by senior futurist Richard Worzel, C.F.A.
The future of health care in North America is going to be difficult, full of arguments, budget controversies, regrettable patient outcomes, and political interference. Yet, contained within this problematic outlook is a surprising fact: nurses may be in a crucial, pivotal position to affect the health care system for the better – if they choose to be. Nurses can choose to move us towards a better health care system, one that will reward them better, produce better, more affordable patient outcomes, and that will produce a better future for almost all stakeholders. But before I get to why this is so, let me start by reviewing the pretty obvious reasons why the health care system will experience enormous stress for at least the next 25-30 years.
The Three Factors that Will Determine Health Care’s Future
There are three primary factors driving change in health care: the aging of the boomers; technology; and money. These three are all well-known, and interrelated, but the implications of the changes they are driving are not well-appreciated – or at least, are not being properly discussed. Let me briefly outline why each one is critical.
The aging of the boomers will matter because annual health care costs per person remain reasonably stable (with some variations) until around age 55. At that point, they start to expand almost exponentially: the older the person, the more health care they are likely to need and want.
While there is no standard definition of what constitutes the baby boom, mine is that the baby boom generation was born roughly from 1947 to 1967, with the largest cohort being born either 1960 (in the U.S.) or 1961 (in Canada). This means that at the high end, the boomers are about to start turning 68, and at the trailing end, they’re about to start turning 48, with the peak cohort pretty much hitting that pivotal age of 55. We are, in other words, at the tipping point where the aging boomers – the biggest generation in history – start piling into the high rent district of the health care system in sufficient numbers to be a massively disruptive force. What’s worse is that the boomers are politically potent. If they vote as a group, which they will when it relates to their access to health care, they suck the oxygen out of the room for every other generation. Politicians all know this, and are careful to at least appear to give the boomers what they demand.
Next, technology is creating marvelous results, and promising even more. We can repair hearts, and before very long we will be able to create complete replacements from a patient’s own stem cells, for hearts and most other organs, eliminating any problems with immune system rejection. Pharmaceutical research, although currently stunted by the obsolete business model of the major pharmaceutical manufacturers, is nevertheless advancing through a plethora of small, smart start-ups that are creating new prognostic and diagnostic tests, new treatments, and new drugs by making use of computers. This means that advances are starting to come at computer speeds (albeit slowed by an antiquated government approval process). And the introduction of Big Data and Analytics to health care is revolutionizing the fields of diagnostics, drug discovery, and wellness assessment.
But technology is expensive, at least at first. This isn’t new, and has been happening for decades. When penicillin was first made available for widespread civilian use, following World War II, a course of penicillin cost thousands of dollars. Today it costs pennies, with the dispensing fee far overshadowing it. So technology starts out expensive, but gradually becomes cheap. Yet, when technology keeps advancing, and new, more effective tools and treatments come into the market, the people these advances could help want them.
Which brings us to money. We have the biggest generation in history reaching the point in their lives where they want and need the most health care. And, simultaneously, we see technology making new, more effective – and more expensive – treatments available. The combination is making the cost of health care explode. And that has major implications.
Some Implications of Exploding Costs
Health care is going to be rationed in every developed country in the world. Indeed, it already is, but no one talks about it. In Canada, with its single-payer system, health care is rationed by standing in line. If you die before you reach the front of the line, too bad. In America, it’s rationed by the nature of your health coverage, which gives you access to health care. If you have the right access, like the well-funded health care plan Congress has voted for itself, you get the best health care in the world. If your access to health care is poor, then you die, too bad. If you are somewhere in the middle, you get results that are somewhere in the middle.
So with demand and costs expanding far faster than the health care system’s ability to supply or fund health care, rationing of health care is going to become profoundly more widespread, even if it isn’t called rationing.
Next, politics will interfere with rational management of health care. This isn’t the politicians’ fault, but rather the fault of the voters that elect them. People want unlimited health care, and they want someone else to pay for it – which, of course, isn’t possible. But people seem to think they can vote for it, even if it’s impossible, which creates problems for politicians. In response, politicians come forward with bold, new solutions which don’t accomplish the desired result, but which make it appear that something is being done. Meanwhile, the elected officials hope that the voters lose interest.
