ACS Futures Committee takes a good, hard look at the year 2025

Peering into the future requires something of a mental leap. Members of the Futures Committee of the American College of Surgeons (ACS) took on that creative challenge by considering what surgery might look like in the year 2025, the quarter-century mark of the second millennium. They reviewed the past, the present, and current social, political, economic, and health care trends in the process of evoking a vision of tomorrow. Their discussions did not include surgical science of the future or technological advances.

“Essentially, futuring exercises help an organization create a long-term strategic plan,” said ACS Executive Director David B. Hoyt, MD, FACS. “It was a good exercise for the College and helped members of the committee realize the importance of systemness.” Systemness focuses on the significant attributes of health care, and involves creating solid structures for the greater good, as opposed to a collection of independent pieces.

To create a clearer vision for the future and more proactive policies, the ACS Futures Committee reflected on such questions as: What will the health care system look like in 2025? Who will have access to it? Who will pay for it? And what can we do now to build a proactive, responsive system that meets the needs of patients, legislators, surgeons, and other health care practitioners?

Predict the future by creating it

The Futures Committee was formed at the urging of ACS Past-President LaMar S. McGinnis, Jr., MD, FACS (see committee roster at the end of this article). In his final Presidential report to the ACS Board of Regents in 2010 recommending the formation of the committee, Dr. McGinnis emphasized that the best way to predict the future is to create it.

“Many other organizations have done futuring exercises with beneficial results,” he said, “and I think it’s important for the College to cast itself in a proactive rather than a reactive stance.” Dr. McGinnis oversaw a similar study by the American Cancer Society during his presidential year with that organization in 1995 and reminded surgeons that “other organizations are not our competitors. They are our compatriots.”

Dr. McGinnis views the futuring activity as a start toward systemic reviews at the ACS that will center on not only health care issues but that will also focus on such general themes as health policy, medical economics, surgical science, technology, and education and training. This activity should be ongoing, according to Dr. McGinnis, “not episodic and not encumbered by hubris.”

“There was a kind of vision that early College leaders had. They realized that surgeons must work in the proper environment of a hospital, so the founders set out to standardize hospitals,” Dr. McGinnis said. “They set a goal, and in 1917, they created the hospital standards program, which eventually evolved into what we now know as The Joint Commission.” With their attention focused on the well-being of patients, the founders took actions that promoted a principle that continues to guide the College, he said.

“If you look back 100 years and consider what was happening then and how we defined what medicine was, you can view this current time of change and pain as an opportunity to address our mistakes and try to make them better,” said Futures Committee member Tyler Hughes, MD, FACS. “These are going to be tough times for patients and physicians,” Dr. Hughes said, “but we’ve been there before.”

Reviewing alternative futures

To help develop possible scenarios for the future of health care, the College worked with the Institute for Alternative Futures (IAF), based in Alexandria, VA. The committee met face-to-face only once but also communicated through a number of conference calls. During these discussions, committee members considered what health care might look like in 2025, and based on those discussions, the IAF created four scenarios.

Two of the possible scenarios were reactive and two were proactive. Committee member Karen Borman, MD, FACS, pointed to the advantages—and the drawbacks—of considering the scenarios. “Obviously, we can only theorize what health care might look like in 2025,” she said. “The further you go out in time, the vaguer your theories are. You can have the conversation; you just can’t have the work plan. You have to pick some things from each scenario and assume the future will look like parts of each,” she said.

Four scenarios

Succeeding by Changing Just Fast Enough. The reactive first scenario—Succeeding by Changing Just Fast Enough—would find the health care industry reducing its cost growth just ahead of a federal financial crisis. Employers would resist the high annual health insurance premium increases, and the system would shift to shared risk through global payments, bundled payments, and pay for outcomes. Under this scenario, most unnecessary services and medical errors would be eliminated in the system, but it could take as many as 15 years for most physicians and hospitals to make the transition.

