Vision of a Fundamentally Different Future

The following is an except from the book, From Healthcare at a Turning Point: A Roadmap for Change by Rita E. Numerof.

It’s the year 2024. It’s hard to believe that just a decade ago there was intense debate about healthcare in the United States. Today, we have more options than were ever available before. We spend less on healthcare delivery, and we seem to be generally healthier as a nation. Costs have come down dramatically in some sectors of the industry, and dynamic new businesses have sprung up to meet emerging needs. Traditional businesses have evolved with core components re-purposed. Financing mechanisms have changed, and while not perfect, there is better alignment between cost and quality. There Is better coordination of care, more personal accountability for health outcomes, more choice and competition, fewer restrictions, and generally less intervention and fewer procedures.

Of course, there have been some business “casualties” across the industry, as those organizations that held on to old models found themselves unable to adapt and therefore unable to compete in a new marketplace.

Medical tourism is up as the United States has once more become the global destination for elective procedures and continues to be the gold standard for complex care. Innovations here have been taken to other parts of the globe as researchers in the United States continue to work collaboratively with their global counterparts to find ways to improve health outcomes. New investments in research and development (R&D) have had big payoffs, as medical interventions have replaced surgery, and in some cases minimally invasive surgical procedures have replaced chronic medical treatment. Equally important, non-Western approaches to treatment have gained acceptance as the evidence for their efficacy is increasingly demonstrated.

Everyone in the United States has access to health insurance. Typically, it’s attached to the person, although there are still some sectors of the economy where employer-based healthcare is the preferred option. National access opened up competition. Local providers sprang up, sometimes coordinated with more traditional care delivery organizations, which together built comprehensive or “bundled” approaches to disease management, wellness, and prevention. Whereas fragmentation and inefficiency still characterized healthcare in 2012, coordination and cost effectiveness increasingly characterize the industry. Of course, there are still niche players who are quite successful in their market segments.

What’s so remarkable is the creativity brought to bear on what appeared in 2012 to t>e intractable problems that some argued could only be fixed by a single, government payer. Indeed, the creation of true market-based solutions, with very targeted policy (government) intervention, has enabled this magnitude of change in such a relatively short period of time.

Insurance payment reform enabled interstate access and reduced complicated rules and bureaucratic inefficiency. Member retention, once a major problem for the industry, due in part to an over-reliance on employer-based benefit coverage, has dramatically increased in recent years. Whereas average member retention was once pegged at 18-24 months, it continues to increase, with some carriers reporting averages of 6-8 years and a positive trend line. Portability Is characteristic of all insurance since most individuals hold their own policies, with myriad design options for consumers to choose from long-term care, full coverage including vitamins and over-the-counter (OTC) products, basic catastrophic coverage, and specialty options including 10- , 20- , and 30-year life support.

Pooling and tax incentives have leveled the playing field and made this a reality. Tine competition has lowered costs and increasingly put consumers in the driver’s seat. Employers, where they do provide coverage, have almost entirely moved to defined contribution approaches. Employers get to make the determination of what the contribution will be—not the insurance provider or the government. For insurers still in the business, the model has moved to a retail individual-dominated market.

On the delivery side, things are very different. Fundamental to change has been a shift in a basic assumption of the industry—that volume (or at least a certain type of volume based on payer and procedure) is good. In the world of the healthcare continuum—prevention, early diagnosis, intervention, and rehab—traditional hospitalization volume represents a cost, not revenue! Not wanting to repeat the mistakes of capitation in the 1980s, 2012 innovators committed to short- and longterm health outcomes.

This required enormous behavioral change on the part of physicians, social agencies, and consumers. It also required new approaches to metrics and the generation of evidence. Increasingly, healthcare delivery institutions are focused on optimal outcomes—the right treatments) in the right amount, administered in the right way, at the right time, at the right place, for the right patient. Hospitals are less frenetic for caregivers, and they tend to focus more on the things they do best—acute, complex intervention, often in specialty institutions. They are less likely to attempt to l>e “all things to all people.”

Nurses who frequently focused in 2012, on getting through the shift without hurting anyone, now focus on the bedside—on consumer and family education, on rehab, on care management, coordination, and health outcomes—and a smooth transition back into the home and community.

Hospital-acquired infection rates, while never reaching zero, have been dramatically reduced; medication errors also are down below 1%. No longer are hospitals generally recognized as unsafe.

Together with the elimination of redundant and unnecessary care, estimated at between 30% and 40% at some of the best hospitals even in 2012, these changes resulted in the savings that enabled innovation and universal coverage without adding cost.

