Special Feature
Physiatry Practice Now and in 2032: How to Thrive in the PosteHealth Care Reform World Sam S.H. Wu, MD, MA, MPH, MBA, Jonathan Peck, MA, Stuart M. Weinstein, MD, Yasemin Arikan, BA, Kathleen R. Bell, MD, Darryl L. Kaelin, MD Health care reform is upon us, including changes in models of care delivery and physician and institution compensation. The resulting tsunami of uncertainty offers physiatrists the opportunity to relocate to higher ground and help the specialty thrive as well as to identify the possible quagmires into which practices could sink. For this reason, it is prudent for physiatrists to more carefully consider how their professional lives may be altered in the aftermath of reform. We believe that understanding and preparation will facilitate opportunities and mitigate challenges. In this essay, we will discuss various alternative scenarios that represent population health and health care delivery in the year 2032, the real-world opportunities and challenges for the physiatrist in the present and in the next 2 decades, along with ideas as to how physiatry can thrive in the postehealth care reform world. PM R 2014;6:876-881
INTRODUCTION Physiatrists can and should take an active role when it comes to our future, starting in this period of change for health care payment and delivery systems. To do so, physical medicine and rehabilitation specialists will need to recognize what will change, while holding one unchanging assumption, that the core value proposition of this specialty will continue to improve. The many changes coming to health care and American society are described by scenarios that have been proposed by the Institute for Alternative Futures with funding from the Robert Wood Johnson Foundation (www.altfutures.org/health2032). These changes set the context for how physical medicine and rehabilitation can develop out to the year 2032. The Board of Governors (BOG) of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) at their Spring 2013 strategic planning meeting explored these hypothetical scenarios 2 decades into the future to identify key implications and to create strategies that can help the specialty and specialists thrive in a period that may be marked by chaos but also emerging, yet at times fleeting, opportunities. This article describes ways in which the core value proposition for the specialty could get better, even dramatically better, during a time when change leadership becomes crucial. The world of physiatric practice will surely change over the next decade, but how can leaders in the field visualize all the possibilities to respond? Well thought-out scenarios offer an effective way to do so by looking past current developments to alternative futures based on different visions and forecasts. By thinking forward to likely, desperate, and preferred future scenarios, physiatrists can share images from these scenarios for health and health care in the year 2032 with thought leaders from throughout the health care industry and then “look back to the present” to assess decisions and choices that the specialty has to make in the near term. It may seem paradoxical to look backward from the perspective of multiple futures to assure that decisions are sound, but, in a complex environment full of uncertainty, this is a logical as well as pragmatic approach to take. Preparing for only one future is the equivalent of putting all your investments into one unknown company, that is, inadequate, unwise, and too risky. Change brings opportunities as well as potential hazards, and alternative scenarios show changes that will be more or less likely, and more or less preferred; therefore, decisions can effectively embrace strategic risk amidst uncertainty [1]. Physiatrists have an opportunity to influence which future becomes reality. Although PM&R
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S.S.H.W. Department of Physical Medicine and Rehabilitation, Geisinger Health System, 2 Rehab Lane, Danville, PA 17821; Rutgers New Jersey Medical School, Newark, NJ; Rutgers Robert Wood Johnson Medical School, Piscataway, NJ. Address correspondence to: S.S.H.W.; e-mail: [email protected] Disclosure related to this publication: board membership, AAPM&R Board of Governors J.P. Institute for Alternative Futures, Alexandria, VA Disclosure: nothing to disclose S.M.W. University of Washington, Seattle, WA Disclosure: nothing to disclose Y.A. Institute for Alternative Futures, Alexandria, VA Disclosure: nothing to disclose K.R.B. University of Texas Southwestern, Dallas, TX Disclosures related to this publication: travel/ accommodations AAPM&R (travel and board paid for meeting at which this model was formulated) (money to author) Disclosures outside this publication: grants/ grants pending, University of Washington (research consultancy) (money to author); payment for lectures including service on speakers bureaus, Memorial Hermann (money to author); royalties, Lash Publications (money to author); travel/accommodations/meeting expenses unrelated to activities listed, meetings related to Executive Board of the AAPM&R D.L.K. University of Louisville, Louisville, KY Disclosures outside this publication: board membership, secretary, AAPM&R Board of Governors, Brain Injury Alliance of Kentucky (no money); consultancy, Best Doctors, Inc. (money to author); grants/grants pending, PCORI and Allergan (no money); payment for manuscript preparation, Elsevier, Book Associate Editor (no money)
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. 6, 876-881, October 2014 http://dx.doi.org/10.1016/j.pmrj.2014.08.940
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readers can find the full scenarios online (http://www. altfutures.org/pubs/RWJF/IAF-HealthandHealthCare2032. pdf), brief synopses of the 4 alternative images for health and health care in 2032 follow.
FOUR SCENARIOS OF HEALTH AND HEALTH CARE IN 2032 Scenario 1: Slow Reform, Better Health Health and effectiveness of health care vary among states. Health, not health care, becomes the main political issue. Communities address social determinants of health, prevention, and population health while enacting “health in all policies.” Self-care and health knowledge reduce demand for medical care and are enhanced through risk behavior management, social networks, digital technologies, predisease identification, data, and new cures and therapies. Implications for Physiatry. Physiatrists will have access to more cutting-edge diagnostic and treatment tools but will face increased oversight from integrated health systems and reduced demands for traditional therapies. Physiatrists need to fully commit to integrating practice into developing care models or risk becoming marginalized.
