Chapter 14 the future of health services delivery

Health Services

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

• 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

“Will the U.S. have a single-payer system?”

Introduction

The future outlook of health care delivery in the United States is predicated on major current developments and the course these developments might take in the foreseeable future. On the other hand, any attempts to project the future of health care provoke more questions than answers, and the future often turns out differently than people anticipate (Kenen 2011). Even though most of the provisions contained in the Affordable Care Act (ACA) went into effect in 2014, its consequences, both good and bad, will be experienced for years to come. The health care industry has so far reacted by consolidating and forming organizational alliances in which hospitals, physicians, and in many instances, managed care organizations have integrated as major partners (see Chapter 9). The insurance industry has been dropping many individual plans because they do not comply with the ACA’s mandate to include essential health benefits (see Chapter 6). Many employers are trying to cope by reducing worker hours, negotiating new health plans, or sending workers to the government exchanges. By and large, the American people have remained passive, adopting a “wait and see” attitude.

When we look at health care delivery as an institution in and of itself, several external factors can be identified that would exert powerful influences for this institution to change and conform. Certain forces, such as demographic trends, project a foreseeable course, based on which some predictions can be made. For other external factors, even short-term predictions are difficult. For instance, it is impossible to predict the future course of the US economy and family incomes, both of which will affect what individual Americans and the nation may or may not be able to afford.

Future change also relies on historical precedents. Certain fundamental features of US health care delivery, such as a largely private infrastructure and the society’s fundamental values, have, in the past, resisted any proposals for a sweeping transformation of health care. Yet, certain historical precedents have also been used as a springboard for current change (see Chapter 3), and they will no doubt influence future change as well.

This chapter puts the future of health care in the larger national and global context. It also assesses the likely future course of health care reform, clinical technology, and new models of delivering health care.

Forces of Future Change

The framework presented here includes 8 main forces that help us understand why certain changes have occurred in the past, and they can help inform the direction of change that might occur in the future. This framework can be used not only for viewing health care delivery and policy from a macro perspective, but it can also be used by health care executives to craft strategies for their organizations that are aligned with the changes occurring in the broader health care environment.

The 8 forces are (1) social and demographic, (2) political, (3) economic, (4) technological, (5) informational, (6) ecological, (7) global, and (8) anthro-cultural. These forces often interact in complex ways, and these interactions are generally difficult to interpret. Keen observation of these forces, however, can create opportunities for change. How those opportunities are either garnered or forgone determines the nature of change. With the passage of time, some forces become more dominant than others. The directions of change these forces may portend have implications for cost, and hence, affordability; access to services; and power balancing within the health care system (see Chapter 1). Hence, the US health care system will continue to evolve, but nobody knows its ultimate destiny.

Another important point to bear in mind is the fact that for several decades now, the US health care delivery system has not been driven by free-market forces (see Chapter 1). Over the years, the government has become a major player that has controlled a growing segment of health care financing (see Chapter 6), and has increasingly wielded control over the private sector through its legal and regulatory powers. Yet, the government needs the private health care sector to serve its millions of beneficiaries in various public health insurance programs. At least for the foreseeable future, tension and power balancing between the private and public sectors will continue, and for better or for worse, we will see ongoing changes in the way Americans receive health care.

Another important point to keep in mind is the fact that health care encompasses almost one-fifth of the nation’s economy. The ongoing ability to deliver health care is, therefore, closely tied to the nation’s economic health, regardless of whether health care is delivered through private or public insurance programs.

Social and Demographic Forces

Demographically, the United States is getting bigger, older, and more ethnically diverse. Shifts in the demographic composition of the population, cultural factors, and lifestyles affect not only the need for health care but also how those needs will be met. Demographic trends will also continue to affect a nation’s ability to afford health care services.

The elderly, vulnerable populations, and people with certain health conditions all present varied needs. These groups are also among the highest cost drivers. Trends pertaining to the growing elderly population are covered in Chapter 10; almost all receive health care through Medicare, and a small proportion from both Medicare and Medicaid. Among vulnerable populations, disabled Medicare beneficiaries under the age of 65 have also been on the rise, from 13.3% of all Medicare beneficiaries in 1999 to 16% in 2009 (DHHS 2003a, 2012). During this same time period, Medicaid recipients (another vulnerable population group) increased by 56% (DHHS 2012). These expanding government programs are on an unsustainable financial path. According to the 2013 Medicare Trustees Report, the Hospital Insurance (Part A) trust fund will be insolvent in 2026 (Davis 2013). Supplementary Medical Insurance (SMI) trust fund is not projected to become insolvent simply because the government is obligated to fund the deficits from general tax revenues. In other words, general taxes must be raised or spending must be cut in other areas to keep funding SMI, which mainly covers payments to physicians (Part B) and cost of prescription drugs (Part D). Both Medicare and Medicaid face future challenges that still remain unresolved. According to the 2013 report of the Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds, retirement of the baby-boom generation—which started in 2011—will increase the number of beneficiaries much faster than the increase in the numbers of workers who will pay taxes. Cost projections by the Congressional Budget Office (CBO) estimate that Medicare, Medicaid, and Social Security will account for more than 90% of the growth in mandatory federal spending1 between 2013 and 2022 (CBO 2012). Only after 2050 will the baby-boom generation be gradually replaced at retirement ages by historically low-birth-rate generations, causing the beneficiary-to-worker ratio to decline. Until 2050, the state of the nation’s economy will be one of the key factors that will determine the future of Medicare, Medicaid, and also Social Security, the nation’s retirement program funded through workers’ payroll taxes, similar to Medicare.

An equally challenging factor is how population shifts affect the composition of the health care workforce, because health care delivery is labor intensive. In a free society, people choose their professions and where they work. As pointed out in Chapter 4, social and demographic factors have played a significant role in determining the number of health care professionals and their geographic distribution. Future immigration will be one factor that will affect the supply of health care professionals.

The society’s cultural mix, also based on the rate and quality of immigration, will continue to slowly transform health care delivery. For example, language and other cultural barriers affect both the patient and caregiver. Language training and posting of signs in different languages are only one small piece of the more complex cultural puzzle. Social and cultural factors affect exposure and vulnerability to disease, risk-taking behaviors, health promotion and disease prevention, and health care–seeking behavior. For example, non-Hispanic whites are more likely to visit physicians’ clinics, whereas non-Hispanic blacks more frequently seek care in emergency rooms. The large number of illegal immigrants, estimated to be around 13 million (Shrestha and Heisler 2011) and not covered by any health insurance program, including the ACA, also tap into the nation’s health care resources. The United States has failed to craft and pursue a well thought-out immigration policy. Hence, the effects of immigration on the economy and on health care remain unclear. Social and cultural factors also play a role in shaping perceptions of and responses to health problems.

To a large extent, population growth and aging are noncontrollable factors. Even individual responsibility for one’s own health is largely beyond the control of employers and the government, except that incentives created for people to engage in healthy behaviors to prevent disease and disability can have some effect. Personal lifestyles significantly impact the future of wellness, prevention, health promotion, and the burden placed on financing and delivery of health care. Despite its heavy focus on prevention, it is not clear to what extent the ACA will successfully change individual behaviors to make any significant headway in reducing the burden of disease in society.

Economic Forces

The national debt, economic growth, and employment are major forces that will determine the availability of health care services, their cost, and affordability. Besides employment, household income is a fundamental determinant of affordability, and both employment and personal income depend on the nation’s economic health. Yet, as more and more people start depending on government handouts, it will not prove to be a recipe for economic growth, just the contrary.

