25 health care trends: what's hot, what's not, and what does the future hold? (2003 and Beyond).

As we usher in 2003, America's health care system remains in a chaotic state.

* Will managed care live or die?

* Will quality improvement efforts pay off?

* Are we ready for the next bioterrorism attack?

* Will the shortage of physicians soon rival the shortage of nurses?

To help gauge where health care stands today and what the future holds, The Physician Executive asked doctors who serve on ACPE's peer review panel to list the hottest health care trends in the U.S. right now.

Then, we took the list to three respected health care futurists--Leland Kaiser, PhD, Jeff Goldsmith, PhD, and Russell Coile, MBA--and asked them for their insights on the trends.

Yes, Kaiser, Goldsmith and Coile are opinionated. Yes, they're controversial. But no matter whether you agree or disagree with their views, the three health care futurists' comments could spark discussions that will help shape U.S. health care this year and beyond.

The trends are presented in no particular order.

Health Care Futurists

Leland Kaiser, PhD

Kaiser is founder and president of Kaiser Consulting, LLC, a health care consulting firm located in Brighton, Colo. He is also co-founder of Kaiser Institute, which offers fellowship programs providing advanced training in integrated medicine and intuition. He is a writer, lecturer and health policy analyst at the forefront of the healthier communities' movement in the United States. He holds an appointment as associate professor in the Executive Program in Health Administration, University of Colorado at Denver.

Jeff Goldsmith, PhD

Goldsmith owns and operates Health Futures, Inc., a firm specializing in corporate strategic planning and forecasting future health care trends. For 20 years, Health Futures has analyzed issues facing the health care industry, including the future of information technology and health care, implications of new biotechnology developments, health care trend analysis, the Internet's impact on medicine, the future of managed care and of integrated health systems. Goldsmith is known internationally and is a popular public speaker at health conferences.

Russ Coile, MBA 

Coile is the editor of Russ Coile's Health Trends, and a nationally recognized futurist who provides market forecasts and strategic advice to hospitals, medical groups, health plans and suppliers. He is the author of 10 books and numerous articles on the future of the health field including Futurescan 2001, the award-winning annual environmental trends report. For the past 10 years, his annual "top 10" predictions for the health field have been 90 percent accurate.

(1) Patient safety/HIPAA

"It's not clear the industry has taken ownership of the problem of patient safety. There's a lot of talk, but is it moving the numbers?" Goldsmith asks. "Compliance is doing what you have to do. Does that qualify as a trend?"

Hospitals and their medical staffs are indeed paying more overt attention to medical errors, Coile says, but it's only one at a time as they occur. "There's no systematic approach. The Quality Revolution is still far off."

For example, one of the most effective methods for improving patient safety, he says, is the use of bar codes to track medications, supplies and even patients. Were it universal, hospital errors could be cut by 80 to 90 percent, Coile claims.

The 100 hospitals honored annually by the American Hospital Association as "Most Wired" are "most likely to have bar-coded everything," Coile says. That means, given the national statistics on the prevalence of bar-coding in hospitals, "the others may not have bar-coded even 30 percent yet."

As for the Health Insurance Portability and Accountability Act of 1996, as a result of all the brouhaha that attended its implementation in 2002 "a lot of places went through the drill as if the rules were going to be much tougher," Coile says. The final version was "not as bad as providers feared. These regs are almost balanced."

Maybe that accords with Kaiser's forecast. "We're drowning in regulations!" he wails. "We've been overdoing it. I see a swing back to the middle."

(2) Six Sigma Quality

"Very few people know what it means" says Goile. "There's a lot of interest in quality improvement in health care, but little interest in importing techniques from other industries. A handful of people are going to look outside their walls, find technologies that are useful and bring them back; eventually others will get it."

"I'm not convinced," shrugs Kaiser, "that medicine is like building automobiles."

(3) The Leapfrog Group

"Bold but fragile," says Goldsmith of the initiative by some of the nation's largest employers to force hospitals to adopt a set of three specific patient safety measures or lose the patronage of their workforces.

"They've definitely made an impact in computerized physician order entry," says Coile. But the emphasis on intensivist staffing of ICUs is more problematic--there just aren't enough of them--and some of the Leapfrog Group's volume criteria for establishing competency at certain surgical procedures are simply "bogus," he says.

