This document discusses the future of health services delivery. It identifies 8 forces that will drive future changes: social/demographic, economic, political, technological, informational, ecological, global, and cultural. It examines implications of these forces, including the future of health reform, insurance coverage, costs, and workforce needs. New models of care delivery and payment emphasize primary care, prevention, care coordination, and patient engagement. Emerging technologies will transform diagnosis and treatment.

2. Chapter 14
The Future of Health Services
Delivery

3. Learning Objectives
• To identify the major forces of future change
and how they will affect health care delivery
• To assess the future of the Affordable Care Act
and health care reform in the United States
• To discuss the components necessary to build
a delivery infrastructure for the future
• To understand the special skills needed by
future nurses, physicians, and other health
care workers

4. Learning Objectives
• To evaluate the future of long-term care
• To appreciate the role of international
cooperation in dealing with global threats
• To obtain an overview of new frontiers in
clinical technology
• To survey the future of evidence-based health
care based on comparative effectiveness
research and patient-oriented outcomes
research

5. Introduction
• Future direction of health care is governed by:
– Current developments, e.g., the ACA has already
triggered changes, but its full effects will not be
known for some time to come
– Forces external to health care delivery, e.g.,
demographic change, the economy, family
incomes, etc.
– Historical precedents, e.g., private infrastructure
and societal values, state-based health reform,
etc.

6. 8 Forces of Future Change
• Social and demographic
• Economic
• Political
• Technological
• Informational
• Ecological
• Global
• Anthro-cultural

7. Implications of External Forces
• The nature of change in health care depends on
complex interactions between these forces and the
way opportunities are garnered or foregone
• Implications for cost (affordability), access, and power
balancing
• Free market forces do not drive US health care – the
government has been a major player that wields legal
and regulatory powers. Yet, the government needs the
power sector. Tension and power balancing between
the two sectors will continue.
• Delivery of health care is closely tied to the nation’s
economic health

8. Social and Demographic Forces
• The US is becoming bigger, older, and ethnically diverse
• Effects on the need for health care and how the needs
will be met
• The nation’s ability to afford health care; growing
populations of the elderly, disabled, and Medicaid
beneficiaries:
– Expanding government programs are on an
unsustainable financial path
– Implications for supply of health professionals
• Cultural factors will create ongoing challenges
• Uninsured illegal immigrants tap into resources
• Personal lifestyle choices cannot be fully incentivized

9. Economic Forces
• National debt – spending cuts, tax increases, and
economic growth will be needed
• Economic growth – growth has been slow; growing
dependency on government handouts does not bode
well
• Employment and household income: incomes has fallen
• National health expenditures are expected to consume
almost 20% of GDP in 2022
• A golden prospect: The US is now the world’s largest
energy producers – but, much will depend on future
energy policy

10. The ACA and the Economy
• Effect on employment and incomes is uncertain
• Some evidence that employers are delaying or
cutting hiring, and reducing worker hours to skirt
the law’s mandate
• Part-time workers could get government
subsidies to buy health insurance through the
exchanges
• However, the affordability of exchange-based
plans is unclear

11. Political Forces
• Education and immigration policies the
number and qualifications of health care
workforce
• Americans remain divided on major policy
issues, including health care
• Politics also has an effect on the economy and
taxes
• So far, raising the debt ceiling rather than
reducing spending has occupied US politicians

12. Technological Forces
• Technology will continue to revolutionize
health care, but cost increases will create
challenges
• Technologies that increase self-reliance and
cost efficiency will receive much attention
• Utilization control measures could also receive
attention

13. Informational Forces
• Garnering IT’s potential for health care
delivery and management of health care
organizations will continue well into the future

14. Ecological Forces
• Major implications for public health
– New diseases
– Natural disasters
– Bioterrorism
• World population growth will intensify human-
animal-ecosystems interface engendering new
diseases
• Technology will find new applications in public
health and safety
• Dealing with public health threats also divert
resources from routine health care

