Long-Term Thinking About Future Health: Seven Trends That Should Concern Us

This country is in a healthcare crisis today -- but we're not thinking enough about tomorrow either. Here are seven trends to watch, starting with the short-term and ending with what may seem more like science-fiction.

The seven trends are: Doctors leaving the public system, a shortfall in primary care, underutilization of medical treatment, "superbugs," virtual health care, climate change, and radical self-redesign and enhancement.

1. Doctors Leaving the Public System: Medicare dodged a bullet when Congress stopped a substantial pay cut for physicians this month. But doctors continue to leave the Medicare system -- in Texas, in Washington State, in Tennessee, and elsewhere. And many doctors already limit the number of Medicaid patients they accept. Shortages will become more acute as SCHIP and other reforms (hopefully) increase the number of Medicare and Medicaid recipients, and they'll hit lower-income and minority communities first and hardest.

2. Unavailability of Primary Care Doctors: Primary physicians (internists, family practitioners, gerontologists, etc. ) aren't paid enough. It's part of a general tendency to under-compensate for "cognitive services" -- thinking, talking, and diagnosis. Doctors are economic actors like the rest of us. So the result of this payment bias is a critical lack of "cognitive" physicians who should be the drivers of the medical process. Instead, young doctors are being lured into high-cost specialties. This increases the use of costly (and sometimes unnecessary procedures), according to studies conducted at Dartmouth and elsewhere.

This shortage is already crippling health reform in Massachusetts. The idea of increasing compensation for primary care keeps circling around in health circles, as it is now -- along with the concept of a "medical home," which is a re-articulation of health reform ideas that appear at regular intervals like comets. The thinking is probably correct, but the problem will persist -- until there is fundamental reform in the way doctors are educated, compensated, and rewarded with social status. And meaningful reform will be difficult without adequate primary care.

3. Underutilization: Medical policy types are well-versed in the cost problems and health complications that stem from over-utilization of health services. Over-utilization is a central tenet of the McCain health proposals. But, while it occurs -- especially in certain specialties -- the reverse problem of under-utilization is prevalent and growing.

As insurers and employers shift more and more costs to individuals' pockets people are seeking less and less treatment, as this California survey (warning: pdf file) demonstrates. 38% of respondents said they avoided seeking medical care -- either preventive or curative -- because of health costs. That's up from 34% three years ago, and it's a problem. Failure to seek needed care increases health costs, adds to individual suffering, and can allow untreated contagious conditions to spread. Which gets us to...

4. Superbugs: A study of MRSA "superbug" infections published last year found a dramatic increase in occurrence among Chicago's urban poor. Crowded living conditions in jails and public housing could be a factor, according to the study's authors, and illegal tattoos may also be contributing to their spread. Now British hospitals are facing a new superbug called "Steno" that is at least as hard to treat as MRSA.

As new viruses mutate and spread, ready access to preventive and curative medicine becomes more critical. Superbugs would be a concern even if we had a fully functional health system. With the system we've got, the impact of new mutated pathogens could be serious -- and potentially catastrophic.

5. Virtual Health Care: Online healthcare holds great promise for the future - both as a way for people to manage their own health, and as a tool that links doctors and patients in a unified network. But even now, before "Health 2.0" is a reality, we're seeing a wave of health data losses and thefts. (They've become so common that I have a whole blog section devoted to privacy issues.)

The combination of electronic medical records, electronic prescriptions, and other online tools could result in new forms of crime -- with scary enough potential results that I'd rather not describe them in public. (Why serve as a think tank for the bad guys?) Virtual health could also cause substantial shifts in the kind of medical care people demand. While that might actually be a thing, failure to plan for it could result in some temporary inconveniences.

6. Climate Change: Global warming could change the way we use medical care - and how much we need. As an Australian study found (and we summarized here), overall hospital admissions went up by 7% during heat waves, while mental health admissions went up by the same percentage -- and kidney-related admissions increased 17%. That adds up to a snapshot of medical conditions on a globally-warmed planet. Other changes, like a dramatic increase in the occurrence of mosquito-borne diseases, could also take place.

7. Radical self-redesign: 'Transhumanism' -- the movement to re-engineer the human body -- isn't a well-known term today. But the process is already underway, and it will gain momentum in the coming decades. Choosing our children's genetic characteristics, building computer technologies into our bodies, extending our lifespans, all of these will come into being in the coming years. This will raise a series of questions in fields like medical ethics and health financing, as we've discussed before.

What should we be allowed to do to ourselves and our children? Which changes should be paid for as a social right, and which are a personal choice? Will we create a 'two-tiered' race of human beings? These science-fiction questions will become increasingly concrete as we consider the health care reform issues of the coming century.

RJ Eskow blogs:
A Night Light
The Sentinel Effect: Healthcare Blog
RJ Eskow at the Huffington Post

Comments

[Dap]

Dear Brother RJ,

Just dropped in to say thanks for an excellent report and the heads-up on what's going on. Agape.

[obroni]

RJ: Is the government thinking about forgiving student loans for primary care physicians who practice family medicine for a certain period of time? Thinking about funding malpractice insurance for these folks?

[RJ Eskow - Huffpost Blogger]

The loan idea gets raised from time to time. It's a good one. The second one I haven't heard about, but it's a good idea -- if costly.

[schatsie]

The government does give a premium (not much) to providers serving in HealthCare Shortage areas.

Years ago in the days before the Great Devolution (Regan, etc), there was tuition forgiveness or somesuch for teachers and nurses in lousy locations...

