Dr. Clement Bezold, Chairman of The Institute for Alternative Futures

(Music)

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, the dog days of summer are here. It is hot, hot,
hot out there.

Margaret Flinter: It certainly is. We have been getting one heat wave after
another here in Connecticut. We hope everyone is taking good care of
themselves.

Mark Masselli: Well, speaking of hot places, the governors of the nation got
together at their annual meeting of the National Governors Association and
guess what one of the hot topics of discussion was there.

Margaret Flinter: That wouldn’t be hard at all. And the echoes of the Supreme
Court’s decision on the Affordable Care Act just keep reverberating loudly
through statehouses across the nation. I hear there were lively debates in two
pretty distinct camps at the governors’ gathering.

Mark Masselli: Those who say they will hold out for enacting certain aspects of
the health care law like expanding Medicaid and forming insurance exchanges
for individuals and small businesses I think were the two topics.

Margaret Flinter: And those who are already hard at work implementing the
ACA’s directives, still pretty much a partisan divide on the talk of health care
reform Mark, with the opposition coming largely from the GOP. But we should
note that some democratic governors expressed concern about expanding
Medicaid as well, noting that their budgets are already under extreme duress.

Mark Masselli: The economy has hit most states pretty hard and governors are
concerned about controlling expenses, even if it means expanding health
coverage for more of their vulnerable populations.

Margaret Flinter: Well Mark, we should remind folks that the Medicaid expansion
portion of the Affordable Care Act is going to be completely funded by the federal
government for the first decade. So states will have plenty of financial support in
their efforts to expand Medicaid coverage, still seems more political than financial
when you look at it that way.

Mark Masselli: I think you are right. And we don’t need a crystal ball to see that
this discussion will be ongoing for some time.

Margaret Flinter: But at least we are past the Supreme Court decision, and for
that, we are grateful. Speaking of seeing into the future Mark, our guest today is
somebody who is practiced at the art of predicting and gazing into the future.
Futurist Dr. Clement Bezold is the Chairman and co-founder of the Institute for
Alternative Futures, a leading research organization that makes long-term
predictions on what the future, and in this case, the health care of the future is
going to look like.

Mark Masselli: He will be talking about his organization’s latest report on what
health care is going to look like in this country in the year 2025 and beyond. He
will also look into the growing impact technology is going to have on health care
delivery.

Margaret Flinter: And FactCheck.org’s Lori Robertson uncovers the truth behind
yet another misstatement from the campaign trail regarding health care.

Mark Masselli: But no matter what the topic, you can hear all of our shows by
Googling CHC Radio.

Margaret Flinter: And as always, if you have a comment, email us at
www.chcradio.com , or send a message on Facebook at Conversations on Health
Care; we love to hear from you.

Mark Masselli: We will get to our guest Dr. Clement Bezold in just a moment but
first, here is our producer Marianne O'Hare with this week’s Headline News.

(Music)

Marianne O'Hare: I am Marianne O'Hare with this Headline News. Taxpayers
and the health care law; who will pay? According to a report out by the
nonpartisan Tax Policy Center, middle income earners will seek relatively little
additional burden as a result of the law. The Affordable Care Act is projected to
raise about $800 billion in revenues over the next 10 years but the bulk of that
money will come from corporations and households earning more than $200,000
per year. About seven million people could pay more because the law makes it
more difficult to deduct medical expenses. About four million workers could pay
more because of the new $2500 limit on flexible spending accounts, which can
be used to shield medical expenses from taxation. Several small taxes such as
the one on indoor tanning salons also could reach average taxpayers. Still fewer
than 10% of the nation’s 140 million tax filers are likely to pay more.

Meanwhile, a recent Gallup Poll shows the nation is pretty much split on how
they view the impact of the health care law. A slight majority think the law will
improve things for most Americans especially those who are sick or uninsured.
At the same time, Americans say the law will make things worse rather than
better for taxpayers, businesses and doctors.

The amount of Trans fat consumed by New Yorkers has fallen significantly since
the city banned the sale of foods containing Trans fats in 2007. According to a
recent report, there has been an average drop of 40 Trans fat calories per day
consumed by the average New Yorker which may not seem like a lot but it's a
significant reduction when taken overtime. Health analysts say that even a
moderate daily consumption of Trans fats, 23 calories per day, leads to a higher
incidence of heart disease. I am Marianne O'Hare with this Headline News.

