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.

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. 

• 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?

"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 yo

  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

1. 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.

1. 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.

1. 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.

1. 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: