Representación de la alternancia y mezcla de códigos

Putting the trends in these two chapters together, and relating them to the scenarios for US health care identified in Chapter 1, what are plausible forecasts for managed care in 2010? If vision and value-added planning are used, we could see something like the

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first forecast below: Healthy Managed Care 2010 (which corresponds roughly to Scenario 4—Healing and Health Care, described in Chapter 1).

A second image, which we call Managed Self-Care 2010, explores the growth of

sophisticated self-care and the capacity for consumers themselves to better manage the professional care they purchase—in effect moving the risk management aspect of health care back to consumers. (This image corresponds roughly to Scenario 3 in Chapter 1.)

Note: Italicized text is written from the point of view of an observer in 2010.

Forecast 1: Healthy Managed Care 2010

• The Pew Commission on the Health Professions was accurate: in 2010, 90% of

the insured US population receives care through integrated managed care delivery systems. These systems are characterized by a high degree of consumer satisfaction, significant improvement in individual and community health and a broader array of preventive and therapeutic choices, all for relatively far less cost than in the 1990s.

• While there are many variants, the defining characteristic of managed care

remains payment of a monthly fee by the employer or individual in exchange for a relatively comprehensive set of health care services. In effect, managed care continues to assume responsibility for the management of health care and the risks of costs for the individuals covered.

• The information revolution has been profound. Telemedicine allows sophisticated

health care to be delivered virtually anywhere; expert systems have decentralized much expertise and decision-making to less formally trained providersfrom specialist physicians to general practitioners to nurses and other

formerly complementary and alternative providers. Also, the managed care organization has provided all of its members with very sophisticated personal biomonitoring and home health management systems. This equipment and the advanced state of videophones mean that only rarely do patients need to meet with their providers, except to establish or renew their personal relationships and to receive therapy involving touch or high-tech equipment.

• Most health care systems, individual providers within systems and provider

teams routinely generate outcome measures that, when aggregated (with appropriate privacy safeguards), are publicly evaluated, allowing comparison of managed care organizations, health care teams, specific providers and specific therapies. These “report cards” on community providers also provide the “batting averages” of providers in relation to both major conditions and the most common genotypes and phenotypic groupings in the community.

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• The bargain between consumer and provider has shifted. Given the Forecast,

Prevent and Manage paradigm now in widespread use, health care providers agree and are held accountable to lower a person’s life-course morbidity, with the person’s active participation. Thus the job of the managed care organization is not simply to treat well, but to forecast problems that might arise for the individual, prevent as many of them as possible and optimally manage any illness that does arise.

• The US health care market continues to consolidate. Between 2002 and 2005

the information revolution allowed small organizations to compete effectively with large organizations. Also, local and regional managed care players cooperate in region-wide “virtual organizations.”

• Some of the most successful managed care organizations were developed by

CAA groups, such as chiropractors and Oriental medicine providers, using information technologies to integrate a variety of approaches into a package of optimal care customized to each patient.

• Managed care, to be cost-effective, focuses on where it can leverage health

gains in both prevention and treatment. Behavioral approaches are very important.

¾ Most managed care organizations ensure that their subscribers or members

have personal health coaches. These are likely to include both human

coaches (the 2010 equivalent of a primary care physicianalthough they may

be nurses, who take an ongoing, personal and very effective interest in the individual and ensure periodic personal contact) and electronic coaches that can be accessed at home or anywhere, anytime.

• Dramatic therapeutic advances have occurred. Many diseases are preventable

or curable, or their progression can be significantly slowed. This includes most cancers and heart disease. As research develops on the latest modalities

including customization based on the individual's phenotype and genotype, the stages of their disease and related factorsthis information is built into the protocols of managed care providers.

• The shift of managed care organizations to aggressive outcomes research was

aided by sophisticated patient/consumer groups who work actively with the research community and health care providers to ensure that promising leads are pursued and utilized effectively.

• There remain more options for health care than can be paid for. Protocols help

focus on cost-effectiveness, but the need for more conscious priority-setting remains. In most states priority-setting follows Oregon’s model. There is universal access to a basic package of health care. States are allowed to

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determine what will be included in that basic package. Sophisticated analysis of the cost-benefit of a much broader array of approaches factors in the subgroups for which these approaches will truly work. Priorities are then set for the publicly available benefits package.

¾ Individuals can “buy up” to other options, and managed care plans as a whole

can choose to raise their fees and reset priorities within the broader fee structure.

¾ Managed care organizations, as well as their individual providers (especially

CAA providers), routinely provide “wellness” services which go beyond the health care benefit package and are paid for out-of-pocket by individuals.

• As the contribution of managed care to health gains was identified and measured

by outcomes, the definition of “health” broadened. Managed care providers focused on where they could get the greatest long-term leverage. Not only lifestyle but also broader issues, such as environmental pollution and poverty, came to be seen as elements in retarding or enhancing health. Health care providers now share in the responsibility for the health of the communities they serve and community report cards show how well they are contributing. Managed care providers became creative in enabling communities to attack the causes of illness.

¾ Prevention and the focus on causes will lead to health care’s participation in

the process of designing health care systems and societies to “design out illness” wherever possible.

Forecast 2: Self-Managed Care 2010: A Competing

Forecast

• By 2010, who needs ‘em? Individuals and families have largely retaken responsibility

for their risk management. Expert systems, personal biomonitoring and disease forecasting systems based on a person’s genetic profile enable families to self- manage much of the care they sought from HMOs in the 1990s.

• Medical Savings Accounts (MSAs) and other policies encouraging consumers and

rewarding them for effective use of health care reinforced this drive to less reliance on professionals.

• Support for public policies relying more on the marketplace grew in the late 1990s

and early 2000s as the public became aware of the high cost of professional

development for health care providers, particularly physicians, yet only contributed to provider surpluses. "Enough!" said consumers.

• Public policies funded universal access to catastrophic insurance, providing very

frugal backup care to the unemployed, and ensured that all individuals and families could access powerful home health management tools. These tools include

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behavioral coaching for each family member, sophisticated biomonitoring and interactive lifelong health records.

• Policy also ensured quality standards for the competing protocol developers whose

knowledge bases are used by health care systems and individuals.

• While demand has declined significantly for health care providers whose services

could be automated, or curtailed by prevention, a large market remains for those primary care providers who are ready to seriously share responsibility for their customers’ health. In addition there remains a significant demand for services, such as manipulation, which are not amenable to self-care by consumers.