Roughly half of all adults in the U.S. have one or more chronic illnesses, with 25 percent suffering from two or more such conditions.
These people navigate a medical system of widely variable quality, an ever-shifting insurance landscape, and real-world considerations like broken cars, broken marriages, and bad jobs that can shape the patient journey as much as the latest medical discoveries.
Can we get any better at treating chronic illness, particularly when those illnesses become life-threatening? We spoke to some experts in the field on ways to make that happen in 2018 and beyond.
Steering precision oncology toward great safety
Oncology in 2017 resembles the auto industry, circa 1917: great new engines - that, in short order, revealed the need for equally good steering and brakes.
When it comes to cancer treatment, the shiny new engines come in the form of drugs targeted to an individual's genetic profile and immunotherapy.
But a growing number of patients are finding that these drugs can come with their own debilitating side effects, like gastrointestinal distress, autoimmune reactions, and cognitive impairments, among other issues, in some cases derailing treatment.
Will cancer researchers build better safety features for these drugs in 2018?
"I just got back from a panel meeting at the FDA, and they invited me to literally talk with them about the management of diarrhea," said Eric Roeland, an oncologist and palliative care physician and researcher at the University of California, San Diego.
"It just feels like in the oncology world, we've been so much more intolerant of these side effects in other areas," he added. "If this were congestive heart failure or diabetes, we'd never allow for a year of diarrhea, but somehow we're letting it happen in oncology."
With the FDA turning its attention to these side effects, Roeland said, drug makers and physicians will need to follow suit, funding research in this area alongside funding for new cancer treatment discoveries.
"With diarrhea, we're using drugs like tincture of opium, which was discovered by Hippocrates," he said. "We're still using it. That's crazy."
Filling the palliative care workforce pipeline
Medical systems are increasingly turning to palliative care specialists, who are experts in complex symptom management. One problem looms, though: There aren't enough of them.
By some measures, there are at least 11,000 fewer palliative specialists than are needed to care for the current set of patients, and possibly as many as 20,000. As medical systems look to push palliative care further "upstream" - into clinics and in patients' homes, before they arrive in hospitals - the shortage will be felt even more keenly.
Dr. Diane Meier, one of the pioneers of palliative medicine and co-founder of the Center to Advance Palliative Care, identified three areas where the industry should concentrate in the coming year to build palliative care capacity.
First, she said, increase funding for graduate medical education training slots for palliative clinicians, to bolster the ranks of specialists. Second, require medical and nursing schools to provide palliative training, or risk losing accreditation. Third, encourage more training for mid-career doctors who want to strengthen their palliative care skills.
Will it happen? "All we're doing right now is cutting budgets for everything," she said. "This requires a commitment to spend money on the workforce for the future, which is ... hard to be optimistic about it."
One ray of hope: The Palliative Care and Hospice Education and Training Act, which was introduced in March and would require the Department of Health and Human Services to support training and research for these medical specialties, attracted early bipartisan support.
"For one reason or another it didn't get hooked into any of the bills that were moving this year," Meier said. "So I hope it will next year."
Breaking hospice out of the six-months-or-less box
With studies showing that palliative care and hospice care can actually result in longer lifespans than aggressive end-of-life care, clinicians and researchers have pushed to have these services offered earlier in a patient's illness, instead of in the final weeks.
One huge hitch remains: Who will pay for it?
Medicare, which could be targeted for future cuts, pays for most hospice care.
Edo Banach, the chief executive of the National Hospice and Palliative Care Organization, understands the fiscal realities, but sees a path where 2018 could show an expansion of hospice and palliative services: namely, as a way to help health care organizations save money on seriously ill patients.
Banach said that patients who receive supportive services like spiritual care and social work visits tend to spend their last days at home instead of in the intensive care unit, thereby lowering the financial burden on patients and the health care system. Medicare only pays for such services through the so-called "hospice benefit" only when patients are in their final six months, but some insurers are offering their own hospice and palliative care benefits to patients earlier, because it can save money.
Banach cited Blue Cross Blue Shield of California as one of the more aggressive insurers in this respect, and said that as he enters his first full year at the helm of NHPCO, he will work with more private insurers to follow suit, as well as companies that manage insurance on Medicare's behalf.
"There's been so much discussion about care coordination, care management, non-medical supports and services, interdisciplinary care, person-centered care, all these buzzwords have been tossed around for people who have more than six months to live," Banach said.
"You sit around listen to some whippersnapper from McKinsey talk about getting these things into health care and I'm like, 'Wait a minute. Have you ever heard of hospice?'"