ALERT: Major Study on Future of Primary Care Seeks Input on IM Therapies and CAM Practitioners
Written by John Weeks
ALERT: Comments Sought by May 6 on Role of Integrative and CAM Practices/Practitioners in Future of Primary Care
Summary: Your comments are requested for a major Kresge Foundation-funded study on the future of Primary Care in 2025l. The projections will be made by the Institute for Alternative Futures, led by Integrator adviser Clem Bezold, PhD. IAF seeks input on the types and extent of integrative practices/modalities/practitioners will be part of primary care teams and practices in 2025. Also sought is input on the roles of licensed DCs, NDs, LAcs and others such as licensed midwives who may be part of the primary care matrix. Aomng other topics, Bezold seeks qualitative and quantitative information on what are both preferred and likely forecasts for 2025. The document below includes IAF's current draft of forecasts, including #15 on CAM/IM. Respond by May 6, 2011.
Priority Response:
Send your comments to the Institute for Alternative Futures
via Yasemin Arikan.
to help shape the report.
Second Priority Response: Send your comments to
for inclusion in an Integrator forum on the topic.
Comments due by May 05, 2011
Forecasting primary care's future
The Institute for Alternative Futures (IAF) seeks the input from the integrative healthcare community on the future of primary care. One element specifically under consideration is the role of integrative medicine modalities and therapies. A second is the role of distinctly licensed "CAM" practitioners as primary care practitioners and members of teams.
Through a grant from the influential Kresge Foundation, IAF is examining the "likely and preferred futures" for primary care in the year 2025. The study, led by Integrator adviser Clem Bezold, PhD, uses an iterative process to develop a series of forecasts. These are then presented to new audiences, one of which is now you. As of April 21, 2011, 18 such forecasts are included. These are included at the bottom of this posting.
Futurist Clem bezold, PhD
Of particular interest to IAF for your comments is #15, below, which reads.
15.
Integrative
encounters in primary care - Integrative encounters address all
dimensions of health by bringing the knowledge of conventional, unconventional,
complementary, alternative, traditional and integrative medicine disciplines to
bear across the many different cultural traditions of persons cared for.
Bezold and IAF request the following:
Do you have comments on this forecast?
Do you recommend an amended or alternative forecast?
Do you have data or insight on a forecasts for CAM practitioners doing primary care, or
being on the primary care team?
Do you have forecasts for how CAM/IM practitioners will be providing primary care as part of teams in community health centers?
Do you have any forecasts for growth in numbers of CAM/IM practitioners who will be practice in primary care roles or on teams?
Do you have comments related to the other forecasts or different forecasts that have thus far been overlooked?
Do you have comments or forecasts on the nature of CAM modalities in primary care in 2025?
Bezold adds:
"Most of the feedback to the CAM question I am getting in the
focused groups from conventional primary care folks is that they will include
use of the modalities as they are proven effective/cost effective. Any
forecasts on the evidence on behalf of CAM modalities and/or CAM licensed
providers would be welcome."
Funding the study
In short: Do you have data or commentary on the preferred or likely
futures, will be the roles of integrative therapies? What roles will be
played by chiropractic physicians, naturopathic physicians,
practitioners of acupuncture and Oriental medicine (AOM) and also
potentially licensed midwives (for birth) and other emerging
professions? About
Bezold/IAF and CAM/IM: As far back as 1978, Bezold told members of
Congress, in a forum on the future of health care, that one trend to note was
the consumer's use of what was then called "alternative medicine." In 1998, for another in an
ongoing series of these Congressional briefings, Bezold invited U Maryland integrative
medicine leader Brian Berman, MD, NCMIC president Lou Sportelli, DC and Integrator publisher-editor John Weeks to serve on
a futures' panel at the Rayburn House Office Building focused on this topic. IAF’s 1978 forecast has proved prescient. IAF’s client list and donor base includes many
of the most prominent organizations involved in health policy.
IAF’s most up to date iteration of forecasts for Primary Care in 2025 is below.
Priority Response:
Send your comments to the Institute for Alternative Futures
via Yasemin Arikan.
to help shape the report.
Second Priority Response: Send your comments to
for inclusion in an Integrator forum on the topic.
___________________________________
Primary
Care 2025
Forecasts Used at the Time of a Focus Group at the New York Academy of Medicine April 21,
2011
-- Clement Bezold, PhD, IAF Chairman
Below
are specific preliminary forecasts for aspects of primary care in 2025. These
forecasts generally assume a high degree of change by 2025. During the focus group we will review some of
these and get your sense of whether they are relevant primary care practice. Will there be more or less change by 2025 on
these different dimensions?
At
the end of this list, you will find room for other areas to forecast. What other areas of primary care will see
significant change over the next 15 years?
