The future of health care: What to expect

Your medical care team will expand

The U.S. faces a critical physician shortage, and by 2034, the gap between physician supply and demand will range from 37,800 to 124,000, with shortfalls in both primary and specialty care, according to the Association of American Medical Colleges. Patients in Connecticut should expect to see advanced practice providers (APPs), including physician assistants (PAs), nurse practitioners (NPs), certified nurse midwives (CNM) and certified registered nurse anesthetists (CRNA) filling that gap. These licensed health care providers diagnose and treat patients, prescribe medications and perform or assist with surgical procedures. 

APPs undergo extensive education at the undergraduate and graduate school level, with training in both medicine and “soft skills” such as communication, listening, leadership, compassion and professionalism. On a basic level, NPs, Advanced Practice Registered Nurses (APRNs) and CRNAs are registered nurses with advanced clinical training; a PA is trained following a disease-centered medical model like physicians. The number of people in each profession is expected to grow quickly — 31 percent between 2019 and 2029 for PAs and 45 percent for NPs, according to the U.S. Bureau of Labor Statistics. 

The need for additional providers came into greater focus during the COVID-19 pandemic, which led to delays in other medical care. That left patients and providers trying to catch up on services, including screenings and chronic-condition follow-up, says Johanna D’Addario, president of the Connecticut Academy of Physician Assistants. “In many cases, PAs have availability to see patients who need urgent appointments when the physician is not available,” she says. “It might be helpful for patients to know that PAs work closely with physicians in a team approach, and are able to arrange for the patient to see the physician as soon as possible when needed.”

The medical community is aware of the doctor shortage, but medical school seats are limited. PAs, meanwhile, don’t have to do a residency like doctors and can get “out into the workforce more quickly than physicians,” says D’Addario, a physician assistant at Yale New Haven Hospital, “but we’re still limited by the number of seats in PA programs across the country.” Physicians, PAs and NAs all need training sites. “We have to be very cognizant of not overburdening the current medical system with students.”

“I work with PAs, nurse practitioners and APRNs. They play a very important role in my own practice,” says cardiologist Dr. Bruce T. Liang, interim CEO of UConn Health. “If I see a new patient, the next visit could be with a nurse practitioner or a PA. We alternate. There’s mutual respect and dependence. We work as a team.” — Theresa Sullivan Barger

You might pay a medical membership fee

The future of health care for some looks a lot like health care did a century ago, as doctors fed up with dealing with insurance companies are opening direct primary care (DPC) practices that don’t take insurance. Instead, people pay a monthly membership fee for access to their doctor for physicals and sick visits, and, potentially, discounts on medications, tests and health screenings. 

In today’s health-care delivery system, most private practice primary care doctors have been absorbed by large consortiums. With the fee-for-service, insurance-billing model, clinicians are reimbursed the same amount, whether they spend 10 minutes or 30 minutes with a patient.

“Primary care docs have become the gatekeepers. They are loss leaders for hospital consortiums,” says Dr. Tonya Cremin, founder of Balance Family Medicine in Monroe. In the fee-for-service model, primary care practitioners send patients to specialists such as a cardiologist for hypertension and an endocrinologist for a thyroid issue, she says. By contrast, Cremin treats people from all walks of life with a full range of health conditions, just like her family doctor did in the small town in which she grew up. When she encounters a challenging case, she checks in with a network of providers to see if her patient needs to see a specialist. As a doctor of osteopathic medicine, she says, she practices holistic, integrative medicine. “It saves everybody time and money,” she says. Four patients texted her while she was on vacation with what she termed “simple problems,” she says; she was able to help them and save them a trip to urgent care.

In addition to Balance Family Medicine, the other membership-based practice in Connecticut is 4 Elements Direct Primary Care in South Windsor and Rocky Hill. (There are five hybrid practices in the state which offer a combination of direct primary and fee-for-service care.) Direct primary care is different from concierge medical care, which caters to wealthier patients. Both state DPC practices serve uninsured, middle-class and affluent patients.

