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Choose Your Own Health Care Adventure, Part II

Strap on the goggles and fire up your DeLorean, it’s time to go back to the future of American health care. Unfortunately, Marty McFly’s booked. So our traveling companion is Mary — a 50-year-old, middle-income, single woman with diabetes.

Last week, we met up with her to examine some of the ways the medical, technological, and political ideas swirling around in 2012 — ideas still unhatched and far beyond her control — might impact her future health 13 years from now. Using potential scenarios for U.S. health care as defined in a new report, our “time-traveling” pals at the Institute for Alternative Futures laid out four possibilities for Mary’s health care in the year 2025.

Watch the videos below for a refresher on the four scenarios. Then, as promised, read the analysis of Clem Bezold, founder of IAF, who explains what would need to happen over the next 13 years for each of those scenarios to become reality.

And don’t forget to check out the final results of our audience poll from last week — found at the bottom of the post — to see where your ideas on the future of U.S. health care stack up with the other participants.

SCENARIO 1: “Many Needs, Many Models,” or the “Expectable Future”

Bezold: “Among many health care experts, this is the most likely forecast for U.S. health care. It may not be the most preferable, but there’s enough inertia in the system to prompt a fair amount of positive change. In this scenario, we have electronic medical records that work, there are advances in system integration, digital coaches have become relatively effective, and the personalization of health care has improved significantly. The good news is we double the percentage of people in integrated care from 20 to 40 percent — but the bad news is we only double it. The rest remain in fee-for-service or semi-integrated care. So we see improvements, but they’re not uniformly distributed.

“To get to this scenario, we assume the Affordable Care Act has been implemented fairly successfully, but the improvements in changing the health care system are modest. We add people to the rolls for health coverage, but we end up with shortages. The employers generally look at the new health insurance exchanges and say they’re effective enough, and that they’d prefer to get out of providing health care. So employers continue dropping coverage or shifting to consumer-directed health plans with defined contributions and high deductibles. The triple aim of health care reform — enhancing the patient’s experience, reducing per capita health care costs, and improving the overall health of the population — has been accepted by most integrated health care systems. Most providers, though, remain unintegrated and the payers don’t require it. And that’s largely because health reform’s Accountable Care Organizations, which were designed to integrate care, haven’t been implemented as widely and successfully as they could have been by 2025.”

SCENARIO 2: “Lost Decade, Lost Health,” or a “Challenging Future”

Bezold: “In this scenario, the Supreme Court has ruled the individual mandate of health care reform unconstitutional, eliminating a major component of the Affordable Care Act. The United States has made huge investments in electronic medical records but they’re not fully interoperable and therefore aren’t very effective. In the meantime, prices keep going up, and a lot of people are now uninsured. So they seek out free digital coaches to substitute for regular check-ups. The problem is that advertising revenues fund many of these digital coaches that are free to patients, and many independent providers of these free digital coaches don’t adequately check the quality, safety or efficacy of what their advertisers are selling.

“To top it all off, the United States has suffered recurring recessions, several tied to the European financial crisis. And due to that fact, there have been periodic and significant budget cuts — 10 percent cuts in health care spending happened twice within two or three years of each other. One was in 2013 when Congress failed to find a patch for the Sustainable Growth Rate formula that reimburses doctors for their Medicare services. The second slashed Medicare and Medicaid reimbursement rates yet again to cope with ever-rising health care costs. Physicians are being told to do more and get less — and their stresses continue to get worse. Some health care providers just go out of business, including some community health centers. To be sure, there have still been some developments, including the discovery of a successful treatment for Alzheimer’s, but you have to be rich to get them. Even if you have health insurance, most plans have stopped covering a number of the cutting-edge, expensive treatments.”

SCENARIO 3: “Primary Care That Works for All,” or an “Aspiring Future”

Bezold: “In this scenario, the Affordable Care Act has done very well in moving people toward integrated care. In general, the system also continues to move health care delivery systems into integrated care that focuses on prevention, takes full advantage of digital health coaching and utilizes the entire health care team. Leading health care officials have made a concerted effort to ensure that patient-centered medical homes have evolved into robust community centered health homes. In practice, they see themselves as treating the entire community and addressing social determinants of health in a neighborhood or region, in addition to treating patients. Things have gone well due to a combination factors, including the successful implementation of the ACA – particularly the success of Accountable Care Organizations which have fully integrated and simplified care — as well as greater transparency of costs and real competition among providers.