(Music)

Mark Masselli: We are speaking today with Dr. Clement Bezold, co-founder,
Chairman and Senior Futurist at the Institute for Alternative Futures, which was
formed in 1977 to encourage anticipatory democracy and to analyze global
trends, particularly in the future of health care and other social issues. Dr. Bezold
is the author of more than 10 books as well as the author of numerous forecast
and research papers and is the consulting editor of the Journal of Future Studies.
Dr. Bezold, welcome to Conversations on Health Care.

Dr. Clement Bezold: Thank you, my pleasure.

Mark Masselli: Dr. Bezold, you founded the Institute for Alternative Futures along
with the noted author of Future Shock Alvin Toffler. That groundbreaking book,
published in 1970, analyzed how society is undergoing an enormous structural
change, and this accelerated rate of technological and social changes really quite
overwhelming to the society. Technology is revolutionizing so many aspects of
our lives, especially in the delivery and use of health care. Help us understand
the key ideas of Future Shock and the changes in technology as it relates to
health care.

Dr. Clement Bezold: Yeah. Alvin Toffler published it in 1970. He had been
writing it during the course of the ‘60s. And what he anticipated, what he saw
was the speed of changes we were moving from an industrial society to an
information society and that there was a stress of this degree and pace of
change that is Future Shock. And he identified his prescription for it was
anticipatory democracy. But in health, what he anticipated was and identified
eustress which was good stress and health affecting negative stress, and that
was part of the biggest aspect that he identified. In more recent years, there are
a whole host of issues about genomics, about genetic engineering, about artificial
intelligence, that are increasing the pace of change and so that thread of Future
Shock remains out there.

Margaret Flinter: So Dr. Bezold, as a futurist, you have looked into the future
from here and done some long term projections on everything from the impact
that we will realize of the diabetes crisis to the future of community health centers
and also have predicted what primary care is likely to look like in 2025 and

beyond. And you, of course, use some pretty sophisticated predictive techniques
to do that. So what’s your unique approach to forecasting these trends; how do
you arrive at the conclusions that you do? And maybe share some of those
predictions with us.

Dr. Clement Bezold: Basically, there is an agreement that you look at the
experts, you understand what the current trends are. You identify key drivers of
change, you forecast those and you do that both with experts looking at the
literature. But what we add then is you ask both what is likely to happen given
current trends but also what challenges are out there, what could go wrong, and
then finally, ask what visionary or surprisingly successful outcomes would look
like. And so you then use the forecasting scenarios to paint a path to what’s
expectable and most likely, what’s challenging or difficult, and what’s visionary or
successful and you put all those three together. That leads in health care to a
fairly different forecast for health care itself.

Mark Masselli: Now, the Institute for Alternative Futures recently produced a
report with support from the Kresge Foundation entitled Primary Care 2025: A
Scenario Exploration. Now, that explores several different views of what primary
care could look like in 2025 and beyond from a low zone of growing desperation
to a zone of high aspiration. But tell us a little more about the partners who
participated with you in crafting this document and how did this come about.

Dr. Clement Bezold: The Kresge Foundation does a lot in primary care and they
agreed to fund these scenarios. We partnered with the National Association of
Community Health Centers, NACHC, and David Stevens was one of our major
partners. But for the Primary Care 2025 Report, we actually started interviewing
experts, and 56 experts later, we had gotten very rich sets of input. We then
went to 10 primary care provider groups, Kaiser Permanente, Group Health, the
Surgeon General of the Air Force, Surgeon General of the Army, small clinics,
and put in front of them various forecasts and said, how will your primary care,
what will it be in 2025, what will it look like. We used those focus groups to help
us develop those scenarios as well.

Margaret Flinter: Dr. Bezold, I would like you to spend some time maybe sharing
with us these scenarios that you have developed. And I understand there are
sort of four likely scenarios that you envision. Maybe we could just look at the
first two of them for a moment. And you titled them Many Needs, Many Models,
and the second Lost Decade, Lost Health. Maybe you could share a little bit
about these scenarios with our listeners.