As a result, Coile says, "there's getting to be an anti-Leapfrog backlash. Some state hospital associations have refused to cooperate. The Leapfrog initiative is really more symbolic than real. The average person is not going to be aware of what it means, and it's not even clear that employers are going to comply. But obviously it's well intended. And if they're smart, their tactics will evolve."

(4) Open-access scheduling

Accommodating patients the same day they call for an appointment is a great idea, Goldsmith says, "if people are able to figure out how to do it."

"It's like chaos theory applied to office Visits," suggests Goile. "There is a little science to it--figuring out patterns and patient volume and staffing adjustments. But when patients become accustomed to it, the level of cancellations goes way down--there's no such thing as a no-show--and that creates capacity."

Donald Berwick, MD, is pushing the concept through his Institute for Healthcare Improvement, Goldsmith says. "It could save a lot of money and make it easier to see a doc."

(5) Concierge medicine 

Kaiser is a big-picture man. He considers most of the items on this trend list to be sketchy details: "ho-hum stuff that everybody knows and nobody's debating."

But many do fit into the grander scenarios he sees taking shape in his crystal ball. Concierge medicine is one of them--part of a broad movement that, he forecasts, will increasingly turn on the discretionary spending of health care consumers.

So the elitist approach, in which patients who can afford it pay an upfront fee ranging from $300 to $5,000 to receive preferred access to a physician's extraordinary attentions--leisurely consultations, "ombudsperson" intermediation with specialists and, often, house calls--is not only a natural expression of a free marketplace, according to Kaiser, but also a niche with plenty of upside potential.

Especially, he reasons, as businesses continue to lay off more of the costs of health care on their employees.

"If people have discretionary dollars, why shouldn't they have the privilege of buying more health care than insurance pays for?" Kaiser asks. To be sure, he says, government and private insurers will continue to cover the basics. But there will be a burgeoning discretionary market in which very high quality, high-value-added services like genetic testing, for example, will be paid for out-of-pocket.

As a consultant to hospitals and health systems, Kaiser says he's encouraging boards to set aside 1 percent of revenues for research and development into new product lines tailored to tap this revenue source.

"Most hospitals [and doctors] have the attitude 'we're here to take care of sick people and our primary source of payment is third parties,'" he says. "They've got to get out of that mentality."

Rather than defining their mission as "we provide what insurers pay for," he says, providers need to break new ground through consumer research and "Internet-mediated" advertising that hawks new discretionary preventive services in cheap, populous, populist cyberspace.

As to concierge medicine itself, Russ Coile and Jeff Goldsmith are less than bullish.

"We're definitely going to see more of it, but how large the market is remains an open question," says Goldsmith.

Coile agrees. "This takes the concept of two-tier medicine to a whole different tier" he observes. "But it's a mini-trend that's not going to affect many doctors or large medical groups. There just are not enough cash customers and there never will be for more than a handful of physicians to make a living this way. Especially when the NASDAQ's at 1,100--forget about it."

What's more, he points out, charging for access violates Medicare rules and puts a physician's practice off-limits to those patients.

(6) House calls

Analogous to and usually parcel with concierge medicine, house calls are a service that sounds attractive to many consumers but will not be reimbursed by insurance and is perhaps less tailored to an era of two-income families than it was in Marcus Welby's day.

"Who's home?" wonders Coile. Still, he adds, "let's let consumers have what they want if they're spending their own money.

At least two Florida-based companies are offering house calls by doctors around the clock for about $200 per visit.

(7) Bioterrorism preparedness

'Starting from zero, which is where we are (with bioterrorism preparedness), we've got a long, long way to go," sighs Goldsmith. "It seems to me there's minimal understanding of how unprepared we are on the part of most health care executives."

Only Kaiser of the three futurists is optimistic that real progress will be made in readying the nation to handle the chaos and casualties generated by a major bombing or the release of a toxic agent like anthrax or smallpox.

"It's a slam dunk--we've got to do it!" Kaiser exclaims. But even he worries that it'll take more incidents to get the funding.

Coile says experience with the bombing of the federal building in Oklahoma City and the September 11 tragedy in Manhattan drove home the futility of developing a national network of designated terror-trauma centers.