DPC practitioners don’t need the staff to process claims and argue with the insurance companies for coverage and payment, says Dr. Vasanth Kainkaryam, an internist, pediatrician and the founder of 4 Elements. Some patients pay a monthly fee directly, while some patients’ membership fees are paid by their employer. Depending on the age of a patient, 4 Elements’ monthly fees range from $35 or $40 for people under age 40 to $100 for those 65 and older. Cremin charges a flat $100 monthly fee that covers annual physicals, sick visits, disease prevention and maintenance. 

Both doctors’ patients have access to them through in-person visits, phone calls and texting. DPC practices help people save money on prescription medications, lab tests and screenings, Kainkaryam says. After working as a chief medical officer for a large community health center, Kainkaryam says, he learned about the DPC model and was hooked. “This is such a better way of giving care,” he says. “I do house calls. When the weather’s nice, we’ll sit outside in the backyard of my office.

“When a patient joins my practice, I spend an hour getting to know them,” he says. Annual physicals last about 90 minutes, he adds, “because health and wellness extend beyond what happens in the office.”

According to a study by the Society of Actuaries, DPC patients’ demand for health services is 53 percent less than patients of traditional practices, they have a 41 percent lower use of emergency departments and 20 percent fewer hospitalizations. In traditional practices, doctors carry a patient load of 2,000–3,000 patients and spend an average of 10 minutes with a patient, he says, leaving them little time to get a full picture of what each individual patient is dealing with. 

The DPC model may keep some primary care providers from leaving practice, since it allows physicians to spend time with patients and still make a living. “Everyone wins,” Kainkaryam says. “The patient wins because they have direct access to their doctor. The doctor wins because they control their practice.” — TSB

Demand for mental health care will expand

While the pandemic has caused demand for mental health services to outpace supply, there have been a few upsides. Interest in some careers in mental health is on the rise, a growing societal openness about anxiety and depression has lowered stigma, and patients’ comfort with virtual visits has skyrocketed. However, at least in the short term, mental health professionals are feeling burnt out and retiring early, and many therapists and psychiatrists’ positions at Connecticut hospitals go unfilled. 

Even with an increase in tele-therapy services, some low-income residents are unable to access therapy, since an internet connection and a smartphone or tablet are required. Increasingly, psychiatrists, psychologists and mental health therapists are switching to private pay and refusing to take health insurance, says Dr. Charles Herrick, network chair of psychiatry for Nuvance Health, further reducing access for less affluent residents. 

“Mental health care has always been poorly reimbursed and poorly paid,” he says. “The paperwork demands are so onerous. Mental health clinicians don’t have to take insurance, so they don’t. More than 50 percent of psychiatrists don’t take Medicare or Medicaid.” The problem of providers not taking insurance is especially pronounced in southern Fairfield County, he says.

“All the hospitals are struggling with staffing. We’re down six psychiatrists,” he says. “I have interviewed so many psychiatrists. They can pick and choose. We are often competing against one another.” To address staffing shortages, he says, he applied for and received designation for Danbury and Norwalk as an underserved region and was granted the U.S. State Department’s permission to recruit psychiatrists from outside the country with J-1 visas. 

On the good-news front, tele-mental health has been so well received by patients and clinicians that it’s expected to continue. In a UConn Health survey of more than 500 patients, more than 90 percent of adults said they liked virtual therapy and would like the option of it continuing, says psychiatrist Dr. Neha Jain. It’s especially beneficial to residents of rural parts of the state where there are fewer mental health providers and to those concerned about the stigma associated with mental health, she says. 

She expects behavioral health care to become a hybrid system where people alternate between in-person and virtual visits while also allowing their therapists access to smartphone data that tracks patients’ movement. For example, clinicians can collect data from patients’ phones that shows whether they’re leaving their homes. “Suppose someone is depressed and has stopped going out? The app is a way for me to track that data,” Jain says, and check in with a patient.