Dr. Clement Bezold: Yeah. The first Many Needs, Many Models is sort of the
extrapolation of where we are going now. Ultimately, we get some additional
movement into integrated system. We still have a lot of fee-for-service. Primary
care moves to the patient-centered medical home. But we also get a large influx
by 2025 of digital health coaches, and what that is, is the capacity to have each

individual often through their provider but sometimes buying on their own. And in
effect, an expert physician, the way that IBM’s (09:43 inaudible) humans in
jeopardy, we are going to have Doc Watson and other things like that that take all
knowledge, personalize it to you, and will personalize our vital signs. That will be
integrated into health care and it will have very rich primary care teams including
greater emphasis on nurse practitioners.

Scenario two is Lost Decade, Lost Health, and the challenge is that we could be
going in for a double-dip recession or worse depending on a variety of things.
This scenario assumes that we don’t get our act together, we don’t get health
care reform, many health care providers actually go out of business including
many community health centers. We do get advances in this second scenario
including cures for Alzheimer’s. The challenge is they tend to be very expensive.
So the $60,000 a year cure for Alzheimer’s is great for rich people but most
people don’t get it, and that minute clinics become more important than
emergency rooms, stay important, particularly for those people who don’t have
access to community health center.

Mark Masselli: We are speaking today with Dr. Clement Bezold, Chairman and
the Senior Futurist at the Institute for Alternative Futures, a leading organization
that provides industry forecast for policymakers and stakeholders in health care
and other social disciplines. Let’s pull the thread a little more on those primary
care models. There are two other scenarios that you predict which seem to
incorporate some ideas central to the themes of the Affordable Care Act. And the
third scenario is Primary Care That Works for All, which focuses on the triple aim
of health care reform. And the fourth scenario I am My Own Medical Home
which you call a surprisingly successful integrated care model. Can you tell us a
little more about those two scenarios?

Dr. Clement Bezold: Yeah. Scenario three, Primary Care That Works for All, it
says we want to lower per capita cost while we increase the excellence of health
care experience and we increase population health. That leads to a movement
of primary care from the patient-centered medical home to this community-
centered health home. But it also focuses on the community to analyze these
community conditions and health care providers become, along with other
community partners, community health advocates for shaping the social
determinants of health. We get community health workers going into people’s
homes supported by the digital health coach and advanced practice
management. We also do community mapping in ways that say, we are the
hotspots for ill health, many of which involve the social determinants of health
beyond clinical care.

Scenario four is I Am My Own Medical Home. And what that says is we don’t get
quite the assurance that we did in scenario three that you will never spend more
than 10% of your income on your health care insurance. And so consumer-
directed health plans where you pay out of pocket for the first several thousand

dollars become the norm for about 40% of the population. The good news in this
context and why we called it I Am My Own Medical Home is that those 40% have
very powerful tools for doing their own self management self care. They also
have transparency so that if they want to go and buy something, they know the
success rate of the doctors and the primary care teams in their community; they
know from, there is now group called PatientsLikeMe in this scenario, (12:45
inaudible) basically segments of your gene that define certain health conditions.
Those are grouped together in a way so that you are getting advice from people
who have conditions very much like you, who have gone shopping for doctors.
So, all of that transparency and knowledge will come together.

Margaret Flinter: It's very interesting. We, just in the last month at our Annual
Weitzman Symposium, we had leaders both from the retail clinic movement and
from PatientsLikeMe join us as really exemplars of disruptive innovations in
health care. But let’s talk for a few minutes about community health centers. Tell
us why you have concluded that community health centers figure so significantly
in the future of health care and in the future of primary care.

Dr. Clement Bezold: We have a major health equity project at the Institute for
Alternative Futures and in looking for innovations about 8 years ago identified the
collaboratives within the community health centers as one of the most significant
quality improvement, disparity reducing advances in US health care. And that
has led us to pay attention to health centers and their unique role in providing
both increasing quality, team-based care while serving poor and marginalized
populations. The job of a community health center is to increase access not only
to health care but to services and resources for the people they serve. And the
people who first founded community health centers, particularly Dr. Geiger, had
had the experience of community-oriented primary care working as an intern in
Africa, where there was not a separation between what the primary care
providers did and how they worked to improve community conditions to the way
we put it is working on the social determinants of health is in the DNA of
community health centers.