On October 31, 2013 (this is just an arbitrary date), the national debt of the United States stood at $17,156,117,102,204.49—surpassing $17 trillion (Department of Treasury 2013a). This is over 100% of the nation’s gross domestic product (GDP), estimated to be $16.7 trillion in 2013. The debt is the cumulative result of spending more than the revenues generated mainly through taxation. The deficit spending amounted to $1,089 billion in 2012, compared to $455 billion in 2008 (Department of Treasury 2013b). Deficit spending has to be financed by borrowing money. Whether this much debt can reach a point of crisis is a matter of controversy, but common sense suggests that all debts have to be repaid, nor can there be a default on the outstanding debt without jeopardizing the nation’s economy. If the debt was not a matter of concern, the United States Treasury would need not bother publishing the extent of national indebtedness. There also would not be a need to waste public resources on publishing the trustee reports for Medicare and Social Security; in fact, there would not be a need to have trustees. So, there are obvious concerns that the public debt must be reduced. The obvious solutions are the reverse of what creates debt—a combination of spending cuts, tax increases, and economic growth. High rates of economic growth can lower the need for spending cuts and raising the tax rates.

The recession ended in June 2009, but the pace of economic recovery and employment has been slow. In 2012 alone, the before-tax median household income of Americans, adjusted for inflation, had fallen 8.3% from the prerecession level in 2007 (Center on Budget and Policy Priorities 2013). The CBO projected the economy’s output to remain below its potential until the first half of 2018. Beyond that date, it is almost impossible to predict the timing or magnitude of fluctuations in the economic cycle (CBO 2012). One silver lining on the horizon is that the growth in the gross domestic product (GDP) is expected to exceed the growth in federal expenditures between 2012 and 2018 (CBO 2012). These projections assume that provisions of the Budget Control Act of 2011, which established automatic enforcement procedures to restrain both mandatory and discretionary spending, remain unchanged. In making these projections, the CBO made three main cautionary assertions: (1) Spending per enrollee for Medicare and Medicaid has generally grown faster than the GDP; if per capita costs grew just one percentage point faster per year than what the CBO has projected, spending for Medicare and Medicaid would increase by approximately $800 billion over the following 10 years. (2) The potential budgetary consequences of the ACA were uncertain. (3) According to the Sustainable Growth Rate (SGR) formula, which is part of the resource-based relative value scale (RBRVS) payment system to reimburse physicians (discussed in Chapter 6), physicians’ fees were to be reduced by 27% in 2012. Each year since the SGR was made part of RBRVS reimbursement, Congress has overridden fee reductions for physicians. If physicians’ fees are allowed to stay at their 2012 levels (without the reduction called for by the SGR formula), spending would increase by $316 billion over the following 10 years. In short, a lot remains unknown about future health care spending. National health expenditures are projected to grow one percentage point above the rate of GDP growth from 2012 to 2022, reaching 19.9% of GDP by 2022, up from 17.9% in 2011 (CMS 2013).

A golden prospect that has been left out of the CBO projections, and something that even most Americans are unaware of, is the oil and gas renaissance in the United States. Thanks to new technology and private initiative, the United States has become the largest energy producer in the world. This statement may surprise some, but it is true. Declaring energy self-sufficiency at this point, however, would be like counting chickens before they hatch. Yet, to the dismay of many in the business world, the trustee of the precious energy resources, the United States, does not have an energy policy for the future. Hence, much will depend on future energy policy which can either turn an abundant God-given resource into helping Americans financially or it can turn into a self-destructive weapon that “kills the goose that lays the golden eggs.” Judiciously harnessed, this one resource may well be the key to solving America’s looming economic crises.

At present, it is uncertain what effects the ACA would have on employment and household incomes. According to a CNNMoney poll of 14 economists conducted in September 2013, 9 indicated that businesses were putting off hiring in light of health care reform, even though the employer mandate had been pushed back until 2015 (Hargreaves 2013). Small businesses, for example, could cut hiring and reduce worker hours to keep their full-time equivalent to below 50 employees. Under the ACA, employers do not have to provide health insurance to workers who work less than 30 hours a week. The nonpartisan Employee Benefit Research Institute, however, has found that the trend toward more part-time workers—and less employment-based health insurance coverage—started in 2007, well before the passage of the ACA (Fronstin 2013). If this trend continues, the ACA could be a boon for part-time workers who can get government subsidies to buy coverage through the exchanges. However, the affordability of exchange-based health insurance remains unclear. In the long run, businesses make strategic decisions in the light of the various forces discussed in this section; hence, much remains unknown about future directions in employment and household incomes.

Political Forces

Chapter 13 discusses the role of politics and its influence on health policy. As should be apparent throughout this book, policy is closely intertwined with almost all aspects of health care delivery. Policies that affect education at home, as well as immigration policies, can determine not only the number but also the qualifications needed for the future health care workforce. The history of health care in the United States and in other countries is replete with examples of major changes brought about through political will. Politics serves a nation best when it is subservient to the people’s will. However, Americans remain divided on major policy issues, and health care is one such issue. It is anyone’s guess whether the ACA would have passed or failed had there been adequate transparency and public debate. The nation’s total economic spending and tax policies also lie in the hands of the politicians. Will they have the resolve, for example, to cut runaway government spending? Will they raise taxes to a point that severely stifles economic growth? These issues make national headlines during squabbles between the two political parties about raising the debt ceiling, meaning increasing the spending levels. Ironically, we do not hear about any collaborative efforts to reduce the debt ceiling.

Technological Forces

It is widely believed that technological innovation in medical sciences will continue to revolutionize health care. Americans strongly favor ongoing innovation, availability, and use of new technology. The high cost of research and development and subsequent costs of unrestrained use of technology, however, do raise questions about how long this can continue, given that the growth in health care spending will continue to surpass GDP growth. Yet, technologies that promote a greater degree of self-reliance and/or achieve cost efficiencies will receive much attention in the future. Nevertheless, the overall effect of technology is to increase costs unless it is accompanied by utilization control measures.

Informational Forces

Information technology (IT) has numerous applications in health care delivery, as Chapter 5 points out. IT has also become an indispensable tool for managing today’s health care organizations. Garnering IT’s full potential is still evolving and will continue well into the future.

Ecological Forces

New diseases, natural disasters, and bioterrorism have major implications for public health. These factors can even have global consequences. Diseases that are communicable—such as new strains of influenza—and those related to environmental agents—such as vector-borne diseases (for example, West Nile virus and chikungunya virus)—can bring about mass hysteria, particularly in large population centers, especially when the disease remains mysterious and treatments are not readily available. Zoonoses refer to any diseases or infections that are naturally transmittable from vertebrate animals to humans. Growth of populations around the globe will intensify the human–animal–ecosystems interface, raising the probability of engendering diseases that are yet unknown. When a significant number of people are affected or threatened by disease, research and technological innovation go into high gear. Technologies, such as remote sensing and geographic information systems (GIS), will find ongoing applications in public health and safety.

Natural disasters disrupt not only people’s daily lives, but also create conditions that pose serious health risks through contamination of food and water. Health problems and psychological distress often follow. Initiatives, such as biosurveillance and infrastructure upgrades, undertaken to cope with natural and man-made disasters are discussed in Chapter 2. The roles of the Centers for Disease Control and Prevention (CDC) and other partnering agencies will continue to evolve as new challenges emerge. On the down side, the growing need for combatting new ecological threats will divert resources from providing routine health care to patients.

Global Forces

The economies of the world are becoming progressively more interdependent. Globalization has become an extremely complex phenomenon, because the various forces discussed here interact as this phenomenon continues to evolve (Huynen et al. 2005). For example, Rennen and Martens (2003) define contemporary globalization in terms of an intensification of cross-national cultural, economic, political, social, and technological interactions. Hence, health and health care in various countries will continue to be affected in diverse ways through multiple pathways. To give a simple example, “brain drains” of physicians, therapists, and nurses from developing countries to relieve shortages in developed countries generally occur for personal economic reasons, but social, cultural, and technological factors may pose hindrances in the full utilization of their talents and learning. Economically backward countries have received “brain gains” as the number of health professionals from developed countries on medical missions to provide care in poorer countries has grown globally (Martiniuk et al. 2012). Medical missionaries do charity work out of a sense of deeply rooted personal ethics and compassion, but cross-cultural factors have at least some diluting effects on their optimum performance.

