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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