Scenario 2: Health If You Can Get It Medicare and Medicaid experience severe budget cuts, most Americans are underinsured, medical tourism increases, epidemics spread, and health and inequality worsen. The primary care physician shortage exacerbates access problems. Besieged community health centers struggle to treat many new patients who otherwise use expensive emergency departments for routine matters or visit inconsistent fee-for-service private clinics. The public overlooks the potential shown in thriving transition communities and becomes highly fractured and disillusioned with ineffective governance. Implications for Physiatry. Physiatrists will migrate to institutional practice because fewer private practices are sustainable due to federal and state budget cuts, underinsurance, and fragmentation. Disillusionment will take a toll on the profession. There may develop a crisis of conscience. Physiatrists will confront deep-rooted ethical questions when traditional services are no longer reimbursable. Regression of health care and its delivery system is likely, and physiatrists will need to muster all of their skills and experiences to access necessary services and equipment for their patients.
Scenario 3: Big Data, Big Health Gains Health becomes the primary concern for policy makers and the public alike. Initiatives regarding health innovation, health equity, the social determinants of health, and health
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in all policies reduce health care expenditure. The public demands anticipatory democracy, cooperation, sustainability, and transparency. Innovative technologies, “big data,” and knowledge transform manufacturing, the economy, and health care, which yield cures for neurologic conditions (eg, spinal cord injury), effective management of cancers, and widespread implementation of personalized medicine and health avatars. Implications for Physiatry. Propelled by access to large databases, physiatrists’ roles expand to include participation in population health, including the prevention of injuries and illnesses. Physiatrists’ value proposition increases as functional needs are met successfully with technology and innovation. Outcomes research demonstrates the value, and this increases demand for physiatric services that in turn attracts a greater number of passionate people into the field.
Scenario 4: A Culture of Health Leaders create environments to support and improve all domains of health as a “health culture” arises. The nation’s focus shifts to disenfranchised minority groups, for example, the disabled, and to bringing new resources for development and comprehensive health for children. Health care spending is capped. Health avatars, enhanced self-care, and transparency in health education and medical knowledge all reduce demand for medical interventions. “Health wisdom” expands as social networks “crowd source” health. Environmental monitoring is implemented widely among communities. Implications for Physiatry. Physiatry revolutionizes medicine’s focus from treating disease to improving function. Physiatrists will serve as gurus of function, particularly for persons with disabilities and for children. Physiatrists also will provide care seamlessly across the continuum from emergency departments to remote outpatient environments by using advanced communication tools. Physiatry transcends traditional medical care by restoring, renewing, and maintaining health and well-being of the whole person within his or her environment. In essence, this becomes the highest aspiration of our specialty.
MIND THE GAP IN LIKELIHOOD AND PREFERENCE At the aforementioned AAPM&R meeting, the BOG assessed the likelihood and preference of these scenarios for health care over a 20-year period, specifically to identify broad approaches for physiatry within those scenarios to position AAPM&R to better serve the needs of its members and their patients. The BOG found scenario 1 and scenario 2 to be most likely, with scenario 2 most desperate, whereas scenario 3 and scenario 4 are much preferred. To take the next theoretical step, a goal for our specialty should aim to
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increase the likelihood of the more highly preferred futures, while defending against the least desirable but somewhat more probable image of “health if you can get it.” Visionary leaders in the field should start with the aspirational scenarios that describe futures they prefer so to create strategies that alter the likely trajectory of health care toward those goals. The BOG also identified 4 overarching strategies to be applied as AAPM&R proceeds with its activities in the future: 1. Physiatrists will need to become “the conscience of function” as a determinant of health. Physical medicine and rehabilitation physicians have the opportunity to be at the center of defining health in a period of massive change in health care. To do this, AAPM&R leaders will have to engage members in the definition of health as “function” and perhaps, to engage patients and the community in this conversation. 2. As payment shifts to value, physiatrists will have an opportunity to become gatekeepers in health care utilization discussions. However, physiatry will first need to have sufficient research data on its treatments and care to support its value proposition. 3. In the shift to prevention, physiatrists will need to be present at many levels of the health care system, not just in the postacute event or in a single level of health provision. Other fields in medicine also may incorporate physiatric principles and philosophy. Physiatrists, therefore, will need to enhance their role as teachers and as content and knowledge creators. 4. Increasingly shared responsibility and interactions between patients and providers will require physiatrists to explore and define their role in the context of the new patient-provider relationship. To this end, physiatrists should be able to thrive in this environment.
CAPITALIZING ON STRENGTHS LEADS TO OPPORTUNITIES TO THRIVE The best method to change the odds in favor of a preferred future is to work with the strengths that our specialty possesses. To align the development of health and health care with the preferred futures described by the Institute for Alternative Futures, physiatrists can build on the 4 existing strengths listed here. We chose these themes as representative of modern physiatric tenets that can serve as the framework in the evolutionary model: (1) improving function for greater wellbeing, (2) leading teams for higher performance in health and health care, (3) incorporating technologies for health and health care, and (4) integrating systems of care.
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system-based knowledge. Although these strengths have been well polished when providing health care, they may prove even more powerful when defining and incorporating function as a health parameter at a population level. Function may find its greatest contributions outside the institutional settings of rehabilitation hospitals and clinicians’ offices. The ability to incorporate function as a health parameter at a population level, rather than in a single patient or family unit, would elevate the role of physical medicine and rehabilitation when health care systems must meet the “triple aim” of affordability, quality, and population health. Indeed, the premise of developing accountable care organizations is to deliver medical treatment and health maintenance at a population level. To take this lead position, physiatry will need to define functional health in terms that address individuals, families, and communities who seek well-being; in fact, physiatry should drive this agenda throughout society. Defining and developing functional outcome measurements and being the clearinghouse for newly proposed ideas should fall under the auspices of physiatry. In the decades ahead, the value proposition will grow for improving population health. If systems and cultures support the highest potential function in the least restrictive environment for individuals, families, and communities, then the boundaries of health care will expand. Indeed, the evidence that function may improve through interventions that go beyond the conventional limits of medicine suggests that physiatry has a larger future role than just restoring what was lost to genetics, accident, or disease.
