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 doubledigit 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 systemwide 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, contd:
AHRQs 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
Technologys 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, contd
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
Systems chronic care focused on acute
interventions w/ little attraction to
maintenance services that will be

Changing Population
Composition (3)
Older population, contd
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-forservice to holistic approaches will not

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,
contd
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 systems roles
Nurse training in behavioral &
preventive realms, coordinating care
with multiple disciplines and lessertrained colleagues aligns well with
goals of reformed system

Future of Employer-Sponsored
Health Insurance
For 5 decades, employer-sponsored health
insurance protected workers
Industrys 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 notfor-profit corporate networks; where many
small competing hospitals served one
geographic areas 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 individualcentered 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)

ACAs 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 healths
centrality

Summary of Predictions
and Future Challenges (1)
Publics prevailing belief in privatelysupplied 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, contd
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 betterdepends 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?