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What Lies Ahead for Health Care?

Forecasting the biggest changes in medicine over the next decades

The New Physician September 2007
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For the past several months, The New Physician has been gathering comments from a wide swath of the medical community seeking an answer to the question, “What will be the greatest change in health care over the next 10 to 15 years?” The diversity of answers we received reflects the current state of health care—in constant flux, evolving rapidly and with plenty of problems that must be solved by the time today’s premeds finish up their residencies.


SEN. HILLARY RODHAM CLINTON (D-N.Y.)

2008 presidential candidate


“Advances in genetic testing will change the ability to predict illness, an advancement that will overwhelm our insurance system and place millions of individuals at risk for being denied coverage.


“At the same time, stem cell research, nanotechnology and other medical advances will lead to more effective treatments than we ever dreamed possible. These advances will not occur in isolation. In three decades, the number of Medicare beneficiaries will double. We will have to change how we finance health care in order to maximize the impact of our medical advances and meet the growing demand for health care without bankrupting our system. I believe the solution will be guaranteed, affordable health-care coverage for all.”


SUSAN F. WOOD

Research Professor, The George Washington University School of Public Health and Health Services, and former director of the Office of Women’s Health, Food and Drug Administration


“I hope that the regulation of pharmaceuticals moves along a path that strengthens both the use of the science and the decisions being made, with the priority on public health and benefiting patients. FDA is at a turning point now, and we have to turn it back toward a very strong and independent FDA. That’s going to take resources, competence and skill—and it’s going to take leadership. If we have all of those elements, we’ll have an agency that regulates the pharmaceutical industry fairly but rigorously...with the public as its first priority.


“There are many, many issues that FDA has to deal with right now, even limited to just pharmaceuticals. We have to be both creative and innovative in our thinking about drug safety, comparative benefit of products, and honest communication with both patients and physicians. We have to grapple with all of that and more. I hope we come out of this experience moving in that direction. But because there is a great deal at stake and a great number of players, I can’t predict. I’m either feeling optimistic or pessimistic at any given moment.”


DR. SIDNEY M. WOLFE

Director, Public Citizen’s Health Research Group


“The following uniquely American scenarios will force the necessary changes in our so-called health-care system: 45 million uninsured and at least another 55 million underinsured; about one-third of the population without adequate insurance; medical bankruptcy caused by inadequate health insurance being one of the most common causes of personal bankruptcy; and (support our troops) 1.8 million American veterans without health insurance or access to the VA health system. This is the only country with most care delivered by or through for-profit entities such as insurance companies, HMOs, nursing homes and dialysis centers, [with] annual excess administrative costs and waste of more than $350 billion a year because of multiple payers and a system that employs tens of thousands of people to specialize in denying care: non-health-care professional private-sector bureaucrats.


“Common to all presidential ‘plans’ to solve this problem is the retention of the major cause of the problem, the health insurance industry. A single-payer system eliminates these middle men and uses the freed-up funds to provide health care and, as articulated by the [U.S.] Labor Party, Just Health Care.”


BIOTECHNOLOGY



GREGOR F. BENNETT

President, American Academy of Physician Assistants


“I think that, in the next 15 to 20 years, the face of health care as we know it is going to change drastically. We are presently at the dawn of the Genomic Era, poised to enter a time when truly dramatic changes in the way we view health care will be unfolding at an exponential rate. We will soon begin to have understandings of diseases and of human response to disease states that will radically alter our approach from one of pure treatment of pathology to the prevention of life-altering events. As this evolves, we will undergo a paradigm shift in the economics of health that will place far more emphasis on stopping illnesses before they appear than on treating them after they do. I think that it is going to be the most exciting time in medicine since the advent of germ theory.”


PATIENT CARE



DR. RICK KELLERMAN

President, American Academy of Family Physicians


“If we look out 15 years from now, we have to consider the aging of baby boomers and what that’s going to mean to the health-care system in a number of ways. No. 1, they’ll have more chronic disease, which will put a tremendous burden on a health-care system that is already not functioning well. We have a very costly system that under-performs in terms of the quality it provides. We also have patients and physicians who are not happy. And we need to start asking ourselves the questions of how to realign health care to meet the needs of the American population in five, 10 and 15 years. That will probably be painful. It won’t be business as usual.


