The Future of NC: Positive prognosis

 In Features, February 2016

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They shudder at the sight of him, even the seasoned surgeons. Long delayed, the bridge over the Haw River north of Greensboro, which had been scheduled for completion four years earlier in 2022, was nearly finished when an accident brutally mangled a worker’s face. Only from family photographs could the team of doctors determine what he had looked like. Days later, the worker lies anesthetized in a cocoon-like
operating room. His images have been mapped by computers vastly more powerful than those 11 years earlier in 2015 when Wake Forest University’s Institute for Regenerative Medicine, as part of a $75 million military project, began researching how to re-create skin, cartilage, bone and muscle of the faces of soldiers who suffered devastating combat wounds.  3-D printers have used cells from his body to replicate the worker’s features. Now, the surgeons transplant his face. Dramas of similar scale unfold elsewhere. Microscopic robots course through bodies, seeking hidden cancer. Soon, doctors expect to use technology similar to that of re-creating the worker’s face to print out whole, implantable hearts.

Only then, in year 2026, will a soul-wrenching and often futile medical chapter common a decade earlier finally have been closed. Hearts regenerated from patients’ own tissue will “eliminate the need for donors and the need to take anti-rejection drugs,” says Sanjeev Gulati, medical director of heart failure and transplant services of Carolinas HealthCare System’s Sanger Heart & Vascular Institute in Charlotte.

A preview of Tar Heel health care a decade in the future is not science fiction. Pioneers at Wake Forest Baptist Medical Center have grown and implanted bladders, vaginas, male urethras and other organs and body parts, says spokeswoman Karen Richardson. Personalized drugs that can target an individual’s particular genetic makeup, developed by GlaxoSmithKline PLC and other Tar Heel pharmaceutical companies, are already in use but will be multiple times more precise. Even research will be revolutionized, with “body on a chip,“ miniaturized human organs, enabling scientists to test new drugs more accurately than using laboratory animals. In medicine, a decade is like an eternity.

“If you turn back the clock 10 years, the technologies we see today would be hard to imagine,” says Terry Akin, CEO of Greensboro-based Cone Health. In 2026, Carolinians might simply pass through scanners that determine if they’re predisposed to diseases such as diabetes long before there are symptoms. “We’re not that far away now,” says Robert Seligson, CEO of the North Carolina Medical Society, which represents more than 12,000 state doctors.  “At least, certainly not for those of us who grew up on Dick Tracy with his wrist TV and The Jetsons.”

It is by no means a cloudless future. As the amazing becomes routine, many physicians, insurers and others expect magnified conflicts between dazzling possibilities of technology and sobering realities of cost, access and ethics. By 2026, more than 2.1 million North Carolinians will be at least 65, an increase of 36% from present, predicts state demographer Jennifer Song. They’re the focus of nearly universal agreement: Geriatrics will be the single most profound factor confronting health care.

“One prediction I’ll make with 100% certainty,” says Jonathan Oberlander, professor of social medicine and health policy and management at UNC Chapel Hill. “Ten years from now, there will be much, much more care and attention to the medical needs of elderly Americans. We have a long-term care system that’s a mess, a nursing-home system that’s a mess, and we’re not doing a good enough job preparing doctors to go into geriatrics.”

A typical 2026 conundrum? By then, most predict dramatic advances in the treatment of age-related diseases such as Alzheimer’s. Even if not cured, it will be possible to essentially download the essence of human beings, based on almost certain exponential advances in computing power and brain mapping. But what to do with the results?

“A lot of great things will happen in medical technology, cures and treatments, but the ethical aspects of it are, when do you stop giving those procedures?” asks Seligson. “We don’t want to make those decisions, but they’re going to continually surface.” Maybe the most rending factor in those decisions?  Some medical economists see cost in a crucial race with technological advances.

The most visible changes in 2026 health care may involve where and how it is delivered. The state’s 130-plus hospitals will remain pivotal, though their roles will differ. A scenario might start with a grinding automobile accident.

“Based on our experience in the wars in Iraq and Afghanistan, trauma care will be pushed out closer to the accident site,” says Peter Fischer, a Carolinas HealthCare System trauma surgeon. “This is already happening with medication, tools and techniques that help improve outcomes for the critically injured.”

