Seven Tensions Driving Health Care's Future

The November/December issue of the journal Health Affairs contains a number of articles about the current health care challenges and where we might be headed next. What seems to be missing is an overarching driver to direct us to the future. Are we moving to a more government-controlled system or will it be more driven by the consumer? Will individual professional groups stretch their independence or will teams become the fashion? Will the system continue to grow or will the necessity for controlling cost finally limit its size and determine its shape? Will technology solve all of the problems or will it generate a cost basis, which will eventually sink the system?

Obviously these are complex questions and probably, for the most part, unanswerable at a particular level of specificity. But, as we design educational programs, delivery structures and systems and craft private and public policies it will be important to know, with some level of precision, the general direction and shape of the health care system of the future. Here are seven trends, which I offer as sets of tensions. The first part of each pair is more or less where the health system has been and the second is where it seems, from my perspective, to be moving. The forces behind each of these are complex and may interact with one another. Collectively these trends will create the backdrop for strategic success whether the perspective is a small clinic setting, large public hospital, health plan, professional school or public agency. Successful leaders will be those that grasp the meaning of these tensions for their organization and translate them into effective strategies over the next decade.

From Passive Consumer to Engaged Consumer

Over the past fifty years the American health care consumer has become a passive participant, whether shopping for price, assessing quality, demanding accessibility that is consumer- responsive, or proactively taking care of his or her own health through diet to exercise. Not everyone will change in the same way at the same time, but a number of trends point to the creation of a more engaged, less passive consumer. First, the cost of care will inevitably push many consumers to become aware of costs first, which will lead them to shop for bargains. As employers step away from their historical commitment to underwriting insurance costs, this transformation will accelerate. In turn, this may mean trips to Canada for drugs or Mexico for surgery, but it will also mean more critical assessment of health plans and their offerings, patterns of use of providers, and more interest in self-care and prevention. There is a new and growing set of alternative providers from Target to the Virgin Corporation who will offer new services to join the host of other non-traditional providers from acupuncture to message therapy.

Consumers will also be more engaged as they are able to access reliable information on the quality and performance of physicians, medical groups, hospitals, and health plans. The availability of such information is mixed across the various segments of the health system and geography, but it gets better with each passing year. Not everyone uses Consumer Reports as a guide when they make a purchase, so many consumers may never become as engaged as would be optimal. Today consumer engagement is the exception in health care and so, for many, the attraction to become more involved is just not there. As alternatives emerge, offerings become more individualized, and costs become more variable, more people will choose to the route of engagement and derive the benefits associated with relating to health care in a different manner.

From Profession Driven to Consumer Driven

As consumers become more engaged they will find themselves inevitably in competition with professionals as to who is running the show. Professionals are conflicted on this front; many want an active and involved consumer in all dimensions of prevention, diagnosis, and treatment. Many of the ills of the current health system stem from this disconnect. However, an awakened consumer will also be a demanding consumer and many of the demands will strike the professional as irrational or just plain wrong. We don't have to go any further than the angst that most health professionals express over a patient's use of the Internet to inform them about their visit to the clinic.

It will take time for professionals of all stripes, from those that see patients in the exam room to those that run the hospital, administer public health efforts, or design insurance plans, to listen to their customers, give up their positions of power and move to develop ways of practice that are built around consumer demands, needs, and preferences.

It is difficult for those inside the system, the incumbents, to truly see just how the current arrangements function to serve their interests and needs. In part, this deception comes about because this orientation is mingled throughout with a deep commitment to serving others. However, those adopters that do involve and engage the consumer in a fierce fashion will increasingly benefit by having their market share grow, their consumers engaged in the organization and delivery of health, and their services carefully focused on what is beneficial and is perceived to be beneficial.

From Disaggregated Professionals to Aligned Work

The silos of professional work define much of what happens in health care and a lot of this is good. The sub-specialization of knowledge is the hallmark of the progress that marked the advance of the last century. However, many of these patterns from the past keep health work from being aligned to serve a shared set of outcomes for the system, the groups within it, and the individual patients.

For all of the rhetoric about teamwork in the health professions, most work is fractiously divided. The lack of a common conceptual framework for care and service, the inability to communicate clearly across professional lines, and the continued issues of power and responsibility keep even well intentioned professionals from moving to address this concern.

The principal challenge to address is to create new ways to value both the reductionism of specialized knowledge, which produces so much that is positive in health care, and the synthetic qualities, which are brought together in the best of generalist's perspectives; a value which is too often missing from health care today. The kind of radical focus on the customer described in the first two tensions will help move this forward, but it is an area which demands attention across the professions. On the research front it will help to broaden the range of considerations of outcomes of well-being. Education will not likely bring about this change on its own by pushing for more interdisciplinary or team training, but it can partner with those that are developing such integrated approaches and build future orientated programs of education that can serve such integrated environments.

One of the most critical challenges in realigning the health care system will be the task of remaking practice models, which expand access, use resources wisely and build innovative ways to improve quality. This will need to be accomplished in ways that bring the professions, labor unions, and management together in new ways to focus on these outcomes. This will require sustained leadership across each of these institutions.