Other signs suggest that globalization in health care will intensify. Increasingly, generic drugs are being manufactured in Asian countries for export to Europe, Canada, and the United States. This trend has made drugs more affordable in the United States, but insuring safety and adequate supplies to meet demand on a consistent basis poses major challenges for the Food and Drug Administration (FDA). Medical tourism is likely to increase if high-deductible health plans (see Chapter 6), which give greater control to the consumer on how to spend their own savings on health care, continue to grow. Given the high cost of health care services in the United States and Europe, providers from other countries are providing or will soon be able to provide lower cost, but almost identically high-quality health services, and these services often come with greater amenities (Reeves 2011). Moreover, cross-border telemedicine used in conjunction with medical tourism is becoming a rapidly developing trend (George and Henthorne 2009). In the future, we may also see foreign hospitals and clinics providing services within the United States. Countries such as Japan, Norway, Australia, and India have asked for standardization of licensing and qualification requirements in the United States and/or to allow service providers licensed in one state to practice in all states (Arnold and Reeves 2006).

Anthro-Cultural Forces

Here, by anthro-cultural we mean a society’s beliefs, values, ethos, and traditions, which, in the health care context, are discussed in Chapter 2. It would also be helpful to review that the beliefs and values discussed in the previous chapters are espoused primarily by middle-class Americans. As pointed out in Chapter 3, American beliefs and values have historically acted as a strong deterrent against attempts to initiate radical changes in the financing and delivery of health care. Gallup poll results published in July 2013 showed that 52% of Americans disapproved the ACA, up from 45% in November 2012 (Gallup 2013a), as many more have learned about some of the details in this complex law. A survey in September 2013 conducted by the Pew Research Center (Pew) and USA Today also found that 53% of Americans disapproved of the ACA; 42% approved. Pew commented, “opinions are now as negative as they have been [at] any point since the bill’s passage” (Pew Research Center 2013). Looking ahead to the coming years, more Americans anticipate negative personal effects: 41% said the effect on themselves and their families would be negative; 25% said it would be positive, according to the Pew/USA Today poll. It is certainly not beyond the realm of possibility that the American public may end up deciding the final fate of the ACA.

The Future of Health Care Reform

Speculations abound that the ACA would eventually lead to a single-payer system , which is a national health care program in which the financing and insurance functions are taken over by the federal government. In fact, Senator Majority Leader, Harry Reid (D), one of the chief architects of the ACA, confessed in an interview that the United States needed to work its way past an insurance-based health care system and suggested that that would absolutely happen. He further stated, “Don’t think we didn’t have a tremendous number of people [Democrat lawmakers] who wanted a single-payer system” (McHugh 2013). So, will the United States have a single-payer system in the future? Perhaps, yes; perhaps, no. Much will depend on the ACA’s promises becoming reality, how it will affect the majority of middle-class Americans, and how the forces just discussed play out in the future. For example, if health insurance premium costs and out-of-pocket costs rise beyond what most people consider to be unaffordable, there could be a push for a single-payer system; however, it would require control of the presidency and the Congress to be in the hands of the Democratic Party, just as it was with the passage of the ACA. Conversely, mass dissatisfaction with the ACA would kill the prospects of a single-payer system regardless of who controls the White House and Congress.

Lessons From Massachusetts

Experience in Massachusetts may provide a window into the future of the ACA, because the basic features of the federal health care reform law were patterned after the Massachusetts health plan (see Chapter 3). Hence, with some caution, lessons can be drawn regarding the future of the ACA.

The Massachusetts plan has achieved some successes, but problems with costs remain the primary issue. As was expected, health insurance coverage increased markedly in Massachusetts between 2006 (before the plan was implemented) and 2010, including for those most in need of health care, such as individuals reporting poor physical or mental health (Dhingra et al. 2013). The proportion of uninsured fell to 12-year lows, from 11.5% in 1996 to 3.5% in 2008. The overall increase in premiums between 2009 and 2011 was 9.7%, far exceeding the rate of inflation. In 2012, 59% of the total enrollment was in HMO plans (Massachusetts Center for Health Information and Analysis 2013). For health insurance offered through the exchanges (called Health Connector in Massachusetts), the state set limits on the rise in premiums (Robillard 2010). It is possible that insurance companies were able to absorb the slack through the volume of newly insured customers and by shifting costs to employer-based plans. Among Massachusetts residents, 62% had employer-based coverage (Massachusetts Center for Health Information and Analysis 2013). Whether limits placed by the government on rises in premiums can continue in the future remains to be seen.

The overall prevalence of unmet needs because of inability to afford health care fell from 9.2% in 1996 to 7.2% in 2008. However, this was not the case for middle-income earners, Hispanics, Blacks, and those in fair to poor health (Clark et al. 2011). Although disparities may remain in some areas, for some surgical procedures racial disparities were actually reduced (Loehrer et al. 2013). The overall volume of emergency department utilization has continued to rise, with only a small decrease in the rate of low-severity visits (Smulowitz et al. 2011). The likely reason is a shortage of primary care physicians (PCPs), even though Massachusetts has a high number of PCPs and the state improved its primary care capacity by increasing the number of nurse practitioners and physician assistants. Conversely, hospitals experienced a significant decline in charity care and uncompensated care (Edwards 2010).

In the 2013 health care public opinion survey, the Massachusetts Medical Society reported 56% of those surveyed were satisfied with the health care they received. Two main concerns expressed were cost and waiting times to see a physician (Massachusetts Medical Society 2013).

The Massachusetts law focused on expanding coverage, leaving cost containment “for another day” (Mechanic et al. 2012). As time progressed, health care expenditures became the biggest challenge. After three rounds of reform legislation, a fourth round, called Chapter 224, appointed a health policy commission with a variety of regulatory powers that include limiting health care cost growth to mirror the state’s economic growth and reducing Medicaid payments to providers (Barr 2013). Governor Deval Patrick also proposed an income tax hike, in addition to higher taxes on gasoline and tobacco.

Likely Experiences Under the ACA

One main caution in translating everything from Massachusetts and applying it nationally is that one state does not represent the ethos of the entire country. As pointed out earlier, before the ACA was fully implemented a significant proportion of Americans were opposed to the law. In 2011, even though 96% of physicians were accepting new patients, 31% were unwilling to accept new Medicaid patients (Decker 2012). The main reason is low reimbursement and delays in receiving payment from Medicaid after services have been delivered. To assess physician perspectives about the ACA and the future of the medical profession, a 2013 survey of US physicians conducted by the Deloitte Center for Health Solutions (Keckley et al. 2013) pointed to a relatively high level of dissatisfaction, particularly among PCPs, among whom only 59% were satisfied with their profession. Six in 10 physicians indicated that many would retire earlier than planned based on how the future of medicine was changing. Six in 10 physicians also indicated that the practice of medicine was in jeopardy. In addition, physicians thought that their take-home pay was decreasing as a result of the ACA; inadequate reimbursement in the future was one of the main concerns expressed by 90% of physicians. To address the problems in the US health care system, 44% of the physicians thought that the ACA was a good start, while 38% believed that the ACA was a step in the wrong direction. These results contradict findings from Massachusetts where a large number of physicians (70%) supported health care reform (SteelFisher et al. 2009). Of course, it is possible that negative sentiments expressed by the American public and physicians could dissipate as time progresses. For example, it is possible that as time progresses, an increasing number of people would feel like winners under the ACA. Physicians who feel like quitting may find that they have no other choice but to carry on in their chosen profession. Conversely, it is also possible that the concerns expressed could pose serious challenges to the ACA in the future. The general public and the physicians may hold the key to the future of the ACA.

Based on the experiences in Massachusetts, the ACA will decrease the number of uninsured, particularly among vulnerable and low-income population groups. However, the law fails to achieve universal coverage, leaving 25 to 30 million uninsured, even though reductions in the number of uninsured would be quite significant. Of greater concern, however, is access to health care by the 25 million newly insured between 2014 and 2023, as estimated by the Congressional Budget Office (CBO 2013). The shortage of primary care physicians (PCPs) will be a major barrier to access. The access dilemma is compounded by the fact that states with the smallest number of PCPs per capita overall, generally in the South and Mountain West, will also see the largest percentage increases in Medicaid enrollment (Cunningham 2011). Mirroring the experience in Massachusetts, the ACA presages greater government control over health care through stifling regulations, lower reimbursement for providers, higher costs, and higher taxes.

