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Chapter 13

Future of Health Care

Chapter Objectives

  • Summarize directions and trends in the health care delivery system discussed in prior chapters
  • Present expert data and interpretations to projections for future delivery system changes
  • Draw some tentative conclusions about the future American healthcare system

Introduction

  • Predictions are highly risky as system moves into uncharted territory
  • Trend extrapolation most reliable under stable conditions; reform scope and complexity will produce much instability
  • National changes to cost, quality, access historically produced many unanticipated, sometimes adverse effects
  • Institutions’ adaptations may produce unintended consequences

Paradox of U.S. Health Care (1)

  • Policies of six decades yielded:
  • Medical advances
  • World-wide scientific & clinical acclaim
  • Investments in the NIH, NSF for university basic & applied research
  • Investments in academic health centers, hospitals & technology
  • Medical, other professional proliferation and specialization

Paradox of U.S. Health Care (2)

  • Successes contrast with failures to recognize a social mission beyond meeting individual needs of those able to access services:
  • Inequitable access, variable quality, uncontrolled costs
  • ACA symbolic of discontent with system that:
  • Cannot cover basic services for 16% of citizens
  • Provides services of doubtful necessity & benefits
  • Is fraught with uncontrolled costs, errors, waste

Continuing Challenges Facing Health Care in the Reform Era

  • Sluggish federal, state economies, rising health care costs cause drops in insurance
  • State government budget deficits affecting all services
  • Employers discouraged by double-digit premium increases; predictions that more may forgo benefits under the ACA, leaving 7 M workers without employer coverage

Demand for Greater Fiscal & Clinical Accountability (1)

  • Persistent resistance to change among major stakeholder groups deterred system-wide reforms despite overwhelming evidence, e.g. IOM report on medical errors and failures to meet 5 year targets
  • Failures are system leaderships’, not individual practitioners
  • Hopeful signs:
  • Purchasers (employers & government) more cost, quality conscious

Demand for Greater Fiscal & Clinical Accountability (2)

  • Hopeful signs, cont’d:
  • AHRQ’s Morbidity and Mortality Rounds on the Web stimulates anonymous provider input and discussion of errors
  • DHHS Hospital Quality Information Initiative provides public access to hospital quality of care data
  • CMS reimbursement incentives & disincentives on hospital medical error rates; “never events”
  • ACOs’ care coordination imperatives

Growth of Home, Outpatient & Ambulatory Care

  • Emphasis on community-based care, aging demographics will result in continued home care growth; since 2000, agencies increased by 1,000 to 12,000 in 2010.
  • Outpatient medical & surgical procedures will continue growth fueled by technology advances, high provider and consumer satisfaction

Technology

  • MRIs: coercive power of glamorous, expensive technology over cost-benefits; extensive research demonstrates no patient benefits in therapeutic choices or outcomes
  • Technology’s mixed blessings: imposes barriers between consumers & practitioners; technology investments contribute nothing to solutions for access barriers, health disparities, other major health determinants

Changing Population Composition (1)

  • Older population size & diversity increasing & surviving to very old age
  • Intact families to care for older adults decreases with divorce, single-parenthood, adult child out-migration
  • Changing racial & ethnic composition w/minority groups, esp. Hispanics a growing proportion; differences from whites in e.g. mortality rates, chronic conditions, service preferences, attitudes toward medical care

Changing Population Composition (2)

  • Older population, cont’d
  • Inadequate supply of culturally competent providers at all levels in acute & long-term care for home & institutional care; difficult to recruit & retain; most long-term care facilities now proprietary with uneven quality track records
  • System’s chronic care focused on acute interventions w/ little attraction to “maintenance” services that will be required

Changing Population Composition (3)

  • Older population, cont’d
  • Effective chronic illness care will require major shifts in health service priorities; more geriatric services in an acute care system is not a solution
  • Health professionals must change entrenched acute care mindsets, values, clinical behaviors
  • ACOs’ care continuums may help, but widespread movements from fee-for-service to holistic approaches will not come easily or quickly

Changing Professional Labor Supply (1)

  • Institutional employment practices disrupted by hospital size & service reductions; inpatient to outpatient shifts; needs for new classifications of workers
  • Employment will grow in home care, practitioners’ offices, nursing & residential care facilities
  • Aging workforce will contribute to many job openings through retirements

Changing Professional Labor Supply (2)

  • ACA will present many challenges w/30M+ newly insured & realignment from volume to value-driven services
  • NHCWC if empowered, will evaluate and recommend new approaches to professional training & education, efficient workforce deployment, compensation, coordination among different types of providers

Changing Professional Labor Supply (3)

  • Physician Supply & Distribution and Other Primary Care Practitioners
  • Managed care principles made primary MD roles paramount, increased demand for services; shortage gaps filled w/NPs and PAs
  • 2011, 2012 studies predict 20% shortages of advanced practice nurses & PAs and shortage of 52,000 primary MDs by 2025, respectively; ACA incentives viewed as inadequate to attract needed numbers of primary care providers

Changing Professional Labor Supply (4)

  • Physician Supply & Distribution and Other Primary Care Practitioners, cont’d
  • Predicted shortages suggest future policy changes to expand non-physician scopes of practice
  • Future efforts needed on wide variations in distribution of physicians by geographic location, in addition to supply; rural & inner-city areas will be special focus

Changing Professional Labor Supply (5)