15. Global Forces
• Globalization intensifies cross-national cultural, economic,
political, social, and technological interactions – health
and health care will be affected in diverse ways through
multiple pathways
• Example: cross cultural factors affect the effectiveness of
professionals that are part of “brain drains” or “brain
gains”
• Some signs of increasing globalization:
– Drugs manufactured in Asia are exported to western
nations
– Medical tourism
– Cross-border telemedicine
– Desire of foreign hospitals and clinics to move into the
US

16. Anthro-Cultural Factors
• Beliefs, values, ethos, and traditions espoused
primarily by the middle class
• Historically, these have acted as a strong
deterrent to radical changes in health care
• Disapproval of the ACA has increased among
Americans
• The American public could end up deciding
the ACA’s final fate

17. The Future of Health Reform
• Will the US have a single-payer system in the
future?
• Much will depend on the ACA’s successes and
failures and how the forces discussed earlier
play out in the future

18. Lessons from Massachusetts
• With some caution, lessons can be drawn about the
ACA
• The Massachusetts plan has achieved some
successes, but cost remains the main issue
– Remarkable increase in insurance coverage
– 62% have employer-based coverage
– In the Connector (exchange), premium increases
surpass inflation; the state had to set limits on the
rise in premiums

19. Lessons from Massachusetts
• The Massachusetts plan has achieved some
successes, but cost remains the main issue
– Some mixed results on ability to meet health care
needs
– Emergency department use has continued to rise
– Over 50% of the public is satisfied with care,
except for cost and waiting times
– Income tax hikes are proposed

20. Likely Experiences under the ACA
Caution: One state does not represent the ethos
of the entire country
• High level of dissatisfaction among physicians
• ⅓ of MDs not accepting Medicaid patients
• Low reimbursement is a primary concern
• Views among MDs about the ACA are mixed
• The general public and MDs may hold the key
to ACA’s future

21. Likely Experiences under the ACA
Under the ACA there will be
• Decreased uninsurance among vulnerable populations
• 25 to 30 million uninsured will still exist
• Shortage of PCPs will be a major barrier to access
• Massachusetts’ experience suggests stifling
regulations, lower reimbursement, higher costs, and
higher taxes
• Small businesses expect negative effects
• Pervasive negative sentiments could lead to a repeal of
the ACA’s major provisions

22. What If?
• The seeds for health care reform have already
been sown
• Any future reforms will build on the ACA, but
some mandates would be relaxed
• HDHPs could play a significant role because of
their promise to reduce health care spending
• Regardless, overall cost control will remain a
nagging issue

23. Universal Coverage and Access
• Without a reformed health care infrastructure,
universal access would be hard to achieve
• To achieve this, Americans will have to give up
the dream of universal care for any ailment
freely available on demand

24. An Ideal System
• A philosophy based on value in health care will be
needed
– Individual responsibility for one’s own health
– Self-management support
– Patient activation
– Preventive services and health education
– Public-private collaboration to create strong
incentives to help build an infrastructure based on
primary care
– A combination of HDHPs, regular health insurance,
employer contributions, reformed Medicaid and
Medicare, and charity care can all play a role in
bringing about near-universal coverage

25. Single-Payer System
– Many developed nations have been able to provide
basic care to nearly all citizens, with supply-side
rationing and higher taxes
– A government-run single-payer system does not
achieve universal access
– In the US, such a system is not feasible in the near
future
– Rationing and higher taxes will be resisted by most
Americans and physicians

26. Delivery Infrastructure of the Future
• The health care infrastructure will continue to evolve by
incorporating
– High-value health care
– Lowered costs and improved quality
– Patient engagement
• One model will not suffice to meet a variety of needs
• Emphasis on evidence-based care
• Cost-saving technology
• Targeted programs to the needs of patients in the
community
• Training of practitioners for a wellness-oriented model
• Remote monitoring and virtual consulations

