A few months ago I was invited to deliver the commencement address for a graduating doctoral class. In the process of thinking about what I would say, I realized that I would be addressing many who would retire from practice sometime around 2045. That sounded so distant while we are currently facing a brand new administration and their approach to health care reform. These new grads will be beginning practice right in the midst of what may be a tumult.
Subsequently, I have been pondering what the world of health care might be like then. As Niels Bohr once said, "Prediction is difficult, especially about the future." Since looking so far ahead may have little validity and offer equally little utility, I will look at some of the data instead, and offer some opinions.
New Administration and Health care Reform
While many policy wonks and political pundits are focused on economic bailouts and stimulus packages, there is also some puzzling being done on the Obama and Biden healthc are reform. What we do know, as stated on their Website (16 February 2009) concerning such reform is that ".the American people are too often offered two extremes - government-run health care with higher taxes or letting the insurance companies operate without rules." The new administration has ".proposed a plan that strengthens employer coverage, makes insurance companies accountable and ensures patient choice of doctor and care without government interference (and) . provides affordable, accessible health care for all Americans, builds on the existing health care system, and uses existing providers, doctors and plans to implement the plan. Under the Obama-Biden plan, patients will be able to make health care decisions with their doctors, instead of being blocked by insurance company bureaucrats."
So we can see that coverage, accountability, choice, affordability, accessibility, availability, expansion of the existing health care system, collaborative care, and mitigation of insurance company government interference are the critical factors. I have no disagreement with any of these; however, what I am concerned about is the complex interaction of all of these factors/variables and risk of unintended consequences versus synergies and economies.
To better understand this complexity, I needed some help. I went to biologist Edward O. Wilson's book Concilience (1998) which provided a fascinating discourse concerning the unification of knowledge across various disciplines. I then tried string theory as it looks to provide an integrated model from the molecular to the quantum. But when it comes down to health care, it seems that actually no one is in "control." There is no one-stop venue for understanding change or reform in health care.
There are public and private venues of care; for- and not-for-profit provider entities; and federal and state governments that are involved in certain areas and at certain times. So are academics and researchers; patient advocates and related groups; guild and professional organizations; the sway of public opinion; policy advisers and lawmakers; managed care and insurance companies; and likely a few others I've neglected to mention. But not even the Surgeon General is in control of health care reform.
Back to the Future: Some Predictions
So where will the future of health care reform start? The short answer is likely "everywhere." A friend and health care futurist, Jeff Bauer, PhD, has identified an excellent set of trends that may help to guide us in navigating these potentially treacherous reform waters.
For practitioners, he predicts growth in multidisciplinary groups with a concomitant rise of non-physician providers within "least-cost qualified practitioner models." Physicians may more likely be employed by large groups, organizations or hospitals, or they may become entrepreneurs and start their own groups, but solo practice may be more challenging.
There is a general decline in U.S. medical school admissions and currently some residencies are almost entirely filled with foreign medical school graduates. Both of these situations conspire to diminish the number of physicians in general.
Podiatric physicians are lobbying (in Illinois) for expanded scope of practice in their licensing acts in order to perform surgeries and procedures higher up from the foot ("working their way up the patient").
I think we will also see an uptick or continuing demand for physical therapists and assistants as we are already seeing expanded roles for nurses and physician assistants - both in situations of augmenting physician services and replacing physician services.
Bauer predicts that reimbursement trends will favor privatization with an array of choices and pricing; multiple tiers of care; a preference for "democratized" competition and increased consumer protections. Governmental policy will diminish, regulations will likely be chaotic (thus no change), and courts may sometimes set direction (by fiat). Health insurance will continue shift from work-based to individual-based, from defined benefit to defined contribution, and a proliferation of new types of plans and packages will evolve including wellness.
Health care technology will likely provided advances in the marvels of interventional radiology, 3D modeling, genetic markers, real-time monitoring, personal pharmacogenomics, regenerative biology, intelligent records, a shift in professional practice from "knowing" to "finding and interpreting," and greater consumer knowledge and empowerment.
No changes occur overnight or easily, no matter how welcome they may be. Health care consumers (formerly known as "patients") will be expecting choice but they may be more willing to pay for it, all care will be informed by if not also managed by evidence (and maybe paid for as well). Information may become the most valuable treatment commodity.
Our Leadership Responsibility
While I have a lot of faith in Bauer's prognostications as well as my own sprinkled herein, I believe we not only have the capability to shape our own futures as health care professionals, but when we have good ideas combined with innovative technologies, we can effect marked change and benefit care for all.
Physical therapy is already becoming more evidence based in its approach. More research is being published. More knowledge is being created. It is incumbent upon us to channel and utilize these tools as reform takes place and takes shape, and to take a leadership role in demonstrating our value in patient care-now and in the future.
Dr. Stout is the director of research at ATI Physical Therapy and a widely published author, lecturer, and researcher in health care. He is co-editor and author of The Evidence-Based Practice (Wiley & Sons, 2005).