Keeping cost escalations within reasonable limits will remain the major challenge. People will negatively react to any significant increases in their out-of-pocket costs. Physicians particularly will react to cuts in their personal earnings. The ACA’s effect on jobs and the economy is uncertain, although a number of employers have reduced worker hours to avoid offering health insurance. In a Gallup poll, 41% of the small business owners indicated that they had held off on hiring new employees, while others had reduced their number of employees or had reduced employee hours (Gallup, 2013b). In addition, 48% of small business owners indicated that the ACA would be bad for their business; only 9% thought that it would be good.

As stated previously, it is too early to draw definitive conclusions at this point. Yet, prevailing current negative sentiments may be difficult to overcome and may actually intensify if the promises of the ACA do not materialize. If negative sentiments intensify, the lawmakers will have no choice but to repeal the major provisions of the ACA. Can that happen? Absolutely, yes. There is precedent for it. The now-forgotten Medicare Catastrophic Coverage Act of 1988 was passed by a wide margin by both houses of Congress and was signed into law by President Reagan. In short, this law had proposed some reductions in out-of-pocket costs in both Part A and Part B, and had added prescription drug coverage beginning in January 1991. The expanded benefits would be paid for by an additional income tax to be paid by an estimated 40% of the elderly. This law became highly unpopular among the elderly, many of whom did not even understand it. Roughly 45% of the elderly had private health insurance, mainly through a previous employer, and they were satisfied with their coverage. A ground swell of negative public reaction forced Congress to repeal the legislation only 17 months after it had become law (Rice et al. 1990). Whether Republican or Democrat, politicians react to overwhelming concerns expressed by their constituents.

Finally, how much the ACA will end up costing is a major issue. Suspension of enrollment in the Pre-existing Condition Insurance Plan (PCIP–see Chapter 6) is perhaps an early warning sign of trouble ahead. On February 16, 2013, the federal government suspended acceptance of new enrollees in PCIP, even though it was a temporary measure until the mandate for insurance companies to cover all pre-existing conditions went into effect in January 2014. The explanation given by the government was that suspending further enrollment “will help ensure that funds are available through 2013 to continuously cover people currently enrolled in PCIP” (US Government 2013).

It would be fair to say that the ACA still faces headwinds, and its repeal is not completely out of the question. If a repeal should occur, however, that would not kill the prospects for future health care reform. Hence, the question, “What if?” is still a legitimate one as it could well pop up in the future.

What If?

What if the law gets repealed? Or significantly altered? Or funding to implement it gets slashed? Or it fails to deliver on its major promises (outlined in Chapter 13)? These are big questions that will be decided in the near future, most likely between 2014 and 2016. Regardless of what happens, the seeds for health care reform have already been sown, and it will no longer remain a dead issue. Any future reforms would build on rather than scrap completely some of the provisions in the ACA. For example, the exchanges established under the ACA would likely survive, as they have been proposed by Republicans in the past. Medicaid would likely be left up to each state to deal with, although it would be difficult to scale back in states that have expanded Medicaid under the ACA. Federal subsidies, in one form or another, to assist individuals to buy health insurance would likely be retained as the Republicans in the past have proposed tax credits and vouchers to purchase health insurance. In terms of coverage, requiring health plans to cover preventive services would be retained, but other ACA mandates would be relaxed. High-deductible health plans (see Chapter 6) could play a significant role in any future health care reform. Researchers Haviland and colleagues (2012) estimated that growth of these plans from the current level of 13% to 50% would reduce annual health care spending by about $57 billion.

To reduce health insurance premiums, coverage of pre-existing conditions would likely be returned to the states who would manage their own high-risk pools as before. High-risk pools were created by about 35 states to make health insurance available to people who otherwise would have been uninsurable because of pre-existing health conditions. What could be repealed are the most contentious requirements of the ACA, namely, the individual mandate, the employer mandate, and the mandated essential health benefits. Other changes could include tort reform to mitigate the effects of malpractice lawsuits against physicians. Overall cost control, however, will continue to be a nagging issue for which there are no easy solutions.

Universal Coverage and Access

There is no question that the United States needs some type of universal coverage, but the nation first needs to strengthen the health delivery infrastructure. Lamm and Blank (2005) cogently stated that universal coverage is feasible, but, to financially sustain such a system, Americans will have to “give up a cherished dream: the dream of total, universal care for any ailment freely available on demand.” Hence, a change in mindset will be necessary. As Paulus and colleagues (2008) have proposed, the underpinnings for a change in philosophy should be to seek value in health care. It necessitates asking the questions: What do we propose to get in return for what we pay? How much should we pay for what we should reasonably expect to get? The pillars of a value-driven system will be individual responsibility for one’s own health, self-management support, patient activation, preventive services coupled with health education, and an infrastructure based on primary care. A health care system built on these pillars has the potential to return the biggest dividends in improving health at a reasonable cost.

The main barriers for moving the US health care delivery system toward an ideal state, of course, pertain to the American mindset in terms of expectations and inadequacies in the existing infrastructure that fall far short of what is necessary. Government policy that works collaboratively with private payers and providers to create strong payment incentives will be needed to tip the scale toward primary care in which both physicians and nonphysician practitioners will play mutually supportive roles. Regrettably, crafters of the ACA did not seek this type of consensus; they merely believed that creating a law with stiff mandates would automatically achieve the results most Americans would desire.

The big unknown factor is whether US medical students would react to incentives and choose to enter primary care in sufficient numbers that tip the scale. It can perhaps be achieved over time by working collaboratively with the Council on Graduate Medical Education. Immigration reform could also entice sufficient numbers of physicians to practice in the United States. These efforts, however, would take several years to achieve their goal, and may also raise concerns about the quality of care.

To get some perspective on universal coverage in the United States, Hawaii and Oregon have the longest running programs that have attempted to eliminate the uninsured in these two states. In Oregon, despite the expansion of Medicaid and rationing of care, 15.6% of the state’s population was uninsured in 2006 (Office for Oregon Health Policy and Research 2007). In Hawaii, 8% of the total population was estimated to be uninsured in 2009, according to the Henry J. Kaiser Family Foundation (Kaiser 2014).

What the nation should try to achieve is a near-universal system that provides basic health care to at least 95% of the population. As described in Chapter 1, Singapore switched from a British-style governmentrun system to one in which the markets and people’s self-reliance play a greater role and the government is responsible for providing health care only to the most needy. In the United States, high-deductible health plans with savings options, regular health insurance, defined contributions by employers toward purchase of individually desired health plans, financial contribution toward health care by everyone (with only a few exceptions), reformed Medicaid and Medicare, and charity care can all play a role in bringing about near-universal coverage and access under the umbrella of a consensus-driven government policy.

Under such a system, delivery of health care to all citizens is not the primary function of government. Experts sometimes decry the administrative costs and inefficiencies in the US health care system, but they do not take into account the inefficiencies and loss of productivity attributable to ever-increasing government regulations.

Single-Payer System

Many developed nations have been able to achieve universal coverage through a single-payer system, and their citizens have been able to accept supply-side rationing for specialty care and higher taxes. Thanks to a strong primary care system, these countries are able to provide basic services to nearly all citizens. In the United States, if this possibility exists, it appears to be far in the future.

As discussed previously in this book, despite notions to the contrary, a government-run, single-payer system does not achieve universal access —the ability of every, or nearly all, citizens to obtain health care when needed. This is because rationing is easier to achieve in a system financed entirely by the government.

One major advantage of a single-payer system is that all Americans and lawful residents would be entitled to some benefits. Private insurance plans and government entitlement programs (that is, Medicaid, Medicare, TriCare, and the Federal Employee Health Benefits Program) would no longer be necessary, although the market for some private insurance will remain for those desiring coverage beyond what a basic government plan might offer. Given that the United States has largely a private infrastructure for health care delivery, an American single-payer system would resemble the system in Canada (see Chapter 1). Costs would be contained through supply-side rationing, and higher taxes would be necessary to sustain the system. However, both rationing and taxes are likely to be resisted by the American public and most physicians.