And health care costs threaten the financial stability of the governments that sponsor them. The financial woes of Medicare in America have been well publicized, and the Canadian health care system is the greatest vulnerability of the public sector, although this is not as well publicized. Which means that as payers start feeling significant pain, they are going to look for ways of cutting their costs, even if their solutions for doing so don’t make medical sense.
This means that solutions will be imposed by the political system, whether they make sense or not, as politicians strive to look like they’re solving the problems voters want solved. This produces political meddling in health care – and as the cost problems become more severe, so will the meddling.
Cost management and cost containment will become more widespread. In the US, this appeared when insurance companies denied treatment or a particular prescription, or insisted on something less costly, even if it wasn’t effective. When only costs are considered, medical results will suffer.
What should happen is that health care consumers should be directed to the best, long-term, cost-effective solution for their current need. It may be that this requires more money up-front, but less money overall. Hence, an expensive new drug prescribed today may be a better solution than a refusal of said drug, followed by even more expensive surgery and follow-on care later on. This also means that home care should become far more widely available, receive better support, and be the focus of new technologies, and new billing procedures. And it means that evidence-based medicine should be widely promoted and developed.
And let’s not overlook how these things will affect the prospects and working lives of nurses. While it may not be true always and everywhere, in general these trends imply that nurses will have to carry bigger caseloads, have less time to devote to patients, and spend more time doing paperwork and hassling with administrivia. It also implies that remuneration will be under pressure, as payers and health employers alike struggle to keep costs over control. So, despite a booming market for the services nurses offer, nurses themselves are not likely to enjoy great careers.
There will be many other implications for health care than I’ve briefly listed here because the field is so complex and widespread. Moreover, these are just some of the primary effects of the cost pressures emerging for health care. This list doesn’t take into account the downstream or domino effects that will inevitably emerge.
Nurses and the Health Care System
Before I describe why I think nurses are critical to the future of health care, let me acknowledge that it’s easy for me to sit back and comment on this. I’m not on the front lines, I don’t have to undertake the things I’m proposing, and I’m neither educated, trained, nor active as a health care professional. It’s easy for me to comment without having to act.
Yet, sometimes people within a system get so caught up in it that they wind up seeing the trees, and not the forest. Moreover, I believe that users, including me, also have a role to play in creating a more responsive, more effective health care system. This blog post is part of what I hope to do about that. With that disclaimer, let me now turn to why I think nurses are so important to our future.
Nurses occupy a unique position within the health care system. Like physicians, nurses are fully involved and aware of what’s going on inside the health care system, even if they are not as aware of the outside forces at work, like cost management or technological advances. Yet, unlike physicians, they are not generally captured by their position within the system because their compensation is usually in the form of a salary rather than based on the number of patients they see.
Physicians are, obviously, critically important to health care. Yet, because of the way they are compensated, they tend to view any change in the system as an attack on their status and, more importantly, their incomes. As a result, even though they are dedicated professionals, they still tend to fight against changes, even changes that will serve their own long-term interests, if it comes at the cost of their short-term incomes. The same is not true of nurses. And nurses are held in high esteem by the general public, and so have a high degree of credibility, particularly when they speak with one voice.
So, what could nurses, as a group, do with this voice? Well, among the things nurses might choose to work for include: making the best possible use of the health care professionals and assets available; extending those assets as much as possible; and aiming for the best possible outcomes for patients and society. And, as it happens, I believe advocating for these things would also improve the professional prospects for nurses as well. Let me explain.
Gatekeepers
First, there are going to be more patients, and fewer doctors for a given body of patients. This is due to the aging of the boomers, but also demographic and sociological changes for physicians. Boomer doctors are starting to retire in significant numbers, which will reduce, at least in relative terms, the number of doctors available to serve patients. And a steadily increasing percentage of doctors are women. Women doctors tend to pay more attention to work-life balance than men, which means they work shorter hours, do more part-time work, and don’t see as many patients as men. All of this means that the ratio of doctors to patient is going to worsen as far into the future as we can see.