27. Implementing the Medical Home Model
– Mechanisms for qualifying medical homes: four
main pillars are accessibility, continuity,
coordination, and comprehensiveness
– Mechanisms for matching patients to homes:
transparency, fairness, matching of clinical needs,
predictable revenues for physicians
– Information exchange outside the medical home
– Reimbursement that captures critical nonclinical
activities, such as care coordination

28. Implementing Community-Oriented
Primary Care (COPC)
– High-impact, high-opportunity areas of focus
– Social and behavioral sciences should supplement
the biomedical model
– Primary care should include primary, secondary,
and tertiary prevention
– Public health functions must be strengthened as
an adjunct to clinical interventions

29. Lessons from the Vermont Blueprint
• Integration of medical home and COPC
models
• Community health teams responsible for a
defined population
• Reduced emergency department use and
hospitalizations are necessary for financial
viability

30. The Role of Patient Activation
• Requires more informed and engaged consumers
• A person’s ability to manage his or her own
health and utilization of health care
• Individual knowledge, skills, and motivation to
make decisions in partnership with health care
providers
• Changes in one’s own health promoting
behaviors
• Considerable differences in activation levels
across socioeconomic and health status
characteristics; lowest among Medicaid enrollees

31. The Role of Patient-Centered Care
• Respecting and responding to patients’ wants,
needs, and preferences
• Promotes patient activation
• Roter Interaction Analysis System is used to
evaluate physician-patient interactions and to
train physicians in patient-centered
communication

32. Future Workforce Challenges
• The nursing profession
– Scope of practice and residency in community
settings
– Higher levels of education and training to cope
with increased clinical demands, collaboration,
and coordination
– Full partnership with physicians and other
professionals
– Better data and improved information systems

33. Future Workforce Challenges
• Training of primary care physicians
» Training needed for PCPs to function as
comprehensivists. Expertise is needed in these areas:
• Anticipate, prevent, and manage complex
conditions
• Manage complex pharmacology
• End-of-life issues and ethics
• Care coordination
• Leading health care teams
» Reformed payment model that incorporates education
and outcomes

34. Future Workforce Challenges
Training in geriatrics
»Critical shortage (only 2.5 geriatricians per 10,000
population). The numbers will drop further.
»Problem has been ignored, even though elder care
by geriatric professionals yields better outcomes
without cost increases
»Shortage of geriatric faculty in medical and nursing
schools
»Geriatric courses not required in other disciplines as
well
»Geriatric training is also necessary for areas other
than long-term care

35. The Future of Long-Term Care
• Baby boomers will start needing LTC in 2025
• Six main areas of concern need to be
addressed:
1. Financing: reform is needed in both public and
private financing
2. Resources: HCBS has not reduced Medicaid
spending
3. Infrastructure: (1) models of culture change, (2)
care coordination and transitioning, (3) single
point of entry into the LTC system

36. The Future of Long-Term Care
Six main areas of concern need to be addressed:
1. Workforce: a deficit of direct care workers is
projected
2. Regulation: contradictory and inconsistent
application of regulations; no quality monitoring
in HCBS
3. Information technology: interoperable IT
systems are needed

37. Global Threats and International
Cooperation
• Natural disasters, industrial accidents, and large-
scale bioterrorism put strains on a single nation’s
capacity to deal with mass casualties
• Global travel can spread infectious diseases;
containment requires international efforts
• Antibiotic resistance of infectious agents
• Decline in antibiotic research and development
• Lack of health infrastructure in developing countries

38. Global Threats and International
Cooperation
– Transatlantic Task Force for Antimicrobial
Resistance
– Biological Weapons Convention
– International Health Regulations
– The CDC’s Global Disease Detection Program will
be increasingly involved in global surveillance,
detection, and control
– The US DoD is also involved (Global Emerging
Infections Surveillance and Response System)