Delivery Infrastructure of the Future

The future health care delivery infrastructure will evolve by incorporating the models and concepts described in this section. Some of these models and concepts are referenced in the ACA, but with little concrete proposals. They have been used on a small scale, and their widespread adoption is a few years away. Yet, some organizations have implemented the ideas presented here and have achieved positive results.

The health care infrastructure will continue to evolve, driven by an overarching concept of high-value health care focused on lowering costs, improving quality, and engaging patients in health care decisions. Yet, one model will not suffice to meet a variety of needs. Hence, many of the current structures of health care delivery will remain.

Future payment methods will also incorporate at least a value component. The evolutionary changes will also transform some of the traditional processes of health care delivery by placing an increased emphasis on evidence-based care and processes that eliminate waste. For example, improved surgical scheduling practices can reduce delays and cancellations of elective surgeries (Cosgrove et al. 2012). Redesigned workflows can improve efficiency. Cost-saving technology will play an increasing role in reformed processes of care. Finally, new approaches will be used to target programs to the needs of patients in the community who present specific health risks.

Physicians and nurses will have to be trained to practice in a wellness-oriented model of care delivery. To some extent, the delivery system will evolve to replace periodic encounters between patients and providers with an ongoing relationship that includes remote monitoring of health status and virtual consultations (Adler et al. 2009).

Implementing the Medical Home Model

The main concepts behind the medical home model are discussed in Chapter 7. Four critical issues have been identified in the implementation of this model:

1. Qualifying a physician practice as a medical home: A valid tool should capture the capabilities a medical practice should have to qualify as a medical home. This can help medical practices focus on the most important activities that would improve care. Research shows that four key primary care elements—accessibility, continuity, coordination, and comprehensiveness—positively affect health outcomes, satisfaction, and costs. An ideal qualification tool would ensure that medical homes are built on a firm foundation of these four pillars (O’Malley et al. 2008).

2. Matching patients to medical homes: For medical homes to achieve their potential to improve care, payers must link each eligible patient to a medical home practice in a way that ensures transparency, fairness, and matching of clinical needs. Equally important are adequate choice and awareness of the medical home model for patients. Also, physicians must be able to predict the additional revenue they can expect for acting as a medical home (Peikes et al. 2008).

3. Information exchange: There must be effective mechanisms for exchanging clinical information with patients and providers outside of the medical home. Adequate information exchange is necessary for care coordination across providers, care settings, and clinical conditions (Maxfield et al. 2008). This is because healing relationships grow in number and complexity when patients face serious or chronic illnesses. These patients have connections with multiple clinicians (Epstein et al. 2010). Accordingly, health care organizations should support more loosely affiliated “communities of care” besides individual clinician–patient relationships (Ubel et al. 2005).

4. Paying for medical homes: Existing payment systems do not compensate physicians for important activities such as care coordination and patient education. One major challenge is to determine an ideal array of services that result in high-quality and efficient patient care. Another challenge is that care coordination activities are difficult to itemize, may occur outside face-to-face encounters, and can vary in type and intensity across different patients. Hence, an effective payment system would require some sort of capitation or bundled fees that include an allowance for nonclinical patient care–related activities that physicians must perform.

Implementing Community-Oriented Primary Care

Community-oriented primary care (COPC) was introduced in Chapter 7. COPC would require developments on at least four fronts:

1. Primary care must take a central place in the delivery of health services. However, it will also require a refocus on how physicians are trained. Competencies needed for future practice include an understanding of the patients’ community, delivery of care within rural settings, and chronic disease management (Dent et al. 2010). For example, chronic disease registries have been used in Denver to target high-impact and high-opportunity areas of focus, such as diabetes, hypertension, and cancer screening. High-risk patients are then assigned to a medical home and a PCP (Cosgrove et al. 2012).

2. The biomedical model that has dominated both research and health professionals’ education must be broadened to include a stronger element of the social and behavioral sciences (Engle 1977).

3. Primary and secondary prevention (see Chapter 2) must be appropriately linked in a clinical setting with population-based health programs. Primary and secondary prevention, as well as certain aspects of tertiary prevention, are essential elements of primary care.

4. Public health functions must be strengthened as an adjunct to clinical interventions because clinicians alone cannot deal with most population-based health problems. Community organizations, such as schools, social service agencies, churches, and employers, must become partners in strengthening public health programs (Lee 1994).

Lessons From the Vermont Blueprint

In 2006, Vermont launched a program called Vermont Blueprint for Health. The pilot program has been shifting to a statewide program since the passage of the ACA. In essence, the Vermont Blueprint integrates the medical home model and COPC. It is based on a foundation of medical homes supported by community health teams and an integrated information technology infrastructure. Each community health team is staffed by five full-time equivalent employees and led by a registered nurse to serve a population of approximately 20,000. The teams offer individual care coordination, health and wellness coaching, and behavioral health counseling. For the program to be financially successful, there must be a measurable reduction in avoidable emergency department visits and hospitalizations (Bielaszka-DuVernay 2011).

The Role of Patient Activation

The choices patients make regarding daily management of their own health care profoundly affect utilization, costs, and outcomes. Many experts acknowledge that improvements in quality, cost containment, and reductions in low-value care will not occur without more informed and engaged consumers.

Patient activation refers to a person’s ability to manage his or her own health and utilization of health care. Activation necessitates patients to acquire some basic knowledge and skills and to be motivated to make effective decisions about their own health in partnership with their health care providers. In addition, activation often coincides with actual changes in behavior, such as changing one’s diet, engaging in physical activity, and having regular check-ups. Patient activation will continue to advance with the growth of information technology such as e-health, m-health, and the Internet become more widely used (see Chapter 5). For example, a self-management and telemonitoring program has been tried in Massachusetts to help patients with heart failure manage their health at home. The program yielded $10 million in savings and a 51% reduction in hospital readmissions (Cosgrove et al. 2012).

The challenge is that activation levels differ considerably across socioeconomic and health status characteristics. For example, among all insurance groups, people enrolled in Medicaid are the least activated (Hibbard and Cunningham 2008). Information and support may help close some of the gaps among various population groups, such as racial and ethnic minorities. Achieving this goal will require a close relationship, partnership, and mutual respect between providers and patients.

The Role of Patient-Centered Care

The IOM identified patient-centered care as one of the main elements of high-quality care. It defined patient-centered care as “respecting and responding to patients’ wants, needs and preferences, so that they can make choices in their care that best fit their individual circumstances” (IOM 2001). Patient-centered care seeks to increase the health professionals’ understanding of patients’ individual needs, perspectives, and values; gives patients the information they need to participate in their care; and builds trust and understanding. Patient-centered care is also a critical element in promoting patient activation. In patient activation the patient is more actively engaged and takes a greater degree of responsibility for his or her own health compared to patient-centered care. The patient-centered approach has a positive impact on outcomes, such as patient satisfaction, adherence to treatment regimens, and self-management of chronic conditions. One of the most frequently used systems to analyze physician–patient communication is the Roter Interaction Analysis System (RIAS), which also has been used for developing training programs in patientcentered communication for practitioners in primary care settings (Helitzer et al. 2011).

Future Workforce Challenges

An adequate and well trained workforce is a critical component of the health care delivery infrastructure. Chapter 4 discusses some of the workforce-related issues and challenges. This section highlights future needs and recommendations for change.

The Nursing Profession

In 2008, The Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) launched a 2-year initiative to highlight the need to assess and transform the nursing profession. A committee was assigned the task of producing a report that would make recommendations for an action-oriented blueprint for the future of nursing. Four recommendations have been put forth (National Academy of Sciences 2010):

1. Nurses should practice to the full extent of their education and training. Uniformity on the scope of practice for advance practice nurses, who have master’s or doctoral degrees, currently does not exist across states because of varying licensing and practice rules. Also, current residency programs for nurses focus primarily on acute care. To address future needs, residency programs must be developed and evaluated in community settings.