Leading Teams for Higher Performance in Health and Health Care The key to taking on a larger role may well be the ability to lead teams that combine disciplines and knowledge of complex systems. This ability is typically more developed in physiatry than in other medical specialties. The medical conditions for which physiatrists are consulted are frequently influenced by a construct of physical, psychological, and social parameters. Certain medical conditions may have cures within the next quarter century, but one should not expect that, in the next 15-25 years, these aforementioned parameters will be any less relevant toward defining active state and recovery potential. Developing diagnostic and treatment teams to recognize and embrace these parameters may keep population outliers in check. Even if the relative growth of formally trained physiatrists remains stable, being able to influence team development and dynamics increases the relative impact of the specialty.
Improving Function for Greater Well-being
Incorporating Technologies for Health and Health Care
Both conceptually and practically, function is the greatest unifier for the field of physiatry, followed closely by the ability of physiatrists to excel as leaders of teams that integrate
Society is poised to take technological leaps that will impact health and health care for good and for ill. Physiatrists are trained, and thus naturally suited, to guide the adoption of
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some of the most powerful applications that are at the threshold of changing lives to enable better functioning. Since World War II, physiatrists have been implementing technology in the delivery of rehabilitation services to injured soldiers. Catastrophic injures to physical and mental capacities during recent wars in Afghanistan and Iraq have inspired efforts in regenerative medicine, robotics and neuroscience. With stem cells and 3-dimensional printing, the ability to provide a substrate for regrowing tissues and organs will move beyond wounded warriors and more widely into the general population that is also serviced by physiatrists. Robotics and exoskeletons will augment human locomotion in work, daily living, and play. Whether it is robotics for in-home care after in-patient rehabilitation, robotic cars taking over driving, industrial machines displacing labor, exoskeletons enhancing workers or patients, or thrilling new sports in which humans enhanced with bionics compete with each other or with robots, we are near the beginning of the new technological capabilities that bionics and robots will usher into our lives. Physiatrists through their training and experience are well suited to serve as guides to higher functioning for humans. The combination of human intelligence and computerbased processing has already led to chips implanted in brains to extend human thought and to power artificial limbs through brain computer interfaces. The combination of biologic manipulation, computers, and new materials (which include nanotechnology and biomimetics) means that there will be innovations coming into health and health care that will be highly disruptive with both remarkably good and terribly bad implications. This will create a terrific need for scientifically knowledgeable and humanly wise people to shepherd those technologies into medical settings and could be a growing role for physiatrists. To the extent that the profession can organize efforts to look ahead and scout out the technology that can best serve function, the aspirational scenarios show a world of new opportunities opening for the field. This future world need not restrict physiatry to the medical applications through which function gets restored to patients. By placing function in the larger context of health and well-being, the technologies that help patients will have an even greater reach in extending human function beyond limits defined by historic human capabilities. For example, advances in video technology have jump-started the revolution in functional prosthetic eyes, which have been called “bionic eyes.” With further refinements in resolution over the next decades, these technologies will continue to turn science fiction into reality for persons with disability. If a wounded warrior loses an eye, then he could have a replacement in the future that could provide sharper vision with telephoto capabilities and thus exceed current human functioning. Technological enhancement will enable new capabilities that may extend beyond the boundaries of health care (ie, treatment) but within the domain of health
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(ie, functional restoration and expansion). This could open possibilities for physiatrists that cannot be found in the expectable or undesirable scenarios but could prove attractive in aspirational futures. Physiatric training and skill sets will need to be honed toward this evolution in health, but the current principles of physiatric training, including a firm grasp of the bioethics and the biopsychosocial model of human function, provide a ready pathway toward change leadership in this technical evolution.
Integrating Systems of Care By using the team organizational capacity to integrate systems of health rather than just health care, the potential to deliver more valuable outcomes could be realized as the pinnacle for population health. Evidence for this potential may be seen in the National Research Council report, U.S. Health In International Perspective: Shorter Lives, Poorer Health [2], which indicates that spending more on medical care will not give us the outcomes we seek: longer lives and better health. Leaders in physiatry who are seeking a larger role in the health of society can join others already working to change systems at the local, state, and national levels. For example, the Robert Wood Johnson Foundation has formed a network campaign by using LinkedIn (LinkedIn Corp, Santa Monica, CA) to join leaders dedicated to creating a culture of health. The Institute for Alternative Futures and the Samueli Institute have formed a public-private partnership called the Creating Wellbeing Leadership Group, which seeks to show that community well-being efforts can contribute to a thriving and prosperous country. Perhaps the highest value proposition that physiatry will discover as society moves into and through an era when knowledge becomes as ubiquitous as information is today will be to provide a form of health wisdom beyond the boundaries of health care. One way to understand the world we are headed into is by recognizing how big data convert to information, then knowledge, and potentially even wisdom. The ability to collect, store, and manipulate data created an information revolution over the past few decades. Now we are escalating to a knowledge revolution as the combination of human and machine intelligence feeds networks that disseminate innovative ideas around the world at dizzying speeds. The transition from an information revolution to a knowledge revolution may well be facilitated by “brainlike computers” that learn on their own with “neuromorphic processors” that “mimic biological synapses” [3]. The likely impact of smarter computers is smarter networks that, in turn, make the aspirational scenarios for health and health care all the more likely. Physiatrists are better positioned than other specialists to process the unfiltered functional information and render the wisdom for decision making through the knowledge gained from their training and experience in team-based models of care and bioethics, and a biopsychosocial model of human function.
