4 possible scenarios for the future of primary care

For some 30 years now, I have been tracking the work of a gifted “futurist” — one Clement Bezold, PhD.

In this context, a futurist is a social scientist who specializes in making systematic predictions of the future of society, either in general or with respect to a particular segment.

Dr. Bezold has done considerable thinking about the future of healthcare, much of which he has captured in his books (“The Future of Work and Health” and “Health Care 2010: Health Care Delivery, Therapies and the Pharmaceutical Industry”).

Recently, I received a letter from the Institute for Alternative Futures where Dr. Bezold is chairman and senior futurist.

Included was a report that explores alternative scenarios for primary care in 2025 — a topic that is right up my alley!

By now, most of us are acutely aware of the uncertain future ahead for primary care physicians as our health system undergoes some radical changes.

As a futurist, Dr. Bezold gives us a better understanding of the possibilities.

Using four scenarios that depict various ways the future might look, he offers insights into those possibilities and their likely ramifications.

In Bezold’s first scenario — “Many Needs, Many Models” — the new health reform initiatives (e.g., the Patient-Centered Medical Home, electronic health records) improve the quality of primary care; government programs promote primary prevention; employer-sponsored health insurance shifts to health insurance exchanges where employees gravitate toward high deductibles and catastrophic coverage; and the primary care “team” concept takes root.

The down side is that, while primary care improves in the aggregate, care disparities persist among certain populations (e.g., urban poor, minorities, rural populations).

As its title suggests, the second scenario — “Lost Decade, Lost Health” — is far less optimistic.

With persistent economic issues leading to substantial cuts in government spending on healthcare, the shortage in primary care providers increases, the remaining fee-for-service primary care providers gravitate either toward serving the rich (i.e., in concierge practices) or the uninsured (i.e., in minute clinics), and most Americans turn to integrated health systems or online primary care solutions of varying quality.

Without question, the third scenario is my favorite — “Primary Care That Works for All”!

In this scenario, the Triple Aim — enhancing patients’ experience of care, reducing per capita healthcare costs, and improving population health — is realized; patient-centered medical homes evolve into community-centered health homes with primary care teams that include social workers and community health workers; and sophisticated payment systems operating on the principle of “if it’s smart, we’ll pay for it” offer rewards for improved health outcomes.

The final scenario — “I Am My Own Medical Home” — pushes the envelope a bit farther.

Advanced technologies enable all of us to take over much of our own primary care.

We are able to buy high quality health related products and services at reduced costs through competitive markets.

Integrated health systems provide primary care as part of comprehensive healthcare packages — and the demand for primary care providers declines.

With this food for thought, how do you think things will play out?

Whether it is along the lines of one of Bezold’s four scenarios or a totally unforeseen construct, I’ll be watching from a front row seat as the future of primary care unfolds.

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

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  • http://nonmaleficence.wordpress.com Nonmaleficence

    May I ask, in what direction do you think we’re heading toward with ACO? Or more importantly, what do you think will be the outcome?

  • http://twitter.com/mkePediatrician Mehul Sheth

    I think have the tools to get to the third and fourth scenarios.  In particular, the government incentives have improved the aggregation of large amounts of data from across health systems throughout the US.  If we continue on this path, big data will take over and we should be able to “normalize” our management of preventative and chronic diseases. As we begin to understand in real time the best way to manage a disease, individuals will begin to take over their own health care as they will realize it is much cheaper than insurance premiums and will opt for high-deductible/catastrophic coverage.

    Of course, predicting to 2025 is fraught with numerous considerations that have not even been thought of.  Think of the way healthcare was in 2000, during the infancy of the internet and before the explosion of EHR.  It will be interesting to see what new technologies and paradigm shifts will occur in the next 13 years.

  • DrJMike

    The more I read about and experience the future of primary care, the happier I am to be near retirement,having unsuccessfully tried thruout my career of 35 years  to preserve the traditional doctor -patient relationship from birth to death.Family Practice can be very rewarding, if not in a monetary sense, at least in a sense of felling needed and respected and loved by the patients we serve on a day by day basis.It is too bad that the focus of medicine has been to cast off the primary care doctors and discourage their entry into this worthy specialty from medical school teachers to residency recruiters to the all important dollar reward (one or two more years in many other narrow focused specialties can double or triple the salary of a F.P. So..now we will replace the “Marcus Welbys”(the thinking,caring,avaliable-emotionally and timewise Docs) with the lesseser trained P.A.s and N.Ps who many times think their training and experience qualifies them to do everything a physician can do, and with the backing and blessings of Internal Medicine and Surgery specialists who probably dont care if their referrals come from monkies as long as they get those referrals..I have been recently watching a TV show on Netflicks called ‘Doc Martin” about an English Surgeon who, for medical reasons, needed to leave his posh surgical practice to become a small town G.P. and for the first time in his life is EVERYTHING to a population of patients and had to relate to them whether or not their problems interested him! His office consists of one helper, a computer a very rudimentary patient record system (a small envelope with 6×8″ cards for date of service/Dx /and Rx-recs) and his BRAIN  with the training he got in Med School-you know, this is all you really need to practice if you are not forced to make a 5 page medical outline for a URI visit, as we are, just to get a $3.00 Medical Assistance payment!! The more expansive and clever we have become, the more ridiculous our system seems…Just sayin.. Good luck in the future Docs