2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Increased clinical demands call for higher levels of education and training. Patient needs have become more complicated, and nurses need to attain requisite competencies to deliver high-quality care. These competencies include leadership, health policy, system improvement, research in evidence-based practices, teamwork and collaboration, and competency in specific content areas, including community health, public health, and geriatrics. Nurses are also being called on to fill expanding roles and to master technological tools and information management systems, while collaborating and coordinating care across teams of health professionals.

3. Nurses should be full partners with physicians and other professionals in redesigning health care. Being a full partner involves taking responsibility for identifying problems and areas of system waste, devising and implementing improvement plans, tracking improvement over time, and making necessary adjustments to realize established goals.

4. Effective workforce planning and policy making require better data and improved information systems. Data collection and analysis should drive a systematic assessment and projection of workforce requirements by role, skill mix, region, and demographics to inform changes in nursing practice and education.

Training of Primary Care Physicians

The shortage of PCPs and its exacerbation in the future is only one aspect of the challenge that must be addressed. Caudill and colleagues (2011) argue that the PCPs trained today will not have the requisite skills to fulfill their contemplated responsibilities because of a variety of factors. Future health care demands—mainly because of a growing number of people with complex chronic conditions—will require PCPs to function as “comprehensivists.” These comprehensivists will need to be experts in (1) anticipating, preventing, and managing the progression and/or complications of common complex conditions; (2) managing complex pharmacology; (3) understanding end-of-life issues and medical ethics; (4) coordinating care; and (5) leading health care teams. Their practice environments will need to contain the elements and systems to support comprehensive care, such as advanced information systems. Comprehensivists will also need to be able to direct and coordinate a health care team that includes expertise in patient education, mental health and behavioral modification, physical and occupational therapy, pharmacy, and home health. Care delivery will have to be consistent with evidence-based medicine, while incorporating the patient’s values (Caudill et al. 2011).

To train future PCPs, education must be more efficient, integrated, and longitudinal. Time must be created for medical students to learn essential elements of patient safety and quality, teamwork in the health care environment, health maintenance, and continuity of care, without sacrificing fundamental knowledge. A pay-for-educational-performance-and-outcomes model, with organizational bundling of educational costs, may need to be piloted in a similar way to the piloting of new care delivery models (Caudill et al. 2011).

Training in Geriatrics

Based on current trends, a shortage of health care professionals schooled in geriatrics is a critical challenge. Although coverage of geriatric issues at medical schools has been increasing, only about 9,000 practicing physicians in the United States (2.5 geriatricians per 10,000 elderly) have formal training in geriatrics. Without sustained efforts to improve training, this number is expected to drop to 6,000 in the future. Among nurses, fewer than 0.05% have advanced certification in geriatrics (CDC/Merck 2004). Evidence shows that care of older adults by health care professionals prepared in geriatrics yields better physical and mental outcomes without increasing costs (Cohen et al. 2002).

Current trends in the education and training of health care professionals shows that future demand will far outstrip the supply of physicians, nurses, therapists, social workers, and pharmacists with geriatrics training. This problem is compounded due to a shortage of faculty in colleges and universities who are trained in geriatrics. Only 600 medical school faculty out of 100,000 list geriatrics as their primary specialty. Due to this and other reasons, only 3% of medical students take any elective geriatric courses. In other disciplines as well, such as nursing, pharmacy, and dentistry, the majority of educational curricula do not require geriatric training. For example, 60% of nursing schools have no geriatric faculty (CDC/Merck 2004). Health professionals prepared in geriatrics are needed not just in long-term care. Geriatrics training is also important in other types of health services, such as oncology, neurology, rehabilitation, and critical care (Kovner et al. 2002). Even though there are encouraging signs that initiatives are being taken by educational institutions in recognition of a critical deficit in geriatric training, to date few concrete efforts have been made.

The Future of Long-Term Care

Financing and delivery of long-term care will remain a major challenge. The good news is that long-term care is typically needed later in life. Even though the first wave of baby boomers started retiring in 2011, they are not likely to need professional long-term care services until 2025 or later. However, the system must be reformed before that time comes. In their report to the National Commission for Quality Long-Term Care, Miller and Mor (2006) identified six main areas of concern that must be addressed: financing, resources, infrastructure, workforce, regulation, and information technology. In addition, a “scorecard project” proposes that a high-performing long-term care system must focus on support for family caregivers, ease of access and affordability, choice of settings and providers, quality of care and life, and effective transitions and organization of care (Reinhard et al. 2011).

Financing

Most middle-class families are unprepared to meet long-term care expenses. Most people think that Medicare will pay for their long-term care needs. Medicare covers only short-term, postacute care and, for reasons discussed in Chapter 10, only a small proportion of adults have private long-term care insurance. Unless policy initiatives are established to promote long-term care insurance plans, the public sector will see its expenditures grow rapidly. The CBO (2004) recommended improving the way private markets for LTC insurance currently function. For instance, private insurance could be made more attractive to consumers by standardizing insurance policies to allow competing policies to be more easily compared. Standardized policies could also stimulate price competition among insurers and help keep premiums lower than they would otherwise be. However, reform is also needed in the public financing system.

Resources

The Home and Community-Based Services (HCBS) waiver program (see Chapter 10) has achieved some successes in moving patients out of nursing homes to receive community-based care. However, research shows that Medicaid spending, which covers a substantial share of long-term care expenses, has actually increased, not decreased. It appears that the waivers may actually induce more people to enter the Medicaid program (Amaral 2010).

Infrastructure

The institutional long-term care sector has been going through a cultural change that has led to the creation of enriched living environments in nursing homes. New architectural designs, living arrangements, and worker and patient empowerment are improving the quality of life in nursing facilities that have adopted these innovative models, such as Eden Alternative, Green House Project, and Wellspring. Over time, traditional living and care arrangements will be replaced by these and other innovative models (for an overview of these models, refer to Singh 2010). Yet, care coordination and ease of transition between various settings is essential for a high-performing system. In addition, to navigate the multitude of services, a single point of entry is recommended (Reinhard et al. 2011).

Workforce

The aging of America will shrink the overall pool of workers. Experts think that this will have a drastic effect on long-term care in particular because of low pay and hard work. Between 2000 and 2010 alone, a deficit of 1.9 million direct care workers was estimated (DHHS 2003b).

Regulation

Many experts see fundamental contradictions between the existing regulatory mechanisms that address quality issues in nursing facilities through periodic inspections and sanctioning and regulations that require the same nursing facilities to implement quality improvement programs. Also, one of the most disconcerting aspects of government regulation of long-term care is its inconsistent application, both within and across regions over time (Miller and Mor 2006). These issues need to be resolved. In addition, quality monitoring is needed in home-and community-based services.

Information Technology

Interoperable IT systems (discussed in Chapter 5) will enable providers to track patients’ care across hospitals, nursing homes, home health agencies, and physicians’ offices. Such systems are particularly critical in long-term care because the elderly frequently make transitions between long-term care and non-long-term care settings. Currently, such transitions rarely occur smoothly because of high rates of missing or inaccurate information (Miller and Mor 2006).

Global Threats and International Cooperation

The prevention and control of infectious diseases globally will continue to pose major challenges. Examples include natural disasters, such as the earthquake and tsunami that killed thousands in Japan in March 2011; industrial accidents, such as the oil rig explosion in the Gulf of Mexico in April 2010; and large-scale bioterrorism, which has not yet occurred, but global unrest amid the rise of extremism makes it a real possibility in the future. Often, such events occur without warning. Large-scale devastation, such as that caused by the Haiti earthquake in January 2010, can severely strain a nation’s capacity to deal with mass casualties and rebuilding efforts. Increasingly, disasters will require international assistance, cooperation, and joint efforts.

