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positive prognosis

nanoterminators that destroy cancer at its root, prosthetics controlled by our brains,

personalized drugs and high-tech house calls will transform how we heal and stay well .

B y E d w a r d M a r t I n

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.

2026

The Future of North CarolinaHEALTH CARE

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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 direc-tor 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 individ-ual’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 Greens-boro-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 symp-toms. “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 technol-ogy 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 uni-versal 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 prepar-ing 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 essen-tially 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 de-livered. The state’s 130-plus hospitals will remain pivotal, though their roles will dif-fer. A scenario might start with a grinding automobile accident.

Scientists at the WakeForest Institute forregenerative Medicineare developing lab-grown reproductive organs and tissues to enable soldierswith devastating pelvicwounds to procreate.

55F e b r u a r y 2 0 1 6

“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 am-bulance, the wreck victim will have become part of another 2026 medical phenomenon. Hospitals will be pushed by insurers, regula-tors, 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, includ-ing for mental-health concerns, says John San-topietro, the hospital’s chief behavioral health officer. “This will make treatment more acces-sible and convenient for patients, and most importantly, we will reach them upstream, be-fore 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 con-solidation in North Carolina health care will accelerate. By 2026, most of the state’s 11 mil-lion residents will be served by no more than five health care systems, about half the pres-ent number. Each will be an infinitely more powerful umbrella incorporating the major-ity of physicians and clinics in sometimes overlapping regions. Cone Health, Akin says, already has 1,000 doctors in its Triad Health-Care 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 dramati-cally. 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 main-ly 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

some other potential dramatic advances:

• Gene therapy will be used to prevent diseases such as diabetes, cystic fibrosis, Down syndrome and sickle cell anemia.

• Scalpels will be out — robots, lasers and other noninvasive technology will take their place.

• Amputees will control prosthetic limbs with their minds.

• Cancer cases may increase as people live longer, while new drugs and treatments could enable four out of five sufferers to survive five years or longer.

• Dementia diseases may be cured. At minimum, genetic mutations that cause Alzheimer’s will be unraveled to permit better treatment and delay onset.

• Cryopreservation may be possible, most likely to save severed limbs or tissues.

In the future, biodegrad-able liquid-metal “terminators” may carry drugs that target and eliminate cancer cells. research-ers at uNC Chapel Hill and N.C. State university created these nanoterminators by placing bulk liquid metal into a solution that is hit with ultrasound, which forces the liquid metal to burst into

nanoscale droplets. The droplets soak up cancer drug Dox and attach themselves to cancer cells. Like the fictional Terminator, nanotermi-nators can transform. Smashed from bulk ma-terial, they are fused in-side cancer cells where they are degraded and filtered out of the body. Scientists plan a large animal study as they get closer to potential clinical trials.

Medicine in the next decade

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Attacking cancer, using nanotechnology to deliver drugs

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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 hos-pital 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 antibi-otic apocalypse, in which pathogens evolve to defeat all treatments. In 2015, more than 23,000 patients nationwide died from untreatable in-fections, 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 consolida-tion 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 concen-tration 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.

who will pay for all those medical advances?One dollar in 10 spent on tests, drugs, doctors and

other health care expenses was once viewed as a doomsday economic scenario. “We thought more than that would be impossible to afford,” says Jonathan Oberlander, a UNC Chapel Hill professor who wrote a 2003 book on the Medi-care senior-insurance program. Health care spending has risen to 17.4% of GDP and is headed to about 20% by 2026, federal forecasters say. Evidence of health care boom times is shown in hospital expansions around the state, greater access to care for low-income citizens because of federal reforms and steady increases in health care wages and medical-equipment costs. But how will North Carolinians pay for all this care, especially as longevity increases?

It is a near certainty that consumers will pay more — and employers less — of the $80 billion in annual N.C. health care spending. Employer-sponsored plans now cover about half of those under age 65, down from more than 80% in the 1980s. High-deductible policies and more health savings plans are already taking hold. Hopes for lower insurance costs in 2026 hinge on better prevention of illness and other efficiencies such as virtual care and telemedicine, but it’s likely consumers will bear more of the financial burden.

Key aspects of the the Affordable Healthcare Act will survive regardless of the outcome of the 2016 presidential election, the professor says. The big hope is that health care inflation will remain at or below the 4% annual range of re-cent years, a big improvement over the 9% average increase for the 30 years before the 2007-09 recession.

“All over the state, [big health systems] are in a struggle with insurers,” Oberlander says, a key factor explain-ing why big hospital systems are gobbling up smaller peers. “The more market power hospitals have, the more leverage they have in negotiations.” Consolidation helps restrain costs, but opponents say less competition among health systems reduces pressure to hold down costs.

One key change may involve “value pricing,” in which hospitals are penalized for readmissions, hospital-induced infections and other breaches. Medicine has been one of the few endeavors in which mistakes were rewarded: If an er-ror causes a patient to return, the hospital collects a second time. That may change.

“Clearly health care is becoming unaffordable,” says Susan Jackson of Blue Cross and Blue Shield of North Carolina. “Increased value to the patient is an equation of quality and cost, not just cost.”

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Though doctors might miss their inde-pendence, 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 com-pensation 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 residen-cies, doctors will be joining the front lines in 2026 armed with universal electronic medical-records portability and other improved tech-nologies. 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.”

By Beverly Perdue, N.C. governor, 2009-12

The driverless car pulls up to the office or front door, air condi-tioned or heated at the click of a smartphone. At home, the temperature adjusts when the kids arrive from school. This is not the future. It is today, and some of that technology is being designed and built right here in North Carolina.

It is not enough to merely imagine what North Carolina will look like in 2026; we need to start today working toward the North Carolina we want. To take its deserved place as a top leader in national and global affairs, it must provide:

• Access to a quality education to all students.• Workers with the training and skills to meet the demands of the most innovative employers.• Communications and energy infrastructure and resources that are reliable and competitively priced.• An environment that sustains and supports growth with clean air and water.

Drones delivering meals personalized to each individual’s unique nutritional needs; finance conducted remotely without cash and in cur-rencies making bitcoin seem old-fashioned. Robotic bartenders, DMV bureaucrats and sales clerks capable of responding to voice commands. These aren’t unreasonable expectations when futurists say we will lose 60% of our service workers to technology in the next 10 years. If North Carolina is going to be a leader, it needs to move toward these goals today.

Teachers, from preschool to postgraduate, need to be the best of the best — better trained and compensated. We aren’t going to provide an innovative and adaptable workforce without the best instructors. We need to embrace new technologies that will provide the best instruc-tion, no matter the subject area, to every student in North Carolina, no matter where they live.

I imagine that by 2026, North Carolina’s business and civic leaders will heed a call to action to provide — and pay for — schools that will be the envy of the nation, not nestled darkly at the bottom of every national ranking. Our workers, no matter the category, will be among the best compensated. Technical innovation will be commonplace.

Our state’s history makes it the proud birthplace of race cars, Pepsi and the first public university. By preparing for the future today, North Carolina in 2026 will be the birthplace of innovations and technologies to make our lives better, our economy strong and reverberate around the world.

Voices for the future