Anticipating the Anticipating the

Future of Future of Healthcare RegulationHealthcare Regulation

Les Wallace, Ph.D.Les Wallace, Ph.D.

Welcome the New Normal:Permanent Whitewater

2009 BOC Athletic Trainer Regulatory Conference

Remember the 1990s…Remember the 1990s…

401Ks… Unemployment 4% Prozac… Tina Turner Retires… Christian Science Monitor… 1,000 new Starbucks a year… “This Bud’s for you!”

“The future ain’t what it used to be.”A Legacy of 21st Century Leadership

21C the new Normal…21C the new Normal…

Economic turmoil

War and Terrorism

Nuclear proliferation

Governmental Debt

International Trade

Global Warming

Energy

Pandemic

Integrity

A Series of A Series of “once in a hundred years” crises“once in a hundred years” crises!!

Chrysler bailout 1980 Savings and Loan collapse ‘86-’95 1990’s Banking closures 9/11/01 Terrorist Attack 12/2/01 Enron collapse Katrina U.S. in two wars:

ongoing smoldering in

Middle-East, Indonesia, Africa,

S. America 2008 World Financial Meltdown

“Caught between the Dow and the Tao.”

Reform and RegulationReform and Regulation on a Tightrop on a Tightropee

Emotion of Healthcare reform and regulation heating up

Perspective depends on where you sit Complexity creates niches of expertise—

not one agreed upon body of knowledge

50 States demanding to be players Health professions slugging it out for

expanded scope of practice

Topics with “Informational Asymmetry”

Healthcare ReformHealthcare Reform Google “healthcare reform” and “healthcare

regulation” you’ll get 87 screens for each--averaging 9 entries each screen.

…“healthcare professional licensing” and get 91 screens averaging 9 entries each.

…“State healthcare regulation:” 85 screens averaging 9 entries each.

“Information Asymmetry!”

Our Journey…Our Journey… before we hear from the Experts before we hear from the Experts

Health Care For fun—from Futurists

Reform From the White House

What we might know

What we don’t know

Navigating the “Regulatory Trilemma”

““The future ain’t what it used to be.”The future ain’t what it used to be.”

2012 will see massive use of genetic prediction science

DNA is likely to be available on-line by 2025

Longevity medical practice will be commonplace by 2020

2020 stem cell applications will reach Two Billion folks

Nano robots will search the bloodstream for disease

“Smart” drugs are likely to be in Pharmacies by 2020…

“Refresh”—eases brain fatigue & enhances alertness

“Recall”—provides total recall and photographic memory

The Extreme Future

““The future ain’t what it used to be.”The future ain’t what it used to be.”

SERMO Medical Social Networking

…55,000 Physicians convening peer to peer knowledge around their cases, test results, and treatment plans through Net 2.0 models

eICU: a Physician manages up to 120 patients from a distance in 5 different ICUs [20-30% reduction in mortality and complication rates]

UltraClinic: same day interpretation of breast-biopsy tissue and technical consultation using advanced optics converted to video monitor. (U. AZ)

WalMart Clinics: 30 (3,289 domestic stores)

““The future ain’t what it used to be.”The future ain’t what it used to be.”

Myca / “Hello Health”—a face book-like physician storefront: twitter and paypal patient interaction

Kaiser tested IT interfaces to reduce patient visits to Drs. and found a 25% reduction impact

Remote Sensing…“OnStar™” for healthcare:

EKG, Temp., Blood O2, motion orientation

Remote sensing in the works:

eNose, Blood Count/Chemistry, Internal Organ Viewing

The New Future: The New Future: Healthcare from the White Healthcare from the White

HouseHouse

“Weekly Address: Health Care Reform as the Key to Our Fiscal Future”

“White House: Health care Reform will pass this

summer”

“Obama Signals Flexibility on Health Overhaul”

The New Future: The New Future: Healthcare from the White HouseHealthcare from the White House

Universal coverage options (+/- 46 million people) Prevention and public health (currently .04 cents per $)

HealthCare or SickCare Plan? Incentives for excellence / quality Competition in the insurance industry (2 companies

dominate 1/3 of all healthcare insurance) Tax credits / Taxable Benefits??? Pharmaceutical Cost Management Efficiency through Electronic Medical Records Medical malpractice reform Medicare waste and fraud crack down

“Comprehensive health reform by the end of the year!”

The New Future: HealthcareThe New Future: Healthcare $19 Billion in stimulus package for EMR

RAND corporation estimates EMR can save $625 Billion over 15 years

72% of the $2+ Trillion spent on healthcare in the U.S. is spent treating chronic disease

Regulatory costs for healthcare is estimated to be $256 Billion (Duke University)

“Doing nothing, # of uninsured could hit 62 millions in ten years.” (Urban Institute 6/09)

The New Future: HealthcareThe New Future: Healthcare

“Reform that slowed annual rate of health

costs by 1.5% would boost economic output by

over 2% and increase household income by

$2,600 in 2020.” President’s Council of Economic

Advisors

72% of Americans favor expanding the

Federal Government’s role in the healthcare system.

