Transcript Prediction is difficult, especially of the future… -Neils Bohr

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…”

Some Sources
U.S. Census Bureau
RAND corporation
Kaiser Family Foundation
Concord Coalition
WHO
The Transformation of American Health Care:
The Arduous Road to Value John L. Haughom, MD
Senior 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 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
Table 1-6: Annual Expenditure On Luxury Items Compared With
Funding Needed To Meet Selected Basic Needs
Product
Annual
Social or
Additional
Expenditure Economic Goal Annual
Investment
Needed to
Makeup
Reproductive Achieve Goal
$18 billion
Pet food in
Europe and
United
States
Perfumes
$17 billion
$15 billion
Ocean
cruises
$14 billion
Ice cream in
Europe
$11 billion
health care for
all women
Elimination of
hunger and
malnutrition
Universal
literacy
Clean drinking
water for all
Immunizing
every child
$12 billion
$19 billion
$5 billion
$10 billion
$1.3 billion
U.S. Population Changes
Aging Americans

By the mid-2020s at the latest, America
will become a nation of Floridas ….and
then keep aging.
20.5%
18.6%
18.2%
Today 18.6% of Floridians are age 65
and over – the highest senior citizen
ratio in the country.
12.5%
20.5%
4.1%
% of the total U.S.
population age 65 and over
1900
1940
1995
2025
2040
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: Growing
Social Pressures
Almost 44 million people have no health insurance

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
The “L” Curve
$100,000 = 10-cm (4-inches) high,
$1 Million = 1 meter high
<-this is
not the
top of
the
line…
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 the top of the L curve
Mount
Everest
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
Age 65 and over
$17,688
$21,122
in 2010

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
$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 NonElderly
38.9 million
38.3 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
PerCapital Heath Expenditures
$0
$1,000
$2,000
$3,000
$4,000
$5,000
0
$2,369 France
$2,373Japan
10
United Kingdom
20
DALE rank (WHO)
$1,303
30
40
$131
Cuba
Canada
$1,783
$1,730 Australia
50
60
70
$240
Mexico
$4,187
United States
80
#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

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…..
Managing care does not mean managing physicians and nurses. It
means giving physicians and nurses the tools they need to manage
optimal care….
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
$2600
Per capita spending (US. dollars 1989)
$2400

USA
$2200
$2000
Despite spending more than any
other country in the world, healthcare
satisfaction among US consumers
lags behind similar ratings in many
other industrialized countries*
$1800
Canada
France
Sweden
$1600
$1400
Australia
$1200
Italy
Netherlands
Japan
$1000
United Kingdom
$800
10
20
30
40
50
Satisfaction rating
60
* From the Center for Economics Research
Rising Consumerism in America

A new consumer is emerging
–
–
–
–
Assertive (better educated, less time)
Focused
Pragmatic
Demanding (not tolerant of inadequate information, poor
service, inconvenience, poor value, etc.)

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!
What Consumers Will Want from
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
Source: Kaiser Foundation
Physicians’ Use of the Internet 2001
Source: Kaiser Foundation
You Ain’t Seen Nothing Yet

Here come the Baby Boomers
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
Cost
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.
LOS on Clinical Practice - A Review,” BMJ,
– ”Effects of Feedback of Information
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.
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…
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!
2027
S1
2008
1989
1970
“We know that 1/2 of what we teach will be wrong
in 20 years- we just don’t know which half!”
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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.
Things Would Change About Family Practice:
Compensation, Regard, Managed Care
- Most common responses 21
Make it more financially
rewarding
21
14
Make Family Medicine
more highly regarded
among the public
16
5
11
7
17
Ged rid of managed care
8
11
Insurance companies
should not dictate
policies/procedures
Eliminate some of the
paperwork
9
8
7
5
12
Q26. If there was one thing you could do to change the practice of family medicine, what would that be?
Base: FP National
Cross-section
Urban
Rural
Wild Cards
Political
Economic
Social
Technological
Environmental
Medical
Berlin Wall, Iraq
War, Jesse Ventura
Japan's Financial
crisis, Oil embargo
Race relations
Materials, Microchip,
DNA testing
Global Warming,
Ozone hole, Oil
crisis
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...