The marketplace would become slightly more integrated, with various types of capitation—paying health care providers a set amount for each enrolled person assigned to them for a specified period of time—accounting for roughly 45 percent of all new costs. Hospital and physician fees would decline, and quality improvements would lower the costs of providing health care, minimizing waste and unnecessary therapies. A severe primary care shortage would partially resolve itself over time, as more medical students would realize the opportunities in primary care. For surgeons, the scenario would lead to more collaboration to control costs.

There would be a slow but steady movement toward the wider use of effective patient-centered medical homes (PCMHs), but without an engaged cultural change among providers. The marketplace would become somewhat more integrated, with accountable care organizations (ACOs) providing much of the care to patients. It is estimated that in this scenario, some 40 million Americans would be uninsured.

Today, health care spending consumes more than 17 percent of the nation’s gross domestic product (GDP), substantially more than in any other country in the world.1,2 Among developed countries, health care costs represent approximately 8.8 percent of their economies.2 The U.S. government’s current projections are that medical services will consume almost 20 percent of the nation’s GDP by 2021.3 In the Succeeding by Changing Just Fast Enough scenario, health care costs would continue to represent 17 percent of the GDP by 2025.

The Lost Decade. The second scenario, The Lost Decade, paints another reactive but even bleaker picture. The health care industry would stay fixed on “business as usual,” resulting in a system that inflates government debt and significantly diminishes employer competitiveness. An anemic economic recovery would plunge into a double-dip global recession in 2014, when Greece defaults on its sovereign debt, according to this scenario. Health care professionals would not collaborate to improve efficiency and reduce errors and would receive increasingly austere Medicare reimbursements. Many hospitals would close, and most states would move Medicaid to a capitated plan, reducing rates and enrollment. Medical school enrollments would drop and, except for primary care, the demand for health care services would decline.

The Medicare eligibility age would increase to 67. Capitation would account for roughly 15 percent of the non-Medicaid market and 80 percent of Medicaid cases. In 2014, intermittent reductions would follow a 10 percent reduction in Medicare reimbursement. The number of uninsured Americans would rise to approximately 80 million that same year and level off at about 50 million in 2025. ACOs would advance little. Although many surgical practices would struggle—and some would be displaced and relocate, retire, or face bankruptcy—because of the decline in demand, revenues, and quality of care, it would still be possible to find pockets of excellence and concentrated demand.

As a means of controlling costs, a system of limited, or “tiered,” networks, setting up different copayments and providing patients with financial incentives for selecting more cost-effective physicians and hospitals, would be more widely used. This system would also cut insurance rates for employers.

The percentage of insurers moving to capitation and vouchers for Medicare and Medicaid would significantly increase. PCMHs would remain works-in-progress. Health care costs would spike in 2012 to 18 percent of GDP and drop to 13 percent in a depressed 2019 economy.

Health Care Systemness. In the more proactive third scenario, strong leadership and a shared vision among practitioners, patients, and industry would save the day, as a majority of stakeholders would realize that the current path is unsustainable. In this scenario, there would be proactive campaigns for public health and preventive care, along with the provision of well-planned and cost-effective care to patients. An honest dialogue among all parties would address responsibilities and entitlements. And almost all surgical procedures—roughly 80 percent—would be reimbursed under capitated or bundled payment models.

Innovations would center on such developments as a health advocate avatar—a vision of a patient as the master of self-care, with the avatar as the patient’s trusted assistant. Other features of this system would include: a knowledge portal; virtual care involving the support of a human being in a remote location; and automated care, with the support of a robot or computer—including implantable drug delivery systems. Patient self-management would reduce the demand and cost of providing care. The government would strive to blend global payment, capitation, and incentives to control the costs of Medicare and Medicaid. PCMHs would change the way community clinics deliver care and interact with patients. It is anticipated that the result of this scenario could result in improved health outcomes and reduced systemwide costs due to improved management of chronic conditions.

The number of uninsured would be manageable, in this third scenario. The lowest tier, including approximately 15 percent of the population, would be covered through Medicaid, which would provide good care, with the support of PCMHs and technology. The middle tier, roughly 65 percent of the population, including Medicare patients and individuals with employer-based or individual health insurance policies, would receive good care but pay high deductibles. And the top tier would comprise approximately 20 percent of the population, including the affluent and patients with high-end coverage. Research would flourish in this scenario, and most of the market would be integrated with ACOs. Health care costs would represent 15 percent of a robust GDP.

