The Future of Healthcare

Healthcare - the management of the resources of healing - is one of the most complex and difficult enterprises on the planet, and in the mid-1990s it is changing with great speed and turbulence. This turbulence is likely to continue for some time into the future, for a combination of reasons both within healthcare and outside it.

Where we are now

In the mid-1990s, relatively few nations around the world are satisfied with their healthcare systems. In the United States, continuing rapid increases in costs have ballooned healthcare into a $1 trillion industry accounting for nearly 15 percent of the world's largest economy - yet U.S. statistics for such benchmarks as infant mortality and longevity consistently fall behind those of many other industrialized nations, and some 40 million U.S. residents lack health insurance. Despite these facts, the chance for significant healthcare reform seems to have come and gone after the defeat of President Bill Clinton's plan and all of its rivals in late 1994.

Other developed nations, though their per-capita costs are far lower, also face tough political struggles over rising costs and constricted resources. At the other end of the scale, the World Health Organization (WHO) estimates that more than half of the world's 5.6 billion people lack access to the most essential drugs - vaccines, antibiotics and painkillers - and more than a third of the world's children are malnourished. Many Third World governments spend less than 1 percent of gross domestic product on healthcare.

Factors in the future of healthcare

A number of outside factors will effect healthcare in the future. A less predictable climate worldwide means an increase in natural disasters such as floods, droughts, famines, typhoons. The absence of the constraints of the cold war, the continued devolution of the former Soviet countries, the increase in effectiveness and the lower cost of many weapons (especially conventional small arms), growing atomization along ethnic and nationalist lines, and the growing scarcity and depletion of natural resources, point to the likelihood of increased chaos and war. For healthcare this means an increase in trauma, in malnutrition (as the chaos disrupts food supplies), of infectious disease and stress-induced illness, as well as a diversion of resources away from healthcare toward arms and reconstruction.

Other trends point toward continued and locally increased industrial pollution, which affects people's health over wide areas. Continued population growth will stretch all resources thinner. Increasing industrialization and urbanization around the world tend to break up the family, clan, and village support systems that have traditionally supported health. The increasing power and size of global corporations, less stable global finances, the increasing influence of donor nations, of central finance agencies such as the World Bank and the International Monetary Fund, and of the central government banks and finance ministries of wealthy countries, may mean even more constraint on resources for healthcare in many Third World countries.

Finally, certain purely medical changes endanger healthcare around the world. In the ongoing war between pathogens and antibiotics, overused antibiotics seem to be losing their effectiveness against the rapidly evolving pathogens. And the rapid increase in cheap international travel allows new epidemics rapidly to become global. The spread of HIV has gone essentially unchecked in much of the world. As of 1994, HIV was infecting 13 million adults a year. The WHO expects 5 million children worldwide to become infected with HIV between 1995 and 2000. Southern Asia and Sub-Saharan Africa are expected to bear the brunt of this epidemic.

All these changes will tend to push national health systems increasingly into crisis and chaos. The effect will be most marked at the ends of the economic spectrum, in the bloated U.S. healthcare industry and in the highly strained economies of the Third World. It will be least marked in the other industrialized nations and in the robust "Tiger" economies of East and Southeast Asia.

China, with the world's largest population (1.17 billion) presents an enigmatic future. Since the 1949 revolution, China has built a healthcare infrastructure that has been widely admired for its comprehensiveness, wide social base, preventive focus, and efficient use of the country's scant economic resources. China's economy is growing rapidly, and it is expected within a decade or so to become an economic powerhouse, a middle-income country, which always bodes well for healthcare. But early signs are showing up of an increasing gap between classes, between urban and rural areas, and between coastal and inland areas, as well as signs of increasing social strain, such as the open re-emergence of infanticide, baby-selling, and prostitution, and a rise in the death rates of children under five. Some observers, as well, express concern over China's long-term political stability. The most hopeful signs for the future of health in China are 1) the government's strong, widespread, family planning programs, 2) its focus on strengthening the corps of low-cost, primary health professionals in the neighborhoods and villages, and 3) its focus on educating girls, and the relatively high literacy rate of its women (68 percent). Studies by the World Bank and the WHO have shown the education of females to be the most effective method of improving the health of populations.

