The “Preferred Futures” of Primary Care

I freely admit that a few summers back, I read Rhonda Byrnes international best seller, The Secret. For those of you who don’t already know, the book introduced popular culture to something called the “Law of Attraction” –a belief that says your dominant thoughts will ultimately find some way to manifest –so think positively or be careful about what you wish for! Since reading the book, I have tuned my frequency to a dream state of six pack abs and unlimited overdraft protection, despite my daughter’s insistence that giving up beer, chile rellenos and allowing her to manage my finances would be more effective.

The Institute for Alternative Futures (IAF) is a not-for-profit (NPO) think tank founded in 1977 by Clement Bezold, James Dator and Alvin Toffler. The IAF helps its clients create their “preferred futures” by more systematically integrating futures planning into their strategic planning. In other words, these guys have added a disciplined process to its version of the Law of Attraction –just in case.

Its process relies on heavy research and articulating various types of future scenarios using what it calls the “Aspirational Futures” technique.  And as you’ll see, it has created a bias toward successful futures to counter our tendency to emphasize the futures we fear. Imagine that; I’m liking these guys more already.

The scenarios they create fall into the following zones:

• A “zone of conventional expectation” reflecting the extrapolation of known trends. Call it a future that most of us expect;
• A “zone of growing desperation” which presents a set of plausible challenges that an organization may face.  Call it the “melt down” scenario;
• A “zone of high aspiration,” in which a critical mass of stakeholders collectively pursue a “preferred future.” (Two scenarios are developed in this zone in order to offer two alternative routes to the favored outcome).

The Kresge Foundation sponsored the IAF to conduct a study of the future of Primary Care in the US. The study is entitled Primary Care 2025: A Scenario Exploration and I encourage you to read it. This IAF project considered the full range of challenges and opportunities shaping primary care and settled on four future scenarios which are summarized below (taken from its report):

The Zone of Conventional Expectation

• The patient-centered medical home (PCMH) model expands, and sophisticated electronic medical record (EMR) systems improve the quality of primary care.
• Federal and state leaders adopt strategies to promote the prevention of health care conditions.
• Employers reduce their health insurance rolls, and employees increasingly use health insurance exchanges mandated by the federal Patient Protection and Affordable Care Act (ACA) of 2010 to buy health insurance (including many employees seeking high-deductible, catastrophic care plans).
• Primary care teams broaden, and nurse-managed health centers expand.
• Primary care improves in aggregate, but disparities in care persist among some poor, minority, and rural populations.

The Zone of Growing Desperation

• Recurring economic challenges prompt significant cuts in federal health care spending.
• Payment reductions leave many health care providers ever more dissatisfied. Many providers retire as soon as they can (many providers cannot retire). Shortages in primary care providers leave many insured individuals without access to actual care.
• The predominantly fee-for-service (FFS) primary care providers split between “concierge” practices for the rich and “minute clinics” for the poor.
• Integrated and semi-integrated health systems become the provider of choice for urban, middle-class consumers and those with access to community health centers.
• Many uninsured Americans turn to online primary care solutions of variable quality and pedigree.

The Zone of High Aspiration –#1

• Policymakers in the United States actively pursue the “Triple Aim” in health care initiatives: (1) enhancing patients’ experience of care; (2) reducing per capita health care costs; and (3) improving population health.
• The patient-centered medical home (PCMH) evolves into community- centered health home (CCHH) that focuses on the individual and the community and that effectively leverages the social determinants of health at the community and neighborhood levels.
• Primary care team expands to include social workers and community health workers.
• Advanced knowledge technologies and community mapping allow for identification and remediation of “hot spots” of ill health.
• Payment systems use sophisticated statistical methods and apply the decision principle, “If it’s smart, we’ll pay for it.” Most payments to health care providers are capitated payments with additional rewards for improved health outcomes.

The Zone of High Aspiration –#2

• Advanced knowledge technologies allow individuals using self-care to take over many functions of primary care.
• Consumers buy health-related products and services through competitive markets that offer high transparency of costs and quality; health costs are significantly reduced.
• The insurance market divides between consumer-directed health plans and integrated health systems, with some remaining fee-for-service (FFS) options.
• Integrated health systems provide primary care to patients who prefer a whole package of care services, including procedures and hospitalizations, from a single entity with competitive annual fees.
• The demand for professional primary care providers declines.

Healthcare Matters would like to thank the IAF for permission to share its insight.

—Tom Finn

Tagged as: Future Scenarios of Primary Care, IAF, Institute of Alternative Futures, primary care