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Prediction is difficult, especially of the future Neils Bohr atomic physicist

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... strongly about going to a hospital and allowing a surgeon to slice them open? ... Memory-enhancing drugs should reach clinical use by 2010. ... – PowerPoint PPT presentation

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Title: Prediction is difficult, especially of the future Neils Bohr atomic physicist


1
Prediction is difficult, especially of the
future-Neils Bohr(atomic physicist)
  • The Doctors World 2004 to 2054

2
Goals
  • Look at the future, with a critical eye
  • Draw conclusions regarding your training needs
  • If you dont know where youre going, you might
    end up there

3
U.S. Census BureauRAND corporationKaiser Family
FoundationConcord CoalitionWHOThe
Transformation of American Health Care The
Arduous Road to Value John L. Haughom, MDSenior
VP, Healthcare Improvement Also, Drs. Bagley
and Greene, from the AAFPs Graham Center for
Policy ResearchMost graphs souces annotations
in Notes view of this presentation
Some Sources
4
Some scenarios..
  • .Or, where the heck is my flying car?

5
1. Demographics Population Environment
6
Demography is destiny?
7
Growth implies age distribution changes
Watch the greater than 50 years old as years go
by.
8
Most of the growth is in the Developing World..
9
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10
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11
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12
Richard Smalleys notes on technology Note that
explosive population growth is a result of
technological advance
13
And technology is causing some problems
14
Major scientific groups agree that the globe is
warming
Not everyone thinks thats a bad thing..
15
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)
16
Population growth correlates with environmental
health risks
17
As population grows, so does demand for scarce
resources
The End of CHEAP Oil
18
Petroleum Use
19
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20
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21
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22
U.S. Population Changes
23
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24
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25
Aging Americans
  • By the mid-2020s at the latest, America will
    become a nation of Floridas .and then keep
    aging.

18.6
18.6
18.6
Today 18.6 of Floridians are age 65 and over
the highest senior citizen ratio in the country.
of the total U.S. population age 65 and over
26
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27
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28
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.
29
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30
Yet some areas will lose population..
31
Rural areas with a high proportion of population
gt65 y o
32
2 Economics
33
General Economic Trends GrowingSocial 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

34
The L Curve
lt-this is not the top of the line
100,000 10-cm (4-inches) high, 1 Million 1
meter high
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/
35
This is the top of the L curve
36
Income Inequality is at historic levels
37
Ownership and Wealth in America is more disparate
than any other industrialized country on Earth
38
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39
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40
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).
41
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42
Income Inequality is a great predictor of
homicide rates! (Equal to income alone)
Higher Inequality-?
Higher Income-?
43
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
44
What is our government response to this?
45
A look at the private health care sector...
46
Total Health Costs A Larger Share of our
Economy..
47
Health Coverage for the Non-Elderly
38.3 million
38.9 million
The economic boom of the 90s did not lift all
boats
48
Health Plan Enrollment for Covered Workers
1998-2001
Source Kaiser Family Foundation
49
No cost containment effort has worked for long
50
The debate over health care is less a pure
macroeconomic issue than an exercise in the
political economy of sharing. Uwe Rheinhardt
51
And most people are not happy.
Source Kaiser Family Foundation
52
What about government funded health care? (e.g.,
Medicare, Medicaid, etc.)
53
The Federal Budget somethings gotta give..
54
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55
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56
At current rates, Trust Fund runs dry in 2026
  • So, we will have to
  • Pay more
  • Do more with less
  • Deliver less (ration)

57
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58
3 Competition and Consumerism
  • In a setting of excessive costs, focus will be on
    cutting costs by new efficiencies, and
    controlling demands for service

59
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.

60
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
61
Healthcare Satisfaction Ratings
2600
  • Despite spending more than any other country in
    the world, healthcare satisfaction among US
    consumers lags behind similar ratings in many
    other industrialized countries

USA
2400
2200
2000
1800
Canada
1600
Per capita spending (US. dollars 1989)
France
Sweden
1400
Australia
1200
Netherlands
Italy
Japan
1000
United Kingdom
800
10
20
30
40
50
60
From the Center for Economics Research
Satisfaction rating
62
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!

63
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, TVs 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

64
Source Kaiser Foundation
65
Physicians Use of the Internet 2001
Source Kaiser Foundation
66
You Aint Seen Nothing Yet
  • Here come the Baby Boomers

67
The Internet Consumerism
What is the Consumer Report on Dr. Zelnick?
68
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69
The Internet Consumerism
70
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 Mar89(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 13186-7.
  • 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. 127726-732.
  • Effects of Feedback of Information on Clinical
    Practice - A Review, BMJ, 1991303398-402.
  • 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.

71
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 arent good, wouldnt you want to
    proactively know that and demonstrate you can
    improve?
  • Wouldnt riding the wave of change be a better
    long term survival strategy than refusing to
    participate?

72
Prescription Drug Benefits
  • An Example of Consumer Demand

73
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74
Prescription coverage has increased since 1990
75
And a large now have ? coverage
76
As a result,direct-to-consumer ads tripled over
just 4 years
77
The 4th Irresistible ForceMedical 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!
78
We know that 1/2 of what we teach will be wrong
in 20 years- we just dont 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 lt300
  • 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 gt90 of
    time

79
Some guesses about new areas you might need to
know about...
80
5th Irresistible Force I dont want to make
the wrong mistake.-Yogi Berra
81
Proportion of Medical Professionals Who Have
Witnessed Serious Medical Errors, 2001
82
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.

83
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.

84
And Family Medicine is having an Identity
CrisisThe 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.
85
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
86
Wild Cards
87
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88
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"--nutritio
    nal 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.

89
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
    youve learned?

90
My Goals for You.
  • Learn to expect and embrace CHANGE creatively
  • If youre not part of the solution, youre part
    of the problem
  • Think about SYSTEMS of care
  • Become a life-long Un-learner, as well as a
    LEARNER

91
The end of the beginning...
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