Wednesday, February 25, 2009

The Future of Health Care

No one can really forecast the future of health care in the United States.

There is much talk about health care reform. There are a multitude of ideas. Indeed, there are some programs in place that may lay the groundwork for a new system of care.

Many constituencies have their favorite plans--single payer, managed care expansion, mandatory insurance, open access, regulatory control, pay for performance, etc. etc.

Yet, the future is uncertain, to say the least. And many of us wonder how the ultimate "decisions" about reform will be made. Who will have influence? How will it happen? Will it actually be a "rational" choice, or will the result merely be a "tumble down the road?"

Who can say? Yet, there are some "solid" realities that appear to me--and to others also.

In the US, we spend about $7,000 per year on health care for each and every resident in the country. Systems of care in other countries, that are considered models, spend less than half that amount. Meanwhile, our population health care outcome measures fall below many of those in model countries. In essence, we don't receive a very high quality product for our expenditure--raising the question of whether or not health care is really the "product" of our health care system.

With our economy in free fall, the sources of our health care dollars are quickly shrinking--government revenue, business revenue, investment revenue are all direct "hits" during the "recession/depression." In a world where many already feel that we are paying too much for health care, there is now considerably less to even think about spending.

As we divide up the $7,000 per person, we all wonder who truly benefits the most from these expenditures--drug companies, Wall Street, insurance companies, hospitals, technology companies, doctors, nurses, other employees of health care systems, or the patients? In the face of declining outcome measures and high rates of harm, it is hard to make the case that the patient is the primary beneficiary.

Human nature teaches us that the strongest opposition to change will be the ones who benefit most from the current system. If they are the most powerful of the constituents also, the road to change will be difficult without a revolutionary pressure to change. Kuhn raised a similar concept in his seminal explanation of change, "The Structure of Scientific Revolutions."

What we call the "health care system" actually is what mathematicians call a "complex adaptive system." Such a system changes always and changes like an amoeba--based upon rules, but slowly, incoherently, unpredictably, but adaptively. Some call this type of system a "chaotic" system. "Chaotic" in the sense that, in accord with Heisenberg's uncertainty law of physics, it is impossible to be certain of "where" the system is now, and "where" it is going at the same time.

Although the last century has seen a dramatic increase in the life expectancy of Americans (from 47 years in 1900 to about 77 years now), what we call "modern medicine" has accounted for very little of that improvement. Public health, sanitation, and improved socio-economics are responsible for most of the change. Medicine only contributed relatively small amounts with antibiotics and improved perinatal care. Although medicine "does" a lot, the contribution to population health is relatively small. And, for that matter, we have as a society nearly reached the limit of human life expectancy expansion.

So, I wonder if those six "solid" realities mean;

We are in the midst of a revolutionary change in the US health system, pressured by economic collapse and a general failure to produce increased quality of life. Individuals and groups who made a profit off of the old system of "care" will resist change and press for new profits, new enrichment. Those others who want more quality from the system will push for their version of quality. More and more people will become dissatisfied with the "disease treatment" paradigm of modern medicine and abandon it in favor of a "wellness" model of some sort. The client will generally want more focus upon increased quality of life rather than the mere avoidance of death.

Although we know that US health care will change, we will not be able to really see, predict, or understand any of the change except that which is "local" to us. The place where we can make a difference is that "local" part of the system--the individual contact with a client, the attention of the needs of family, the ongoing effort to improve, redefine goals based upon client desires, and the willingness to be a part of the solution.

Akin to any revolution (the American Revolution, the Industrial Revolution, etc.) the change happens locally, moment by moment, person by person, small action by small action. And that is our part in the process.

It is hard and frustrating work sometimes, yet it has a point and a purpose--maybe a goal that is not seen because it appears over the horizon, but still a purpose to improve and meet a need. And although "hope is not a plan," and we need plans to make progress. Hope is a sustaining resource that helps us all to maintain in the revolution.

I would not say, "hang in there, just keep your head down and move." That is NOT what we need. We need thoughtfulness, heads up and strong. But, strength comes from a center inside us all and hope nourishes that center.

Vaclav Havel, when talking about the Czech Revolution, said it much more eloquently than I can, "Hope is definitely not the same thing as optimism. It is not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out."

In the end, our local actions will make it make sense.

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