Monday, January 4, 2010

Ten Predictions About the Organization of Health Care for the Coming Decade

While other blogs have their Top Ten past year in review or next year’s predictions list, the intrepid Disease Management Care Blog is going one log-step further with a series of predictions for the next decade. What's more, ten year prognostications about genetics, heart disease and cancer are for amateurs. Your DMCB offers up bigger stuff about the organization of health care.

Call it Thoughts on the Looming Teens, Divinations on the Coming Decade, Augury Ver. 10-19, or.... mere speculation, the DMCB offers up these trends for your consideration:

1. The Democratization of Medical Information – We are getting to the point where data storage and processing is about to hit us like a Gutenberg Bible.

Persons will not only be able to obtain, review, store and modify their personal information, they’ll have the final say over the use of their data for growing need for applied health services research. For many reasons (including their personal benefit and less concern about privacy), the majority will willingly opt-in (or elect to not opt-out) and participate.

What’s more, thanks to the demand of lay persons for useful insights about their health and disease as well as the increasing number and sophistication of multiple media outlets (including blogs), complex research information and analyses will be made understandable to non-professionals. In fact, medical journals that fail to cater to this audience will find themselves sidelined to serving insular niches of pyknotic academia.

Last but not least, the granularity of this perfect information storm will enable society to drive a stake through the heart of a crumbling mainframe medical approach of managing to the average outcome. Subgroup analyses, confidence intervals and genetic information will facilitate a far more personalized and distributed approach to care. Let's hope we figure out how to pay for it.

2. Classic Health Economics Fades to Black – The lingering inability of ultra-specialized academic economists to adequately explain the interplay between the demand and the use of health care services will be altered by the lifeblood infusion of the sciences of anthropology, sociology and psychology. If you want to succeed in this field, now is a good time to be a well-read non-specialist. If you're a medical journal, now's the time to think about the make up of your reviewers and editors.

3. Whither medical devices? Unable to shake our morbid fascination with gadgets and using them to cheat death, the increasing use of internal and external devices, monitors, pumps, stickers, probes, wires and radios will drive their alliance with an army of professional non-physicians who will advise, coach, text, prompt and educate. Think Batman Utility Belts and Dick Tracey Radio Watches unrestrained by notions of size or the presence of a skin barrier, especially since 99% of us will be permanently tethered to the internet. This will power old fashioned disease management.

4. The demise of 'single line' primary care – Yes, this is painful thought, but thanks to the emergence of cheaper better faster options such as self care, remote care, eVisits, convenience clinics, health information technology support, nurse practitioners, physician assistances, nurses and community health workers, my primary care colleagues are going to get sidelined. Outside of Number 10 below, the PCP's options include geriatric medicine, tatoo removal or writing to their Congressman. Only one of these options will pay well, and the sooner they - and policy makers - realize it, the better.

5. The fading of subsidies and rise of government costs – Despite the generosity of the current Congress and a landmark healthcare bill, the inexorable demand for health care in the face of limited resources combined with a failure to restrain costs will force a future and more conservative government to turn to the old tricks: higher eligibility thresholds, higher out of pocket costs, caps on benefits, co-pays and denials of coverage over notions of medical necessity. There will be law suits over interpretations of the entitlement language, Congressional hearings, more Czars and the growth of a unwieldy. overlawyered and hyper-regulatory blob. Think today's commerical insurers have too much overhead? You ain't seen nothing yet.

6. Black Swans – the health care system will be rarely but severely rocked by unexpected stresses. Examples include a new pandemic, an act of terror or the election of Sarah Palin. Equally unpredictable will be how society responds by altering the health care system. If severe enough, this is how single payor advocates will finally get their wish.

7. Health insurers become regulated utilities – Semi-public and heavily overseen, expect them to become functional regional monopolies (technically they'd be monopsonies) that are brought to heel with paper thin profit levels, public hearings over rates and an occasional stab at competition. Unless number 6 happens, this will be the closest we get to a single payor.

8. Congress will not give up control - A well run enterprise overseen by a smart Board of Directors is typically guided by the adage of ‘nose in’ (ask a lot of questions, give smart counsel) and ‘hands off’ (other than setting policy, don’t run things unless you really really have to). Despite noises about an insulated Federal decision-making body, the various Committees of Congress will continue to behave like a well intentioned activist and meddlesome Board of Directors: nose in, hands in. Heaven help us.

9. Conservatism will become cool again - While this prediction is somewhat dependent on our cultural sine wave, Ron Paul’s run at coolness combined with an inevitable overreach of Washington DC makes the DMCB think that the tweeners will embrace notions of personal liberty, private enterprise, profit motive and capitalism in all things including health care. It will start as a backlash against penalties for unhealthy living -- like failing to eat veggies or brazenly dancing like Matrix partygoers the night before the Machines come.

10. The DMCB Can't Let Go of Unification Theory - After trying every siloed approach to increasing clinical, humanistic and economic outcomes for populations, 'care management' will finally unify the personal/electronic health record, accountable care organizations, the medical home, disease management and pay for performance/partial capitation into synergistic and overlapping approaches to care. Everyone will agree that one cannot exist without the others. Between here (2010) and there (2019), there will be winners and losers.

Finally, the DMCB offers up this freebie. The Next Big Social Issue will be the failure of higher education to prepare college graduates for competition in the global economy. Consumers, parents and elected officials will attack the high cost and poor outcomes of an insular not-for-profit university system that caters to itself. If you're thinking of running for office in four to eight years, it's time to bone up on this. You're going to need it. Come up with solutions and you will be elected.


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