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FAILURE TO EVOLVE LEADS TO LIKELY MARGINALIZATION In addition to opportunities, physiatrists and the specialty also face serious challenges in keeping pace with changing models of health care and care delivery. Failure to meet these challenges moves us all closer to scenario 2: Health If You Can Get it. There is no status quo and the pace of change is likely to accelerate over the next decade. The greatest threats are the following: (1) failing to maintain requisite clinical and management training, (2) failing to adequately represent the value proposition of the physiatric role and methods, and (3) failing to keep pace with the growth of technology and evidence.
Failing to Maintain the Requisite Clinical and Management Training Today, even “traditional” areas of physiatric practice are at risk for reform that will affect both the inpatient rehabilitation facility and outpatient settings. Advanced technology and evidence for the efficacy of increased intensity of rehabilitation for such disorders as stroke and brain injury are moving us toward a different model that incorporates a seamless program that crosses settings for rehabilitation. For example, care maps and rehabilitation guidelines must cross the barriers of acute care, inpatient rehabilitation, other areas of postacute services, and community living. In addition, managing high technology treatments, such as robotic exercise, weight-supported ambulation, smart orthotics, and transmagnetic cortical stimulation, will require knowledgeable physiatrists who can view the whole patient and the entire system of payment and service administration, and can provide the targeted treatment that will avoid overtreatment and misuse of modalities.
Failing to Adequately Represent the Value Proposition of the Physiatric Role and Methods In response to health care legislation, hospitals, and health care networks are merging to capture a larger market share and to reduce costly duplication of services. In addition, these networks are hiring physician practices to control patient flow and utilization of services. Specifically, hospital systems are purchasing or developing preferred provider networks with postacute providers to manage quality of care, costs, and outcomes. What this means for independent groups and solo practitioners is unclear. But what is certain is that, as these organizations evolve, physiatrists must compete with other providers to have a place at the decisionmaking table and to maintain a valuable role in health care delivery. To that end, educating medical colleagues and health care administrators regarding physiatry skill sets remains a vital driver of the field’s growth and even survival
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because in either the expectable or desperate scenarios described, physiatrists will likely find current practice patterns unsustainable.
Failing to Keep Pace With the Growth of Technology and Evidence Exciting advances in medical science and technology are occurring exponentially. Also, the traditional practice of adopting such advanced technologies, with the expectation that payment systems will respond favorably, is at great risk. On the horizon of disease management are life-enhancing techniques that are likely to revolutionize medicine. In this new wave of technology, it is incumbent on physiatrists to play a coordinated role in outcome data acquisition and assessment across multiple parameters, including function, quality of life, and cost containment. Physiatrists will need to become part of research teams, with well-defined roles and responsibilities. Proper evidence can demonstrate that physiatrists skilled in teamwork and managing patient care through the service continuum from acute to postacute and into the community can effectively provide the best functional outcomes and patient satisfaction at the least cost. Physiatrists must become primary managers of specific areas of comprehensive care, such as back pain and stroke, but will likely face stiff competition from other specialists attempting to secure market share.
CONCLUSION By looking toward the future, the Health and Health Care in 2032 scenarios invite critical thinking about potential failures as well as what surprising success would look like for physiatrists. Although the 2 scenarios, recognized as more likely and desperate, offer strategic value in recognizing what change can bring, the 2 aspirational scenarios prompt consideration of greater opportunities for physiatry. For some practitioners, the most rewarding future may come from shepherding the remarkable new technologies that can improve health care and health. Other physiatrists may lead by expanding function beyond medical rehabilitation into the larger realm of well-being. The great skills that physiatrists have for integrating complex systems, long evident in addressing physiological and psychological domains of knowledge, can also gain prominence as health care systems integrate and engage the other systems that support health and well-being: education, vocation, entertainment, transportation, housing, and others. Finally, the opportunities for leading teams in health care will expand greatly in the years to come, particularly in the aspirational scenarios. Although the medical profession as a whole faces great uncertainty in the manner in which health care will be delivered in the next 20 years, there are certain to be opportunities that promote the strengths of physiatry. In a turbulent environment with surprises that emerge suddenly,
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a small and highly adaptive specialty can thrive by being agile when addressing near-term gains yet remain strategically focused on long-term opportunities. These opportunities can be recognized as aligned with the aspirational scenarios. It, therefore, is paramount to capitalize on our strengths and make certain that strategic success is defined by a shared vision for the specialty. With the intertwining of vision, strategy, and leadership, the next few decades can be a period when the specialty of physiatry further evolves. Also, although the physiatric leadership focuses the specialty’s vision and develops objectives and strategies, individuals’ grassroots efforts also can advance the process. One must first assess his or her strengths that match with future opportunities, such as those described, then identify likeminded physiatrists and establish networks with them. Next, it will be important to link these networks with physiatrists working toward different but complementary
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value propositions for the specialty. The shared vision for the field must allow physiatrists to integrate their diversity of strengths and align these strengths with activities to achieve multiple goals. Whether at organizational, network, or individual levels, being proactive and not reactive will be critical to long-term strategic positioning, sustainability, and, most importantly, evolving an essential specialty in the new world of health and health care delivery.
REFERENCES 1. Williams SA. Decision-ability. The skill to make your decisions productive, practical and painless. Boulder, CO: Decisionability LLC; 2010. 2. National Research Council and Institute of Medicine. U.S. health in international perspective: Shorter lives, poorer health. Washington, DC: The National Academies Press; 2013. 3. Markoff J. Brainlike computers, learning from experience. The New York Times December 29, 2013: A1, A4.
