Prediction is difficult, especially of the future…

-Neils Bohr(atomic physicist)

The Doctor’s World: 2004 to 2054

Goals:

Look at the future, with a critical eye Draw conclusions regarding your

training needs “If you don’t know where you’re going,

you might end up there…”

U.S. Census BureauRAND corporation

Kaiser Family FoundationConcord Coalition

WHOThe Transformation of American Health Care:

The Arduous Road to Value John L. Haughom, MDSenior VP, Healthcare Improvement

Also, Drs. Bagley and Greene, from the AAFP’s Graham Center for Policy Research

Most graph’s souces & annotations in “Notes” view of this presentation

Some Sources

Some scenarios…..

….Or, where the heck is my “flying car”?

#1. Demographics: Population & Environment

Demography is destiny?

Growth implies age distribution changes

Watch the % greater than 50 years old as years go by….

Most of the growth is in the Developing World..

Richard Smalley’s notes on

technology: Note that explosive population growth is a result of technological advance…

And technology is causing some problems…

Major scientific groups

agree that the globe is warming…

Not everyone thinks that’s a bad thing…..

2 out of 3 Australians will have a skin cancer at some point in their lives

-National Geographic

Death from Air Pollution:

300-500k/yr Africa,

500k-1M/yr Asia

Water Pollution:

By 2040, 3.5 billion people will not have potable water (10x the number in 1995)

Population growth correlates with environmental health risks

As population grows, so does demand for scarce resources…

The End of CHEAP Oil

Petroleum Use

Product Annual Expenditure

Social or Economic Goal

Additional Annual Investment Needed to Achieve GoalMakeup

$18 billionReproductive

health care for all women

$12 billion

Pet food in Europe and

United States

$17 billion

Elimination of hunger and

malnutrition$19 billion

Perfumes$15 billion

Universal literacy

$5 billion

Ocean cruises

$14 billionClean drinking

water for all$10 billion

Ice cream in Europe

$11 billionImmunizing every child

$1.3 billion

Table 1-6: Annual Expenditure On Luxury Items Compared With Funding Needed To Meet Selected Basic Needs

U.S. Population Changes

Aging Americans

By the mid-2020s at the latest, America will become a nation of Floridas ….and then keep aging.

% of the total U.S. population age 65 and over

18.6%

1900 1940 1995 2025 2040

20.5%

18.2%

12.5%

20.5%

4.1%

Today 18.6% of Floridians are age 65 and over – the highest senior citizen ratio in the country.

18.6%

18.6%

New Data Projects Alzheimer's Disease in U.S. Could Affect up to 16 Million by 2050 Research Estimates Current Alzheimer Population at 4.5 million Stockholm — New research released today at the 8th International Conference on Alzheimer's Disease and Related Disorders, sponsored by the Alzheimer's Association, indicates that the prevalence of the disease in the United States will increase from 4.5 million in 2000 to between 11 and 16 million by the year 2050.

Yet some areas will lose population..

Rural areas with a high proportion of population >65 y o

#2 Economics

General Economic Trends: GrowingSocial Pressures

Source: Employee Benefit Research Institute estimates from the Current Population Survey, March 1988-2003 Supplements.

a - Results are based on Census 1990-based weights.b - Results are based on Census 2000-based weights.

See appendix in Fronstin, Paul. "Sources of Coverage and Characteristics of the Uninsured: Analysis of the March 2003 Current Population Survey." EBRI Issue Brief number 264, December 2003

Almost 44 million people have no health insurance

The “L” Curve

Partial Graph of the U.S. Income Distribution.   The graph represents the population of the United States lined up, left to right, according to income.  The height of the graph at any point is the height of a stack of $100 bills equaling that person's income. From “The L Curve”: http://www.davidchandler.com/lcurve/

<-this is not the top of the line…

$100,000 = 10-cm (4-inches) high, $1 Million = 1 meter high

Mount Everest

This is the top of the L curve

Income Inequality is at historic levels

Ownership and Wealth in America is more disparate than any other industrialized country on Earth…

In 2002, 12.1 million American children younger than 18 live below the poverty line, and one out of every six American children (16.7 percent) was poor. That is more children living in poverty today than 25 or 30 years ago. A child in America is more likely to live in poverty than a child in any of the 18 other wealthy industrialized nations (for which

data exist).