Integral Society and Health Care. Finally, in the fourth scenario, and in what Dr. Hughes refers to as the “Kumbaya” vision of the future, the U.S. would move toward a higher level of consciousness. But this state of transcendence would occur after a period of struggle—after years of worsening economics, politics, and health care. A major environmental, climatic, socioeconomic disruption sometime between 2012 and 2014 would create this proactive change.

Corporate and civic leaders would unite to support the new system, ultimately transforming the culture. With investigations into the social determinants of health, chronic disease would drop 25 percent in a system relying on global payments and incentives for healthier outcomes.

Preventive care and health maintenance would help to reduce the demand and cost of health care in a culture of continuous quality improvement. The system would also effectively employ alternative medicine. Advanced PCMHs with accountability, patient engagement, and predictive and preventive medicine would become the norm. And life would not be prolonged needlessly—a concept essential for the future.

“Living longer is not necessarily better,” said Futures Committee member H. Randolph Bailey, MD, FACS. “And somehow, physicians have to come to grips with the reality that they don’t help much in the patient’s final illness. We need to convince patients and their families of that.”

ACOs would advance significantly in an integrated market. Capitation would increase to about 80 percent. Surgeons would grow into the role of “procedural biologists,” working collaboratively with other professionals. Health care teams would focus on specific organ systems and tailor procedures to each individual. In all, 3 percent of the population would choose to be uninsured. The low tier of coverage would involve Medicaid, which would provide good care through the use of medical homes and advanced technologies. The middle tier, about 75 percent of the population, would constitute the insured, including those on Medicare, who receive quality care. The top tier of affluent patients—about 10 percent of the population and those with high-end employer coverage—would receive concierge medicine, or direct care, where the patient pays an annual fee or retainer for the services of a primary care physician. The predicted percentage of health care costs to gross domestic product: 14 percent.

Where are we headed?

At the conclusion of the futuring exercise, committee members indicated the likelihood and the favorability of each scenario on a scale of one to 10. The Lost Decade (the second scenario) seemed the most likely to become a reality in the view of the participants, with a score of 6.17. The first scenario, Succeeding by Changing Just Enough, followed with a rating of 6. The third scenario, Health Care Systemness, seemed the third most likely to come to fruition, with an average score of 4.67, and the Integral Society and Health Care Scenario seemed the least likely with a score of 2.33. But members of the committee preferred Health Care Systemness (7.08) and Integral Society and Health Care (6.25). The least preferred outcome is the doomsday scenario, The Lost Decade (favored by just 1.25 of the committee), followed by Succeeding Just Fast Enough (4.75).

“I was disappointed that the group chose the most reactive scenario as the most likely,” said Dr. McGinnis. “But that was the majority opinion and the logical conclusion of the exercise.” “Change will probably be incremental and messy,” said Futures Committee Chair Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), “which makes it even more important that surgeons embrace the concept of the team approach for disease management. The College should position itself as a repository of information and engage in a two-way dialogue with the public, including reaching out to other professional organizations.”

“Surgeons need to define practice standards,” Dr. Pellegrini added. “This goes beyond the operation itself and involves questions about patient safety, who should practice, and who should be paid.”

Health care’s funding predicament

Committee members discussed the future, but by necessity, their focus is on what’s happening today. The health care environment today is a complex sociopolitical setting that focuses largely on the rising cost of health care. Most health policy experts agree that health care spending in the U.S. is rising at an unsustainable pace. Health expenditures in the U.S. neared $2.6 trillion in 2010, more than 10 times the $256 billion spent in 1980.4 The lingering impact of the “Great Recession” that began in December 2007 is high unemployment, which has contributed to the fact that nearly 50 million Americans are uninsured.1

Committee member Frank Opelka, MD, FACS, sees only three options for controlling the cost of health care. “You can change the price per unit, or you can reduce the number of people eligible for care. The third option is to totally change the way we purchase care, and the Affordable Care Act [the health care reform legislation enacted in 2010] is an attempt to do this,” Dr. Opelka said. “Cutting access and price are not socially responsible actions, and what we have driving decisions today is politics rather than policy.”