Even before his stretcher reaches the ambulance, the wreck victim will have become part of another 2026 medical phenomenon. Hospitals will be pushed by insurers, regulators, quality monitors and simple economic necessity to assume far greater ownership of the total care and recovery of their patients. Routine “virtual visits,” for example, will screen all patients entering the system, including for mental-health concerns, says John Santopietro, the hospital’s chief behavioral health officer. “This will make treatment more accessible and convenient for patients, and most importantly, we will reach them upstream, before things get worse.” Prevention will become paramount. Insurers will increasingly mine massive claims data banks for information on which treatments are best.

The expanding role of hospitals, however, constitutes one of the paradoxes of future care. Many industry officials predict that consolidation in North Carolina health care will accelerate. By 2026, most of the state’s 11 million residents will be served by no more than five health care systems, about half the present number. Each will be an infinitely more powerful umbrella incorporating the majority of physicians and clinics in sometimes overlapping regions. Cone Health, Akin says, already has 1,000 doctors in its Triad HealthCare Network, and about 1,300 on its medical staff. About 400 are directly employed by the system. Duke’s primary-care network alone employs more than 200.

Massive sites such as the 957-bed Duke University Hospital, which in 2014 had more than 40,000 inpatients, will change dramatically. Despite population growth, some might even shrink physically as more care is provided outside their walls. Akin describes it as “the change away from a hospital-centric model of health care,” with inpatient care reserved mainly for acute episodes of disease and trauma.

A signal of the future is the accountable-care organization, a feature of health care reform in which hospitals serve as anchors while coordinating patients’ treatment through outpatient clinics, physicians’ offices and even their homes. While hospitals will always be needed, Akin says, by 2026 they will treat mainly the desperately ill.

Reasons are twofold: In 2014, the latest year available, the average cost of a three-day hospital stay in North Carolina exceeded $30,000, and that is likely to double in a decade. Second, despite dramatic advances in safety and quality monitoring, hospitals may have an increased potential to harm, by way of clinical mishaps and induced infections. By 2026, for example, some researchers fear what they call an antibiotic apocalypse, in which pathogens evolve to defeat all treatments. In 2015, more than 23,000 patients nationwide died from untreatable infections, says the Atlanta-based federal Centers for Disease Control and Prevention, prompting some scientists to predict the end of what they call the antibiotic age.

Such realities, along with pressure from Medicare and ever more powerful commercial insurers such as Blue Cross and Blue Shield of North Carolina, will accelerate consolidation of hospitals that “have traditionally been firewalled from each other,” in the words of one administrator. Blue Cross insured more than 3.9 million N.C. residents in 2015. While some health care economists say more concentration could stymie efforts to control costs, semi-monopolies also could facilitate universal, portable medical records. So far, consumers and providers have resisted technology, such as implanted medical data chips, which could produce efficiencies.

Though doctors might miss their independence, they could be driven increasingly into the arms of health systems by the need to spread their risks and steady their incomes in a 2026 health care environment in which compensation will be based more than ever on how well they perform.

“It will be a new perspective for doctors and hospitals,” says Seligson. “’We don’t care how much care you’ve given the patient, what’s the outcome? Are they getting better?’”

Medical training in 2026 will evolve with a new medical school in Charlotte as part of the solution. Recommended in 2015 by Tripp Umbach, a Pittsburgh, Pa.-based consultancy, UNC Medical School-Charlotte, established at Carolinas Medical Center in 2010, might have expanded into a separate, four-year medical school. As with the Brody School of Medicine at East Carolina University, many graduates will stay in the state, where more than half of the 100 counties have shortages of health professionals.

Growth of homegrown medical training, such as the Campbell University School of Osteopathic Medicine, founded in 2011, plus the absorption of small rural hospitals into larger health care systems, could make practice in rural communities more attractive to doctors. Almost certainly, doctors a decade forward will be younger and more technology-savvy than in 2015, when a majority of Tar Heel physicians were older than 40, according to Tripp Umbach.

Each North Carolina medical school had waiting lists in 2015: At Duke, more than 6,000 applicants vied for about 200 admission slots. With typical four-year medical programs, combined with four-year or longer residencies, doctors will be joining the front lines in 2026 armed with universal electronic medical-records portability and other improved technologies. Disparities between urban and rural medical abilities will be fewer.

Despite challenges, many doctors today are optimistic. At Charlotte’s Levine Cancer Institute, researcher Edward Kim envisions an age of precisely targeted medicine in which molecular genetic testing will diagnose cancer and other diseases with precision that will make 2015 state-of-the-art technology obsolete.  From his vantage point as chairman of cancer research, tumor oncology and investigational therapeutics, a decade hence, Kim says, will be “an exciting time to be in medicine.”

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