“For family physicians in particular, there is a new understanding of the role of primary care: providing prevention, management of chronic illness, cost-effective acute care, and end-of-life care. This new role of primary care has been called the patient-centered medical home, a concept where patients have a personal physician who provides coordination of and access to care using health information technology to better manage individual patient problems and also improve the overall quality of care patients receive.”



DR. RUTH L. KIRSCHSTEIN

Acting Director, National Center for Complementary and Alternative Medicine, National Institutes of Health


“Large numbers of American consumers are using complementary and alternative medicine (CAM) in an effort to pre-empt disease and disability or to promote health and a sense of well-being. Driven largely by this demand for CAM, integrative medicine is rapidly becoming a major force shaping health-care systems in the United States and around the world. [Our] mission
is to support rigorous research intended to fill the CAM knowledge gap,
and to disseminate information regarding CAM’s effectiveness and safety to the public and to health-care professionals.”


DR. BRIAN F. KEATON

Department of Emergency
Medicine, Summa Health System, Akron, Ohio, and President, American College of Emergency Physicians


“The future of health care in our country will be shaped by the competing forces of demand and capacity. Advances in pharmacology, technology and medical research, combined with the graying of the “baby boomers,” are creating demand for medical services that far outstrip our capacity to provide them.


“In many parts of the country, the tension is reaching crisis stage as evidenced by hospital closures, ambulance diversions, ER crowding and 45 million uninsured in a nation that spends over 16 percent of GDP on health care. As we look to the future, it is certain that the status quo is not an option. These trends are simply not sustainable. While there is no question that we will provide health care in the future, it is certain that the care we provide will look very different from the care we provide today. It is up to all of us to work to ensure that this transformation results in a system that is fair, equitable, efficient, patient-centered, evidence-based and available to all Americans.”


PUBLIC HEALTH



DR. GLORIA WILDERBRATHWAITE

President and CEO, Core Health


“We are soon to become a nation of the disabled and dependent. Progressive nations are marching into the 21st century resolved to define social justice in practical terms and to provide a fair opportunity for their citizens to live a well life without creating dependency on charity or good will. I do not believe our nation’s leaders have a genuine interest in health and wellness. The hope lies in the fact that most Americans still do; most of us dream of a well life and are willing for our neighbors to have the same. The promise lies in the new generation of health-care providers and leaders who are willing to make professional sacrifices to resuscitate a dying health-care system.


THOMAS J. VAN COVERDEN

President and CEO, National Association of Community
Health Centers


“Exciting things are happening in community health. The focus in health care has turned to primary care and prevention. The nation has come to recognize the value of a community health system that can expand access, reduce disparities, and generate savings in health and prevention.


“Community health centers are reaching out to millions of uninsured and medically underserved. Our programs in chronic disease management, prevention and culturally competent care are publicly cited as models of primary care practice. Moreover, enhanced partnership with the public/private sectors is spurring initiatives to address a multitude of problems from substance abuse to child obesity, hepatitis C and HIV/AIDS.


“For community health providers, the opportunities to improve the delivery of health care have never been greater. Yet, challenges remain, and foremost is the shortage of primary care physicians. Today, we are collaborating with medical schools, governments and communities to develop strategies that will ensure an adequate workforce into the future. We believe health centers will be successful. Community health is the future of our nation’s health.”


QUALITY



DR. JEFFREY SEGAL

Neurosurgeon and Founder and CEO, Medical Justice Services, Inc.


“I hope as a physician, a patient, a husband and father that the future of medicine will go beyond new medications and new treatments. Medicine will be transformed into a team sport where reimbursement will be based on what happens—outcomes—and not on what is done. Excellence will stand out and be rewarded. Further, if patient safety is ever to be taken seriously, those who identify system-wide problems will be rewarded and not punished, as they currently are. The biggest change to health care over the next 10 to 15 years will be physicians leading the way to true reform.”