"Casualties are taken to the nearest hospital," he points out, "so everyone got to have some preparedness, which means we'll go through the exercise. If it comes to real biological or chemical or nuclear warfare, though, forget about it. We're dead."

Short of that, he says, "the important thing is that at least people have gone out back and dug up their disaster preparedness plan."

Nevertheless, says Goldsmith disdainfully, "when it comes to response, and diagnosis, and preparing and deploying vaccines, and giving timely advice to people on how to cope with an attack... we're still buck naked. The problem is it's not clear how much what we're doing is going to change anything. A trend implies that something is being done."

(8) Cost shifting from payers to patients

"Until we get to a single payer model, cost shifting is going to be the dominant mode," Coile says.

Americans pay less than one-third as much for health care coverage today as they did as recently as 1960, reports Goldsmith. The beneficiary's share has declined steadily throughout the 1990s. "Clearly this is going to reverse," he says.

Indeed, Kaiser says his own health insurance premium as a member of the faculty of the University of Colorado will go up 45 percent this year. "Ultimately the patient is going to end up paying much more," he adds.

But, Goldsmith says, "How much difference that's going to make [in curbing the rise of health care costs] remains to be seen."

(9) Consumer-driven health care

The futurists aren't sold on consumer-driven health care.

"As opposed to what?" snorts Goldsmith. "Nurse-centered health care? Physician-centered health care? There's a lot of hot air here."

Coile, for his part, worries that "consumer-driven health care" is a euphemism for the abdication of responsibility by employers to provide a defined health benefit. Rather, in growing numbers they're simply handing their workers a defined contribution.

"Will anybody practice prevention?" Coile wonders. "Or even buy insurance?

(10) Shortage of medical/surgical specialists

A shortage is coming by the end of the decade, Coile says. "It's going to be exactly like the nursing shortage. RNs historically quit at fifty, physicians at sixty. It's very predictable."

There would already have been a big "non-incremental" drop in the number of practicing baby boomer docs if the stock market hadn't crashed, shattering their retirement nest eggs, Goldsmith says.

And it's not just specialists who will be in short supply, warns Kaiser. Among the healing professions "there'll be a shortage of everything."

"Where we're going to get young people to take care of us baby boomers I don't know," frets Goldsmith.

"Medical school applications are down," Coile says, "but the long-term concern about the physician pipeline is the issue of women in medicine. Women now make up almost half of all medical school classes, and women are just not willing to work as many hours and clays as men. So will these graduates truly be replacements? Two female physicians who want to work a thirty-hour week are needed to replace one fifty-hour-a-week male."

(11) Physicians as chief executive officers

"Is there a new group of victims out there willing to offer themselves up?" as CEOs, chuckles Goldsmith. "Physicians are remarkably unsympathetic to their colleagues when they take off the lab coat."

"One of the strengths in our country is that we have non-physician GEOs," Kaiser says. "It's an awfully expensive way to train a CEO, too, running him through medical school. So, yes, there will be some, but I don't see them as a majority."

(12) Hospitalists

"Hospital practice is going to be a distinct discipline in medicine," says Goldsmith. "And not just because Leapfrog says so."

(13) Emergency room as primary care provider

Sixty percent of U.S. hospital ERs are operating at capacity, reports the American Hospital Association; one in 10 is on diversion on any given day.

Coile cites several reasons for this trend's sustained momentum:

* The relaxation of managed care rules on prior approval

* The fact that 2 million people in this country lost health insurance last year and another 2 million are likely to have joined them this year

* An ongoing influx of immigrants, half of whom historically lack health care coverage

It's an inordinately costly system. "You're attaching hospital overhead to something that ought to be very inexpensive," Goldsmith says.

It is at least somewhat self-correcting, observes Coile. A certain percentage of patients shuffle away undiagnosed, muttering, "This wait's intolerable."

ER crowding won't abate any time soon, though.

"Primary care physicians are plenty busy," says Coile. "They don't feel the need or have the capacity to extend their hours."

(14) Hotel-like environments in hospitals

We are in the midst of a massive hospital building boom, Goldsmith says. "I have proposed that there are unelucidated endorphin pathways that radiate out from construction cranes," he jokes, and one of its aesthetic themes is "hotel-like."

