consumers
A person’s ability to manage his or her own health and utilization of health care
Individual knowledge, skills, and motivation to make decisions in partnership with health care providers
Changes in one’s own health promoting behaviors
Considerable differences in activation levels across socioeconomic and health status characteristics; lowest among Medicaid enrollees
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The Role of Patient-Centered Care
Respecting and responding to patients’ wants, needs, and preferences
Promotes patient activation
Roter Interaction Analysis System is used to evaluate physician-patient interactions and to train physicians in patient-centered communication
Future Workforce Challenges
The nursing profession
Scope of practice and residency in community settings
Higher levels of education and training to cope with increased clinical demands, collaboration, and coordination
Full partnership with physicians and other professionals
Better data and improved information systems
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Future Workforce Challenges
Training of primary care physicians
Training needed for PCPs to function as comprehensivists. Expertise is needed in these areas:
Anticipate, prevent, and manage complex conditions
Manage complex pharmacology
End-of-life issues and ethics
Care coordination
Leading health care teams
Reformed payment model that incorporates education and outcomes
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Future Workforce Challenges
Training in geriatrics
Critical shortage (only 2.5 geriatricians per 10,000 population). The numbers will drop further.
Problem has been ignored, even though elder care by geriatric professionals yields better outcomes without cost increases
Shortage of geriatric faculty in medical and nursing schools
Geriatric courses not required in other disciplines as well
Geriatric training is also necessary for areas other than long-term care
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The Future of Long-Term Care
Baby boomers will start needing LTC in 2025
Six main areas of concern need to be addressed:
Financing: reform is needed in both public and private financing
Resources: HCBS has not reduced Medicaid spending
Infrastructure: (1) models of culture change, (2) care coordination and transitioning, (3) single point of entry into the LTC system
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The Future of Long-Term Care
Six main areas of concern need to be addressed:
Workforce: a deficit of direct care workers is projected
Regulation: contradictory and inconsistent application of regulations; no quality monitoring in HCBS
Information technology: interoperable IT systems are needed
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Global Threats and International Cooperation
Natural disasters, industrial accidents, and large-scale bioterrorism put strains on a single nation’s capacity to deal with mass casualties
Global travel can spread infectious diseases; containment requires international efforts
Antibiotic resistance of infectious agents
Decline in antibiotic research and development
Lack of health infrastructure in developing countries
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Global Threats and International Cooperation
Transatlantic Task Force for Antimicrobial Resistance
Biological Weapons Convention
International Health Regulations
The CDC’s Global Disease Detection Program will be increasingly involved in global surveillance, detection, and control
The US DoD is also involved (Global Emerging Infections Surveillance and Response System)
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New Frontiers in Clinical Technology
Genetic Mapping
Rational Drug Design
Advances In Imaging
Minimally Invasive Surgery
Gene Therapy
Vaccines
Artificial Blood
Organ transplantation
Regenerative medicine
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New Technology
Genetic mapping:
Genometrics - identifying genes with specific disease traits
Prevention and gene therapy (molecular medicine) – cancer treatment is a prime candidate
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New Technology
Personalized medicine and pharmacogenomics:
Pharmacogenomics – how genes affect a person’s response to drugs
Specific gene variations will be matched to individual patient responses to medications
Drug design and delivery:
Multidisciplinary advances will shorten drug discovery time
Rational drug design at the molecular level will also reduce labor cost and lab expenses
New drug delivery systems (e.g., cellular uptake of nanoparticles) will improve drug delivery to targeted sites and improve drug effectiveness
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New Technology
Imaging technologies:
Research in four areas:
new energy sources that minimize damage
finer detection of abnormalities
3D technology
higher resolution displays
Increased emphasis on the brain for medical interventions
Applications in pain management, minor strokes, and Alzheimer’s
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New Technology
Minimally invasive surgery:
cost efficiency and improved quality of life
Vaccines:
Therapeutic use in noninfectious diseases, such as cancer
New vaccines for emerging infections
Safer vaccines for widespread use, for example, against bioterrorism
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New Technology
Blood substitutes:
Necessary when supplies of real blood fall short
Xenotransplantation:
to overcome the shortage of transplantable tissue
Regenerative medicine:
Repair damaged tissues and organs
Both in vivo and in vitro
Cure for virtually any disease: diabetes, heart disease, renal failure, osteoporosis, etc.
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Care Delivery in the Future
Application of medical imaging, molecular medicine, and distant monitoring
Shift from acute care to prevention and aftercare
Use of a patient’s risk profile for screening
Image-guided minimally invasive surgery, when needed
Individualized pharmaceutical treatment through continuous measurement of drug concentration
Miniature implanted devices to take over damaged body functions
Regenerative medicine to revive damaged organs
Continuous monitoring of chronic conditions
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Future of Evidence-Based Health Care
High spending does not deliver better outcomes
Better value through evidence-based medicine (EBM)
Quality can be improved while reducing costs by reducing misuse and overuse
Evidence-based clinical practice guidelines—best practices, proven therapies
EBM’s full potential still lies in the future
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Comparative Effectiveness Research
How well a chosen intervention would work compared to other available treatments
To assist in making informed decisions to improve health care for individuals and populations
The goal is to improve outcomes and reduce waste
The ACA has established a Patient-Centered Outcomes Research Institute:
To enable patients and caregivers collaboratively assess the value of health care options
The big question: Will the government’s efforts improve people’s health and save money?
Strategies for Evidence-Based Care
Ongoing emphasis on the adoption of EBM
Ongoing development of computer-based models
Ongoing clinical trials
Keep guidelines current
Incorporate economic analysis into clinical protocols to enhance cost-effectiveness of care delivery
Restructure reimbursement to reward best achievable outcomes
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Strategies for Comparative Effectiveness and Patient-Centered Research
Identify new and emerging clinical interventions
Review and synthesize current medical research
Identify gaps between existing research and clinical needs
Promote new scientific evidence and tools
Train clinical researchers
Disseminate research to diverse stakeholders
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Strategies for Comparative Effectiveness and Patient-Centered Research
Reach out to stakeholders via a citizens forum
Tap the voluminous unused information in existing research
Use of CER for benefits design and payment reforms are still in the future
The American public remains opposed to using research to allocate resources or mandating treatment decisions