From Technology as Cost Driver to Cost Saver

Technology has been one of the biggest drivers in cost of health care over the past fifty years. By some measures, it accounts for over half of all cost increases. It is not just the direct cost of technology, but with improvements through innovation, there is a growing demand by consumers and an obligation by providers to deploy new, safe technologies, even when the overall impact is not fully understood. As consumers and providers are generally removed from the impact of costs, there is little reason not to use what new tools are available. This, coupled with the anxiety of malpractice suits, has created a tyranny of the standard of care, which endlessly elevates the use of new or at least different technology driving costs up. As costs increase, there will be someone's bottom line that benefits. This is a curious development since, in most other parts of the economy, newer and wider use of technology usually means lower costs, more services, and a higher quality of what is offered.

To achieve some savings from technology, some push from the first three tensions will be required. Consumers will need to feel some reason to demand less expensive care, which will, in part, be mediated by technology, and there will need to be some sort of aligned system with goals that combine strategies related to costs, access, and quality that lead to a competitive position in a local market. Once that scaffolding is built, technology can come fully into play to assist in the reorganization of services. Consumers have an incentive to get and use information online. Practices have an incentive to attract new patients to scheduling and information services because it makes them more active, saves time and money, and provides an opportunity to introduce other non-visit interactions. By deploying new ways to manage chronic conditions, health plans attract a more engaged and active population and provide them with tools to do more themselves and stay healthie.

Labor costs account for 60-70 percent of all health care costs. Any significant effort to decrease costs will need to use technology as a substitute for some of this labor. The good news is that such substitution can also expand access and improve quality if done in the right way. As bio-medical technologies morph with information and communication technologies in the emergent field of care management technology over the next decade, there will more and more tools with which to make these substitutions.

From Acute Treatment to Chronic Prevention and Management

As people live longer and the population ages, this trend has been anticipated for over two decades. However, much of the delivery capacity of the existing system remains orientated toward the delivery of acute care services. That which is aligned to serve a population with growing chronic service and care needs is generally concerned with acute manifestation of chronic disability, not its prevention or management. Clearly active and engaged consumers, particularly those with widespread access to new types of services offered through new technology channels, overseen by professionals who collaborate in new and different ways, will go a long way toward giving this movement a boost. Still, there are other essential steps.

More than any of the other of tensions, this one will be thwarted by poorly aligned financial incentives. Public budgets, which are most at risk as the population ages, should have the most incentives to explore alternative ways to finance care, thereby driving it to new forms and new locations. Along the way, these financing sources should find a way to provide incentives for new aligned practice models to emerge.

Unlike some of the other tensions, this one has a well-established research base behind it and, at least, at the public level, few detractors. What are needed are a few breakthrough demonstrations of how quickly the financing realignment can shift behavior.

From Homogeneity to Diversity

This tension speaks first to the growing diversity of the population. As we understand the needs of an ethnically plural culture in terms of health, costs, and disparity of health outcomes, then the drive toward culturally competent care will continue to be a dynamic source of motivation for change, but diversity does not stop here. Under girding much of the need for change in health care is the growing diversity in ages and what they demand and need from the health care system. An aging population with expensive care needs will increasingly be in tension with a younger generation being asked to pay for those needs.

Diversity will also be increasingly important as a measure of the type of health services offered. Today there is a fairly standard set of professionally defined services provided through a traditional set of institutions from hospitals to clinics. Over the next decade, new entrants such as for-profit providers, communities, families, religious organizations, and employers will reshape the way in which care is organized and delivered. A homogenous approach to health service has led to the advocacy for universal insurance coverage. Perhaps the better debate and move would be to provide universal access funded in a myriad of fashions and provided through a greater diversity of entities.

From a Closed to an Open Work and Education Environment

Part of the shaping of the modern western health system has been the creation of a tight and closed relationship between accreditation, education, licensure and practice. The story of success in the past was one of the professions escaping the work environment to create itself in a purely educational world. The tension of the next decade will be in how to reinvent that relationship with work, in order to build less expensive, more responsive, and better programs of education.

The isolation of separate systems of education and work was probably desirable in the second half of the twentieth century. Today the resources needed to sustain both the number and the quality of health professionals that will need to be trained over the next two decades will have to come from a more integrated education and work environment.

As care delivery systems look to derive more value from their professional workforce, they will need to draw upon the research and analytical resources of the academic health professions. They will also benefit from a closer association with training institutions as they seek to develop a closer fit between the challenges of practice and what is offered in education.

Education will find that isolation from practice will only make the type of customer responsiveness described in the first two tensions nearly impossible. Access to practice settings, technology and the opportunity to assist in the process of practice redesign, will make the strategic success of these efforts more likely.

These seven tensions will manifest themselves in different ways and at different speeds across the spectrum of health care professions and institutions. Understanding them and building off of them to direct and leverage change will be the key to sustained strategic success over the next decade.