"Everybody's going hotel-like," Coile agrees. He whips out an ad for The Woodwinds, a new 70-bed hospital in Woodbury, Minn.: "Like a destination resort in the North Woods."

"People love open areas," explains Kaiser. "But the point I make is, 'Does the design heal people?'"

It's hard to imagine a less attractive place to be sick than in a hotel atrium.

(15) Physician-owned specialty hospitals

"A micro-mini-trend in retreat," Coile says of physcian-owned specialty hospitals. The other futurists agree.

"We are definitely in the middle of a wave of 'em," observes Goldsmith. "There's going to be a lot of surplus, unused hospital capacity. You're going to see cardiac hospitals doing hips, knees, delivering babies. And there are going to be a lot of disappointed physician investors."

(16) Managed care

"Consumers have voted against it," declares Coile. "Growth in HMOs has absolutely stalled. PPOs have won the war. And in many places even the HMOs have transformed themselves into Lite HMOs.

"[The original concept of managed care] has pretty much been abandoned by health plans," he adds. 'Why do this?' they say. 'Let's just raise premiums.' But they need to develop a new long-term business strategy."

Nevertheless, argues Goldsmith, eight out of 10 of the 156 million Americans with private health insurance are enrolled in some form of managed care.

"People just don't call it that," he says. "It's in the process of being reinvented."

(17) Disease management

Disease management-identifying risk groups and developing protocols to interact with them-is "one of the two most significant trends in private health insurance," according to Goldsmith. (The second is the "Web-driven service model for patients," he explains, in which consumers interact with their health plan via a personalized Internet page.)

"If the challenge of the 21st Century is managing an elderly population, this is how we're going to do it," Coile says. Unfortunately, "some of the momentum has gone away as the power of managed care has waned. So now we're left in the position of having providers being the only ones who're doing this. And I suspect, because the more you treat the more you make, their commitment may be less than whole-hearted."

(18) E-health

E-health was "strangled in its crib," snaps Goldsmith. "It got about two years and it needed ten."

That's not to say, he adds, that applications for electronic data interchange over the Web aren't alive and well in the health plan sector, anyway. "The most interesting developments," he says, "are happening in 'payer space.'"

For most institutional providers, however, "the Internet was a UFO that flew in one window and out the other without making much of a dent in the wall."

Muses Coile, "You don't hear the term 'e-' very much any more. But call it anything else and it's still happening."

In fact, he says, about a quarter of all wired Americans log on to the Internet at least once a month to glean health care information. And it won't be long, he predicts, "before Internet access will be as universal as the telephone. Certainly before the end of the decade."

Meanwhile, lack of sustained investment means the e-volution of health care is going to take a lot longer than pundits anticipated. But eventually, says Kaiser, "every bed will be wired to the Internet. And patients will have computer access to everything. It just has to be financed in a totally different way."

(19) Clinical information systems

"Full disclosure: I'm a board member of Cerner," admits Goldsmith. "But the country is now on the cusp of a complete digital conversion. We'll have spent $150 billion to $250 billion by the time we're finished and we 11 have saved a very large number of lives."

"I'm strictly Star Trek in this case," agrees Kaiser. "Computerize everything we can. More than twenty percent of the cost of a hospital is going to be in computer systems. It used to be seven percent."

"The hot ticket!" echoes Coile. "The digital transformation of medicine is picking up speed. There's no longer an upward learning curve. This is the natural way young residents practice medicine."

(20) Electronic medical records/PDAs

"There'll be nothing but," electronic medical records, Kaiser says. His colleagues agree. "And not to have a personal digital assistant will be a violation of the medical license."

(21) Telemedicine

Telemedicine is "almost here!" exclaims Coile. "There are still payment issues and cross-border licensure issues, but the latter will disappear when payment shows up."

"This one's a keeper" Kaiser says, "double, triple, quadruple. There's no end to it. Eventually, we'll be able to do everything in the country from a central point."

(22) Alternative or holistic medicine 

"Please! Integrative medicine is the term," Coile says.