And what that means is that doctors should fulfill their highest function – and that means they should reduce the amount of time being gatekeepers to the health care system. And, as it turns out, this is a role that nurses can fill to some extent now, and will get steadily better at filling as time goes on because of technology. In particular, smart computers, acting as interpreters of huge databases of medical information, can be used to assist nurses in filling the gatekeeper function. Here’s how it might work.
As one example of a smart computer, consider IBM’s Watson computer system. Watson is best known as having beaten the two human champions at the television game show, Jeopardy! back in 2011. However, this was merely a proof of principle illustration on the part of IBM to demonstrate that their computer system could interact with humans using human language, and, using a large database of information, come up with a list of answers, along with the probabilities those answers were correct.
For instance, Watson is currently being used, in conjunction with both Wellpoint, Inc. and Memorial Sloan Kettering Cancer Center to assist in the diagnosis of cancer. To do so, Watson was fed more than 600,000 pieces of research data, and more than a million pages of text from medical journals, as well as 1.5 million cancer patient records developed from decades of cancer treatment. In combination with an oncologist, machine and physician can arrive at diagnoses better, faster, and more accurately than either could alone.[1]
Now transpose this ability to screening people for health treatment. A patient who is not feeling well, instead of going to their GP, would see a nurse working with Watson, or similar system. The nurse would question the patient as to the problem, input the symptoms to Watson, and then, based on both the nurse’s experience and common sense, and data provided by Watson, perform a triage and:
- Recommend a specific treatment, or prescribe placebos to trivial cases;
- Prescribe tests for further examination; or
- Refer to the appropriate health care specialist, whether a GP, specialist doctor, or some other health care professional.
In fact, properly educated nurses could do something like this today without a smart computer, although they will be far more effective on a much broader scope of issues once they can have the backing of such a computer with the necessary database of information. This would free up doctors to take on the more complex cases. In addition, they would start with much more information once they did see a patient, based on the nurse’s notes, and the computer’s assessment and recommendations, plus the results of any tests that had been performed. Fewer patients would need to see a physician, and a doctor’s time would be used more effectively.
Home Health Care
Hospitals are expensive, dangerous places. They should be the last resort for health treatment. Instead, they are often the first resource called up, which is a horrible waste of resources, plus it puts patients at risk of picking up infections. Much of what happens at hospitals can be done elsewhere, either at clinics for acute care issues, or outside of hospitals for chronic care.
With a rapidly aging baby boom, the demand for chronic care is going to expand rapidly. To the extent that home care can be used instead of hospital beds, or even in place of a clinic, it will usually be more cost-effective, and will frequently result in better outcomes because the patient is physically and psychologically more comfortable. And visiting nurses, along with telemetry of data, and online testing of distant patients, will provide a way of extending the variety of conditions and ailments that can be treated at home.
I haven’t spent a lot of time on this one issue, but it may well be the most important cost saving of all the ones I mention – and nurses can be the key to making it work.
The Statistical Significance of Compassionate Care
I believe, but do not have the data to prove, that compassionate care, notably by an informed and involved nurse who has adequate time to assess a patient, leads to faster, better, and therefore cheaper results. Trends today are pushing for greater efficiency – i.e., more throughput – but I believe this leads to patients who are rushed through care, and largely ignored by overloaded health care professionals.
If nurses were to support research on this issue, I believe it would lead to both better results and lower costs. No one else is going to sponsor this kind of research. And meanwhile, nurses are being asked to do more and more administrative work, given too-large patient caseloads, and, as a result, have minimal time to spend with patients.
I believe this is a false economy – but I can’t prove it.
Leading Users to Effective Action
As I said earlier, I believe people who are or will be users of health care have a part to play in creating a better system. Ultimately, as voters, we are the ones who tell politicians what to do. As insurance subscribers, we are the ones who choose which policies to buy. As patients, we can approach our needs intelligently or not.
But there’s no one out there to inform us how to be good users of the system. There’s no instruction manual, and not many people to whom we would listen on this subject. And here again, the credibility of nurses is a factor. The nursing community might consider publishing a series of short, direct articles about subjects like: how to prepare for, and be a good patient during a physical exam; how to get the most out of your hospital stay; what to expect and how to prepare for major surgery; and so on. Such articles would have credibility because they were offered by someone without an axe to grind, and would offer the insights that nurses have gleaned from decades of watching patients interact with the health care system.