Income Inequality is a great predictor of homicide rates! (Equal to income alone…)

Higher Inequality-

Higher Income-

Inadequate Investment in Future Generations

What the federal budget spends on each elderly American dwarfs what it spends on each child. Per capita federal benefit spending in FY 2000, by age group

Under age 18

Age 65 and over

$17,688$21,122 in 2010

$2,541 in 2010

What is our government response to this?

A look at the private health care sector...

Total Health Costs: A Larger Share of our Economy..

Health Coverage for the Non-Elderly

38.3 million38.9 million

The economic boom of the 90’s did not “lift all boats”

Health Plan Enrollment for Covered Workers 1998-2001

Source: Kaiser Family Foundation

9.5

7.4

No cost containment effort has worked for long…

“The debate over health care is less a pure macroeconomic issue than an exercise in the political economy of sharing.” –Uwe Rheinhardt

And most people are not happy….

Source: Kaiser Family Foundation

What about government funded health care?

(e.g., Medicare, Medicaid, etc.)

The Federal Budget: somethings gotta give…..

At current rates, Trust Fund runs dry in 2026

So, we will have to:

•Pay more

•Do more with less

•Deliver less (ration)

Spending vs. Outcomes

$2,369$2,373

$1,303

$1,783$131$1,730

$240

$4,187

0

10

20

30

40

50

60

70

80

$0 $1,000 $2,000 $3,000 $4,000 $5,000

PerCapital Heath Expenditures

DA

LE r

ank

(WH

O)

United States

United Kingdom

Mexico

Cuba

Japan

France

Canada

Australia

#3 Competition and Consumerism

In a setting of excessive costs, focus will be on cutting costs by new efficiencies, and controlling

demands for service

The Most Expensive Medical Instrument in the World

Managing care does not mean managing physicians and nurses. It means giving physicians and nurses the tools they need to manage optimal care….

Studies have shown….– Over 80% of the costs and most of

the quality is driven by physician decisions

Experience has shown….– Failure of Efforts to Change

Actual Medical Practices Gets Much of the Blame. [for the failure to control health care inflation]” (Wall Street Journal, May 19, 1998)

– PeaceHealth…..

New Competitive Pressures

Healthcare is now exposed to market forces, and must respond as any business

Providers will have to– drive their costs down – improve productivity just to remain in the game.

Cost efficiency will be necessary for survival in the new healthcare market,

but it will not be sufficient for long-term success.

43

Healthcare Satisfaction Ratings

10 20 30 40 50 60

$800

$1000

$1200

$1400

$1600

$1800

$2000

$2200

$2400

$2600

USA

CanadaFrance

Sweden

AustraliaNetherlands

ItalyJapan

United Kingdom

* From the Center for Economics Research

Despite spending more than any other country in the world, healthcare satisfaction among US consumers lags behind similar ratings in many other industrialized countries*

Per

cap

ita

sp

end

ing

(U

S.

do

llar

s 19

89)

Satisfaction rating

A new consumer is emerging– Assertive (better educated, less time)– Focused– Pragmatic– Demanding (not tolerant of inadequate information, poor

service, inconvenience, poor value, etc.)

Rising Consumerism in America

This consumerism is dramatically changing other industries– Many examples (e.g., retail, financial services, etc.)– Case history: Book retailing

The same forces will impact health care!

Convenience– Give me good information and let me participate in my care– Help me do it myself

Information– “Consumer Reports” of health care– If they care enough about toasters, TV’s and cars, do you

doubt they will feel equally strongly about going to a hospital and allowing a surgeon to slice them open?