"It should be called appropriate medicine," Kaiser objects with equal alacrity. "Appropriate medicine is anything that's evidence--based and works. Whether it's from a shaman in Tibet or a research lab, if it works, we should do it."

As it stands, says Goldsmith--whose primary care provider is a homeopath--"in large parts of the country allopathic medicine is alternative medicine.

"Consumers are saying it's important," Coile notes, "not just an amenity." What's more, "faith and spirituality are a cultural thing, not a capital expenditure. This is going to be the way medicine is practiced in ten years."

(23) Malpractice insurance rates/crisis

"No relief in sight," for skyrocketing malpractice insurance rates, summarizes Goldsmith.

"Rates will increase, government will try to set caps and insurance companies will continue to drop out," Kaiser says.

"We're feeling the dynamics of the insurance business," explains Coile. "Insurers can't subsidize the medical malpractice line because of the collapse of Wall Street. As far as any concept of social responsibility, forget about it. The pain threshold is already so high that it means the train wreck is going to have to take the locomotive and most of the cars into the gulch before anybody acts."

(24) Clinical trials in physician offices

"We have more trials in the pipeline and we have to find a way to do them," says Coile.

"A good idea and growing," says Goldsmith.

(25) Direct-to-consumer pharmaceutical advertising

"The cocaine of drug marketing," quips Coile. "Once you start it's hard to stop. And, hey, this is just the way things are."

"There are elements of backlash present," says Goldsmith, "but voluntary stimulation is not going to put it back in the box."

"I want the purple pill!" laughs Kaiser. "I have no idea what it does, but I want it."

What's missing from the list?

"Health reform and the medically uninsured," are missing from the peer reviewers' trend list, says Coile. "In five years we could have fifty million people in this country who have no health insurance. Then we'll have a new debate. But do we get any closer to a solution?"

Kaiser foresees one.

"Our mental model of health care has got to change," he says. "And it is changing, as local communities begin to take responsibility for providing health care to their citizens.

"We need covenants--not contracts, which are things you sign with people you don't like, but covenants, which are sacred agreements--that bring government, industry and the voluntary sector together the way they've done it in Hilton Flead, South Carolina."

There, he notes, a retired physician, Jack McConnell, MD, has enlisted retired colleagues in setting up a free clinic that serves every single person on the island.

"If we can repeat that throughout the country," exclaims Kaiser, "our problems are solved! It's fascinating! The whole idea that we don't have enough resources in this country is dead wrong. We just have to think about the problem differently.

Kaiser has always been an apostle of New Age applications in health care delivery. He was an early promoter of the Planetree concept, which incorporates soothing architecture, music, scents and the inclusion of family members in hospital treatment plans, even allowing patients to maintain their own charts. So this rubric overarches much of Kaiser's personal list of "next big things."

Among them, he says, will be:

* Growing emphasis on the "spiritual" dimension in health care (which is not the same as "religious," he stresses. Rather than God and dogma, spirituality focuses simply on maintaining "a right relationship with all that is.")

* The emergence of "destination" hospitals, not necessarily large, but famous for ambience and competency in mind-body treatment of particular conditions.

* Expansion of health maintenance and vitality programs for people over 60 ("We've equated old age with poverty," he observes "Wrong! Old people have all the money.")

* "Conscious deathing"--in which today's "barbaric" IGUs are supplemented by comfortable places where "deathing midwives" and "music thanatologists" ease dying patients and anguished families through a sort of "graduation service.

* Direct involvement of hospitals in "child potentiation" through cooperative extramural programs with community agencies and schools.

"It's my prediction that this is going to become a major health care delivery modality. The Kennedy-Kassebaum bill already has a provision that says if a physician practices for free and gets sued for malpractice the Public Health Service will pay the cost of defense. I believe it will be funded within a year. And then we can activate thousands of retired physicians who'd love to do this.

"I'm very optimistic," Kaiser declares. "I believe things really do get better. Old people don't start wars and, as this country ages, it will become more civilized and loving. In the next ten years health care will no longer be seen as just a business, but a responsibility humankind has."

David O. Weber is a frequent contributor to this journal and 2002 winner of the eighth annual award for trade journalism presented by the National Institute for Health Care Management Research and Education. He can be reached in Mendocino, Calif., at [e-mail].