by Joe Flower


International Copyright 1995 Joe Flower All Rights Reserved
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It is the best of times, it is the worst of times. This is a decade of consolidation and layoffs; a decade of bringing healthcare to all; a decade of closing hospitals, and of medical breakthroughs; a decade of uncertainty and fear, and of new hope; a tight-fisted, tough, remorseless decade, and the decade when we have the chance to lay the foundation for a truly healthy America.

The great "healthcare" debates in Washington over the last few years have not really been about health, or even healthcare, but about insurance and access. They have obscured vast and deep changes taking place throughout healthcare, the practice of medicine, and the communities in which we live.

These are not ordinary changes, they are revolutions. Unlike incremental and ordinary changes, revolutionary changes effect every part of the organism. They shift every relationship, every incentive, and every career. Perhaps more important, they change the way each of us sees our world.

Each of these changes by itself has shown that it has the power, now or in the near future, to turn healthcare inside out. But they are not coming one at a time, they are coming together, combining and reinforcing one another in chaotic ways. We cannot predict what healthcare will look like in five years, let alone 10 or 15 -- it will be an "emergent phenomenon" that organizes itself out of a turbulence far greater than particular pieces of legislation, business trends, or medical advances. But we can describe that turbulence with some clarity, and attempt to pick out the first evidence of that emergence.

The Seven Revolutions

I invite each of you reading this to spend a moment contemplating the profound forces forming the future of healthcare, and list them. I count seven:

1) New management strategies

Team-building, vision-building, re-engineering, quality management, benchmarking -- all these tools take enormous time, attention, and leadership. But they give the organizations that use them the tools they need to endure change, even to thrive on change. Despite the impression that we might get from the abundance of seminars and consultants teaching all of these techniques, healthcare has come late to the new management. Some of these techniques, such as benchmarking, have only taken root in the most advanced institutions. Yet the results of these techniques are becoming increasingly clear, and as other shifts increasingly drive healthcare organizations to the wall, skeptics as well as believers will be forced to adopt them -- and they will completely change what it means to come to work in a healthcare organization.

2) Healthy Communities/Healthy Cities

The image of the healthy community, the original goal of all medicine and healthcare, remained submerged for many years under the immediate and expensive concerns of medicine and "sick care." The converging change vectors of the Nineties are moving healthcare organizations steadily beyond concerns for high quality and low cost, through new risk-based incentives, past even outreach and prevention, to an ultimate realization: building healthy communities is becoming not only a nice thing to do, but actually a necessary survival strategy.

3) The information superhighway

Advances in "HOTS" (health-oriented telecommunications), medical imaging, massive databasing, memory miniaturization, satellite technology, and other information systems lay the groundwork not only for medical advances, but 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.

4) Outcomes management

The advent of broadly-based, truly comparable outcomes measurement allows us, for the first time, to turn the practice of medicine into a science, rather than a craft. This not only will re-shape medicine, driving costs down and quality up, it will also open the gates to a number of highly effective and inexpensive non-medical "alternative" or "complementary" methods. The ability to measure all interventions by outcome and cost will push all therapies toward greater unity, bring a wider range of therapies into the "reimbursed" tent, and allow true comparison of intervention and prevention strategies. The result will be a complete re-shaping of both medicine and healthcare.

5) The next stage of medicine

Medical advances have continued apace through the past few decades -- advances in imaging, pharmacology, surgery, indeed in every facet of medicine. But all these advances have been refinements which have not changed basic practices, points of view and ways of organizing in any deep way. We are now beginning to see advances that will take us to the next stage, advances that will rank in the history of medicine with the inventions of anesthesia, painkillers, X-rays and antibiotics. These include such breakthroughs as the development of genetic engineering, genetic-marker prediction and prevention, nanotechnologies, and such tools as polymerase chain reaction (PCR), ligase chain reaction (LCR) and other related "no judgment" diagnosis and treatment regimens. These advances will re-shape the roles of doctors and other medical professionals, as well as their relationships to patients, to compensation, to the community, and to research institutions.

6) Systems integration and restructuring

Pushed and squeezed by all these forces, healthcare will continue to consolidate into an unpredictable variety of systemic shapes -- and this very consolidation is becoming a force of its own, altering every relationship and incentive within healthcare, and between healthcare and the community. The role of the acute hospital will continue to shrink drastically, while the role of interventionary medicine will grow at a slower pace than it has, and the role of healthcare -- preventive, community-based, health-oriented -- will grow rapidly. It will be some time before any one dominant model of payment, treatment, and incentives emerges, but we can feel confident that when it does, it will not look like anything we are using at present.

7) Reform

Reforms in Medicare, welfare, and other federal programs will join scores of other reforms from outside healthcare: state and local legislation, as well as reforms forced on healthcare by insurance organizations and business alliances. These reforms, more than any other vector of change, are wild cards tossed into the deck of the future. The other six revolutions are emergent phenomena, bubbling up without any single cause from the complex environment of healthcare in our society -- so they have a natural coherence and force, rather like waves. Reforms, shaped as they are by political forces pushed by lobbyist's donations and pressure, as well as the scramble for votes, have a much more random nature -- less like waves and more like Rube Goldberg designs. Their influence will not be predictable, even once we know their final form. They will interact with the other forces re-shaping healthcare, sometimes advancing them, sometimes slowing them or sidetracking them, often simply increasing the turbulence.

These forces arise independently, from a number of different causes, but each of them interacts with each of the others. They cannot be completely teased apart. Any one of them can become a dead end, just another game to play while the world spins its way into chaos -- yet each of them has the potential to become a forceful tool in the building of truly healthy communities, a piece of an emergent whole that is healthier, happier, and far saner than America in the middle 1990s.

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