Just possibly we’ve reached a reform tipping point

Government Programs that WorkGovernment Programs that Work

State Children’s Insurance Program (SCHIP):

“One of the most cost effective means of expanding health insurance.” MIT Economist James Gruber

“Medicare Part D” drug benefit:

…in 2008 projected to cost nearly 40% less than originally estimated.

…87% of participating seniors are satisfied with their coverage

Health Care the Government WayHealth Care the Government Way

“VA Hospital Philadelphia botched 92 of 116 Prostate Procedures” (NY Times 6/21/09)

Medicare is underfunded by $36 Trillion

Food and Drug Administration under attack to increase transparency on inside deals with pharmaceutical companies

800 Federally funded CHC’s provide care to 10 million uninsured/underinsured at evidenced based outcomes comparable to the private sector

What We Don’t KnowWhat We Don’t Know

? Exact model of “universal coverage”

? How “national standards” for health insurance and federal authority might impact a tradition of state authority

? What changes in reimbursement will mean to Non-MD providers

? How health professional regulators will get squeezed—more work, less resources, more complexity, greater transparency

NY Times/CBS News PollNY Times/CBS News Poll

85% want major healthcare reform

72% favor a gov’t. administered health plan like Medicare that would compete with private plans.

57% are willing to pay higher taxes to make it so.

86% felt rising costs posed a serious economic threat

65% believe providing for uninsured more important than “keeping costs down.”

“2009: do you think the government would do a better or worse job than private insurance companies?”

50% better 34% worse

30% (2007) 44% (2007)

“The future ain’t what it used to be.”

So let’s go with what we know:

Demographic Trends

Healthcare Economics

Credentialing Diversification and practice expansion

Geometric Growth in Non Hospital care

What we most likely know:What we most likely know:DemographicsDemographics

76 million baby boomers retire in the next 20 years…

…and bring with them some of the most expensive healthcare demands of a generation.

“Walkers may likely outnumber strollers in the U.S.”

NEWS FLASH: As of today…1/3 of retirees are re-entering the workforce for Encore careers.

What we most likely know:What we most likely know:Non-Hospital CareNon-Hospital Care

Remote sensing and outpatient care will keep all but the most serious out of the hospital

Boomers won’t be caught dead in a nursing home— “Aging in Place” is the new vision of the last 1/3 of life

73% of Americans would prefer to die at home

“Engage with Grace”—the viral movement about maintaining dignity in death represents the developing motif of 76 million Americans

[see “The One Slide Project”]

What we most likely know:What we most likely know:DemographicsDemographics

30-40 million new insured will enter the active health care access pool

Disability rates are declining dramatically in the U.S.

-.05% 1984 -1.5% ‘89-’99 -2.2% 2004-08

Healthcare provider shortage: PT shortage for older Americans (PT Bulletin) 9,000 geriatricians vs 36,000 needed in 2030 500,000+ nurses short by 2025-2030 Looming crisis in Obstetrics

What we most likely know:What we most likely know:EconomicsEconomics

On current trajectory, healthcare costs will increase 50% by 2082

Price Waterhouse estimates the inefficiency in healthcare to be 20%--maybe as high as 50%

U.S. deficit $1.8 Trillion

Estimated costs of health care reform legislation developing in Congress…$1 – 1.6 Trillion (CBO)

Doing nothing, the number of uninsured could hit 62 million in ten years. (Urban Institute, 6/09)

What we most likely know:What we most likely know:EconomicsEconomics

Reform must pay for itself through efficiency, quality, disease management and prevention.

When reimbursement, access and regulation all shift…health care practice shifts quickly.

While the Federal Government will be hard pressed to pay for healthcare reform—States will feel additional burden on regulation—insurance, practice scope oversight, citizen involvement.

Social Security reserves are projected to be exhausted by 2041

If middle class boomers maintain their current standard of living and don’t cut costs—3 out of 5 will outlive their financial assets in retirement. Americans for Secure Retirement

What we most likely know: What we most likely know: Economics Economics

Costs will be squeezed—more bundling based on evidence based outcomes

Healthcare productivity will have to increase by about 50% to keep pace with demand and resources

Hospitalization will require a increasingly stringent pre-approval—with lots of disapproval.

Spending on last two years of life:

UCLA $93,000 Mayo Clinic $53,432[Dartmouth University Study 2009]

What we most likely know: What we most likely know: Economics Economics

You’re in Luck if your profession… Includes a heavy dose of patient education!

Care can be delivered in a non-traditional setting (out of Drs. Office and Hospital)

You have data backing evidence based outcomes of best practices

You’re profession is looking to collaborate with “sister and brother professions”

What we most likely know:What we most likely know:Credentialing DiversificationCredentialing Diversification

With a little cash and a high speed connection you too can create a credential: Niche credentials—many nothing more than sophomoric sales engines—continue to crop up

How might an unsuspecting public discern safety and integrity? National Commission for Certifying Agencies (NCCA) and Regulatory stamps of approval become even more critical!

Reimbursement shifts will create “scope of practice” tussles among existing credentials.

Can you say HR 1137—Athletic Trainers Equal Access to Medicare?