  • Physician Supply & Distribution and Other Primary Care Practitioners: New Physician roles
  • Hospitalists will continue to proliferate throughout the system
  • Physicians entering roles in management and administration in pharmaceutical companies, managed care organizations, hospitals & large group practices; ACO management is another option; frustrated by private practice, health care administration is attractive option

Changing Professional Labor Supply: Nurses

  • At 3 million, largest component of health professions & best positioned for reformed system’s roles
  • Nurse training in behavioral & preventive realms, coordinating care with multiple disciplines and lesser-trained colleagues aligns well with goals of reformed system

Future of Employer-Sponsored Health Insurance

  • For 5 decades, employer-sponsored health insurance protected workers
  • Industry’s predominant role in ACA parameters reaffirmed influential policy role
  • Under ACA, may opt to drop health coverage and endure penalties
  • Significant, uncertain speculations on employer decisions as market changes & reform proceeds

Changing Composition of the Delivery System: Hospitals

  • No longer system “hubs;” acute care hospitals will become combinations of high-level intensive care units & full-service facilities for most serious conditions, the uninsured & indigent
  • Almost all will become part of for-profit or not-for-profit corporate networks; where many small competing hospitals served one geographic area’s needs, smaller numbers of hospitals divided among a few networks will meet regional needs

Changing Composition of the Delivery System: Outpatient facilities

  • Privately-owned ambulatory surgery centers, urgent & immediate care facilities, diagnostic facilities, specialty hospitals will continue growth trajectory fueled by entrepreneurial opportunities, technology advances, provider, consumer, payer preferences & demands
  • Growth will displace numerous services and revenue of traditional acute-care hospitals

Health Information Technology (1)

  • Ideal future: providers & health plans will replace voluminous, disorganized medical records with standardized, reliable, clinically relevant electronically delivered information
  • New EHRS will minimize transcription & misinterpretation errors & interoperable systems will allow easy information transfer among care providers, reduce costs & improve quality

Health Information Technology (2)

  • Obstacles & Solutions
  • Complex confidentiality, compatibility, transferability, organization cultural issues and complexities of patients service receipt at multiple sites
  • Academic medical researchers & developers with private HIT corporations will combine resources to build workable infrastructures to create a new era in HIT, a giant step forward in advancing safety, efficacy, efficiency of medical care

The ACA and Reemergence of Public Health: Closing the Gap (1)

  • Historical “great divide:” different value systems of population health-oriented public health practitioners and individual-centered private health providers, increased by scientific advances & MD education focused on individual “cures”
  • Closing the gap: Core ACA tenets with reimbursement incentives aligned with population health outcomes

The ACA and Reemergence of Public Health: Closing the Gap (2)

  • ACA’s Prevention and Public Health Fund, the first mandatory funding stream for public health to eliminate unpredictable federal budget allocations for public health and prevention programs at local, state, federal levels
  • National Prevention, Health Promotion and Public Health Council to build on existing programs, e.g. Healthy People 2020, and recommend federal policy changes to the President & Congress

The ACA and Reemergence of Public Health: Closing the Gap (3)

  • U.S. Prevention Services Task Force recommendations on no cost preventive services for Medicare & Medicaid
  • Support of programs to decrease disparities, increase MD and public health personnel in underserved areas
  • Future challenges: changing perceptions & behaviors of public health & clinical medicine practitioners about public health’s centrality

Summary of Predictions and Future Challenges (1)

  • Public’s prevailing belief in privately-supplied U.S. health care as a “good” despite high costs, redundancies, access & quality problems countered by belief in scientific, technological superiority
  • ACA represents beliefs that U.S. required socially responsible system to end distinction as only Western democracy with sizeable population lacking health insurance coverage

Solutions Envisioned by the ACA

  • Alter focus from diagnosis & treatment to preventing illness & maintaining health
  • Expand accountability from individual patients to population groups
  • Change emphases from individual, episodic care to continuous, comprehensive care & chronic disease management
  • Eliminate incentives for more services, substitute incentives for appropriate levels of care

Summary of Predictions and Future Challenges (3)

  • Solutions envisioned by the ACA, cont’d
  • Change from only coordinating service delivery to actively managing quality of process and outcomes
  • Add serious commitment to resolving community & public health issues
  • Reforms can make care systems different, but alone, they can not make them better…depends on providers in concert with new systems

Summary of Predictions and Future Challenges (4)

  • Health care providers: hopefully freed from purely fee-for-service medicine, will be compensated for wellness/prevention time and efforts to become as effective promoting population health as for individual patients
  • Tax-exempt health care organizations will be required to “prove” the basis for their charitable care
  • Selective secrecy about hospital & other institutions’ quality will be replaced with transparency for purchasers and the public

Summary of Predictions and Future Challenges (5)

  • Long-term care organizations and services will encounter enormous staffing and cost challenges
  • Pressures on government & employers will increase to provide relief for family caregivers of frail elderly
  • Amid system reform turmoil, health sciences will continue advancing with new clinical treatments, genomics, vaccines, etc., accompanied by new ethical, professional, cost and educational & training challenges

Many Future Challenges

  • How will recipients of new technology (transplants, etc.) be chosen?
  • Who will address ethical concerns about genetically altering humans and genetic testing?
  • When/how will stricter competence standards be enacted for medical professionals?
  • When will government rein in unlimited profits of medical & drug suppliers that price their products beyond the means of those who need them most?