Physiatry Practice Now and in 2032: How to Thrive in the PosteHealth Care Reform World Sam S.H. Wu, MD, MA, MPH, MBA, Jonathan Peck, MA, Stuart M. Weinstein, MD, Yasemin Arikan, BA, Kathleen R. Bell, MD, Darryl L. Kaelin, MD Health care reform is upon us, including changes in models of care delivery and physician and institution compensation. The resulting tsunami of uncertainty offers physiatrists the opportunity to relocate to higher ground and help the specialty thrive as well as to identify the possible quagmires into which practices could sink. For this reason, it is prudent for physiatrists to more carefully consider how their professional lives may be altered in the aftermath of reform. We believe that understanding and preparation will facilitate opportunities and mitigate challenges. In this essay, we will discuss various alternative scenarios that represent population health and health care delivery in the year 2032, the real-world opportunities and challenges for the physiatrist in the present and in the next 2 decades, along with ideas as to how physiatry can thrive in the postehealth care reform world. PM R 2014;6:876-881
INTRODUCTION Physiatrists can and should take an active role when it comes to our future, starting in this period of change for health care payment and delivery systems. To do so, physical medicine and rehabilitation specialists will need to recognize what will change, while holding one unchanging assumption, that the core value proposition of this specialty will continue to improve. The many changes coming to health care and American society are described by scenarios that have been proposed by the Institute for Alternative Futures with funding from the Robert Wood Johnson Foundation (www.altfutures.org/health2032). These changes set the context for how physical medicine and rehabilitation can develop out to the year 2032. The Board of Governors (BOG) of the American Academy of Physical Medicine and Rehabilitation (AAPM&R) at their Spring 2013 strategic planning meeting explored these hypothetical scenarios 2 decades into the future to identify key implications and to create strategies that can help the specialty and specialists thrive in a period that may be marked by chaos but also emerging, yet at times fleeting, opportunities. This article describes ways in which the core value proposition for the specialty could get better, even dramatically better, during a time when change leadership becomes crucial. The world of physiatric practice will surely change over the next decade, but how can leaders in the field visualize all the possibilities to respond? Well thought-out scenarios offer an effective way to do so by looking past current developments to alternative futures based on different visions and forecasts. By thinking forward to likely, desperate, and preferred future scenarios, physiatrists can share images from these scenarios for health and health care in the year 2032 with thought leaders from throughout the health care industry and then “look back to the present” to assess decisions and choices that the specialty has to make in the near term. It may seem paradoxical to look backward from the perspective of multiple futures to assure that decisions are sound, but, in a complex environment full of uncertainty, this is a logical as well as pragmatic approach to take. Preparing for only one future is the equivalent of putting all your investments into one unknown company, that is, inadequate, unwise, and too risky. Change brings opportunities as well as potential hazards, and alternative scenarios show changes that will be more or less likely, and more or less preferred; therefore, decisions can effectively embrace strategic risk amidst uncertainty [1]. Physiatrists have an opportunity to influence which future becomes reality. Although PM&R
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S.S.H.W. Department of Physical Medicine and Rehabilitation, Geisinger Health System, 2 Rehab Lane, Danville, PA 17821; Rutgers New Jersey Medical School, Newark, NJ; Rutgers Robert Wood Johnson Medical School, Piscataway, NJ. Address correspondence to: S.S.H.W.; e-mail: [email protected] Disclosure related to this publication: board membership, AAPM&R Board of Governors J.P. Institute for Alternative Futures, Alexandria, VA Disclosure: nothing to disclose S.M.W. University of Washington, Seattle, WA Disclosure: nothing to disclose Y.A. Institute for Alternative Futures, Alexandria, VA Disclosure: nothing to disclose K.R.B. University of Texas Southwestern, Dallas, TX Disclosures related to this publication: travel/ accommodations AAPM&R (travel and board paid for meeting at which this model was formulated) (money to author) Disclosures outside this publication: grants/ grants pending, University of Washington (research consultancy) (money to author); payment for lectures including service on speakers bureaus, Memorial Hermann (money to author); royalties, Lash Publications (money to author); travel/accommodations/meeting expenses unrelated to activities listed, meetings related to Executive Board of the AAPM&R D.L.K. University of Louisville, Louisville, KY Disclosures outside this publication: board membership, secretary, AAPM&R Board of Governors, Brain Injury Alliance of Kentucky (no money); consultancy, Best Doctors, Inc. (money to author); grants/grants pending, PCORI and Allergan (no money); payment for manuscript preparation, Elsevier, Book Associate Editor (no money)
ª 2014 by the American Academy of Physical Medicine and Rehabilitation Vol. 6, 876-881, October 2014 http://dx.doi.org/10.1016/j.pmrj.2014.08.940
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readers can find the full scenarios online (http://www. altfutures.org/pubs/RWJF/IAF-HealthandHealthCare2032. pdf), brief synopses of the 4 alternative images for health and health care in 2032 follow.
FOUR SCENARIOS OF HEALTH AND HEALTH CARE IN 2032 Scenario 1: Slow Reform, Better Health Health and effectiveness of health care vary among states. Health, not health care, becomes the main political issue. Communities address social determinants of health, prevention, and population health while enacting “health in all policies.” Self-care and health knowledge reduce demand for medical care and are enhanced through risk behavior management, social networks, digital technologies, predisease identification, data, and new cures and therapies. Implications for Physiatry. Physiatrists will have access to more cutting-edge diagnostic and treatment tools but will face increased oversight from integrated health systems and reduced demands for traditional therapies. Physiatrists need to fully commit to integrating practice into developing care models or risk becoming marginalized.