However, some mental health apps are unregulated and may not protect users’ privacy, according to a study published in 2018 in Behavioral Sciences & the Law. “I advise people to do their research into who has built this app,” Jain says. “Are their physicians or institutions familiar with this app?” — TSB

More screen time with your doctor

Telemedicine isn’t a practice that started with the pandemic. The idea of “seeing” a doctor remotely existed for years before COVID-induced lockdowns temporarily shut down some doctors’ offices for in-person visits. But it had a hard time catching on, says Jaclyn O’Connor, an internal medicine physician and section chief of telehealth at Bridgeport Hospital’s Bridgeport and Milford campuses.

“It’s always difficult to have people accept and adopt new technologies, but COVID sort of provided a need for it,” O’Connor says. “I don’t think it’s going anywhere.”

A report released late last year by the U.S. Department of Health and Human Services seems to back that up. The report found that Medicare visits conducted via telehealth skyrocketed between 2019 and 2020, from 840,000 to 52.7 million. The pandemic is largely deemed responsible for that jump, but the Centers for Medicare and Medicaid also announced that it will continue to pay for some telehealth services that were temporarily added to its coverage during the pandemic. These include video-based mental health visits provided by Rural Health Clinics and Federal Health Centers. 

O’Connor says she hopes the additional spotlight placed on telehealth during the pandemic will also get providers and patients alike thinking about the wide variety of ways in which this technology can be used. “We have always thought about telehealth as the next best thing,” she says. “If you couldn’t get there in person, you could settle for this. Now we’re talking about providing better care to patients than we were before.”

For instance, she says, at Bridgeport Hospital and Lawrence + Memorial Hospital in New London (which, like Bridgeport, is part of the Yale New Haven Health system), patient rooms are hardwired with telehealth technology. This allows the cameras associated with televisions in these rooms to accept telehealth calls from providers, including specialists.

Despite the growing interest and innovations in telehealth, there are still some limitations to seeing patients remotely, says Dr. Frank Illuzzi, Hartford HealthCare Medical Group’s medical director for Fairfield County. “I think this is a tool that’s here to stay,” he says. “I still think it’s important to see a doctor for regular visits. There are some things telemedicine can’t do. It’s really hard to listen to someone’s heart and lungs over the phone.” — Amanda Cuda

Acquisitions and mergers will continue

You’ll see more consolidation of health systems. But will the legislature step in to provide oversight?

Yale New Haven Health recently announced its intention to buy three more hospitals in Connecticut. If they do as they intend, Yale will own nine hospitals. Hartford HealthCare currently owns eight.

That, according to Lynn Ide, mirrors a nationwide trend of health care consolidation in which independent doctors offices are bought by larger groups, a practice called vertical consolidation, and hospital groups buy other hospital groups, called horizontal consolidation.

“Now there’s a situation where often the hospital is part of a larger system where you live or the two hospitals are both part of larger systems and the doctors and clinics and specialists are all owned by the hospital networks, also,” says Ide, director of program and policy at the Universal Health Care Foundation of Connecticut. “So it puts consumers in a really difficult position.”

Only a few decades ago, Ide says, there were dozens of independent hospitals in Connecticut. Now all but six are part of a larger network. The result is sometimes a consolidation of health care services. At Sharon Hospital, for example, owner Nuvance — which was itself formed by the merger of two large health care systems — announced its intention to end maternity services. Patients would instead be sent to Poughkeepsie or Danbury.

Consolidation also raises issues around insurance coverage, Ide says. Patients are often only allowed to use health care providers who have an existing relationship with their insurance carrier. “In 2015, Hartford HealthCare was negotiating with Anthem Blue Cross Blue Shield, and Anthem wanted to include Hartford in their network of providers, but they couldn’t come to an agreement,” she says. “And so, for a period of time, everybody who lived in my part of the state, in the greater Windham area, had no choice of a doctor to go to because, literally, almost all the practices were owned by Hartford HealthCare.”

