The above links will take you to the Center for the Health Professions
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There are five interrelated drivers that will shape most of health care over the next decade and a half. The first and most overwhelming factor will be the current cost of care. At greater than 16% of the nation's total productive effort, the US approach to organizing and delivering health care services is the most expensive in the world in the aggregate and per person. It amounts to about two trillion dollars, making it the seventh largest economic undertaking on the face of the globe. For most of the past forty years it has risen in costs two to three times faster than other expenditures and currently shows no real hope of abatement. Health care already accounts for the largest share of the public budget and the Medicare Part A trust fund has only about ten years of funding remaining. On the private side, corporations - once considered the backbone of the employer based health insurance system - are abandoning the perk and its run away costs. More than ever, employees fear assuming direct responsibility for their health care costs; a fear that often leaves people in jobs they don't want or flirting with financial disaster without proper protection. These out-of-control costs, embedded in the annual budget cycle, are large enough to make the both the costs of the Iraq war (with total estimates at three trillion dollars) and the projected cost of the sub-prime mortgage fiasco pale by comparison. The second driver is demographic and there are three dimensions that will be important for the next decade and a half. The first is the aging of the population. As more Baby Boomers hit 65 they will place increasing levels of demand for clinical services and financial stress on the health care system. The good news is that the US is aging at a slower rate than most of the nations we will compete with internationally. But every one of those nations has already developed a way to bring every one of their citizens into a health care payment plan and they use that form of control to direct the overall performance of this sector. As just described, the profligate nature of the US system will make it more difficult for our nation to deliver the best care at a price the nation can afford. The spiraling, out-of-control costs of health care are mostly accounted for by the Baby Boom generation, which seems to have done its level best to indebt the two generations following it. This is beginning to create a generational conflict that can only grow. Increasing diversity is the second demographic dimension that will affect our health care systems over the next decade and a half. As our population ages it is also diversifying and it is doing so at a rate that has not been seen since the forty years before and after the beginning of the twentieth century. This transformation is already challenging health care to provide culturally competent care and to ensure that health disparities are not a function of ethnicity. The third demographic trend, which many people overlook, is simply population growth. Between 2000 and 2025 the US is projected to grow by almost 20%. This is already generating a growing demand for new capacity from hospital beds to new providers. Some new capacity undoubtedly is needed, but it would be a great mistake to merely replicate the exact types of health care facilities and professionals we have today, with the future performance of our health care system so much in question. The third driver is the shift in the disease burden of the nation. This is, in fact, a well known story of the dramatic one hundred year change from a population in which mortality was most likely to result from a single disorder such as an acute infection in an otherwise healthy person, to one in which death might be due to a final, opportunistic infection following an extended bout with chronic disease and disability. The tale of this shift is one of the great stories of the efficacy of public health, the increase in upward social mobility, and of course advances in traditional medicine. The average lifespan of the US population is now about 35 years longer than it was one hundred years ago, thus creating greater opportunities for chronic diseases to emerge. This increase in risk of chronic disease will be multiplied by the size of the aging Baby Boom generation. But all of this is known. While population level health care needs have changed, the real driver is that the US health care system is still designed to diagnosis and treat acute care needs rather than to prevent and manage chronic care needs. This mismatch of supply and demand plays no small role in the increasing costs and dysfunctions of the health care system in the US. Some examples of this mismatch exist today; for example, hospital and physician complaints about the shift to greater use of pharmaceutical interventions. But if there are drugs to effectively manage a condition without surgery or the continuous intervention of professionals, shouldn't we encourage such a trade-off? The misalignment of the financing system, which still supports the old epidemiologic reality, is just one problem that must be fixed. There are also challenges involving what types of professionals will be needed to meet future health care needs, what skills they will need, and what the best means are of regulating their practices. Legacy institutions such as hospitals will also be at risk as this driver finds its full head of steam in the near future. The fourth driver has already reshaped most of our society and economy over the past twenty years: technology. As advances in information technology have penetrated health care, they have made substantial changes in administrative functions, and to a lesser extent, have changed clinical care. These change processes will continue, along with a third and most revolutionary change: the redistribution of knowledge from the experts directly to consumer-patients. This movement will take on greater speed over the next few years as information technology merges with biomedical technology to produce care management technology. With these tools patients and their families will be more directly connected to the specialized knowledge of health care, which has for all of remembered time been mediated by professionals. The future will see a growing erosion of this monopoly, and as the system is held accountable for new demands technology will evolve new ways to organize, deliver, evaluate and use the specialized knowledge that is at the core of health care. Today technology is primarily used to speed up the traditional practice model or move it to a new location; for example, by placing a cardiologist at the end of a telemedicine hook-up in a rural setting that is experiencing a shortage of health care professionals. These changes are fine as far as they go, but the real power of care management technology is its ability to place a set of tools in the hands of individuals, families and communities who will use the tools to actively prevent the onset of chronic diseases, and to manage these diseases when they become symptomatic. There are many possible drivers that could occupy the final slot among my five. Certainly there is a case to be made for quality and access as two important drivers. However, I believe that the most robust inspiration for the changes that are needed will come from health care consumers. As costs increase and desired services are less likely to be covered by payers both public and private, individual consumers and new types of purchasing groups will emerge to express their demands in the market. They will submit to fewer of the restrictions found in the old system. They will look at quality as best they can judge it, as well as convenience, price, satisfaction with services, and a host of other qualities. These factors will influence their decisions to purchase everything from a strep test at a big box health kiosk to a hip replacement by a US trained and board certified surgeon in Costa Rica. Little of what the health care system holds as "sacred" in today's system, from the doctor-patient relationship to the model of primary care, will escape being tested by the comparative scrutiny of the market. Not that all health services will leave their traditional roosts and move to new organizational types, or be provided on an international market. Some will, but regardless, all providers of health services will need to ask this critical question about their services: what is the comparative value of my services in terms of quality, price, convenience and customer experience? I believe that over the next decade and a half, these will be the most
important drivers determining the strategic success of individual practices,
professions, schools, hospitals, and other health care organizations and
businesses. Understanding one's relationship will be of considerable importance
in determining the best strategy for adapting to the new health care system.
Those actors in the system who ignore these drivers will do so at their
own peril.
To e-mail Ed O'Neil, please click here. |
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Last month's From the Director introduced the first of several
pieces I have planned on how various parts of the US health care system
must respond to the challenges and opportunities which now confront it.
I had planned to discuss hospitals this month, followed by other disciplines
and sectors. But many readers of last month's essay have e-mailed, requesting
more details on the drivers of change and how strategic responses must
be driven by the changes themselves. Let me address the drivers first
and then return to how professions and institutions can utilize these
trends not just to survive, but to truly thrive in the years ahead.