Powerpoint/Video Assignment

Chapter 14

The Future of Health Services Delivery

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

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

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.)

Eight Forces of Future Change

• Social and demographic • Economic • Political • Technological • Informational • Ecological • Global • Anthro-cultural

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.

Social and Demographic Forces

• The United States 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

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 have

fallen • National health expenditures are expected to consume

almost 20% of GDP in 2022 • A golden prospect–The United States is now the world’s

largest energy producer–but, much will depend on future energy policy

The ACA and the Economy

• Effect on employment and income 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

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

Informational Forces

• Garnering IT’s potential for health care delivery and management of health care organizations will continue well into the future

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

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

United States

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

The Future of Health Reform

• Will the United States 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

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

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

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

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 United States, such a system is not feasible in the near future

– Rationing and higher taxes will be resisted by most Americans and physicians

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 consultations

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

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

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

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

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

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.

The Future of Long-Term Care

• Baby boomers will start needing LTC in 2025 • Six main areas of concern need to be

addressed: 1. Financing: reform is needed in both public and

private financing 2. Resources: HCBS has not reduced Medicaid

spending 3. Infrastructure: (1) models of culture change, (2)

care coordination and transitioning, (3) single point of entry into the LTC system

The Future of Long-Term Care

4. Workforce: a deficit of direct care workers is projected

5. Regulation: contradictory and inconsistent application of regulations; no quality monitoring in HCBS

6. Information technology: interoperable IT systems are needed

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

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)

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

New Technology

• Genetic mapping – Genometrics–identifying genes with specific

disease traits

– Prevention and gene therapy (molecular medicine)–cancer treatment is a prime candidate

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

New Technology

• Imaging technologies: – Research in four areas:

1. New energy sources that minimize damage

2. Finer detection of abnormalities

3. 3D technology

4. Higher resolution displays

– Increased emphasis on the brain for medical interventions

– Applications in pain management, minor strokes, and Alzheimer’s

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

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.

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

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

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 collaborative 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

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

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