With sponsorship from the Kresge Foundation, the Institute for Alternative Futures recently created four scenarios — coherent stories describing alternative futures — to show what primary care might look like in 2025:

Scenario 1: Many needs, many models. Today's situation will remain more or less intact. There will be a shortage of primary care physicians, increased emphasis on disease prevention, growth in electronic medical record keeping, a shift from employee-based insurance to health insurance exchanges, and growing disparities in access to and quality of care based on income and region.

Scenario 2: Lost decade, lost health. There will be a shortage of primary care physicians, declining income for practicing physicians, and more uninsured patients, some of whom will resort to black market care and unreliable online advice. Patients with good insurance will have access to great care enhanced by advanced technology.

Scenario 3: Primary care that works for all. Americans will enjoy nearly universal health care coverage, with 85 percent of patients using integrated systems staffed by collaborative teams of health care providers, including physician assistants, nurse practitioners and health coaches who work closely with patients. Seeking to provide better care at lower cost while improving the health of the population they serve, primary care teams work with community partners to address factors that affect health, including employment, education, housing, transportation, and access to fruits and vegetables.

Scenario 4: I am my own medical home. Four of every 10 patients will opt for consumer-directed health plans, which include catastrophic insurance with high deductibles. For the most part, savvy consumers will use advanced technologies, including noninvasive biomonitors and wellness and disease management apps, to stay healthy. Large vendors will offer free avatar-based health coaching to consumers who purchase other integrated health products and services. Consumers shop for the best doctor and buy on the basis of quality and price.

These scenarios take into consideration economic challenges and political polarization, as well as technological advances and new delivery systems. To some extent, perhaps, the technological factors could ameliorate the impacts of economic and political upheaval and uncertainty. After all, despite the economic and political upheaval during the current recession, there has been no noticeable slowdown in the advance of technology or the health of the companies that make it.

In February, "PBS NewsHour" featured the scenarios on its website and conducted a poll of visitors. The audience was pessimistic, giving scenario 2 — lost decade, lost health — a 70 percent likelihood of turning out to be correct, and scenario 1 — many needs, many models — a 60 percent likelihood. Scenarios 3 and 4 were 53 percent and 44 percent likely, respectively. In terms of which scenario they would prefer to happen, 23 percent chose Scenario 1; 14 percent, Scenario 2; 37 percent, Scenario 3; and 26 percent, Scenario 4.

There are some key differences among the scenarios — including payment, the nature of the primary care team, the capacity and use of digital health coaches, and whether the patient-centered medical home or the community-centered health home will become the dominant focus.

The Impact of Technology

Health technology plays a key role in all scenarios. In Scenario 2, it is poorly distributed, while in Scenarios 3 and 4, significant advances are widely available. The key technologies are the electronic medical record and its associated technologies, such as biomonitoring systems and genomic tests and scans, and health avatars — artificial intelligence representations of clinicians that are able to supply decision support at the patient level.

There can be little doubt that some technologies will be accessible to nearly everyone under any of the four scenarios. We would venture to suggest that IBM's Dr. Watson is perhaps the lead contender for the avatar role, but Apple's iPhone app Siri and True Knowledge's iPhone/Android app Evi also would seem to have potential to compete with Dr. Watson within a relatively short time, perhaps no more than a year or two and certainly well before 2025, and at little or no cost to the patient.

Nevertheless, there are some technologies that might be limited (in terms of access) by economics (and politics). They include "mainframe medicine" technologies such as enormously expensive proton beam therapy machines and the personalized drugs that accompany the growth of genomic medicine but whose costs, under the present pharmaceutical industry business model, could be prohibitive for all but the very rich. Ultimately, nearly every drug will be an "orphan" drug — one developed specifically for some rare medical condition — because in personalized medicine, every patient's condition is unique.

Scenarios as Tools

The primary care 2025 scenarios identify expected, challenging and visionary paths for U.S. primary care. The scenarios can become a living tool by allowing organizations to see if their current strategies will be effective in the different scenarios. Using these scenarios can help leaders and their organizations more effectively adapt to the changing environment. An approach to using these scenarios in a workshop, including specific instructions and worksheets, is available on the project website at http://www.altfutures.org/primarycare2025.

But it is important to remember that future studies have to be as dynamic as the future they seek to predict. As futurists, we remain committed to revise and extend the scenarios as the actual future unfolds.

Clement Bezold, Ph.D., is the chairman and senior futurist of the Institute for Alternative Futures. A major developer of foresight techniques, Bezold applies futures research and strategic planning methods in studies for Fortune 500 companies and national and international health organizations. He writes and speaks frequently about health futures issues.

David Ellis is a futurist, author, consultant and publisher of Health Futures Digest, a monthly online discursive digest of news and commentary on long-range, leading-edge technological innovations and their consequences and implications for health care policy and practice. Ellis is also a regular contributor to H&HN Daily and a member of Speakers Express.