Health care cost: A global problem

According to ACS Futures Committee member J. David Richardson, MD, FACS, “Cost is an overwhelming global problem,” followed, he said, by access to care. “The payment models are probably broken, and we have to look for different ways of doing things. But I do not believe that we’re going to prevent our way out of spending money,” Dr. Richardson said. “As the U.S. population ages, they’re going to need health care, and I don’t care what we do, we’re not going to be able to prevent the growing demands.”

The “totally fallacious” assumption of the Affordable Care Act, Dr. Richardson continued, “is that if we manage care more efficiently and eliminate fraud and abuse, we can control the costs. Americans want a lot of health care. They come to the physician’s office armed with information from the Internet and with a list of tests they think they need. We consume a tremendous amount of health care as a nation, so if we’re going to continue doing that, we have to find a way to pay for it.”

Dr. Bailey agrees, at least in part. “Encouraging patient responsibility can help,” he said, “but all the doctors and computer calling and reminding patients to take care of themselves won’t stop the aging process and the need for health care. The (futuring) exercise pointed out clearly to me that business as usual is a pathway to disaster,” he added.

“It’s fine to think about the future,” Dr. Richardson said, “but Americans respond only to crises. Once the crisis hits, we’ll probably step up our response to health care and how we’re going to pay for it.”

“I am all in favor of planning strategically for the future, but looking ahead 10 to 15 years is too difficult,” said ACS Past-President and Futures Committee member L.D. Britt, MD, MPH, FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FRCSI(Hon), FWACS(Hon). “There are still so many unknowns.”

Although the committee did not produce a watershed “Copernican Revolution,” as ACS Regent and Futures Committee member James Elsey, MD, FACS, pointed out, it nevertheless fulfilled an important function. “We need to go through exercises like this,” he said. “The years of transition are just beginning.

“It’s not our job to change the economic landscape,” Dr. Elsey continued. “As surgeons, our job is to protect patients and to promote the College, which stands for excellence and quality standards of practice.”

No Pollyannaish solutions

“We all generally agreed on a few things,” said committee member Mark A. Malangoni, MD, FACS. “We agreed that the current system is financially unsustainable, and as a group, we understood that rather than finding some Pollyannaish enlightenment, the U.S. will probably face a new crisis in health care, and it’s likely that different parts of each scenario will take place.

“The hope is that we can work with congressional leadership in some way to formulate effective responses,” Dr. Malangoni continued. “The problem is that Congress right now is pretty intent on putting off problems.”

Dr. Britt tends to think that health care will fall into the first scenario—changing just in time—but he remains optimistic. “Everything is up in the air right now, but if the College stays focused on patient safety and quality care, we’ll be all right,” he said. “It may take several years, but I believe the health care system will overcome the challenges.”

“It can only help to think about how we’re going to incorporate the changes,” added Futures Committee member Michael J. Zinner, MD, FACS. “I do find it a little hard to think about the future when I spend so much time dealing with what’s happening in the present.

“The doomsday scenario seems unrealistic to me, but so do the overly optimistic scenarios,” added Dr. Zinner. “In Massachusetts, we’re a good two to three years ahead of the rest of the country on health care reform,” he continued. The Massachusetts health care insurance reform law, enacted in 2006 under then Gov. Mitt Romney (R), mandates that nearly every resident obtain a state government-regulated minimum level of health care insurance coverage and provides free health insurance for residents earning less than 150 percent of the federal poverty level.5

Lucky to be a surgeon

Like most surgeons, and in spite of the looming challenges, Dr. Bailey considers himself lucky: After 35 years of practice, he still looks forward to every workday. But he worries about the changing status of physicians in American society. “Unless something changes, the cost of going to medical school is making it way too difficult to become a doctor,” he said. “By the time you begin practicing, you have spent and borrowed so much money that the whole idea loses its appeal.”