39. New Frontiers in Clinical Technology
• Genetic Mapping
• Rational Drug Design
• Advances In Imaging
• Minimally Invasive Surgery
• Gene Therapy
• Vaccines
• Artificial Blood
• Organ transplantation
• Regenerative medicine

40. New Technology
• Genetic mapping:
– Genometrics - identifying genes with specific
disease traits
– Prevention and gene therapy (molecular
medicine) – cancer treatment is a prime candidate

41. New Technology
• Personalized medicine and pharmacogenomics:
– Pharmacogenomics – how genes affect a person’s
response to drugs
– Specific gene variations will be matched to individual
patient responses to medications
• Drug design and delivery:
– Multidisciplinary advances will shorten drug
discovery time
– Rational drug design at the molecular level will also
reduce labor cost and lab expenses
– New drug delivery systems (e.g., cellular uptake of
nanoparticles) will improve drug delivery to targeted
sites and improve drug effectiveness

42. New Technology
• Imaging technologies:
– Research in four areas:
• new energy sources that minimize damage
• finer detection of abnormalities
• 3D technology
• higher resolution displays
– Increased emphasis on the brain for medical
interventions
– Applications in pain management, minor strokes,
and Alzheimer’s

43. New Technology
• Minimally invasive surgery:
– cost efficiency and improved quality of life
• Vaccines:
– Therapeutic use in noninfectious diseases, such as
cancer
– New vaccines for emerging infections
– Safer vaccines for widespread use, for example,
against bioterrorism

44. New Technology
• Blood substitutes:
– Necessary when supplies of real blood fall short
• Xenotransplantation:
– to overcome the shortage of transplantable tissue
• Regenerative medicine:
– Repair damaged tissues and organs
– Both in vivo and in vitro
– Cure for virtually any disease: diabetes, heart
disease, renal failure, osteoporosis, etc.

45. Care Delivery in the Future
• Application of medical imaging, molecular medicine,
and distant monitoring
• Shift from acute care to prevention and aftercare
• Use of a patient’s risk profile for screening
• Image-guided minimally invasive surgery, when
needed
• Individualized pharmaceutical treatment through
continuous measurement of drug concentration
• Miniature implanted devices to take over damaged
body functions
• Regenerative medicine to revive damaged organs
• Continuous monitoring of chronic conditions

46. Future of Evidence-Based Health Care
• High spending does not deliver better outcomes
• Better value through evidence-based medicine (EBM)
– Quality can be improved while reducing costs by
reducing misuse and overuse
– Evidence-based clinical practice guidelines—best
practices, proven therapies
– EBM’s full potential still lies in the future

47. Comparative Effectiveness Research
• How well a chosen intervention would work
compared to other available treatments
• To assist in making informed decisions to improve
health care for individuals and populations
• The goal is to improve outcomes and reduce
waste
• The ACA has established a Patient-Centered
Outcomes Research Institute:
– To enable patients and caregivers collaboratively
assess the value of health care options
– The big question: Will the government’s efforts
improve people’s health and save money?

48. Strategies for Evidence-Based Care
• Ongoing emphasis on the adoption of EBM
• Ongoing development of computer-based models
• Ongoing clinical trials
• Keep guidelines current
• Incorporate economic analysis into clinical protocols
to enhance cost-effectiveness of care delivery
• Restructure reimbursement to reward best
achievable outcomes

49. Strategies for Comparative Effectiveness
and Patient-Centered Research
• Identify new and emerging clinical interventions
• Review and synthesize current medical research
• Identify gaps between existing research and clinical
needs
• Promote new scientific evidence and tools
• Train clinical researchers
• Disseminate research to diverse stakeholders

50. Strategies for Comparative
Effectiveness and Patient-Centered
Research
• Reach out to stakeholders via a citizens forum
• Tap the voluminous unused information in existing
research
• Use of CER for benefits design and payment reforms
are still in the future
• The American public remains opposed to using
research to allocate resources or mandating
treatment decisions