There is, however, some interest in setting up what Ide calls “guardrails.” A bill, considered by the state legislature this year, would increase penalties for providers that end services before the state Office of Healthcare Strategy gives its blessing. It would also increase funding to that agency, so it might develop a statewide plan for health care access.

That, Ide says, was surprising. “In my years working on this issue, I have never seen the state show so much interest in this issue,” she said. “I’m discouraged, though, because I feel like it may be too late, like the cat may be out of the bag now.” — Jordan Fenster

The return of the house call?

Dr. Srinivasulu Conjeevaram understands that, for some people, leaving home to see a doctor isn’t feasible. “The other day a patient called saying, ‘My dad — I can’t get him out, he just had a heart attack,’ ” and needs follow-up help, Conjeevaram says. “I help a lot of people who need care and can’t get out to the doctor.”

Conjeevaram provides medical care in the home to clients all over Connecticut through his Hartford-based business Aakaish Health Care. His practice is one of several throughout the state that provides in-home visits with a doctor or other care provider.

In 1930, house calls by doctors were fairly standard, as about 40 percent of visits happened in patient’s home, according to the American Academy of Family Physicians. By 1950, though, the number dropped to 10 percent and fell below 1 percent by the mid-’90s. That number started to pick up in recent years, according to a 2018 survey by the health care company Landmark Health, which found that about 13 percent of doctors reported making regular house calls.

Some groups, including the American Academy of Family Physicians, believe the practice is making a comeback. Last year the Academy published an article stating that the U.S. “is experiencing a resurgence of home-based primary care.” The organization sees several factors at play including “the aging U.S. population, an increase in patients who are homebound, and the acknowledgment of the value of house calls by the public and health care industry.”

Still, others question house calls’ growth potential, as technology-assisted home care, including telehealth, can replace some in-person visits.

In his practice, Conjeevaram sees everyone from those suffering from flu to older people who need repeated house calls. He says house calls have a benefit to both the doctor and the patient. Doctors, himself included, have more flexibility in when they see patients, and patients can get help without leaving the home.

But there are drawbacks, Conjeevaram says, including that providers such as himself have to drive all over to see patients. And, sometimes, home care providers can’t get to a patient as quickly as they like. “It might take a month or so,” he says. “It’s basically how acute the situation is and can you accommodate somebody.”

That’s partly why Dr. Jaclyn O’Connor says that the nature of what constitutes a house call is changing. “House calls will exist where you will have a provider in your home, but they’re going to be there virtually,” says O’Connor, an internal medicine physician and section chief of telehealth at Bridgeport Hospital’s Bridgeport and Milford campuses.

She points to such programs as Hospital at Home, in which patients are “admitted” to a hospital from their home, but doctors perform their rounds using audio and video visits. 

“I think house calls are going to look very different moving forward,” O’Connor says. — AC

There will be more women doctors

Nationally, the percentage of female medical students topped 50 percent in 2019, and women have made up more than half of the UConn School of Medicine for at least the past decade, says its dean, Dr. Bruce T. Liang, interim CEO of UConn Health. 

“We’ve seen more qualified women applicants than men applicants,” he says, which is a primary reason. Women make good doctors, says Liang, a cardiologist, and patients will benefit from more women physicians. “I have learned a lot from my women doctor colleagues. They tend to be more well-rounded with a holistic approach and in listening to patients,” he says. “Gathering [the patient’s] social history becomes so important, and if you miss an element of the social history, that can affect the diagnosis.” 

A study of primary care physicians in the New England Journal of Medicine, published in 2020, showed that women doctors spend 16 percent more time with patients than male doctors.

Having more women doctors will change health care for the better, says Dr. Raman Gill-Meyer, hospitalist-clinician educator in the department of medicine at Norwalk Hospital. Men and women physicians learn from each other, breaking down stereotypical roles, she says. “I think women have some innate traits; they’re empathetic, good listeners and skilled at connecting with patients,” she says. The more comfortable patients are sharing information with their doctors, the better they can be helped by their doctors.