[Sundialsvc4]

"Transhuman" might "gain momentum in coming decades" but ...

... by that time, I will be staring upward at a tombstone.

And (umm, "hate to break it to you this way, but...") SO WILL YOU.

[RJ Eskow - Huffpost Blogger]

Hey, I got four more decades in me - easy. (Knock on wood.) The transhuman initiative's already well underway.

Think positive!

[Sundialsvc4]

"If they are going to die, then they had better do it ... and rid the world of its surplus population."

As All Of Us Fiftysomethings Well Know ... all of this(!) has NOTHING to do with "Us." It only has to do... not with OUR "moms and dads" (good heavens!!) but ... with "Them."

("Them" is ... first-of-all... NOT 'US' ... and 'NOT Mom Or Dad.'" But most of all, NOT 'US.' Good heavens... that would be MUCH too 'personal.')

"Future health," in other words, IS 'future' ... not "us.")

"We" Will Live Forever...

[FrankS]

Thanks for enumerating some of the many sicknesses of our health system. In fact, healthcare providers are abandoning not only the public system, but the private system as well. As one of the supposed lucky ones, I have employer-provided Blue Cross/Blue Shield PPO coverage. However, when I needed surgery this year my primary care physician had to send me to a hospital seven miles from my home rather than to the one five blocks away where I had had another operation last year. In the interim the nearby hospital had dropped out of the Blue Cross network because it and the insurance company had been unable to agree on a schedule of negotiated prices for services. I have since found out that such dropouts are common because the providers find that they can't cover their costs, let alone make money, at the drastically discounted rates the insurers insist on -- as little as a tenth of the providers' normal charges. Opponents of government-run healthcare often make the argument that it would restrict "choice" of providers for consumers, but clearly our choices are being restricted more and more in the current profit-driven system.

[jvarga]

Your link to Stenotrophomonas maltophilia is broken. There's also Clostridium difficile which is causing huge problems in hospitals, and has been genetically tracked from an outbreak in a Quebec hospital to all over North America and Europe. Also, not sure if you're calling them viruses or if you're referring to as of yet known viral pathogens, but the mentioned super bugs are bacteria.

[RJ Eskow - Huffpost Blogger]

I mean both known and unknown pathogens, current and future. Fixed the language - and the link.

Thanks, R

[jvarga]

Thanks for the link update, was interesting to read it. I figured you weren't calling steno and MRSA viruses, but thought that as long as I was mentioning the broken link I'd ask about the terminology while I was at it.

Thanks again for the good post.

[Sundialsvc4]

Killed my uncle stone dead in three days ... it did.

[mommamia526]

How the pharmas are keeping track of my prescriptions was demonstrated to me more than once recently. I acquired a new chronic illness and was prescribed a new medicine, I filled that prescription. I immediately received letters from the pharma company (Merck). I had also received a free sample from my doctor to try the medication out, so I was about 14 days late refilling the prescription. Before that time was up I received a letter from Merck, that I was late refilling my prescription. Obviously, there is a direct link between the store (pharmacy) and the manufacturer. So, who is treating me and whose patient am I? My doctor's or a manufacturer's? With insurers and pharmas interfering in the doctor/patient relationship, and obviously having all my personal data, the difficulty to get paid by insurers for insured patients, as well as cutting of fee reimbursement attempts, lack of revision of fee schedules and stagflation, it is no wonder that children of physicians and even physicians themselves drop out. Moreover, with being a doctor almost completely changed from profession to that of hired employee, with others in charge, those others can now outsource (by importation of physicians) those *jobs* as well. More capital outflow for the U.S. as HMO's, Insurers and Pharmas are, or could easily be, foreign, or international *entities*. Someone let Lou Dobbs get a go at this one.

[mommamia526]

You forgot Medical Malpractice Insurance. Ths is costly overhead, and it forces defensive medicine and prevents innovation. Physicians have been leaving the profession for a long time. Yes, low Medicare reimbursement is one factor. Adjusting fee schedules for inflation is another factor. The most important factor that I hear about from doctors, and even medical support personnel, is the ridiculous maze of insurance policies, having to pursue insurers to get paid at all, procedures doctors deem necessary being denied by insurers, and even dropping of insured patients. Doctors are made more and more, as has already happened to pharmacists, employees, rather than the professionals they are and have always been, of paperpushing CEO's of HMO's, Insurers, etc. I foresee that if this goes on we will only have employees of JCPenney and Walmart providing medical care. As a patient I already now have written evidence of insurers and pharmaceutical companies interfering with doctors' prescriptions. I get letters *suggesting* that I TELL my doctor to prescribe such and such instead. Medicines are also changed with *alternatives* (generics) and I am not being informed. Neither is my physician. Some of those have led, for me, to additionally acquired chronic illness. Yes, something needs to change!!

[SisterAnn]

The medical insurance and some in the health care field are determined it is their time to suck up more of our money. They have already gotten Medicare on the brink of bankruptcy and the first boomers couldn't retire until this year and then they had to 62. They are licking their lips waiting for the boomers to retire.

The insurance companies will cut their payments and raise those of Medicare patients. We will be paying half of the cost plus premiums to them.

Medicare is supposed to give the elderly ,affordable insurance. Make sure they remember it, that is why we have paid in since 1968.

They make everything more expensive than it has to be. They could take a clinic bus with qualified nurses to each town and highly trained nurses can check the elderly. Those who need it can then be referred to a doctor.

They could