Mark Masselli: And one of the issues that health centers have to address in
health care is the sort of lack of effective public policy directing the training of
health care workforce for tomorrow. And you note in your Primary Care 2025 that
there is an oncoming shortage of primary care physicians and at the same time
we are seeing an uptake of those who are seeking nurse practitioner, physician
assistant, diplomas and you predict the growth of increase of community health
workers and digital health coaches. Talk to us a little bit about how do you see
the impact on public policy in training the next generation of health care
providers.

Dr. Clement Bezold: Yeah that’s a great question. And in effect, the forecast for
the shortage of primary care physicians really varies from scenario to scenario.
But the public policy questions, we do massive support to train physicians, and in

particular, give them residencies in hospitals when they should be getting
residencies in primary care in particular, those settings where they are actually
going to practice.

Mark Masselli: We agree.

Dr. Clement Bezold: And hurray for community health centers again because of
the programs they have that are using community health centers as residency
sites. But that’s for physicians. The issue for us in the scenarios tend to support
the notion that primary care physicians will become in effect the caregiver for the
complex primary care patient and that increasingly people on the team, nurse
practitioners, physician assistants will become important as prime providers. And
the community health worker is someone who comes from the community,
shares community’s values, understands what's going on. In most cases, they
are not a college graduate but they do provide a number of important functions.
In fact, Health Affairs had a recent article where a community health worker type
approach was able to save significant money by doing home visits. When we put
that together with the enhanced aids and digital coaching we will have, the
community health worker could be significant. Right now, federal policy is geared
to generate more physicians in more specialties. That needs to be adjusted to
focus on nurse practitioners, physician assistants in this new category or this
growing category of what's the role of a community health worker, the policy
needs to shift.

Margaret Flinter: And in all of these projected health care models there certainly
seems to be one recurring theme and that’s of the empowered patient. You
recently on PBS I think had a hypothetical patient of the future that you talked
about, Mary, an uninsured 50-year-old patient with diabetes, who strongly
engages in her own health care management and does it really pretty effectively.
Describe Mary’s situation for us and how technology is going to make it easier for
her to be an empowered effectively self-managed patient as we go through this
big transitional period that’s ahead of us.

Dr. Clement Bezold: So Mary’s situation varies across the four scenarios. So in
the first, she has got the digital health coach. She has got diabetes but it's under
control. Her primary team member in scenario one is a nurse practitioner but she
does have health insurance. Scenario two, she does not have health insurance
and she doesn’t have a regular physician so she uses the MinuteClinic and the
emergency room. She has access to digital coaches but she can't afford to buy
one so she gets the ones that are for free. There will be free digital health
coaches and they may not be as reliable. So in scenario two she is more at risk;
her diabetes is little more likely to go out of control but she doesn’t have
significant resources. Scenario three, she has got the digital coach but she has
got a community health worker who comes to her home and helps support her in
terms of activity and nutrition being among the most significant things that
enables Mary to keep the diabetes and glucose levels appropriate. And then in

scenario four, she is her own medical home and she has a digital coach. She
has access to care when she needs it but she doesn’t need it as much and since
she is paying out of pocket she uses the digital health coach and the
PatientsLikeMe, (18:08 inaudible) diabetic network to self-manage.

Mark Masselli: Dr. Bezold, you talk about one of the tools that’s going to greatly
reduce health disparities is biomonitoring and you also talk about the future of
health care where food will be as much part of a treatment regime as medicines
are and that evidence-based nutrition information will increasingly become part of
the future patient care protocol and then of course genomics. So talk to us about
these game changers and how they fit into the next larger context of health care
of the future.

Dr. Clement Bezold: In genomics, gene fingerprint will be really important.
Equally important will be our zip code in the social determinants of heath and
where we live, and we will come to understand the role that our community
conditions fit. The genomics piece is we will increasingly understand the
genome, it will be low cost to map it; we will able to have it in our medical
records. At the same time, we will come to understand whether you have a gene
and what it expresses is the function of other factors beyond your genome itself
and that will get integrated. The food question becomes really important both
because we all uptake our food very differently but food is essentially the quantity
of calories, the nature of calories; all of those become very important. For the
biomonitoring, we will take a number of forms. We will have bed pads that we
just sleep on and get a lot of what a sleep lab tells about our sleep quality. We
will have wrist watches or earrings or eyeglasses that we basically understand
heart rate variability. We will come to map that with biomonitoring. But we will
also understand our food intake, what difference it makes for us. Our systems
will also say do you have access to healthy food, is your neighborhood safe, are
you socially isolated, how do you understand that. So individually, and more
collectively, we will focus on understanding those things and on acting on them.

