Anticipating the Future of Healthcare Regulation Les Wallace, Ph.D.

1. Anticipating the Future of Healthcare Regulation Les Wallace, Ph.D. Welcome the New Normal:Permanent Whitewater 2009 BOC Athletic Trainer Regulatory Conference

2. 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.”

3. 21C the new Normal… Economic turmoil War and Terrorism Nuclear proliferation Governmental Debt International Trade Global Warming Energy Pandemic Integrity

4. A Series of “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.”

5. Reform and Regulation on a Tightrope • 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”

6. Healthcare 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!”

7. Our Journey… 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”

8. “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

9. “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)

10. “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

11. The New Future: Healthcare from the White House “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”

12. The New Future: Healthcare 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!”

13. The 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)

14. The 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

15. Government 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

16. Health 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

17. What 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

18. NY 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)

19. “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

20. What we most likely know:Demographics 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.

21. What we most likely know:Non-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”]

22. What we most likely know:Demographics • 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

23. What we most likely know:Economics • 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)

24. What we most likely know:Economics • 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

25. What we most likely know: 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]

26. What we most likely know: 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”

27. What we most likely know:Credentialing 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?

28. The New Future: Credentialing 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

29. The New Future: Credentialing 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)

30. What we most likely know:Credentialing 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

31. What we most likely know:Credentialing 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)

32. The 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)

33. The 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

34. 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.

35. First World Health Professional Conference 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.

36. First World Health Professional Conference 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.

37. Promoting continuing competence and regulatory oversight of competence… pressured by all of these forces: • Individual practitioners • Regulatory bodies • Professional organizations • Credentialing organizations • Employers • Educational institutions • Legislators • Patients and public • Media

38. To whom do regulatory boards turn for guidance? Individual practitioners—NO! • Professional organizations—Hmmm? • Credentialing organizations—Absolutely! • Employers--Yes Educational institutions—Questionable Legislators—Stifle a Laugh • Patients and public—Hmmm? Media—Stifle a Laugh

39. Health 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.

40. 2009 BOC Athletic Trainer Regulatory Conference You’re fortunate leaders… A Visionary Board and Staff have convened you to touch the future. Let the dialogue begin!

41. Interesting 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)