The refusal of the Centers for Medicare and Medicaid Services (CMS) to pay for such error-based never events initially forced healthcare delivery institutions to dramatically change practice—or suffer the financial consequences. Similarly, 30-day readmission payment restrictions drove letter coordination within the hospital setting and facilitated discharge planning and coordination with community agencies and post-acute care settings. Discharge planning now starts pre-admission except in the case of emergent situations, and even there, it begins at the time of admission. Commercial insurers, not surprisingly, followed CMS’s lead.

On the physician front, frightening trends in primary care have been reversed. With balanced payment increasingly recognizing the enormous contribution and broad system expertise of primary care physicians and a decrease in compensation for narrow specialty care, more physicians have been going into primary care medicine as a specialty, thus reversing the disturbing trend in 2012. Where there were significant shortages projected years out for primary care physicians in 2012, now more than 20% have selected this specialty area in 2023. Contrary to what was anticipated, the small business model for independent physicians continues, nurse practitioners have opened offices, and integrated cross-specialty practice models have emerged to offer their customers comprehensive healthcare solutions accessible to local communities. Increasingly, consumers get care they need in their homes, at retail clinics, and sometimes at the office…when they need it.

In 2012 defensive medicine was frequently offered as a major contributor to the problem of overutilization. Essentially, physicians and hospitals felt as though they needed to leave no stone unturned in diagnosis and treatment to protect against potential legal liability. Some patients, unencumbered by the need to actually pay for the services, would likewise demand that no stone be left unturned, even when the downside risk outweighed the upside potential. Clinical judgment was painted as a prisoner of the legal system, and tort reform became the obstacle to rational resource utilization. Mow things have changed in just a few short years.

Today, increased transparency, reliance on evidence, change in payment mechanisms and the redefinition of the consumer’s role in health care decisions have dramatically changed the picture. Patients are more likely to collaborate with their physicians, especially primary care providers, and evidence is used to determine which tests need to be done and when.

In the midst of this change, some hospitals have repurposed bricks and mortar, turning low-occupancy beds into assisted living long-term care (LTC) and long-term acute care hospitals (LTACIIs). Still others have created temporary residences for families visiting sick relatives receiving needed treatment and rehabilitation.

New players, not in the traditional healthcare space, created dramatic disruption by taking advantage of the industry’s inability to see itself in a fundamentally different business model. Primary care began moving, ever so slowly, to walk-in clinics in retail settings in 2010 and 2011, picking up speed dramatically in 2012 and 2013. More and more people turned to convenience and began to trust nontraditional settings for blood pressure and other screenings, flu shots and other immunizations, and even nonurgent care.

Screenings have led to earlier diagnoses and referrals to specialists. Industry leaders including Walmart, Walgreens, and CVS shook up the industry. Capitalizing on location, they brought the health clinic into the retail space, tying in low-cost access to generic prescription medications and store brand over-the-counter products. Their enormous success also disrupted traditional pharmacy benefit managers (PBMs) who, in retrospect, have been a bridge between the old and new model of healthcare.

It’s truly a different world!

Creationism vs. Evolution: The Debate

Bill Nye and Ken Ham debated the origins of life last night live from the Creationist Museum in Kentucky. The great success of the debate was to inform and raise awareness of how vital science is to our future. Nye made this point many times in the debate. In the end, theism and atheism are both positions of faith and have little to do with science. The only tenable position seems to be the Socratic position of not knowing – which is also (usually) the default position of science.

Three questions came up that really get at how little we know about the universe. The best questions came from the audience.

1. How did all the matter and energy in the universe come into being in a single instant from nothing?
2. How does matter become conscious (e.g. brains)?
3. How did matter come alive (e.g. animals)?

These are the big questions in science and as Nye said, we just don’t know. In fact, they seem downright miraculous. We’ve taken some ground in understanding question 2 and 3 but I believe question 1 will remain on the list of unknowns for very long time. There are some scientists like Lawrence Krauss that are trying to answer it but this really isn’t science as much as thought experiment since there is no way to test these theories.

Personally, I love the mystery.

Turtles All the Way Down

I first read the phrase “Turtles All the Way Down” in a book by Stephen Hawking. According to the story, a big name scientist was giving a lecture on astronomy.

After the lecture, an elderly lady came up and told the scientist that he had it all wrong. ‘The world is really a flat plate supported on the back of a giant tortoise.” The scientist asked “And what is the turtle standing on?”

