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