Health Forecast ’93 : What the Doctor May Order

It’s a simple truth that medicine gets better every year: Discoveries are made. Treatments are refined. Research goes on.

But as discoveries have multiplied, the pool of Americans able to take advantage of them has decreased. Fewer people can afford basic health care.

In 1993, more people should have access to health care as reforms are ushered in under the Clinton Administration. Greater access will be the big health news this year, experts say. But there is much more to watch for. Here’s a look ahead:

* For several reasons, 1993 will be the year of the prostate. The prostate specific antigen test, a blood test that can indicate the presence of cancer, is expected to see wider use and to make more men willing to be screened. The test is more accurate and less invasive than a rectal examination and can detect the cancer at an earlier stage.

The debate over prostate cancer treatment will even out as consensus is reached on when to recommend surgery, radiation, chemotherapy or other hormonal treatments. At the same time, advances in understanding prostate cancer will surface, including indications that the disease is caused by hormones. Hopes are placed on the drug Proscar.

High-profile spokesmen, such as Sen. Bob Dole (R-Kan.), will lobby for increased research for prostate cancer much in the manner that women have lobbied for breast cancer research.

Prostate cancer centers, like breast centers, will appear. Many hospitals or clinics that don’t have prostate cancer support groups will start them.

* The good news in the fight against infectious diseases will be the explosion in the field of immunizations. Expect the long-awaited vaccine for chicken pox, the varicella zoster vaccine, to be approved. In addition, combination vaccines will become more common--such as doses of DTP (diphtheria, tetanus, pertussis), haemophilus Type B (which causes meningitis) and, possibly, influenza in one shot.

On the research front, scientists are working on vaccines for middle-ear infection, several sexually transmitted diseases, a type of pneumonia, respiratory syncytial virus and rotavirus (which causes gastroenteritis in children).

* In 1993 and beyond, we’ll see many new screening tests and treatments based on genetics, because the Human Genome project, a decades-long effort to map human genetic structure, is ahead of schedule.

For example, a prenatal screening test for cystic fibrosis is available on a limited basis, and the government may recommend that it be offered to all pregnant women. It’s also likely that the first gene therapy experiments for cystic fibrosis will begin early this year; three groups have received approval for such therapy.

Advances in molecular sciences also will lead to a prenatal screening test for all hereditary diseases: a simple blood test that analyzes the small quantities of fetal blood cells in the mother’s bloodstream. This test will become available in the next two or three years.

* Scientific advances in prevention will be small but significant. For example, a recent study showed that by analyzing the breast tissue characteristics of normal mammograms, radiologists might be able to predict a woman’s risk. Thus, preventive recommendations now issued for the population as a whole can be individualized.

“If we can predict future risk . . . we could then recommend more frequent mammography or other medical examinations for this high-risk group,” says Dr. Martin J. Yaffee of the University of Toronto, who helped develop the risk assessment.

* After a year of focusing on the major killers of women, such as breast cancer and heart disease, the research spotlight will shift to often-ignored chronic, painful women’s diseases, including interstitial cystitis, endometriosis and fibroid tumors.

* Mental health providers will turn activist in 1993, and a unified effort will be made by providers and consumer organizations to push for mental health benefits in all health plans.

Group therapy, which began in the 1940s to help soldiers adjust to postwar life, will re-emerge as a means to lower the costs of mental health therapy. The practice boomed in the late 1960s and is still popular in inpatient hospital treatment but has dwindled elsewhere. Experts will explore ways to revive group therapy in other settings.

Employers will opt for managed-care plans for mental health coverage that emphasize group therapy and favor therapists who can provide effective short-term therapy.

* Advances in contraceptives will include a new, flexible IUD and a radical, ultra-thin condom.

* Officials will strongly emphasize the prevention of injuries, especially in the workplace. Injuries are a major cause of the nation’s astronomical health care bill.

A total of 6.3 million occupational illnesses and injuries occurred in 1991, resulting in the highest number of lost workdays ever--60 million. These statistics have prompted an outcry for a stronger federal Occupational Safety and Health Act, and legislation to strengthen OSHA will surface this month in Washington.

* Health officials are concerned that Americans are setting themselves up for outbreaks of one or more highly contagious infectious diseases because of several factors: 1) lax surveillance; 2) worldwide outbreaks of diseases like malaria and polio; 3) large numbers of people who do not receive basic immunizations.

The Institute of Medicine, a prestigious panel that advises the government, recently reported that an “era of complacency is one of the main reasons microbial threats seem to be on the rise.”

Diseases such as malaria and polio are unlikely in the United States. But officials have warned of the possibility of a massive influenza epidemic like the one that killed 20 million people worldwide in 1918-19.

* The return of tuberculosis to frightening proportions is a signal that infectious diseases remain a threat. Look for the continued rise of TB cases to provoke intense debate for stronger preventive measures. The debate will surface on whether mandatory quarantine may be a needed last resort for patients who either won’t or can’t take TB medication.

* An anti-arthritic drug, naproxen, could move from prescription to over-the-counter (OTC) status, while government officials scrutinize whether to make other medications over-the-counter in the next several years. Included in the latter group will be non-sedating antihistamines, ulcer drugs like Tagamet, tobacco deterrents and drugs to control blood pressure and lower cholesterol.