DR. JAMES MANDELL

President and CEO, Children’s Hospital, Boston, and Chair, Conference of Boston Teaching Hospitals


“Many leaders of academic health-care systems believe that there will be significant changes in the next 10 to 15 years. Many [changes] will be the result of an enhanced ability to measure and report quality and outcomes in a more accurate and timely manner than ever before. Armed with information on outcomes, public and private payers will directly link payment with performance and place a greater emphasis on identifying and eliminating racial and ethnic disparities in health care. Other changes could include a mandated or standardized health coverage system where much of the care will be delivered in large, integrated primary care networks at the expense of small and independent group practices.”


JEANETTE LANCASTER

Dean, University of Virginia School of Nursing, and President, American Association of Colleges of Nursing


“Health-care providers today rely on advanced practice nurses for many front-line services, such as primary and preventive care, managing chronic conditions and teaching patients to navigate the health-care system. Mounting studies show that the quality of care provided by nurse practitioners and other specialists is equal to and at times better suited to the needs of patients and their families than comparable services provided by physicians. As we move toward increased doctoral preparation for nurses engaged in advanced practice, the primary care provided by nurses will promote further advances in patient safety and quality. This care brings the added benefit of being both high quality and cost-effective.”


WORKFORCE



DR. FITZHUGH MULLAN

Murdock Head Professor of Medicine and Health Policy, The George Washington University School of Public Health and Health Services


“The current pressure to open more medical schools will result in major new opportunities in medicine for many more young people than in the past. Medical education will remain expensive, but more “community service” options such as the National Health Service Corps will be funded by governments at the state and local levels. More government-mandated planning in types of training programs will result in less choice for students and residents but a far better balanced and more efficient medical workforce.


“One of the most important aspects of this may well be the training of adequate numbers of physicians for the service needs of the United States rather than the current situation where we train only three-quarters of the physicians we need in medical school and then import one-quarter more at the GME level. More self-sufficiency in medical training will in turn result in a diminished brain drain from developing countries. This will be a huge benefit to countries that desperately need stability in their workforce to deal with the
devastated condition of their health
sectors.”


DR. REGINA GAN-CARDEN

Chair, Women in Medicine Subcommittee, Maryland Chapter of American College of Physicians


“I think the biggest change in health care or medicine in the next decade and a half will be the increasing number of women physicians who are also the primary caretakers of their families, the need for health-care reform and flexible work options, and the loss of physicians going into or continuing in primary care due to burdensome practice regulations and increasing unpaid activities associated with patient care.”


DR. BEN GALPER

Immediate Past Chair, American Medical Association-Medical Student Section, and PGY-1, internal medicine, Columbia-Presbyterian Medical Center


“We need more physicians. The older portion of the population is growing. Every year we need more doctors to take care of them, particularly in underserved areas and lower socioeconomic classes. We need more primary care physicians, and we need to motivate people to go into primary care through funding measures like the National Health Service Corps. We need to entice more people from lower socioeconomic classes to become physicians through programs like Title 7 funding—which both AMSA and the AMA-MSS have worked for—to increase the number of physicians from lower socioeconomic classes and minority [groups]. It takes about 10 years to make a new doctor, so we have to start now, recruiting students in high school and college to go into medicine.”


EDUCATION AND TRAINING



DR. MICHAEL EHLERT

President, American Medical Student Association


“Health care is in a crisis in this country, and medical education has done little to prepare us for the future. My hope is that in the coming years, students will take on the leadership roles as practicing clinicians and be the instruments of change we so desperately need. There will come a tipping point where the medical–industrial complex can no longer squeeze doctors any more, and there will be a revolt for independence. The trend of lower wages, increased debt, growing uninsured rates and centralized control of services underscores the need for active leadership. AMSA provides these opportunities to grow and develop among our peers and strengthens that fiduciary culture toward our patients and our profession.”


DR. SIMON AHTARIDIS

President, Committee of Interns and Residents


“Over the next decade, resident physician training programs will be confronted by two challenges. [One] is finding an appropriate balance between the service and educational aspects of graduate medical education.