Scenario 2: Health If You Can Get It Medicare and Medicaid experience severe budget cuts, most Americans are underinsured, medical tourism increases, epidemics spread, and health and inequality worsen. The primary care physician shortage exacerbates access problems. Besieged community health centers struggle to treat many new patients who otherwise use expensive emergency departments for routine matters or visit inconsistent fee-for-service private clinics. The public overlooks the potential shown in thriving transition communities and becomes highly fractured and disillusioned with ineffective governance. Implications for Physiatry. Physiatrists will migrate to institutional practice because fewer private practices are sustainable due to federal and state budget cuts, underinsurance, and fragmentation. Disillusionment will take a toll on the profession. There may develop a crisis of conscience. Physiatrists will confront deep-rooted ethical questions when traditional services are no longer reimbursable. Regression of health care and its delivery system is likely, and physiatrists will need to muster all of their skills and experiences to access necessary services and equipment for their patients.
Scenario 3: Big Data, Big Health Gains Health becomes the primary concern for policy makers and the public alike. Initiatives regarding health innovation, health equity, the social determinants of health, and health
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in all policies reduce health care expenditure. The public demands anticipatory democracy, cooperation, sustainability, and transparency. Innovative technologies, “big data,” and knowledge transform manufacturing, the economy, and health care, which yield cures for neurologic conditions (eg, spinal cord injury), effective management of cancers, and widespread implementation of personalized medicine and health avatars. Implications for Physiatry. Propelled by access to large databases, physiatrists’ roles expand to include participation in population health, including the prevention of injuries and illnesses. Physiatrists’ value proposition increases as functional needs are met successfully with technology and innovation. Outcomes research demonstrates the value, and this increases demand for physiatric services that in turn attracts a greater number of passionate people into the field.
Scenario 4: A Culture of Health Leaders create environments to support and improve all domains of health as a “health culture” arises. The nation’s focus shifts to disenfranchised minority groups, for example, the disabled, and to bringing new resources for development and comprehensive health for children. Health care spending is capped. Health avatars, enhanced self-care, and transparency in health education and medical knowledge all reduce demand for medical interventions. “Health wisdom” expands as social networks “crowd source” health. Environmental monitoring is implemented widely among communities. Implications for Physiatry. Physiatry revolutionizes medicine’s focus from treating disease to improving function. Physiatrists will serve as gurus of function, particularly for persons with disabilities and for children. Physiatrists also will provide care seamlessly across the continuum from emergency departments to remote outpatient environments by using advanced communication tools. Physiatry transcends traditional medical care by restoring, renewing, and maintaining health and well-being of the whole person within his or her environment. In essence, this becomes the highest aspiration of our specialty.
MIND THE GAP IN LIKELIHOOD AND PREFERENCE At the aforementioned AAPM&R meeting, the BOG assessed the likelihood and preference of these scenarios for health care over a 20-year period, specifically to identify broad approaches for physiatry within those scenarios to position AAPM&R to better serve the needs of its members and their patients. The BOG found scenario 1 and scenario 2 to be most likely, with scenario 2 most desperate, whereas scenario 3 and scenario 4 are much preferred. To take the next theoretical step, a goal for our specialty should aim to
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increase the likelihood of the more highly preferred futures, while defending against the least desirable but somewhat more probable image of “health if you can get it.” Visionary leaders in the field should start with the aspirational scenarios that describe futures they prefer so to create strategies that alter the likely trajectory of health care toward those goals. The BOG also identified 4 overarching strategies to be applied as AAPM&R proceeds with its activities in the future: 1. Physiatrists will need to become “the conscience of function” as a determinant of health. Physical medicine and rehabilitation physicians have the opportunity to be at the center of defining health in a period of massive change in health care. To do this, AAPM&R leaders will have to engage members in the definition of health as “function” and perhaps, to engage patients and the community in this conversation. 2. As payment shifts to value, physiatrists will have an opportunity to become gatekeepers in health care utilization discussions. However, physiatry will first need to have sufficient research data on its treatments and care to support its value proposition. 3. In the shift to prevention, physiatrists will need to be present at many levels of the health care system, not just in the postacute event or in a single level of health provision. Other fields in medicine also may incorporate physiatric principles and philosophy. Physiatrists, therefore, will need to enhance their role as teachers and as content and knowledge creators. 4. Increasingly shared responsibility and interactions between patients and providers will require physiatrists to explore and define their role in the context of the new patient-provider relationship. To this end, physiatrists should be able to thrive in this environment.
CAPITALIZING ON STRENGTHS LEADS TO OPPORTUNITIES TO THRIVE The best method to change the odds in favor of a preferred future is to work with the strengths that our specialty possesses. To align the development of health and health care with the preferred futures described by the Institute for Alternative Futures, physiatrists can build on the 4 existing strengths listed here. We chose these themes as representative of modern physiatric tenets that can serve as the framework in the evolutionary model: (1) improving function for greater wellbeing, (2) leading teams for higher performance in health and health care, (3) incorporating technologies for health and health care, and (4) integrating systems of care.
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system-based knowledge. Although these strengths have been well polished when providing health care, they may prove even more powerful when defining and incorporating function as a health parameter at a population level. Function may find its greatest contributions outside the institutional settings of rehabilitation hospitals and clinicians’ offices. The ability to incorporate function as a health parameter at a population level, rather than in a single patient or family unit, would elevate the role of physical medicine and rehabilitation when health care systems must meet the “triple aim” of affordability, quality, and population health. Indeed, the premise of developing accountable care organizations is to deliver medical treatment and health maintenance at a population level. To take this lead position, physiatry will need to define functional health in terms that address individuals, families, and communities who seek well-being; in fact, physiatry should drive this agenda throughout society. Defining and developing functional outcome measurements and being the clearinghouse for newly proposed ideas should fall under the auspices of physiatry. In the decades ahead, the value proposition will grow for improving population health. If systems and cultures support the highest potential function in the least restrictive environment for individuals, families, and communities, then the boundaries of health care will expand. Indeed, the evidence that function may improve through interventions that go beyond the conventional limits of medicine suggests that physiatry has a larger future role than just restoring what was lost to genetics, accident, or disease.