Support– Reduce costs, document & raise quality, improve access

What Consumers Will Want from Health Care

Source: Kaiser Foundation

Physicians’ Use of the Internet 2001

Source: Kaiser Foundation

Here come the Baby Boomers

You Ain’t Seen Nothing Yet

                                        

The Internet & Consumerism

What is the Consumer Report on Dr.

Zelnick?

The Internet & Consumerism

Does Physician Profiling Work? There are many studies of the effects of profiling, usually

showing that variation declines and outcomes improve. For instance:

– Information sharing can reduce laboratory use by emergency physicians. Ramoska, EA, Am J Emerg Med. 1998 Jan; 16(1): 34-6.

– Effectiveness of a physician education program in reducing consumption of hospital resources in elective total hip replacement. Johnson CC; Martin M, South Med J. 1996 Mar;89(3): 282-9.

– Provider and practice profiling with electronic patient records. Churgin, P, In: Toward an electronic patient record ‘97: proceedings, volume one. Newton, MA: MRI, 1997. :8-12.

– Using profiling for cost and quality management in the emergency department. Ahwah I, Karpiel M. AHSR FHSR Annu Meet Abstr Book. 1996; 13:186-7.

– “Case Study of Physician Profiling,” Managed Care Quarterly, 1994; 2(4):60-70.– “Measuring and Reporting Managed Care Performance: Lessons Learned and New Initiatives,” Annals of

Internal Medicine, Part 2, 15 October 1997. 127:726-732.

– ”Effects of Feedback of Information on Clinical Practice - A Review,” BMJ, 1991;303:398-402.

I especially like the last reference, a review article of more than 30 studies in the British Health Service of the effects of profiling - in every case the variation in care declined

and outcomes improved.

Cost

LOS

Some Questions...

Would it be ideal to have access to your own, reliable, cost and quality data to compare to such “report cards” and disprove them if you feel your “grade” is inappropriately low?

If your results aren’t good, wouldn’t you want to proactively know that and demonstrate you can improve?

Wouldn’t “riding the wave of change” be a better long term survival strategy than refusing to participate?

Prescription Drug Benefits

An Example of Consumer Demand…

Prescription coverage has increased since 1990

And a large % now have coverage…

As a result,”direct-to-consumer” ads tripled over just 4 years…

1970

19892008

2027S1

The 4th Irresistible Force:Medical Information Explosion

Medical knowledge doubles every 19 years, or 4x over a practice lifetime.

The average FP has 12 unanswered, clinically

important, questions every day!

“We know that 1/2 of what we teach will be wrong in 20 years- we just don’t know which half!”

Ulcers are caused by stress. Never give -blockers to CHF patients Steroids are contraindicted in childhood asthma Episiotomies are best for women Nitrates should not be given for Acute MI Circumcisions are good Pneumoencephalogram is best way to image ventricles Must do hernia under general anesthetic. Keep postop in bed x 1 week, no lifting for 3

mos. A normal cholesterol is <300 Order a SMAC-20 yearly in all pts. Have an Annual Physical All Admissions get VDRL, even if done last week Treat MI with 6 weeks of bedrest Treat back pain the same way! Hospitalize uncontrolled Diabetics to get better handle on BS Male sexual problems are psychological >90% of time

Some guesses about new areas you might need to know about...

5th Irresistible Force: “I don’t want to make the wrong

mistake”.-Yogi Berra

Proportion of Medical

Professionals Who Have Witnessed

Serious Medical

Errors, 2001

The Institute of Medicine 2001: “To Err Is Human”

The US health care system is seriously flawed and is a major source of morbidity, mortality and missed opportunities to benefit people.

There is not just a gap, but a chasm between what is and what can and should be provided to people.

The system can not be fixed in its current form; it is in need of fundamental change and must be re-designed.

So! At the beginning of the 21st Century:

The myth that the United States has the best health care system in the world is exposed.

We are witnessing an awakening to the fact that our 70-year commitment to specialism, reductionism and biomedicine, even though productive, has proved insufficient.

A new world of medicine, not yet born but gestating, is coming right at us.