While, historically, women doctors have tended to be obstetricians and gynecologists, pediatricians and primary care physicians, more women are entering specialties dominated by men, such as urology and orthopedics. Nationally, while only 7 percent of orthopedic surgeons attending physicians are women, 14 percent of orthopedic doctors in training are women, says UConn Health’s Dr. Katherine Coyner, an orthopedic surgeon who leads hands-on programs quarterly to introduce girls and young women to medicine and engineering. “They get their hands on drills and saws,” and learn about orthopedic surgery, says Coyner, a former college basketball player with a 1-year-old child.

Women doctors’ lives often mirror their patients’ lives — they may also be raising children and running a household while working, and they understand the stress and challenges of balancing multiple roles. Or, Coyner says, they bring an added level of understanding — such as a mom’s need to run to relieve stress or that shoulder pain may make it difficult for a patient to put on her bra. — TSB

New vaccine tech is on the way

The technology on which Pfizer and Moderna based their COVID vaccines is being used to develop a variety of treatments, and is being hailed by some as the future of medicine.

“I am extremely excited that mRNA technology will expand to many other viruses, including the flu, including combination vaccines,” says Scott Roberts, associate medical director of infection prevention at Yale New Haven Hospital. “They’re even trying mRNA vaccines for RSV, and I’m sure they’ll look at it and HIV and many other viruses.

“I think the opportunities are really endless.”

Respiratory syncytial virus (RSV) is a common respiratory illness that usually causes mild, cold-like symptoms, but it has proven resistant to vaccines. “There’s been a lot of discussion about why vaccines haven’t really worked with the RSV virus,” Roberts says. “Maybe it’s just the virus itself, the way it functions in the human body.” 

But mRNA technology has made that elusive vaccine seem possible. Recent trials achieved over 90 percent efficacy, Roberts says, “something I never would have thought at the beginning of the pandemic.

“I think it really speaks to the value of the technology and the opportunity that these vaccines do lend us.”

Erol Fikrig is employing the technology in a more creative way. “We’ve been using mRNA since 2019, about eight months before the pandemic occurred,” he says.

The Yale School of Medicine researcher had been working on a vaccine for Lyme disease, with only limited success. Then he attended a conference in Ireland where he met Drew Weissman, who Fikrig calls “one of the world’s mRNA vaccine experts.”

Fikrig, with Weissman’s assistance, has developed a way to combat Lyme disease, not by targeting the pathogen, but its delivery system, the deer tick. Deer ticks feed for as much as 48 hours, but the bite is “silent” — it does not itch or hurt — which gives the Lyme bacteria time to go from the tick into the blood. Fikrig’s mRNA-based vaccine makes that tick bite red and itchy, causing the victim to remove the tick before the virus has a chance to migrate.

“We’d been trying the old, traditional protein-based vaccine for quite some time,” Fikrig says. “The mRNA vaccine makes you eliminate all those steps. You don’t need to make the protein; your body makes the protein. So, in terms of discovery, it made things a lot easier for us for sure.” — JF

Surgery will become less of a pain

Technology will make your surgery less invasive, more pain-free and less likely to require a hospital stay, says Dr. Maxwell Laurans, vice president of surgical services at Yale New Haven Hospital. “I think we’re going to see advances in technologies that allow us to do new kinds of surgeries, existing surgeries … more safely” and to move “what are typically considered inpatient surgeries to the ambulatory setting,” he says.

“You now have the ability to put the patient’s imaging up onto a screen.” The image is more reliable and the machine is portable, so it can be used in an outpatient surgical center, Laurans says.

More subtle advances include using TAP (transversus abdominis plane) blocks to numb part of a patient’s body and avoid narcotics such as morphine. Recovering from narcotics is a main reason for an overnight stay. “If you minimize those medications and use these other strategies, now you’re taking an operation that used to take four to six hours, lose half a liter of blood and stay in the hospital four days … make it safer and the patient goes home at the end of the day and recovers at home,” he says.