Technical advances

We cannot expect technical developments with anything like the life-changing power that the inventions of antibiotics, antisepsis, painkillers, and X-rays brought to the early decades of this century. And some technical advances, such as distance surgery, may be spectacular but are unlikely to have a large effect on the health of most people. The areas that show the most promise for actually improving people's health include:

• the Human Genome Project, which may isolate the genetic roots of many human diseases - including many that are not generally considered genetic
• the use of these genetic markers to screen mass populations, and prevent (through diet, gene substitution, or other special therapies) the specific diseases that individuals are likely to develop
• nanotechnology, the just-born craft of building molecular-scale machines that holds the promise of completely new types of drugs: tiny machines with the tools and intelligence to perform specific tasks, kill certain viruses, repair certain cells, manufacture certain needed proteins or enzymes.
• new modes of pharmaceutical research that go far beyond the old blind trial-and-error techniques to actually building the molecules (or evolving the bacteria) that can carry out specific tasks, lock onto specific receptor sites in the body, or defeat specific pathogens.

But in fact the most important effect of technical advances will not come in the invention of new medical techniques, but in the more effective use of the techniques we already have.

Shifts in direction

We can expect to see four major types of change in healthcare around the world in the coming decades, and two others that will be most pronounced in the United States.

• Computers, telecommunications, databasing: Advances in health-oriented telecommunications, medical imaging, massive databasing, memory miniaturization, satellite technology, and other information systems lay the groundwork for fundamental changes in the organization of healthcare. These new technologies not only will allow doctors to communicate far more easily and quickly, they will allow healthcare managers to drive their systems in real time, at the same time that they push consumer awareness about health to an entirely new level through the use of interactive cable systems, online forums, and personal health information systems in a wide variety of formats.
• Outcomes management and expert systems: "Outcomes measurement" uses massive databases scanning millions of cases to determine what therapies actually work best in particular circumstances. Its use as a management tool tends to make the practice of medicine more of a science, and less of a craft, driving costs down and quality up at the same time. Broadly applied, it will also open the gates to a number of highly effective and inexpensive non-medical methods that are considered "alternative" or "complementary" in the Western countries. The ability to measure all interventions by outcome and cost will push all therapies toward greater unity, bring a wider range of therapies into official payment systems, and allow true comparison of intervention and prevention strategies. Outcomes management is spreading rapidly in the United States, but has only begun to penetrate other countries.
  Medical knowledge is expanding faster than any human can learn it. Computer programs called "expert systems" help physicians and other health practitioners move much more rapidly and effectively through the decisions of diagnosis and therapy, isolating rare diseases, differentiating between similar syndromes, and discovering the latest research on the most effective therapies. Their widespread use is likely to significantly change the role of a doctor away from knowing facts and toward the more human elements of the craft, such as making difficult judgments, and helping patients change their behavior.
• Going "upstream:" The focus of healthcare will move increasingly out of the acute-care hospital, and back to clinics, to doctors' offices, and even into schools, workplaces and the home. The focus will change, as well, away from intervening in the acute phase of the disease, and toward early screening, detection, and treatment, and even toward preventing the disease in the first place. This will happen because it is not only more effective to catch diseases early and close to home, it is far cheaper.
• Population health: According to the National Institutes of Health, about half of all health problems are caused by behavior, such as smoking, excess drinking, and poor diet. The majority of the rest are caused by problems in the environment, such as pollution and unsafe working conditions. All these are preventable. A growing number of healthcare professionals around the world see changing the behavior of populations (as Americans changed their smoking habits), and cleaning up the environment as a highly effective use of healthcare funds. One expression of this is the rapid growth of the WHO's "Healthy Cities" movement.

U.S. trends

Within the United States, two trends stand out:

• Restructuring: As healthcare moves "upstream," acute healthcare will continue to shrink drastically. In 1982, for every thousand United States citizens, American hospitals logged 1132 nights in a hospital bed - more than one night per citizen. By 1992, that had dropped to 607. By 1995, some states were as low as 225, and some specific markets (such as San Diego County, California) as low as 160. Health futurist Jeff Goldsmith estimates that within a decade, most markets will only log seventy or eighty nights in a hospital per year for every 1000 citizens. One third to one half or more of all hospitals will close. The rest will shrink, and become much more intensive. Almost all will join one of the many different large-scale organizations that are bringing together hospitals, doctors, payment structures, and many other services under single ownership.
• Reform: Congress is not likely to enact significant healthcare reform any time soon. But we will see a wide array of experiments at the local and state level. Business will become more heavily involved in healthcare negotiations, but in an increasingly sophisticated way, moving from simply bargaining for cheaper rates, to working with the doctors and hospitals to keep quality up and costs down, and finally to working with people from government, healthcare, education, and other sectors to try to make the whole community healthier.

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