And Family Medicine is having an Identity Crisis…

“The Future of Family Medicine”

FFM Charge: Develop a strategy to transform and renew the specialty of family practice to meet the needs of people and society in a changing environment.

12

8

8

11

14

5

9

17

5

21

7

11

7

16

21

Eliminate some of thepaperwork

Insurance companiesshould not dictate

policies/procedures

Ged rid of managed care

Make Family Medicinemore highly regarded

among the public

Make it more financiallyrewarding

Cross-section

Urban

Rural

Things Would Change About Family Practice: Compensation, Regard, Managed Care

- Most common responses -

Q26. If there was one thing you could do to change the practice of family medicine, what would that be?Base: FP National

Wild CardsPolitical Berlin Wall, Iraq

War, Jesse Ventura Economic Japan's Financial

crisis, Oil embargo Social Race relations

Technological Materials, Microchip, DNA testing

Environmental Global Warming, Ozone hole, Oil crisis

Medical AIDS

Wonderful things might happen too…• The Human Genome Project cures for hemophilia, cystic fibrosis, familial hypercholesterolemia, a number of cancers, and

AIDS. Eventually, some 4,000 hereditary disorders may be prevented or cured through genetic intervention. As many as 300 such treatments are expected to enter clinical testing by 2005.

• The discovery that human chorionic gonadotropin (hCG) appears in all cancer cells tested thus far, and (among adults) only in cancer cells, seems to promise the development of a generalized "cure for cancer." If early tests pan out, by 2010 or sooner, tumors could be treated routinely and successfully with simple injections in the family doctor's office.

• Designer drugs to fit specific receptors in the cell. Drugs created through this technology often are much more effective than natural derivatives or the products of "synthesize, scan, and hope" methods, and they are much less likely to cause adverse side effects.

• By 2005, artificial blood will begin to stretch the supply of blood, which is expected to fall short of demand by 4 million units per year for the next 30 years.

• Memory-enhancing drugs should reach clinical use by 2010.• New computer-based diagnostic tools are providing unprecedented images of soft and hard tissues inside the body,

eliminating much exploratory surgery.• "Bloodless surgery" using advanced lasers is reducing patient trauma, continuing to shorten hospital stays, and helping lower

medical costs.• "Magic bullet" drug-delivery systems will make it possible to direct enormous doses of medication exactly where they are

needed, sparing the rest of the body from possible side effects. • Brain-cell and nerve-tissue transplants to aid victims of retardation, head trauma, and other neurological disorders will enter

clinical use by 2005. So will heart repairs using muscles from other parts of the body. Transplanted animal organs will find their way into common use. Laboratory-grown bone, muscle, and blood cells also will be used in transplants.

• Other transplanted tissues will come from cloning and related technologies used to grow stem cells. Radical new treatments for diabetes, Parkinson's disease, perhaps Alzheimer's, and many other refractory disorders can be expected to arrive within the next five to 10 years. Whether American physicians will be allowed to use them is still being debated. Forecasting International believes that cloning and related methods will be accepted for the treatment of disease.

• Surgeons working via the Internet will routinely operate on patients in remote areas, using robot manipulators.• In the next 10 years, we expect to see more and better bionic limbs, hearts, and other organs; drugs that prevent disease

rather than merely treating symptoms; and body monitors that warn of impending trouble. These all will reduce hospital stays.

• "Nutraceuticals" and "food-aceuticals"--nutritional supplements and foods with drugs either added or genetically engineered into them --will be one of the hottest new areas in the health-care industry for the next 20 years.

• By 2025, the first nanotechnology-based medical therapies should reach clinical use. Microscopic machines will monitor our internal processes, remove cholesterol plaque from artery walls, and destroy cancer cells before they have a chance to form a tumor.

So, What Have You Learned From this Session?

What are your learning goals.. What can you expect in the future What is your role and responsibility,

given what you’ve learned?

My Goals for You….

Learn to expect and embrace CHANGE creatively

“If you’re not part of the solution, you’re part of the problem”

Think about SYSTEMS of care Become a life-long Un-learner,

as well as a LEARNER

The end… of the beginning...