Increase in air travel resulted in the spread of severe acute respiratory syndrome (SARS) from China to Canada in 2003 and of polio virus from India to northern Minnesota in 2005 (Milstein et al. 2006). These examples highlight the importance of early identification of infectious threats and subsequent rapid response to prevent further spread, which is often difficult without international cooperation (Johns et al. 2011). Many medical advances that physicians and patients take for granted, including cancer treatment, surgery, transplantation, and neonatal care, are endangered by increasing antibiotic resistance of infectious agents and a distressing decline in the antibiotic research and development pipeline (Infectious Disease Society of America 2004). Antibiotic resistance is both a public health and security threat. Virtually all of the antibiotic-resistant pathogens that exist naturally can be bioengineered through forced mutation or cloning. Also, existing pathogens could be genetically manipulated to make them resistant to available antibiotics. Currently, international efforts, including the establishment of a Transatlantic Task Force on Antimicrobial Resistance, are under way (Hughes 2011). Efforts to strengthen global health security include disease surveillance for outbreaks of international importance and urgency, exchange of technical information on new pathogens, and early warning and control of serious animal disease outbreaks.

International cooperative efforts include the Biological Weapons Convention (BWC) and the International Health Regulations (IHR). As a treaty among participating nations, the BWC bans development, production, stockpiling, or otherwise acquiring/retaining microbial or other biological agents or toxins. It also covers weapons, equipment, or means of delivery designed to use biological agents for hostile purposes or in armed conflict. It also promotes common understanding and effective action on biosecurity, national implementation measures, suspicious outbreaks of disease, disease surveillance, and codes of conduct for scientists. The IHR constitute an international legal instrument that is binding on 194 countries. IHR’s aim is to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide. In addition to the spread of infectious agents, the IHR can apply to other public health emergencies, such as chemical spills, leaks and dumping, or nuclear meltdowns (WHO 2008). Detecting and tracking significant public health threats that may emerge in countries that cannot or might not report such events to the global health community will be a challenge. The CDC’s Global Disease Detection Program will be increasingly involved in global public health surveillance, detection, and control of emerging infectious disease and bioterrorist threats (Christian et al. 2013). Similar efforts will be undertaken by the Global Emerging Infections Surveillance and Response System operated by the US Department of Defense.

Adequate delivery of health care to millions around the world depends on an adequate and well trained workforce. Worldwide, there is a shortage of nearly 4.3 million health workers. Moreover, 57 countries, 39 of which are in Africa, have fewer than 23 health workers for every 10,000 population. Even some of Asia’s burgeoning economies, such as India and Indonesia, can face a health care crisis in the event of a major disaster. The problem in many countries is compounded by an unequal distribution of workers, lack of training, and “brain drain.” Also, in spite of the pivotal role that community health workers play in scaling up essential services, this workforce category does not receive adequate support in most nations (Chatterjee 2011).

New Frontiers in Clinical Technology

Despite its association with cost escalation, technological progress will continue. Increased efforts in technology assessment (see Chapter 5) will go hand in hand with new innovations. To what extent clinical decisions will be influenced mainly by cost effectiveness of technology, however, remains an open question. As cost-effectiveness research continues to advance, its use will likely find its way into health policy.

Medicine is advancing on several fronts. The future looks bright with better cures, higher quality of care, and improved quality of life. Understanding of the human genome has paved the way for a number of ways to prevent and treat disease. Future innovation and progress, however, will not come automatically. Much will depend on the future regulatory posture of the FDA.

Genetic mapping is the first step in isolating a gene. It can offer firm evidence that a disease transmitted from parent to child is linked to one or more genes. The term genometrics is used for the association of genes with specific disease traits. The discovery of genetic susceptibility to certain diseases will improve preventive techniques. The human genome has also opened the way for the new field of molecular medicine , a branch of medicine that deals with understanding the role that genes play in disease processes and treatment of diseases through gene therapy. Gene therapy is a therapeutic technique in which a functioning gene is inserted into targeted cells to correct an inborn defect or provide the cell with a new function. This technique is expected to replace treatment with medications or surgery in some areas. The future challenge in this area is to develop methods that discriminately deliver enough genetic material to the right cells. Cancer treatment is receiving much attention as a prime candidate for gene therapy since current techniques (surgery, radiation, and chemotherapy) are effective in only one-half of cases and can greatly reduce a patient’s quality of life.

Personalized medicine and pharmacogenomics are relatively new fields. Pharmacogenomics is the study of how genes affect a person’s response to drugs. Personal characteristics of individual patients can vary so much that not all medications work for everyone. In personalized medicine, specific gene variations among patients will be matched with responses to particular medications to increase effectiveness and reduce unwanted side effects.

Drug design and delivery: Rational design to discover new drugs will increasingly utilize multidisciplinary advances in computers, statistics, molecular biology, biophysics, biochemistry, pharmacokinetics, and pharmacodynamics. Rational drug design will shorten the drug discovery process. The chief candidates for this process are drugs to treat neurological and mental disorders and antiretroviral therapies for HIV/AIDS, encephalitis, measles, and influenza. Application of knowledge at the molecular level ultimately aims to reduce labor cost, time, and laboratory expenses in the drug discovery process (Mavromoustakos et al. 2011). New drug delivery systems have the potential to provide more effective treatment. For example, cellular uptake of nanoparticles may efficiently translocate drug molecules into cancer tumors without damage to healthy tissues (Ding and Ma 2013). Nanotechnology also has the potential to deliver antiviral formulations to specific targeted sites and viral reservoirs in the body (Lembo and Cavalli 2010).

Imaging technologies have made one of the most dramatic advances in health care mainly because of the exponential growth in the performance of silicon devices (Busse 2006). Current research focuses on four areas: (1) finding new energy sources and focusing an energy beam to avoid damage to adjacent tissue and to minimize residual damage, (2) use of microelectronics in digital detectors and advances in the contrast media for a finer detection of abnormalities, (3) faster and more accurate analysis of images using 3-D technology, and (4) improvements in display technology to produce higher resolution displays. The rise of modern neuroscience and the rapid development of new technologies for imaging, treating, and modulating neural function are leading to an increased emphasis on the brain as the central site for medical intervention. The use of neuroimaging in understanding pain is only one area of intervention. Discovery and treatment of minor strokes and early detection of Alzheimer’s are two other areas where neuroimaging will improve treatment options (Adler et al. 2009).

Minimally invasive surgery is undergoing advances that include image-guided brain surgery, minimal access cardiac procedures, and the endovascular placement of grafts for abdominal aneurysms. The overall impact of minimally invasive procedures on cost efficiency and the patients’ quality of life from early recovery assures the growth of this technology and the growth of ambulatory surgicenters. The use of robotic surgery is in its early stages, and its superiority over traditional procedures has not yet been clearly demonstrated.

Vaccines have traditionally been used prophylactically to prevent specific infectious diseases, such as diphtheria, smallpox, and whooping cough. However, the therapeutic use of vaccines in the treatment of noninfectious diseases, such as cancer, has opened new fronts in medicine. At the same time, development of new vaccines for emerging infectious diseases remains on the research agenda. Making vaccines safer for wide-scale preventive use against bioterrorism in which such agents as smallpox and anthrax may be used will also be an ongoing pursuit.

Blood substitutes will likely be available one day for large-scale use. Even though the safety of blood used in transfusions has been greatly enhanced, substitutes for real blood are necessary when supplies fall short, particularly in war and in natural disasters.

Xenotransplantation , in which animal tissues are used for transplants in humans, is a growing research area. It presents the promise of overcoming the critical shortages of available donor organs. Organs from genetically engineered animals may one day be available for transplantation (Schneider and Seebach 2013).

Regenerative medicine is the first truly interdisciplinary field that utilizes and brings together nearly every field in science. This new field holds the realistic promise of regenerating damaged tissues and organs in vivo (in the living body) through reparative techniques that stimulate previously irreparable organs into healing themselves. Regenerative medicine also enables scientists to grow tissues and organs in vitro (in the laboratory) and safely implant them when the body is unable to be prompted into healing itself. This revolutionary technology has the potential to develop therapies for previously untreatable diseases and conditions. Examples of diseases regenerative medicine can cure include diabetes, heart disease, renal failure, osteoporosis, and spinal cord injuries. Virtually any disease that results from malfunctioning, damaged, or failing tissues could potentially be cured through regenerative medicine therapies (DHHS 2005).