The goal of a futuring exercise is not to predict the future, but to reveal visions of what’s imaginable and desirable. Likewise, the ACS Futures Committee members left the job of predicting the future to the soothsayers and presented their informed thoughts about the present and, based on where we are now, where we are likely headed.

It is doubtful that the ACS Futures Committee will meet again as a group, but the issues that its members raised will likely remain prominent in discussions about health care’s future. In looking to the future, today’s surgeon can draw on the strengths of the U.S. health care system with the hope that the country and the profession will experience positive, proactive change.

American College of Surgeons Futures Committee

  • CHAIR: Carlos A. Pellegrini, MD, FACS, Immediate Past-Chair, Board of Regents; Henry N. Harkins Professor and Chair, Department of Surgery, University of Washington, Seattle, WA
  • H. Randolph Bailey, MD, FACS, ACS Board of Regents, ACS Health Policy and Advocacy Group; University of Texas, Houston, TX
  • Karen R. Borman, MD, FACS, Past ACS Governor; Abington Memorial Hospital, Abington, PA
  • L. D. Britt, MD, FACS, MPH, FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FRCSI(Hon), FWACS(Hon), ACS Past-President; Eastern Virginia Medical School, Norfolk, VA
  • James K. Elsey, MD, FACS, ACS Board of Regents; private practice, Lawrenceville, GA
  • David B. Hoyt, MD, FACS, ACS Executive Director, Chicago, IL
  • Tyler G. Hughes, MD, FACS, ACS Board of Governors; Memorial Hospital, McPherson, KS
  • Mark A. Malangoni, MD, FACS, ACS Board of Regents; American Board of Surgery, Philadelphia, PA
  • LaMar S. McGinnis, MD, FACS, ACS Past-President; past-president and current senior medical advisor, American Cancer Society; adjunct professor, Emory University School of Medicine, Atlanta, GA
  • Lena M. Napolitano, MD, FACS, Chair, ACS Board of Governors; University of Michigan Health System, Ann Arbor
  • Frank G. Opelka, MD, FACS, Assistant Medical Director, ACS Division of Advocacy and Health Policy; Chair, ACS Patient Safety and Quality Improvement Committee; Louisiana State University, River Ridge, LA
  • J. David Richardson, MD, FACS, Chair, ACS Board of Regents; University of Louisville, KY
  • Michael J. Zinner, MD, FACS, ACS Board of Regents, Past Vice-Chair, ACS Board of Governors; Mosely Professor of Surgery, Harvard Medical School, Boston, MA
  • Robert M. Zwolak, MD, PhD, FACS, Past-Chair, ACS Board of Governors’ Committee on Socioeconomic Issues; Dartmouth-Hitchcock Medical Center, Lebanon, NH

References

  1. KaiserEDU. U.S. health care costs. Available at: http://www.kaiseredu.org/issue-modules/us-health-care-costs/background-brief.aspx. Accessed June 26, 2012.
  2. Johnson T. Council on Foreign Relations. Healthcare Costs and U.S. Competitiveness. March 26, 2012. Available at http://www.cfr.org/health-science-and-technology/healthcare-costs-us-competitiveness/p13325. Accessed July 23, 2012.
  3. Martin AB, Lassman D, Washington B, Catlin A. National Health Expenditure Accounts Team. Growth in U.S. health spending remained slow in 2010; Health share of gross domestic product was unchanged from 2009. Health Aff (Millwood). 2012;31(1):208-219. Available at: http://content.healthaffairs.org/content/31/1/208.abstract. Accessed June 25, 2012.
  4. Ginsburg PB. Robert Wood Johnson Foundation. High and rising health care costs: Demystifying U.S. health care spending. The Synthesis Project. 2008;Issue 16. Available at: http://www.rwjf.org/pr/product.jsp?id=35368. Accessed June 19, 2012.
  5. The Massachusetts Legislature. Chapter 58: An act providing access to affordable, quality, accountable health care. Available at: http://www.malegislature.gov/Laws/SessionLaws/Acts/2006/Chapter58. Accessed June 15, 2012.

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