Opening Questions
1
Factors leading to major changes in
primary care What
factors will lead to the greatest change in primary care over the next 15
years? Below is an initial list. Which of these or others do you think will be
most important for affecting change in primary care by 2025.
a. How
might these factors shape or influence "visits" or how primary care is done.
i. Changing
primary care team members
ii. Payment
for primary care
iii. Telehealth,
televisits (phone, email, skype or equivalent) iv. Virtual
health coaches/digital agents/health avatars used by patients v. Personal
biomonitoring (particularly continuous, passive biomonitoring routinely stored
in
the person's EMR)
vi. Anticipation
of changing health conditions vii. Community
health monitoring
viii. Enhanced
self care
Payment
form & primary care-
The form of payment plays an important role in how primary care is
designed and delivered. Given
health care reform, changes in the marketplace, advancing technologies and
other potentially disruptive technologies there is great uncertainty about
payment form. But to provide a base
from which to consider the future of care itself, it's relevant to make
some assumptions about payment. A
base forecast that sees the advance of ACOs with capitated payment, a
residual fee for service (FFS) set of providers, and a set of
"semi-integrated" primary care providers (PCPs) could have the following
proportions. In 2025, roughly
Integrated
payment- 40% of the primary care practices (PCPs) are formally operating within
an ACO-type organization. Most of these PCPs within ACOs operate in medical
home practices, and PCP team members are paid a salary with productivity and
quality incentives.
Semi-integrated
payment - 30% of practices would be contracting directly with a payor as a
"medical home" with a blended per member per month (PMPM) plus fee-for-service
(FFS) type arrangement plus pay-for-performance (P4P) incentives.
Fee-for-Service
- 30% of primary care practices would largely be operating on a fee-for-service
(FFS) model with some type of P4P quality incentive.
We
assume that the proportion of the population with access to health would
parallel the PCP work force in integrated, semi-integrated, and fee for service
care.
As we review the following
forecasts, initially assume that they apply to primary care in the 40% in
integrated payment practices. We'll then
ask how primary care would be different in semi-integrated and fee-for-service
practices.
Forecasts For Specific Aspects of Primary Care 2025
3. Focus on
Primary Prevention - Primary prevention is the major focus of primary
care in 2025
a. Community
focused prevention - Primary care has supported changes that enable the
community as a whole to create an environment that make healthy choices easier including
access to better nutrition, a healthy
activity, and a cultural shift supporting mental and spiritual health, with a strong emotional and ethical base. This focus on health has improved personal
and community health results.
§ To
optimize healthy lifestyle choices in the population, the primary care team
works with community organizations and resources to promote health education,
healthy environments, and healthy nutrition and activity programs to enhance
personal and community health.
4. Continuously
Improving Health- Health is continually assessed and worked on along
multiple dimensions in 2025 so that the physical, medical, nutritional,
behavioral, psychological, social, spiritual, and environmental conditions are
measured and improved for all covered by primary care.
5. Role of
the Primary Care Team - The primary care team members include
the patient, nurse practitioners, physicians, psychologist, pharmacist, a
health information technician and community health workers. A small number of team members have personal
contacts and established relationships with each patient/person. "Visits" are most often phone calls,
televisits or virtual visits, though in some cases the visit is in the
clinic.
a. Prior to any visit the relevant team members
review the summary of data from the patient's history, biomonitoring, and other
lab/test results prior to the visit. The
team can discuss evaluation and treatment protocols in preparation of the
visit.
b. Relational
Agents (Personal Health Avatars) - Besides a strong relationship
between the patient and some of the primary care team members, most patients
have a relational agent or personal health avatar made available by (or
enhanced by) their health care provider.
This virtual agent provides health education, coaching, and
reinforcement, driven by the person's biomonitoring data and advanced care protocols.
c. Community
Health Workers- Some primary care visits involve a community health
worker going to the person's home. Armed
with the person's medical record including personal bio-monitoring data and
neighborhood community health data, the community health worker provides health
coaching and checks for home safety.
Given the systems and protocols these community health workers can
handle many immediate issues, provide referrals and immediately schedule the
person for a physical or televisit when needed.
i. for many primary care patients their CHW is
their lead primary care provider.
6. Patient-Physician
relationships - In 2025, trusting relationships between providers and
patients are the basis of primary care's capacity for promoting health and
managing disease and medical education supports this capacity.
a. The primary care team members work to
instill caring, joy, love, faith, and hope into their relationship with each
person.
b. Once trust has been established usually
through in-person contact, effective communications using responsive and
empathic email, phone calls, and avatar-based "cyber care" reinforce this
personal relationship. Many patients
find that virtual encounters with their personal health avatar, with its
artificial intelligent "personality," provide the empathy they seek but most
people who are ill or dying still seek the compassion provided by human
healers.
7. Focus on
Behavioral Change - Primary care routinely works with individuals to
understand how to move choices from the limbic system of the brain that
unconsciously controls emotionally directed behaviors to the frontal areas of
the cognitive brain which controls conscious behaviors. Behavioral change protocols are personalized,
based on the knowledge of the patient's genomic, epigenetic, and biomonitoring data
as well as their psychological and social dimensions
a. For some patients/persons nanotechnology devices
are used to modulate brain chemistry so that organic damage is countered. The potential for behavior change based on
neural implants confronts ethical issues that society grapples with in 2025.