Once established as a credible source, additional articles could address broader health care topics, like what to look for and avoid in a health care professional; what to look for and avoid in health insurance; how to select a surgeon or a hospital; how not to be a burden to the system and so forth.
I can’t think of another group in health care that has the experience, the authority, the independence, and the credibility to do this. And I also think it’s more than time that someone told patients and users that we not only have rights, but also responsibilities.
The Real Goals of Health Care
Amid all the noise surrounding the debates on health care, no one is really speaking for the health care system as a whole. Consumers speak to the coverage they want, or about access, or choosing their physicians, but they don’t talk about what the health care system is supposed to produce. Payers talk about containing costs, and increasing efficiency, but they don’t talk about results. Legislators try to push voter hot-buttons relating to health care, but these are usually not related to how to get the best results, but rather how to get the most voters to agree with them. Physicians worry about being pressured into using lower cost drugs and treatments rather than the ones they feel are most appropriate, about being denied the time to spend with patients, and about how their income will be affected. And critics take potshots at whoever doesn’t agree with them.
But no one speaks to what the real goals of the health care system should be. Indeed, if you ask someone what our goals should be for health care, you will probably get some combination of all the things I mentioned in the last paragraph. Are those the best goals for the system as a whole? Who speaks for the system?
Again, I believe that nurses are in the best position to do this. To do so would require thought, effort, study, and some money – but if nurses don’t do this, who else will?
How to Get the Best Results
I believe we should be focusing on the most cost-effective health care system, not the cheapest, most profitable, or most efficient. I believe we should embrace new technologies when they are the most cost-effective choices, not when they are the cheapest, or the most profitable. I believe we should be working towards evidence-based medicine, where data and decades of broad experience should be involved in making decisions rather than the much more limited experience and personal preferences of individual physicians. And such decisions should be implemented using known best practices rather than what a particular practitioner has done before. And I believe the objectives of health care management should be a healthier population and a more affordable system. But who will advocate this?
This doesn’t have to happen. In fact, it would be easier for nurses to just let the status quo ride, keep their heads down, and let others battle over the future of the health care system. But I think that would be a mistake.
If I had my druthers, the nursing profession, including the many, varied groups within it, would band together to:
- Define the desire future for health care, producing a possible future towards which we should work, as well as a possible road map for getting there;
- Identify what works, both at home, and particularly abroad. There have been many national, public, and private experiments with variations on how health care can be run. Why not learn from the experiences, and investments, of others?
- Identify what are best practices in the broad strokes of health care management, explaining why we need to work towards these things, and what the benefits of doing so would be.
- Explain why the status quo is not an option, and how financial and demographic pressures are going to unleash a crisis in the not-too-distant future, and how yesterday’s solutions will not work. It’s important that our society develops a sense of urgency. In particular, politicians of all stripes are studiously ignoring the question of medical entitlements. If these are left to run rampant, they may well bankrupt our governments, and will certainly produce a breakdown in the healthcare system.
Doing these things will not be easy, and will arouse a firestorm of criticism. That is certain. But consider what will happen if these things are not done. What will that future look like? What will it feel like to live through?
As I said earlier, nurses have a unique position within they health care system. They are not accorded the respect they deserve, and their voices are not listened to as they should be. And as long as nurses remain quiet on the big issues, that is not going to change.
Nurses should ask themselves which future they want to live and work within: a straight-line extrapolation of the status quo, with all the obvious problems that will bring? Or a future for which they will have to work hard to achieve, but which would be more livable, produce better outcomes, and in which nurses become a more respected voice, contributing to the common good.
And if nurses don't act on these issues, then who will?
© Copyright, IF Research, November 2014.
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[1] ‘IBM Watson Hard At Work: New Breakthroughs Transform Quality Care for Patients’, Memorial Sloan Kettering Cancer Center website, http://www.mskcc.org/pressroom/press/ibm-watson-hard-work-new-breakthroughs-transform-quality-care-patients
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