“With the exponential growth of medical information and constantly updated guidelines, the burden of education has grown considerably over the past few decades. To continue to produce highly trained, competent physicians able to fully implement the advances that new technologies give us, residency will need to focus more on streamlining and organizing the educational experience into something more rational than the current haphazard apprenticeship model.


“For this to happen, resident training will need to meet a second challenge: adequate funding. Over the past decade, graduate medical education funding has come under attack. Most of graduate medical education is funded by public programs such as Medicare, a program that has survived a number of cuts but faces more. Furthermore, hospitals are seeing diminishing revenue streams amid increased costs. The money that hospitals receive for graduate medical education makes a tempting source of revenue to fund services unrelated to graduate medical education.


“If improving the quality of our doctors is a priority, our elected officials should focus both on improving funding and holding hospitals accountable for graduate medical education dollars.”


DR. STEPHEN SHANNON

President and CEO, American Association of Colleges of Osteopathic Medicine


“In osteopathic medical education in the next 10 to 15 years, the influence and impact of our profession on the greater health-care needs of our country will become more evident than it has been in the past. I believe that some of the qualities that are part of osteopathic education will be increasingly recognized and sought after in allopathic medicine, and that there will be increasing integration of osteopathic medicine with allopathic medicine and the other health professions in our health-care system. In the next 15 years, colleges of osteopathic medicine will double the number of their graduates.


“One of the things we’re focusing on is trying to deal with the development of documentation regarding best practices in osteopathic medical education for everybody’s information, and to be cognizant of the public health needs that are out there.


“Given what is currently happening regarding research, graduate medical education and health-care system changes, there will be greater integration, and osteopathic and allopathic medicine, in many ways, will look more similar. Osteopathic medicine has a basic philosophy that includes patient-centered, holistic care. That philosophy is not exclusive to osteopathic medicine, but I think allopathic medicine has embraced it to a larger degree because of our influence. While we are a separate profession in some ways, with a separate medical education system in some aspects, we are all trying to do the same thing—train the best physicians for tomorrow’s health-care system.


“If you are a student today, getting ready to enter an osteopathic medical school, there is real opportunity to be part of a transition and a change that is very exciting. It is a very optimistic time, because there is almost an unlimited future there, assuming this country can ever figure out the health-care system under which we should be operating.”


DR. DARRELL KIRCH

President and CEO, Association of American Medical Colleges


“The way we’ve viewed the training of a physician, it’s been in discrete compartments. You finished your premed training, then moved into medical school, took a whole series of tests and received your M.D. degree. You then were off to separate residency specialty training, and when you finished that, you could become board certified. Once you were in practice, your education was essentially left to you. But the notion of being finished at any point during this process, I think, is proving to be fairly naïve. In fact, becoming a physician means developing increasing levels of mastery and specific competencies over a lifetime.


“The change I see happening is we are beginning to think about this continuum in a much more holistic way, and we are beginning to think about the assessment of competence in a different way. That means we all have to give up our concept of different organizations owning different parts of the continuum, and we need to take an approach of common shared accountability for the whole continuum.


“I’ve been very encouraged that there are active discussions going on at the national level about the ways in which we might do this, and I think it will be of great benefit to physicians and patients. Physicians will have the satisfaction of proving their real-world competence, as opposed to relying on abstract tests to do that. And I know it will be a benefit to patients, because what patients care most about is not what their doctor knows, but how their doctor applies what they know to them.”


FINANCING



DR. DAVID MELTZER

Associate Professor, Department of Medicine, Department of Economics and Harris School
of Public Policy Studies, University of Chicago


“The next 15 years may challenge many medical specialties and the organizations that organize them. At least two forces may drive this. First, the imperative for cost control in the United States seems likely to increase reliance on capitated —as opposed to fee-for-service—medicine. This will mean payment of physicians by salary rather than fee-for-service and greater incentives for health-care systems to pair highly paid specialists with lower-cost providers who can extend their work and ultimately drive down compensation. Second, federal budget pressures will drive down physician compensation, and the hardest hit will be highly paid specialties.”