Leading Teams for Higher Performance in Health and Health Care The key to taking on a larger role may well be the ability to lead teams that combine disciplines and knowledge of complex systems. This ability is typically more developed in physiatry than in other medical specialties. The medical conditions for which physiatrists are consulted are frequently influenced by a construct of physical, psychological, and social parameters. Certain medical conditions may have cures within the next quarter century, but one should not expect that, in the next 15-25 years, these aforementioned parameters will be any less relevant toward defining active state and recovery potential. Developing diagnostic and treatment teams to recognize and embrace these parameters may keep population outliers in check. Even if the relative growth of formally trained physiatrists remains stable, being able to influence team development and dynamics increases the relative impact of the specialty.
Improving Function for Greater Well-being
Incorporating Technologies for Health and Health Care
Both conceptually and practically, function is the greatest unifier for the field of physiatry, followed closely by the ability of physiatrists to excel as leaders of teams that integrate
Society is poised to take technological leaps that will impact health and health care for good and for ill. Physiatrists are trained, and thus naturally suited, to guide the adoption of
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some of the most powerful applications that are at the threshold of changing lives to enable better functioning. Since World War II, physiatrists have been implementing technology in the delivery of rehabilitation services to injured soldiers. Catastrophic injures to physical and mental capacities during recent wars in Afghanistan and Iraq have inspired efforts in regenerative medicine, robotics and neuroscience. With stem cells and 3-dimensional printing, the ability to provide a substrate for regrowing tissues and organs will move beyond wounded warriors and more widely into the general population that is also serviced by physiatrists. Robotics and exoskeletons will augment human locomotion in work, daily living, and play. Whether it is robotics for in-home care after in-patient rehabilitation, robotic cars taking over driving, industrial machines displacing labor, exoskeletons enhancing workers or patients, or thrilling new sports in which humans enhanced with bionics compete with each other or with robots, we are near the beginning of the new technological capabilities that bionics and robots will usher into our lives. Physiatrists through their training and experience are well suited to serve as guides to higher functioning for humans. The combination of human intelligence and computerbased processing has already led to chips implanted in brains to extend human thought and to power artificial limbs through brain computer interfaces. The combination of biologic manipulation, computers, and new materials (which include nanotechnology and biomimetics) means that there will be innovations coming into health and health care that will be highly disruptive with both remarkably good and terribly bad implications. This will create a terrific need for scientifically knowledgeable and humanly wise people to shepherd those technologies into medical settings and could be a growing role for physiatrists. To the extent that the profession can organize efforts to look ahead and scout out the technology that can best serve function, the aspirational scenarios show a world of new opportunities opening for the field. This future world need not restrict physiatry to the medical applications through which function gets restored to patients. By placing function in the larger context of health and well-being, the technologies that help patients will have an even greater reach in extending human function beyond limits defined by historic human capabilities. For example, advances in video technology have jump-started the revolution in functional prosthetic eyes, which have been called “bionic eyes.” With further refinements in resolution over the next decades, these technologies will continue to turn science fiction into reality for persons with disability. If a wounded warrior loses an eye, then he could have a replacement in the future that could provide sharper vision with telephoto capabilities and thus exceed current human functioning. Technological enhancement will enable new capabilities that may extend beyond the boundaries of health care (ie, treatment) but within the domain of health
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(ie, functional restoration and expansion). This could open possibilities for physiatrists that cannot be found in the expectable or undesirable scenarios but could prove attractive in aspirational futures. Physiatric training and skill sets will need to be honed toward this evolution in health, but the current principles of physiatric training, including a firm grasp of the bioethics and the biopsychosocial model of human function, provide a ready pathway toward change leadership in this technical evolution.
Integrating Systems of Care By using the team organizational capacity to integrate systems of health rather than just health care, the potential to deliver more valuable outcomes could be realized as the pinnacle for population health. Evidence for this potential may be seen in the National Research Council report, U.S. Health In International Perspective: Shorter Lives, Poorer Health [2], which indicates that spending more on medical care will not give us the outcomes we seek: longer lives and better health. Leaders in physiatry who are seeking a larger role in the health of society can join others already working to change systems at the local, state, and national levels. For example, the Robert Wood Johnson Foundation has formed a network campaign by using LinkedIn (LinkedIn Corp, Santa Monica, CA) to join leaders dedicated to creating a culture of health. The Institute for Alternative Futures and the Samueli Institute have formed a public-private partnership called the Creating Wellbeing Leadership Group, which seeks to show that community well-being efforts can contribute to a thriving and prosperous country. Perhaps the highest value proposition that physiatry will discover as society moves into and through an era when knowledge becomes as ubiquitous as information is today will be to provide a form of health wisdom beyond the boundaries of health care. One way to understand the world we are headed into is by recognizing how big data convert to information, then knowledge, and potentially even wisdom. The ability to collect, store, and manipulate data created an information revolution over the past few decades. Now we are escalating to a knowledge revolution as the combination of human and machine intelligence feeds networks that disseminate innovative ideas around the world at dizzying speeds. The transition from an information revolution to a knowledge revolution may well be facilitated by “brainlike computers” that learn on their own with “neuromorphic processors” that “mimic biological synapses” [3]. The likely impact of smarter computers is smarter networks that, in turn, make the aspirational scenarios for health and health care all the more likely. Physiatrists are better positioned than other specialists to process the unfiltered functional information and render the wisdom for decision making through the knowledge gained from their training and experience in team-based models of care and bioethics, and a biopsychosocial model of human function.