8. Quality
and Safety Focus-The chronic care model evolves to the expanded care
model and beyond. By 2025 quality in
primary care will include the Triple Aim of excellent health care experience,
lower per capita costs, and improved population health. Metrics for all three aims will be
successfully measured.
a. primary careffort and success in affecting
the community environment and social determinant of health will be routinely
measured.
9. Genome
& Epigenetic Data Use- By 2025 most individuals' genome will be
mapped and in their EHR, with secure access available from anywhere according
to established permissions. The role of genetic and epigenetic influences
will be understood, e.g., how maternal health, prenatal care, injury history,
stress levels, social determinants of health and current health status
influence gene expression and protein
production to predict and prevent adverse outcomes. The
person's genomic and epigenetic data will be included in the patient's records
and primary care protocols will integrate genomic and epigenetic understanding
into the relevant assessments, diagnoses and treatment approaches.
10.
Broadened Vital
Signs-
The nature of vital signs and their collection will have evolved to include a
wider range of bio-physical, mental/neurological, and place/environmental
measures. System biology markers will be
used to predict and preempt major diseases, inflammation, DNA damage, and reactive
oxygen species. Mental health
functioning and allostatic load (physiologic consequences of chronic stress
exposure) will be continuously monitored.
11.
Precision
medicine-
In 2025, primary care encompasses precision medicine where providers model the
genome, metabolomics, and proteomics, as well as a better understanding of how
social determinants affect health outcome of each individual. This analysis captures the upward and
downward causation chains for each person starting with his or her genome,
upward through the cellular level, tissue level, organ level, organism level,
and on to the community level.
a. With this capacity, health care providers
can effectively identify and measure changes in pre-disease and disease, and
predict which therapies will be most effective for each person. Providers will identify healthy patterns for
each person and be able to work with the person to correct deviation back to
the wellness zone.
12.
Personal
and community vital signs- In 2025, primary care is nearly
inseparable from community health. Providers
are networked with neighborhoods and share their data (with appropriate privacy
and security protections) with public health officials, who coordinate
activities to improve population health. Medical records include home location as a
vital sign, with mapping information on the degree of health and safety risks,
unemployment rates and other social determinants. Primary care provider information systems
provide alerts on community health conditions and, as relevant, include that in
each person's record. This ongoing
health data mining is used by local governments and providers to focus on
changing local health threats or specific conditions. Primary care providers take the initiative to
collaborate in addressing community needs.
Community
self-care -
Primary care routinely considers what community conditions may be impeding
their patients' health and in focused ways leverage these social
determinants of health - e.g., starting schools, training for health jobs,
getting access to food stamps, healthy foods, and supporting neighborhood
safety & healthy activity.
Primary care providers and the health systems of
which they are a part work within their communities to identify and address
social and environmental factors that hinder individual and population
health.
Members of communities exchange health information
and services through an increasing variety of informal means and
community institutions, thus reducing the demand for primary care.
For example, rather than immediately scheduling an appointment with a
primary care provider, a mother whose baby has a rash first visits a
local grandmother who "has seen it all."
14.
Person
centered care - In 2025 the individual or person involved in and
receiving primary care will not be considered the "patient" except when they
are in "inpatient care" or having care for acute episodes. Individuals will be doing enhanced self-care. Patient-centered primary care will have
evolved to person and family centered primary care. The whole person will be the focus of care.
15.
Integrative
encounters in primary care - Integrative encounters address all
dimensions of health by bringing the knowledge of conventional, unconventional,
complementary, alternative, traditional and integrative medicine disciplines to
bear across the many different cultural traditions of persons cared for.
16. 24/7 -- By 2025, health care is
available anytime and everywhere. Health Care Access - People seldom need
to be evaluated in the primary care clinic. People can have 24/7 access to their relational
agent, and access by phone, email or televisit, to some human member of the
primary care team much of the time.
17.
Consultation/exam
room space-
When a person needs to be seen face to face, he or she goes to the provider
consultation/exam room. Although the average
amount of exam space has not changed (120 square feet), it looks very
different. The room has a comfortable
sitting area to speak to the provider and a large wall mounted monitor is near to
review tests, treatment protocols, and provider recommendations. In a section of the room is a partial wall
and curtain where the provider can perform an examination if needed.
18.
Total health
care space-
Brick-and-mortar medical centers/offices are smaller than they used to be, though
the combination of rationally distributed clinics and a virtually integrated
healthcare system enables effective care in any space, location, and time.
Other
Forecasts?:
19.
Forecast:
20.
Forecast:
__________________________________________
Priority Response:
Send your comments to the Institute for Alternative Futures
via Yasemin Arikan.
to help shape the report.
Second Priority Response: Send the same comments to
for inclusion in an Integrator forum on the topic.