A drug to curb craving in alcoholics, called naltrexone, will soon become widely used, and other drugs to curb addictions will become available later in the decade.

The first drug specifically approved for treatment of wrinkles, a form of Retin-A with moisturizer called Renova, will be approved for prescription use.

* New medical specialties for adolescents and women will emerge. Adolescent health will surface as a strong sub-specialty while doctors review guidelines on treating teen-agers. These guidelines suggest that adolescents have an annual preventive visit that focuses on traditional medical factors as well as diet, fitness, safety, alcohol and drug use, sexual behavior, depression or suicide risk, learning problems and potential physical or sexual abuse.

Because of lifestyle factors such as drug abuse and sexual activity, “teens are not as healthy today as they were a decade ago,” says Dr. Arthur Elster, director of the American Medical Assn.’s Department of Adolescent Health. “It’s clear that we need a new and expanded approach.”

Meanwhile, specialists in women’s health will provide more than obstetrics and gynecological care, also focusing on addictions, diet, fitness, spousal abuse and other lifestyle and social issues.

* Acupuncture will be the first of the alternative health practices to move more deeply into mainstream medicine as several studies show its effectiveness for the treatment of chronic pain, drug addiction, nausea and allergies.

* Research on the “abortion pill,” RU-486, as well as on fetal tissue will resume in the United States, although under tight controls. The hot areas of research will be the use of RU-486 for treatment of benign meningiomas (tumors that line the brain and spinal cord) while fetal tissue research shows promise for treatment of Parkinson’s disease.

* Expect to see nurse practitioners taking over more day-to-day care of patients, particularly because of a critical shortage of general physicians.

* Perhaps the biggest developments in health care this year, however, will be in economics.

In electing Bill Clinton to the presidency, voters backed the concept of a new system of health care that would include all Americans.

But many experts suggest that Clinton’s restructuring of health care, at least in the first year or two, will be modest, focusing on reducing costs and ensuring that everyone receives minimum care.

“It’s clear that there will be some kind of health reform in 1993. The question for me is how visionary that will be,” says Clement Bezold, executive director of the Institute for Alternative Futures, an Alexandria, Va., think tank for health issues. “We need access to health care for the uninsured. But we also need to reinvent the health care system. There is a lot of talk about the first, but not a lot of talk about the second. The first will dominate the headlines.”

Overall, it is hoped that most people will have, at the least, a basic health benefits package coming from a variety of funding sources, such as government and employers. But the more visionary changes will take longer. Eventually, access to preventive care will be a larger part of the picture. The “predict-and-manage” approach--to identify risks and prevent or minimize the effects of illness, rather than the treatment of acute disease--will increasingly become the focus of health plans.

Americans will notice other, subtle shifts in health care. Employers will focus more on managed-care health plans for their employees, forcing more people to give up longtime doctors and find new ones.

Because of the growth in managed care, physician hospital organizations--where doctors and hospitals market their services together--will continue to appear. Increasingly, large group practices will buy out smaller groups or merge, making solo practice rare.

Billing procedures will be simplified to save administrative costs, perhaps including combining many services in a unified bill.

* Learn this term: outcome data, which will be a watchword for health care in the ‘90s. Using the data involves compiling statistics that will tell consumers, insurers, government and doctors how well certain treatments work and at what costs. When, for example, a proposed National Outcomes Database is established, doctors would list each treatment and how the patient fared, then would use the database to make treatment decisions. Thus, they will refer more to guidelines in treating patients rather than relying on instinct.

Says Bezold: “In the ‘90s, we’ll have the ability to compare our physician with all the other physicians in town.”

The Good News in ’92

* Coverage: Americans make health-care coverage a top issue in the elections.

* Women: Consumers see a surge of interest and funding on women’s health issues.

* Prostate cancer screening: A protein called prostate specific antigen proves to be the best indicator of prostate cancer and becomes widely available.

* Food labeling: The government approves a labeling plan to clarify nutrition information on a majority of food products.

* Cystic fibrosis: Rapid progress is made in prenatal screening of CF and in treatment of the disease.

The Bad News in ’92

* AIDS: HIV-infection rates continue to soar. Research funding is inadequate. Fear remains, as when NBA players overreact to playing with Magic Johnson.

* Fetal tissue research: President Bush vetoes bill to lift the ban on fetal tissue research, which has shown promise in treating Parkinson’s disease.

* Bad doctors: In one of California’s worst cases of alleged patient abuse, gynecologist Ivan C. Namihas of Tustin was accused of abusing dozens of women over decades. Namihas gave up his practice.

* Tuberculosis: The disease that was once almost eradicated soars.

Too Soon to Tell

* Breast implants: Was the FDA’s ban on silicone breast implants prudent?

* Tamoxifen: Is the study on whether tamoxifen can prevent breast cancer in healthy women promising and visionary, or dangerous and misguided?

* Clinton: Will the President-elect make good on his pledge to provide health care to all Americans?

* Coffee: One study shows even a couple of cups may increase heart disease risk. The study is the latest in a long line of contradictions on the health risks of America’s favorite beverage.

* Euthanasia: Americans favor the principle, but can’t agree on the specifics.