The New Future: The New Future: Credentialing ConfusionCredentialing Confusion

Financial Planning: CFPR CFAR CFS

ChFC CIC CLU CIMA CMT

CPA PFS

Business and Executive Coaching Credentials:

International Coach Federation

Association of Business Coaches

International Consortium for Coaching in Organizations

International Association of Coaching

Worldwide Association of Business Coaches

The New Future: The New Future: Credentialing ConfusionCredentialing Confusion

Personal Training / Fitness:American College of Sports Medicine (4)

American Council on Exercise (4)

American Chiropractic Board of Sports Physicians (2)

The Cooper Institute (1)

International Fitness Professionals Association (1)

National Academy of Sports Medicine (1)

National Council on Strength and Fitness (1)

National Exercise and Sports Trainers Association (1)

National Exercise Trainers Association (1)

National Federation of Professional Trainers (1)

National Strength and Conditioning Assoc. Cert. Comm. (2)

What we most likely know:What we most likely know:Credentialing DiversificationCredentialing Diversification

Healthcare Credential holders are looking at their core competencies and seeing much broader scope of practice appropriateness than a decade ago

They are taking this recognition straight to the regulators—with data, convincing arguments and a 21st Century case based on healthcare needs of the U.S. population…

While we speak, traditional credentials are discovering new competency specialties and expanding their appetite for healthcare action: umbrella credentials with certified subspecialties are likely to grow dramatically

The Referees who call in-bounds or out of bounds are the regulators—being watched by a rabid crowd

What we most likely know:What we most likely know:Credentialing DiversificationCredentialing Diversification

Crucial value of National Organization for

Competency Assurance and National Commission

for Certifying Agencies will grow

Quality Assurance of “certificate” programs in

health related professions will increase:

e.g. NOCA 1100 – Quality Standard for

Assessment-Based Certificate Programs (2009)

The Role of RegulationThe Role of Regulation

Government has a basic responsibility to ensure that health plans and providers are qualified and operate in the public interest.

Now there’s an easy regulatory job.

Mike Feintuck

Oxford University

(2005)

The Role of RegulationThe Role of Regulation

Protect the public interest…safety & efficacy:

Without which we have bridges that collapse, Ponzi financial scams,

quacks practicing medicine, dangerous pharmaceuticals, failed banks, and bankrupt insurance companies

Improve healthcare professional practice

Cautious with emerging professional specialties, new technology, and “scope” creep.

Oversee health insurance plans

Teubner’s “Regulatory Trilemma”Teubner’s “Regulatory Trilemma”

“The Politics of regulation are challenged by

the need to be socially responsive and

challenged again by needing to be “coherent”

with the underlying legal system.

Guenther Teubner, Professor Law, University of Frankfurt and London

School of Economics.

First World Health Professional First World Health Professional Conference on Regulation 18 May 2008Conference on Regulation 18 May 2008

Emerging Challenges:

Practice settings diversifying in both location multi-disciplinary collaboration, and competition.

Globalization and increased access to health information by patients are increasing pressures and expectations under which health professionals work and regulators govern.

Efficiency, transparency, accountability and fairness of processes and decisions are under greater scrutiny.

First World Health Professional First World Health Professional Conference on Regulation 18 May 2008Conference on Regulation 18 May 2008

Emerging Challenges:

Drafting legislation to cover all potential situations comprehensively.

High costs to maintain compliance, monitoring, and enforcement.

Professions engaging with regulatory bodies…

increasing mutual need for this dialogue.

Promoting continuing competence and regulatory oversight of competence… pressured by all of these forces:Individual practitionersRegulatory bodiesProfessional organizationsCredentialing organizationsEmployersEducational institutionsLegislatorsPatients and public Media

To whom do regulatory boards turn for To whom do regulatory boards turn for guidance?guidance?

Individual practitioners—NO!Professional organizations—Hmmm?Credentialing organizations—Absolutely!Employers--Yes

Educational institutions—Questionable

Legislators—Stifle a LaughPatients and public—Hmmm?

Media—Stifle a Laugh

Health Care RegulationHealth Care Regulation

Health care regulation is still the most mature,

most advanced, most competent, and most

complex of any regulatory responsibility.

It makes oversight of the banking industry look

like child’s play.

2009 BOC Athletic Trainer 2009 BOC Athletic Trainer Regulatory ConferenceRegulatory Conference

You’re fortunate leaders…

A Visionary Board and Staff have convened you to touch the future.

Let the dialogue begin!

Interesting Books on the FutureInteresting Books on the Future

Patricia Aburdene, Megatrends 2020 (2005)

James Canton, The Extreme Future (2006)

Robert Field, Health Care Regulation in America (2007)

Thomas Friedman, The World is Flat (2005)

Mark Penn, Microtrends (2007)

J.L. Petersen, Out of the Blue: Wild Cards and Other Big Future Surprises (1997)

Peter Schwartz, Inevitable Surprises (2003)

Edie Weiner and Arnold Brown, Future Think (2006)

Daniel Yankelovitch, The Magic of Dialogue (2006)

Y. Wind & C. Crook, The Power of Impossible Thinking (2005)