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FAILURE TO EVOLVE LEADS TO LIKELY MARGINALIZATION In addition to opportunities, physiatrists and the specialty also face serious challenges in keeping pace with changing models of health care and care delivery. Failure to meet these challenges moves us all closer to scenario 2: Health If You Can Get it. There is no status quo and the pace of change is likely to accelerate over the next decade. The greatest threats are the following: (1) failing to maintain requisite clinical and management training, (2) failing to adequately represent the value proposition of the physiatric role and methods, and (3) failing to keep pace with the growth of technology and evidence.
Failing to Maintain the Requisite Clinical and Management Training Today, even “traditional” areas of physiatric practice are at risk for reform that will affect both the inpatient rehabilitation facility and outpatient settings. Advanced technology and evidence for the efficacy of increased intensity of rehabilitation for such disorders as stroke and brain injury are moving us toward a different model that incorporates a seamless program that crosses settings for rehabilitation. For example, care maps and rehabilitation guidelines must cross the barriers of acute care, inpatient rehabilitation, other areas of postacute services, and community living. In addition, managing high technology treatments, such as robotic exercise, weight-supported ambulation, smart orthotics, and transmagnetic cortical stimulation, will require knowledgeable physiatrists who can view the whole patient and the entire system of payment and service administration, and can provide the targeted treatment that will avoid overtreatment and misuse of modalities.
Failing to Adequately Represent the Value Proposition of the Physiatric Role and Methods In response to health care legislation, hospitals, and health care networks are merging to capture a larger market share and to reduce costly duplication of services. In addition, these networks are hiring physician practices to control patient flow and utilization of services. Specifically, hospital systems are purchasing or developing preferred provider networks with postacute providers to manage quality of care, costs, and outcomes. What this means for independent groups and solo practitioners is unclear. But what is certain is that, as these organizations evolve, physiatrists must compete with other providers to have a place at the decisionmaking table and to maintain a valuable role in health care delivery. To that end, educating medical colleagues and health care administrators regarding physiatry skill sets remains a vital driver of the field’s growth and even survival
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because in either the expectable or desperate scenarios described, physiatrists will likely find current practice patterns unsustainable.
Failing to Keep Pace With the Growth of Technology and Evidence Exciting advances in medical science and technology are occurring exponentially. Also, the traditional practice of adopting such advanced technologies, with the expectation that payment systems will respond favorably, is at great risk. On the horizon of disease management are life-enhancing techniques that are likely to revolutionize medicine. In this new wave of technology, it is incumbent on physiatrists to play a coordinated role in outcome data acquisition and assessment across multiple parameters, including function, quality of life, and cost containment. Physiatrists will need to become part of research teams, with well-defined roles and responsibilities. Proper evidence can demonstrate that physiatrists skilled in teamwork and managing patient care through the service continuum from acute to postacute and into the community can effectively provide the best functional outcomes and patient satisfaction at the least cost. Physiatrists must become primary managers of specific areas of comprehensive care, such as back pain and stroke, but will likely face stiff competition from other specialists attempting to secure market share.
CONCLUSION By looking toward the future, the Health and Health Care in 2032 scenarios invite critical thinking about potential failures as well as what surprising success would look like for physiatrists. Although the 2 scenarios, recognized as more likely and desperate, offer strategic value in recognizing what change can bring, the 2 aspirational scenarios prompt consideration of greater opportunities for physiatry. For some practitioners, the most rewarding future may come from shepherding the remarkable new technologies that can improve health care and health. Other physiatrists may lead by expanding function beyond medical rehabilitation into the larger realm of well-being. The great skills that physiatrists have for integrating complex systems, long evident in addressing physiological and psychological domains of knowledge, can also gain prominence as health care systems integrate and engage the other systems that support health and well-being: education, vocation, entertainment, transportation, housing, and others. Finally, the opportunities for leading teams in health care will expand greatly in the years to come, particularly in the aspirational scenarios. Although the medical profession as a whole faces great uncertainty in the manner in which health care will be delivered in the next 20 years, there are certain to be opportunities that promote the strengths of physiatry. In a turbulent environment with surprises that emerge suddenly,
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a small and highly adaptive specialty can thrive by being agile when addressing near-term gains yet remain strategically focused on long-term opportunities. These opportunities can be recognized as aligned with the aspirational scenarios. It, therefore, is paramount to capitalize on our strengths and make certain that strategic success is defined by a shared vision for the specialty. With the intertwining of vision, strategy, and leadership, the next few decades can be a period when the specialty of physiatry further evolves. Also, although the physiatric leadership focuses the specialty’s vision and develops objectives and strategies, individuals’ grassroots efforts also can advance the process. One must first assess his or her strengths that match with future opportunities, such as those described, then identify likeminded physiatrists and establish networks with them. Next, it will be important to link these networks with physiatrists working toward different but complementary
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value propositions for the specialty. The shared vision for the field must allow physiatrists to integrate their diversity of strengths and align these strengths with activities to achieve multiple goals. Whether at organizational, network, or individual levels, being proactive and not reactive will be critical to long-term strategic positioning, sustainability, and, most importantly, evolving an essential specialty in the new world of health and health care delivery.
REFERENCES 1. Williams SA. Decision-ability. The skill to make your decisions productive, practical and painless. Boulder, CO: Decisionability LLC; 2010. 2. National Research Council and Institute of Medicine. U.S. health in international perspective: Shorter lives, poorer health. Washington, DC: The National Academies Press; 2013. 3. Markoff J. Brainlike computers, learning from experience. The New York Times December 29, 2013: A1, A4.