  • http://twitter.com/pjmachado Paulo Machado

    All four are possible & likely to occur…
    Since we are only talking about 2025 (which is right around the corner at the ‘speed’ of Healthcare), all four of these scenarios will be in place around the country.  Healthcare delivery has always been a patchwork (think quilt instead of blanket) of models and healthcare reform is reinforcing the ‘do what works for you locally’ model at your pace.  We already have a WIDE range of approaches in place with a WIDE range of political will to drive change so it is likely that in 2025 at least these four scenarios will be alive & well!

  • csherry

    I believe if the Accountable Care Organization (ACO) is developed in a comprehensive manner, it will include the community. Dr. Kevin talks about adding social workers and community health workers. I would also add in health educators. I am credentialed health education specialist (CHES). Click on the following link for more information. http://www.nchec.org/credentialing/profession/ Those in our profession study, design, conduct, and evaluate comprehensive, evidence-based approaches for improving the health of all people. Health education activities can take place in a variety of settings such as health care facilities, communities, businesses, schools, universities, and government agencies. Health Educators are able to link the health care world with the overall community and connect with the local resources.

  • Anonymous

    I think consumers will continue to drive health care to more comprehensive and collaborative solutions. I think we need integrative medicine. Eastern medicine deals best with chronic health conditions, Western medicine excels at acute care. Michelle Obama has the right idea with teaching our kids to exercise and eat fresh fruits and vegetables. I look forward to seeing consumers acknowledging that every thing we put in our mouths and breath in our lungs matters. I think consumers will continue to take more responsibility for their own health and demand better outcomes from our health care system. We are tired of physicians looking at test results, giving a pill, and treating our symptoms. The Art of medicine is nearly lost.  Consumers are demanding more lasting results. Why am I sick and how can we cure it?  

  • Anonymous

    Having analyzed the business of primary care extensively, I believe that primary care will continue to evolve dramatically as we are faced with continued physician shortage, rising numbers of Baby Boomers, health insurance changes, Medicare cuts vs. SGR fixes, etc. My prediction? Based on the two-toned culture of our government and how it views health care, I predict that eventually, we will have a part-government-subsidized, part-private health care system. Whether or not the Affordable Care Act goes through as written, the train has left the station when it comes to government intervention. Medicare/Medicaid will be expanded to more of the population, if not all the population, in the future. The number of doctors, however, accepting Medicare/Medicaid, will continue to dwindle if the SGR isn’t dealt with, and will only be compounded as the number of primary care doctors remain in shortage. In a simple example of supply and demand economics, there will be too many patients wanting to access government healthcare, and not enough Medicare/Medicaid-accepting doctors to care for them. The result – long waits to be seen, rushed visits, crowded waiting rooms, double-booking, triple-booking, waits for simple imaging, and prior authorizations. There will be those who will look elsewhere… Consumer-oriented healthcare services, such as Direct Primary Care (I started MedLion in California) and concierge medical practices, will continue to rise for this reason. Many different models will be born from the need for patients to go the “private practice” route. As patients/employers/consumers realize that options exist, some of which will not be completely cost-prohibitive, many will drive the growth of such private healthcare models. Thus, the bipolar health system – a government-sponsored healthcare system that will be the safety net, and consumer-oriented private practices for those who “can’t wait.” What will happen in the meantime, and how long it will last should prove to be quite interesting.

  • Anonymous

    As is already developing in other jurisdictions, primary care in the future is less likely to be totally physician-driven.  The U.S. and Canada are already using Physician Assistants and Nurse Practitioners.  Midwives are making a comeback everywhere, and the U.K., Australia, and South Africa have begun to utilize Emergency Care (M.Sc. Paramedic) Practitioners to provide comprehensive primary care whilst keeping non-emergency patients out of overcrowded emergency rooms.  These ‘second-tier practitioners’ perform all sorts of primary care functions (including management of hypertension, diabetes monitoring, suturing and wound management, etc.), and, in many cases, even have limited prescribing authority.  Care is provided safely and effectively, and in cooperation with the physician community (in some cases in the UK, where house calls are still routine, group physician practises routinely hire Emergency Care Practitioners to provide their after hours house call cover!).  As demographics change, with a resulting increase in demand for medical services and a decreasing number of practising physicians, such changes are almost inevitable.  How will such services be compensated?  In systems of socialized medicine, the compensation is direct, but in private for profit systems, there are really only two possibilities:  to have private insurance carriers who adopt an attitude of “if it’s smart, we’ll pay for it” or, by hospitals who will ultimately realize that this is a practical and cost-effective way of keeping inappropriate and uninsured patients in overcrowded and underfunded emergency rooms to a manageable minimum.