DR. OLIVER FEIN

Associate Dean, Affiliations, and Professor, Clinical Medicine and Public Health, Weill Medical College of Cornell University


“We are, in the United States, approaching a critical fork in the road
of health-care delivery, and the most significant thing would be the achievement of a single-payer national health insurance program…. And I think there is a real possibility that we could do that. We have the resources and, really, the ability to do it. And that would be transformative in many respects, in terms of who has access to care and what indeed we can offer people in care.


“However, the other fork in the road is the possibility of returning to the pre-health-insurance era during which individuals were responsible for their own health insurance. This is kind of the way things were prior to the 1930s, and I think that could be a disaster for the health-care system, a system in which your wealth really shapes your access to health care.”


CYNTHIA A. BROWN

Director, Division of Advocacy and Health Policy, American College of Surgeons


“Health-care stakeholders are realizing that price controls do not constrain total health-care spending. New technology, complicated financial incentives for patients and providers, uneven resource distribution, increased specialization and other factors combine to create a health-care labyrinth rather than a health-care system. No one is happy with the result, and physicians are caught in the middle.


“Remarkably, all stakeholders seem to grasp the problem at once, and they are collaborating in unprecedented ways to develop a new model that focuses more on which services are purchased during an entire episode of care, rather than on what price is paid for individual services during a specific patient encounter. Expanded use of health information technology and new payment methods will make this possible. Those physicians and hospitals providing comprehensive, evidence-based, cost-effective care will succeed. But, physicians must be involved in the development and design of this new model, or patients will confront an entirely new set of problems.”


GLOBAL HEALTH



DR. PAUL ZEITZ

Co-founder and Executive Director, Global AIDS Alliance


“We are the first generation in human history that can practically achieve major progress toward realizing the vision of global health equity. We have the medical and development technologies as well as the information, communication and transportation technologies to actualize a new paradigm. Stakeholders around the world are galvanizing themselves in an unprecedented, focused mobilization of political will, resources and actions toward achieving the health-related Millennium Development Goals by the end of 2015. We can halt the spread of AIDS, TB and malaria. We can dramatically reduce the millions of preventable deaths and enslaving morbidity afflicting children and families. Victory in our time!”


DR. DOUGLAS HAMILTON

Epidemic Intelligence Service,
Centers for Disease Control and Prevention


“The change in medicine that will probably have the biggest impact on us is the growing globalization of health and public health. We’ve recently all seen the international impact of a single case of tuberculosis, where the patient traveled between several countries, and I think as air travel continues to get easier and borders easier to cross, we will be faced with public-health challenges created by the rapid movement of people around the world. If we’re not adequately prepared, that’s going to be a major problem.


“In terms of disease threats, the big kahuna that everyone is afraid of is the re-emergence of pan flu. In general, I don’t think people really are aware of the huge impact that pandemic influenza can have. If you just look at the 1918 pandemic, the estimates of the number of people that died worldwide are as high as 50 million. I also think there is a real potential problem with the re-emergence of some old diseases that are drug resistant. Drug resistance can result from inadequate treatment in many parts of the world, and the growing number of people who are immunocompromised—look at the rise ofTB and its relationship to HIV infection—and drug resistance can also be promoted by the overuse of antibiotics in things like animal feed and agriculture. All of these things have led to an environment that is providing us with more examples of drug resistance, which is another big threat.”


HEALTH INFORMATION



BRYON PICKARD

Director of Operations, Vanderbilt Medical Group, and President, American Health Information Management Association


“Empowering citizens to take greater control over their own physical and mental well-being must be a goal for the 21st century. Health care is a global commodity, and decisions to improve health and health care at a sustainable cost will require global solutions. Advances in health IT and managing health information offer a very credible approach to solving the future’s health-care challenges. Putting the right information in the hands of those who need it, when they need it and in the amount they want will be advantageous to both providers and consumers alike.”


DR. CHANTELLE PAYDARFAR

Family physician, Research Triangle, North Carolina


“I predict that many patients, including the elderly and those who suffer from chronic illnesses will begin to solve a lot of their own health problems or be less dependent on their doctors for a number of reasons, including advanced technology such as the Internet, better education about diet and lifestyle, and self-made attempts to lower individual health-care expenses.”