Care Delivery of the Future

Gossink and Souquet (2006) paint a picture of what medical care in the future may look like. This will be achieved mainly through advancements in medical imaging, molecular medicine, and distant monitoring. Medical care will shift its focus from the acute phase of illness to prevention and aftercare. Lifestyle, family history, and genetic factors will be used to develop a patient’s risk profile. Patients with an elevated risk profile will be regularly screened for possible onset of acute disease and to follow the course of chronic disease. Some screening will be possible at home with the patient via wireless contact with the physician. If molecular diagnosis detects disease, the extent and location of the disease will be assessed through molecular imaging. Image-guided, minimally invasive procedures will be used if surgery is recommended. Pharmaceutical treatment will be individualized. A feedback system will determine needed drug dosage by a continuous measurement of drug concentration at the targeted site in the body. Miniature implanted devices will take over damaged body functions. Regenerative medicine and cell therapy will revive organs, such as a damaged heart. If needed, complete artificial organs, such as the pancreas, liver, and even heart, could be implanted. Physicians will be able to continuously monitor the condition of elderly patients with chronic conditions and could be dispatched in case of an emergency.

The Future of Evidence-Based Health Care

Research evidence has demonstrated that high-spending providers do not necessarily deliver better outcomes. The goal of evidence-based medicine (EBM) is to increase the value of health care services. Quality of care can actually be improved while reducing costs—thus, increasing the value of medical care—by reducing misuse and overuse (Slawson and Shaughnessy 2001). The tools for the practice of EBM have been developed for several years, mainly in the form of clinical practice guidelines (see Chapter 12). Evidence-based practice guidelines are intended to represent “best practices” and “proven therapies.” Halm and colleagues (2007) reported a remarkable reduction in the proportion of patients undergoing carotid endarterectomy (a surgical procedure that removes the inner lining of the carotid artery if it has become thickened or damaged by plaque) for inappropriate reasons. However, EBM’s full potential has not yet been realized, and work in this area will be ongoing.

Comparative effectiveness research (CER) is a more novel concept in which a chosen intervention is guided by scientific evidence of how well it would work, compared to other available treatments. In 2009, the Institute of Medicine defined CER as:

The generation and synthesis of evidence that compares the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. The purpose of comparative effectiveness research is to assist consumers, clinicians, purchasers, and policy makers to make informed decisions that will improve health care at both the individual and population levels. (IOM 2009)

The primary agency conducting CER is the Agency for Healthcare Research and Quality (AHRQ). It is hoped that CER will answer important clinical questions about what works best for which patients. It is also hoped that delivery of care informed by CER will lead to less waste and better health outcomes (Sox 2012). The American Recovery and Reinvestment Act of 2009 allocated $1.1 billion for this type of research.

Under the ACA, the Patient-Centered Outcomes Research Institute (PCORI) has been established. According to the PCORI, patient-centered outcomes research “helps people and their caregivers communicate and make informed health care decisions, allowing their voices to be heard in assessing the value of health care options” (PCORI 2013). The PCORI is collaborating with other agencies, such as the AHRQ, the FDA, and the National Institutes of Health (NIH) in its research activities that involve patients and other stakeholders (Fleurence et al. 2013). It remains to be seen how these agencies will work together and move forward in a common direction. Turf protection and other conflicts, typical of government bureaucracies, will result in duplicated efforts and waste, the very problems in health care delivery that are supposed to be minimized according to the stated missions of these agencies.

While the government’s efforts in promoting health services research are commendable, the question remains: Will it improve people’s health and save money? Timbie et al. (2012) have concluded that despite widespread enthusiasm about the potential impact of new investments in research, recent history suggests that scientific evidence has been slow to change clinical practice. Hence, any research efforts will need to be accompanied by appropriate strategies that would motivate providers to make use of research findings. Some critical areas that will require close attention include robustness of research studies, sound interpretation of results, relevance to clinical practice, formulation of clear and specific clinical practice guidelines, performance measures, clinical decision support tools, and properly aligned financial incentives (Timbie at al. 2012).

Strategies for Evidence-Based Care

Future strategies to improve guidelines and protocols and their adherence include:

• Health care leaders must continue to emphasize the adoption of evidence-based guidelines that are revised and updated in light of new research.

• Ongoing development of computer-based models incorporating EBM will facilitate multidisciplinary caregiving based on best practices by various practitioners, including physicians and nurses.

• Robust clinical trials will be the backbone of EBM. Adherence to clinical guidelines is higher when the recommendations are supported by evidence from randomized controlled trials (Leape et al. 2003).

• Future practice guidelines must incorporate economic analysis to promote the delivery of cost-effective health care.

• Financial incentives, including provider payments and patient cost sharing, must be restructured. Reimbursement methods should focus on paying for best achievable outcomes and the most effective care over the course of treatment instead of paying for units of service (Gauthier et al. 2006).

Strategies for Comparative Effectiveness and Patient-Centered Research

The key steps involved in CER are (1) identify new and emerging clinical interventions, (2) review and synthesize current medical research, (3) identify gaps between existing medical research and the needs of clinical practice, (4) promote and generate new scientific evidence and analytic tools, (5) train and develop clinical researchers, (6) translate and disseminate research findings to diverse stakeholders, and (7) reach out to stakeholders via a citizens forum (AHRQ 2011).

Etheredge (2010) has suggested that our collective knowledge about comparative effectiveness will grow more quickly if we can draw on the voluminous information that already exists in clinical trial databases and in other research data sets, rather than on new CER studies alone. Problems of noncomparability notwithstanding, if existing information can be extracted in a meaningful way, CER could then be used to fill research gaps.

Future priorities for CER include the capacity to conduct experimental and quasi-experimental comparative studies; evaluation of broad, system-level strategies, such as benefit designs and payment reforms; focus on population subgroups, including vulnerable groups, most likely to benefit from a given intervention; dissemination of research results; and the actual use of evidence in the delivery of care (Benner et al. 2010). At present, much remains unknown about the extent to which important stake-holders, such as physicians and patients, will be involved in patient-centered research.

Americans support research that would provide information on treatment options. Conversely, public support for research is contingent upon how medical evidence will be used in practice. The public remains opposed to the use of research for allocation of resources or for mandating certain treatment decisions (Gerber et al. 2010). The public’s attitudes may well become the biggest obstacle to cost-efficient delivery of health care in the future and to any attempts by the government to mandate certain types of care or to ration services.

Summary

Health care delivery in the United States and abroad will continue to change. The framework of future change presented in this chapter will help one understand the nature and direction of change. Political factors played a major role in the passage of the ACA, but the public’s experiences will likely determine its eventual success or failure. In any case, the ACA is not the final word on health care reform in the United States. Major challenges will need to be addressed as time progresses. Economic challenges, in particular, will force the need for future reform.

The demographic landscape continues to change, and various models and concepts of health care delivery are at an experimental stage. Eventually, a delivery system that encompasses the best of these ideas is likely to emerge. However, an infrastructure that lacks primary care delivery presents a major obstacle to achieving this goal. The financing and delivery of long-term care will put further strains on the system.

International threats will continue to be a part of globalization. Rapid response to deal with infectious diseases that can quickly spread around the world, natural disasters, and man-made threats of terrorism will increasingly require global assistance, cooperation, and joint efforts. Besides, many developing and underdeveloped countries face critical shortages of trained health care workers.

Progress in scientific innovation and development of new technology will continue. Future emphasis will be on cost-saving technologies.

Standardized protocols for practitioners will continue to be informed by scientific evidence that will include comparative effectiveness research and patient-oriented research. Their adoption into clinical practice, however, will not be automatic. It will require strategies that include financial incentives.

ACA Takeaway

• The future of the ACA in its current form remains in doubt. There is uncertainty about its effects on future employment and household incomes. A significant number of Americans, including physicians, disapprove of the ACA.

• The ACA could be a boon for part-time workers who can get government subsidies to buy coverage through the exchanges. However, the affordability of exchange-based health insurance is unknown.

• Whether or not the ACA will lead to a single-payer system will depend on the ACA’s promises becoming reality, how it will affect the majority of middle-class Americans, and how the external forces play out in the future.

• Mirroring the experience in Massachusetts, the ACA presages greater government control over health care through stifling regulations, lower reimbursement for providers, higher health care expenditures, and higher taxes.