Margaret Flinter: Great. And Dr. Bezold, we like to ask all of our guests this final
question. When you look around the country, and around the world, what do you
see in terms of innovation that our listeners at Conversations should be keeping
an eye on?

Dr. Clement Bezold: I would look at community health centers and this notion of
leveraging the social determinants of health and what it means for health care
providers to do that. I think the food and the nutrient question will be relevant.
The future of Doc Watson is one example of what will become digital health
coach but there will be other competitors as well and watch that in terms of
what’s happening. Those would be among the innovations I would say.

Mark Masselli: We are speaking today with Dr. Celment Bezold, Chairman, and
Senior Futurist at the Institute for Alternative Futures. Dr. Bezold, thank you so
much for joining us today on Conversations.

(Music)

Mark Masselli: At Conversations on Health Care, we want our audience to be
truly in the know when it comes to the facts about health care reform and policy.
Lori Robertson is an award-winning journalist and Managing Editor of
FactCheck.org, a nonpartisan, nonprofit consumer advocate for voters that aim to
reduce the level of deception in US politics. Lori, what have you got for us this
week?

Lori Robertson: Mark and Margaret, as I am sure you are aware, critics of the
federal health care law have claimed that it’s the largest tax increase in history.
But we took a look at this and found that that would only be true in raw dollars, a
rather useless measurement with no adjustment for inflation. Once we adjust for
inflation, the tax increase drops to fourth place since 1968 with Ronald Reagan’s
1982 tax increase taking first place. And if we use the best measurement
according to most tax experts that’s the increase of the percentage of gross
domestic product, then the health care tax increases are smaller than most of
those enacted since 1968. So here is how we measured the increases. We
looked at tables from U.S. Treasury Department tax analyst Jerry Tempalski, who
has worked in both Republican and Democratic administrations. We used the
tax increase for 2014, which is when the major provisions of the health care law
take effect and the largest figure Tempalski has for the law. We compared that
2014 increase to the one year figures for each tax increase since 1968. Now
keep in mind these are estimates and we also don’t have figures for the years
further out. But the health care law can't be the largest tax increase in U.S.
history. We have to go way back to 1942 to find the largest a tax hike of 5% of
GDP used to pay for the country’s war efforts. The health care law would need to
be about 12 times larger to come close to that. And that’s my fact check for this
week. I am Lori Robertson, Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country’s major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com . We will have FactCheck.org’s Lori
Robertson check it out for you here on Conversations on Health Care.

(Music)

Margaret Flinter: Each week, Conversations highlights a bright idea about how
to make wellness a part of our communities and everyday lives. When 22-year-
old college student Ludwick Marishane was on an extended trip to Africa, he and
his fellow students bemoaned the lack of available water to take a shower. The

awareness of that very real problem, lack of water for basic hygiene in many
parts of the world, got him thinking, what if there were a product that could take
the place of a shower, that could perform the same task of cleansing that soap
and water does. When he returned to the University of Cape Cod, he set to
work. Six months of research on biodegradable and antimicrobial products led to
a unique invention simply called DryBath. And it's not just a rehash of hand
sanitizer which is made largely from alcohol and other chemical products,
Marishane’s odorless and bio-degradable body bath gel is a proprietary
combination of biocide, bioflavonoids and moisturizers. The product has been
shown to reduce bacteria by 99% and have a lasting antimicrobial effect. Already
there is keen interest from several sectors including the airline industry which
sees the commercial value of providing the product for folks on long flights. And
Marishane sees numerous potential applications, specifically having the potential
to improve health and wellness through better hygiene in developing regions that
lack basic access to bathing water. DryBath has earned Marishane the 2011
Global Student Entrepreneur of the Year Award. A simple biodegradable gel that
could improve hygiene for areas of the world lacking basic access to clean
bathing water, potentially improving the general health of those communities as a
result, now that’s a bright idea.

(Music)

Margaret Flinter: This is Conversations on Health care. I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Health Care, broadcast from the campus of WESU at
Wesleyan University, streaming live at www.wesufm.org and brought to you by
the Community Health Center.