To which the lady triumphantly replied: “You’re very clever, young man, but it’s no use — it’s turtles all the way down.”

Inequality for All

We’re in the biggest economic slump since the Great Depression, and we can’t seem to get out of it. Why? Because, exactly as in the 1920s, so much of the nation’s income and wealth are going to the top, that the vast middle class doesn’t have the purchasing power to keep the economy going.

I’ve spent most of my working life concerned about what’s happening to American workers – their jobs, their wages, their hopes and fears. My father sold clothing to the wives of factory workers in the late 1940s, 1950s, and 1960s. I watched as the factories began to close, and as those families struggled with a new economy. Households kept their living standards by sending those wives and mothers into paid work – a strategy that did the trick for a time. But when it no longer generated enough income, American families went deeper and deeper into debt – and that’s been the vicious cycle most middle class Americans have been in ever since. — Robert Reich

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Scientists Claim That Quantum Theory Proves Consciousness

A book titled “Biocentrism: How Life and Consciousness Are the Keys to Understanding the Nature of the Universe” has stirred up the Internet, because it contained a notion that life does not end when the body dies, and it can last forever. The author of this publication, scientist Dr. Robert Lanza who was voted the 3rd most important scientist alive by the NY Times, has no doubts that this is possible.

The 10 Dogmas of Science

The science delusion is the nature of reality in principle, leaving only the details to be filled in. This is a persistent delusion within science. Many times in the history of science people have thought that our understanding of nature is almost complete.

Today, there are many people who think that science already understands the nature of minds, the nature of evolution, the nature of reality. But what I show in this book is that conventional science is based on a series of dogmas. There are ten dogmas that underlie science. These dogmas are not normally questioned. What I do in the book is to treat the dogmas scientifically but questioning them – turning them into questions, in fact, and showing that many of them, in fact, all of them, have been superseded by the advances of science itself.

When we feel free to go beyond these dogmas, to question them, science opens up in completely new ways. All sorts of new questions become possible. All sorts of new research becomes possible. I think this will help to liberate science from the restrictions that hold it back at the moment. That’s why in England, the subtitle of the book is Freeing the Spirit of Inquiry and in America the title of whole book is Science Set Free.

Do I have Φ?

Panpsychism, the ancient doctrine that consciousness is universal, offers some lessons in how to think about subjective experience today. Unlike classical panpsychism, not all physical objects have a Φ that is different from zero. Only integrated systems do. A bunch of disconnected neurons in a dish, a heap of sand, a galaxy of stars or a black hole—none of them are integrated. They have no consciousness. They do not have mental properties.

For every inside there is an outside, and for every outside there is an inside; though they are different, they go together.
- Alan Watts, Man, Nature, and the Nature of Man

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The Closing of the Scientific Mind

From David Gelernter in Commentary Magazine:

“The huge cultural authority science has acquired over the past century imposes large duties on every scientist. Scientists have acquired the power to impress and intimidate every time they open their mouths, and it is their responsibility to keep this power in mind no matter what they say or do. Too many have forgotten their obligation to approach with due respect the scholarly, artistic, religious, humanistic work that has always been mankind’s main spiritual support. Scientists are (on average) no more likely to understand this work than the man in the street is to understand quantum physics. But science used to know enough to approach cautiously and admire from outside, and to build its own work on a deep belief in human dignity. No longer.

Top 25 Science Stories of 2013

From Science News: Last year it was easy to choose a story to lead our annual Top 25 list. The discovery of the Higgs boson was a watershed moment, ending a decades-long quest by thousands of physicists to fully describe the subatomic realm.

This year, nothing so momentous came to pass. But science isn’t just about dramatic announcements and tremendous technical feats. Anyone who reads Science News regularly appreciates that great new insights often arise from countless little bits and pieces of new knowledge. This year, careful readers may have noticed a steady accumulation of revelations about the bacterial communities that call the human body home. It has long been known that those microbes are essential to processes like extracting nutrients from food and fighting off their less benign brethren. But this year a growing body of research demonstrated that bacteria engage their hosts so vigorously that in some situations, scientists are left wondering which party is the tail and which is the dog.

Electric Universe 2013: The Tipping Point

This is Part 1 of a talk by Sheldrake at the conference Electric Universe 2013: The Tipping Point, in Albuquerque, New Mexico.

Many scientists like to think that science already understands the ways of the natural world. The fundamental questions are answered, leaving only the details to be filled in. The impressive achievements of science seemed to support this confident attitude. But recent research has revealed unexpected problems at the heart of physics, cosmology, biology, medicine and psychology.