Anticipating the
Future of
Healthcare Regulation
Les Wallace, Ph.D.
Welcome the New Normal:
Permanent Whitewater
2009 BOC Athletic Trainer Regulatory Conference
Remember the 1990s…
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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…
 Economic turmoil
 War and Terrorism
 Nuclear proliferation
 Governmental Debt
 International Trade
 Global Warming
 Energy
 Pandemic
 Integrity
A Series of
“once in a hundred years” crises!
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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 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”
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!”
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”
“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.”
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.”
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:
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”
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!”
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)
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
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
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
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
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)
“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:
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.
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”]
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
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)
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
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]
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”
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?
The New Future:
Credentialing Confusion
Financial Planning: CFPR CFAR
CIC CLU
CIMA
CMT
CFS ChFC
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:
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)
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
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)
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)
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
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
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.
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.
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
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
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.
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!
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)