Nurses will be able to spend more time with patients and less on paperwork with voice-recognition devices that take dictation.

Dr. Nita Ahuja, chair of the Department of Surgery at the Yale School of Medicine and the Yale Medicine board, says you won’t see many technological advances — they’ll be inside you. “We will continue to see innovations in cardiac and vascular surgery with increasingly complex stents, and we will start to adopt more innovative approaches to grafts that look quite different to the ‘open heart’ procedures” we have now, she says.

Advances in shrinking tumors before surgery will make cancer surgery more effective, Ahuja says. She also predicts the use of non-human organ transplants that will “expand our organ supply and further democratize access.”

Your watch and even the blanket keeping you warm will be more high-tech than ever, says Dr. Charles Odonkor, co-director of clinical research at the Wearable Health Lab at the Yale School of Medicine.

“These days you have watches that can monitor heart rate, oxygen-saturation levels” and can send a signal to the doctor if you’re having a seizure, he says. A smart ring can sense vital signs as well, and smart patches can be “wirelessly connected to an app on your phone and can monitor what your sugar levels are,” he says.

Blankets will be able to auto-regulate body temperature, keeping patients warm and sensing where there may be pressure ulcers developing, Odonkor says. “This will be great for patients in nursing homes,” he says.

Smart shirts will send out a signal if you are having an attack of atrial fibrillation. But Odonkor believes accuracy, communication between devices and privacy must be improved. There are still “a lot of false positives” and user errors, and concern that constantly checking a device will increase heart rate. — Ed Stannard

We’ll inch toward preventative care

Insurance plans have historically reimbursed clinicians for treating diseases, ordering tests and prescribing medications when early warning signs appear, not for taking the time to talk to patients about what they can do to reduce the risk of diseases in the first place.

While a full overhaul to prioritize prevention is a long way off, technological advances and medical school training are beginning to shift some patient care toward preventative treatment. In the U.S., a third of all deaths are from heart disease or stroke, according to the U.S. Centers for Disease Control and Prevention. Yet 80 percent of heart attacks and strokes are preventable, says Dr. John Glenn Tiu, a UConn Health cardiologist. 

Blood tests will increasingly be used to spot heart disease and cancer risk and manage it once it’s detected. For example, in addition to the standard lipid panel clinicians order as part of routine annual physicals, if patients have a family history of heart disease or early warning signs, doctors can order a lipoprotein (a) blood test to determine whether the patient is at increased risk for heart-related diseases. 

Although not yet fully FDA approved, the Galleri blood test uses artificial intelligence to check the blood for signs of cancer. It was 63 percent effective at identifying 12 types of cancers — including hard-to-detect cancers such as pancreatic, ovarian and esophageal — at stages 1 to 3, according to a study partially funded by the test’s maker, GRAIL Inc. Doctors can prescribe the $950 test, not covered by insurance, for those with a high risk for cancer.

The U.S. Preventive Services Task Force’s recommendations for when to start standard cancer screenings such as mammograms and colonoscopies now suggest beginning at younger ages, 35 and 45, respectively, while other standard screening tools, such as the EKG, are no longer a routine part of annual physicals, says Dr. Aesha Patel, family medicine physician at New Canaan Primary Care.  Some patients who are overweight and at risk for heart attack, stroke and diabetes can be prescribed medications for weight loss, which can boost the effectiveness of exercise and healthy diet, she says. 

Despite the important role diet plays in preventing many of the biggest killers, medical schools traditionally left nutrition education to dietitians. That’s changing at the UConn School of Medicine, says the school’s dean, Dr. Bruce T. Liang. Medical students are now taught nutritional science and preventative measures such as exercise, physical therapy, access to fresh air and a break from environmental stressors, he says. Based on research in recent decades into introducing preschoolers to healthy lifestyle practices to prevent cardiovascular disease, pediatricians are sharing with parents the link between healthy habits formed in early childhood and later heart health, Tiu says. — TSB