The Ice is Breaking

Slowly you can hear the ice begin to crack in what has been the locked up American health care system. Driven by continually rising costs, uneven quality and sketchy access, even for the insured, the evidence is beginning to accumulate - from the reimbursement polices for Medicare to benefit packages of commercial carriers - showing consumers' preferences for health care that they perceive to make sense, such as obtaining care at the MinuteClinc or in Costa Rica. The movement will take a few more years to fully catch on, but will then, like all things that have reached a tipping point, rapidly increase the speed of adoption. The reason for this transformation is simple: the system that we have is no longer sustainable for those who pay, those who consume and even those who provide.

The particulars of the transformation are not fully knowable, but in general health care in the US will move to balance from the highly idiosyncratic and to a more managed and systematic approach. It will also transition from a system focused on providing acute care in expensive tertiary settings to one that prevents and manages chronicity in the ambulatory setting of community and home. A system that has been cost unaware will become price sensitive along the continuum of production. One that has the patient as a passive participant will change to one that engages patients as active decision makers and contributors. Because labor costs account for 60 to 70 percent of overall health care costs, such a change will require a transformation of the US health care workforce as well.

Today most of the questions of health care workforce have to do with concerns over quantity: will we have enough to provide care? In the first quarter of this century, the US population is projected to grow by about 20 percent. As this population will be older and will likely require more health care, perhaps an additional five percent of capacity might be added to the health professional compliment to accommodate this change. But to use such gross measures to project the need for growth, one has to assume that the current system makes optimal use of the existing health care workforce. Clearly this has not been the case. Regulated at the state level, the practice acts that define professional practice are vestiges of a bygone day. As they emerged in the end of the nineteenth century, they were established to protect both the public and the interests of the profession. Today they still protect the guild interests of the professions, but their capacity to assess what is needed by the public and how it might be best provided has long since disappeared. The critical question remains, what is the least expensive way to provide care at an acceptable level of quality? Institutions that deliver care are increasingly responsible for such reporting and giving them the flexibility to rationalize the way care is produced in order to achieve the cost and quality demands is only sensible.

In addition to the regulation of health professionals, it will also be essential for schools and programs to look anew at what they teach. As the silos begin to disappear in regulation and practice, they will also need to be swept away in the classrooms and clinics. There have been at least two generations of rhetoric around education for team work, but the reality is that most clinicians leave their training unaware of what other professionals bring to the health care enterprise and unskilled in how to work effectively through teams. Until this is corrected, the nation's health will always be at risk.

There are two related areas of reform and change that will directly impact the workforce. Across the country health systems are engaged in a great frenzy to bring the value of information technology to health care. This is long overdue and will move health care from being a cottage industry, in which knowledge is kept by individual proprietors mediated through face-to-face interactions with clinicians, to a usable system of knowledge that can actually serve the complex needs of the patient. The skills to contribute, access and use such systems are already essential for practice and will become even more evident in the near future. The next generation of practitioners will arrive expecting such systems, and the students will become the teachers. The only question that remains is how much effort should be spent convincing the older generation to use the systems and then training them up to proficiency.

In other sectors of our society such an investment in technology would bring about an equal or greater investment in what is called process reengineering. In health care we seem to want to add information technology without much attention to changing the care delivery or practice model. Speeding up a broken system of communications will only make the errors happen faster.

As the financing of care begins its glacial movement in the direction of paying for a system that makes more sense, institutions will begin to understand that they need to derive a different type of value from the enormous investment that is made in health professionals. To make this value proposition will require new regulatory structures, new skills and expectations on the part of the professionals, new information and communications tools and, perhaps most important, the leadership to bring about the transitions.