“All of that has resulted in much more patient satisfaction. Incentives have shifted enough to encourage the medical community to use the entire team more efficiently. There’s less use of physicians and more use of others in the team, including community health workers. It’s been found that more and better care can be provided by using people further down on the chain. Community health workers have less training than nurses, but they can visit patients in their homes and effectively reinforce the information, diagnosis and advice from the health care provider. The recommendations are based on the latest medical protocols, the patient’s bio-monitoring and community health assessments. It’s become increasingly apparent that by focusing on prevention and taking a community-focused approach, you can get better outcomes for less cost.”

SCENARIO 4: “I Am My Own Medical Home,” or a “Surprisingly Successful Future”

Bezold: “In scenario four, much of health care moves into integrated systems that work, but the United States also has some economic challenges that have interfered. So we don’t get the same degree of access to the effective integrated health care we saw in Scenario 3. The individual mandate within health reform has been ruled unconstitutional, and that means no one is forced to have insurance. We’re also seeing a continuing movement where employers stop offering their employees full benefits. Individuals have to be ready to shell out a fair amount of money to get good health insurance — and many people do that — but another 40 percent of them say they can handle their health care on their own.

“In fact, technology, competitive insurance plans, and transparency of quality and price for providers, tests and procedures have allowed many individuals and families to self-manage their health care quite well. Most of these people have determined that they either can’t afford full health coverage and consumer-directed plans help people take control of their own health care. Forty percent end up using technology and consumer-directed plans to become their “own medical home” and an equal amount buy their health care though integrated plans. For those managing their own care, there are very effective tools that allow people to buy health care “by the piece.” For example, if someone needs a test and she can’t do it at home, there’s an equivalent of Angie’s List that links up with that individual’s digital health coach to find the result that will work best for them. The same is true for routine care — it’s easy to shop around. Because this consumer-directed care is so effective and lowers cost, it puts a cost pressure on integrated systems to become more efficient and effective. Another positive development is that consumer-directed plans include a very effective digital health coach, with all accompanying advertisements vetted by health insurance companies to ensure the quality of their messages and the safety of consumers.”

Which scenario do you think is most likely? Check out the results of the NewsHour poll conducted over the past week. While it’s far from scientific, the poll does indicate that many of the participants have a “very gloomy” outlook for U.S. health care, Bezold said. He offers his own assessment below.

Here are the results of a NewsHour poll that asked viewers to rate the relative likelihood of each scenario. Raw scores have been converted to averages:

Scenario 1: “Expectable Future”: 60 percent likelihood (average of 5.95 out of 10 for 65 voting)

Scenario 2: “Challenging Future”: 70 percent likelihood (average of 6.96 with 78 voting)

Scenario 3: “Aspiring Future”: 53 percent likelihood (average of 5.27 with 60 voting)

Scenario 4: “Surprisingly Successful Future”: 42 percent (average of 4.15 with 61 voting)

The above results are based on ballots cast between Jan. 31 and Feb. 7. Continue voting here:

Rate SCENARIO 1: “Expectable Future”

Rate SCENARIO 2: “Challenging Future”

Rate SCENARIO 3: “Aspiring Future”

Rate SCENARIO 4: “Surprisingly Successful Future”

Bezold: “In terms of relative likelihood, my own opinion is that Scenario 1 is about 55 percent likely, Scenario 2 is about 45 percent likely, Scenario 3 is 38 percent likely, and Scenario 4 is 38 percent likely. I pick Scenario 1 as the likeliest because it includes the strongest aggregation of forces in terms of where we’re headed. While I don’t like that it’s most likely — especially because we’ve only doubled the number of people in integrated care — we will see a number of advances in a whole range of things built into that scenario. So it’s not all bad news.”

The scenarios were developed in consultation with some of the top health care experts in the country, and with the support of The Kresge Foundation, which is also a NewsHour underwriter. Read the full report here.

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