The future of healthcare systemsBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7093.1495 (Published 24 May 1997) Cite this as: BMJ 1997;314:1495
Information technology and consumerism will transform health care worldwide
- Richard Smith, Editora
Extrapolation of current trends is a poor way to think about the future, particularly at times of great change. The best method, according to Ian Morrison, former president of the Institute for the Future in California, seems to be to bring together a diverse group of people knowledgeable about the subject of interest, provide them with good data, and ask them to imagine a series of possible scenarios. Earlier this year Andersen Consulting, the world's largest management consulting firm, invited 25 people from different parts of health care and from 10 countries to Singapore to consider how the world's healthcare systems might develop.
The group was particularly interested in what part “managed care” might play. The World Bank has argued that it has much to offer internationally, and many American managed care organisations have already begun to operate outside the United States. One of the main conclusions of the meeting was that the whole system of managed care (if there is such a thing) had little to offer but that the many tools of managed care (see box) had much to offer most healthcare systems.
Some tools of managed care
Advice lines to patients
Review of use
Greater use of guidelines
Greater use of non-doctors
Although every healthcare system is different, they can be grouped into four “archetypes.” Socialised medicine (as in Britain or Sweden) covers everybody, has a single payer, and usually has those who provide care salaried or capitated (paid so much for every person for whom they provide care). Socialised insurance (as in Australia, Canada, or France) also covers everybody and has a single payer but pays those who provide care a fee for each service. Mandatory insurance (as in Germany, Brazil, Japan, Malaysia, and Singapore) again covers everybody but has multiple sickness funds or insurance carriers and provides care through a mixture of salaried public providers and private providers paid a fee for each service. Voluntary insurance (as in the United States or South Africa) does not offer cover to everybody and has many payers and providers and different systems of payment and delivery.
No healthcare system in the world is stable, and everybody at the meeting thought that all systems would undergo considerable change in the next 10 years. The drivers of change in the developed world are reaching the limits of the welfare state, exhausting traditional methods and tools for containing cost, and experiencing increased consumer sophistication and demands. Change is being driven in the developing world by the growth of the middle class, greater demands from that middle class, and the globalisation of economies (as those countries are more exposed to what the developed world has to offer and experience greater competition and economic pressure within their own economies).
Change in the United States is being driven by rising costs, the failure to provide universal coverage, consumer dissatisfaction, and the increasing recognition that the country has poor life expectancy and high infant mortality despite an expenditure on health care far higher than any other country. The main response in the United States has been the growth of managed care. It might be defined as “the arrangement whereby an organisation assumes responsibility for all necessary health care for an individual in exchange for fixed payment” but is probably best seen as a collection of techniques for containing cost and raising quality. More than half of Americans now receive their health care through managed care schemes broadly defined, many of them run by for profit organisations. Managed care markets in the United States are becoming saturated, and a further driver of change worldwide is the enthusiasm of managed care companies to find new markets.
The group was able to imagine six future healthcare systems. The first was socialised medicine but with increased incorporation of the tools of managed care (Britain's NHS already includes many of these–such as capitation and gatekeeping–and is in many ways one giant managed care system). The new tools that will be introduced include those used for managing demand–for example, advice lines to patients, user fees, and consumer education. Socialised medicine may also come to use the tools of medical management, including utilisation review (doctors have to seek permission before referring patients or expending large sums of money), preadmission certification (approval by those paying the bills before a patient is admitted to hospital), and disease management (setting up systems to ensure more cost effective care of patients with chronic diseases). Managed care also has tools for the delivery of care, including telemedicine and greater use of guidelines and non-doctors for managing patients. British and Swedish doctors may wince at the thought of these tools being introduced into their systems, but it is hard to see how governments desperately trying to contain public expenditure and meet the rising demands for health services will be able to resist them. The group also thought that countries with socialised systems would experience increased pressure for growth of private care.
The second scenario was of a “managed mandatory system” where multiple sickness funds were exposed to competition, merged, and linked together by technology into a “virtual single payer.” This system–which might emerge in Germany and Japan–would also use the managed care tools of demand management, medical management, and care delivery.
The third scenario may apply in countries like Singapore that now have a per capita gross national product comparable to that of many developed countries but which spend only about 3% of their gross national product on health care. These countries are keen to avoid the “trap” of an insatiable welfare state and would prefer to keep their spending on health care low. Singapore, which is keen to encourage “personal responsibility,” has mandatory personal saving for health care, and employees must pay for some of their health care out of their personal account. The government hopes that this device will discourage inappropriate use, but Singaporeans can go directly to specialists–and increasingly do. These countries are unlikely to be able to resist the pressure for increased health spending, but some of the tools of managed care may help them.
The fourth scenario is of a multitiered health service with private, fee for service medicine at the top; American style managed care funded from social insurance in the middle; and lower quality, government funded care at the bottom. Some predict that all health systems, including that of the United States, will converge to this model, which is seen commonly in Latin America.
The fifth scenario described a system very different from anything that exists now–“an integrated and virtual” system. This system has been foreseen by forums organised by Andersen Consulting in Australia and may be brought about by new entrants to health care and by transformational use of information technology. The new players include corporations like Disney and Microsoft, which have very different ideas from existing players on how health care might be delivered. The Australians saw four futures: one where new players and transformational technology were resisted, two where only one or the other flourished, and the final one where both flourished. They opted for the integrated and virtual system, where both flourish, because they could not see these forces being resisted– but is not clear what the system may look like. They imagine that services will be provided “anywhere, anytime” by healthcare providers, suppliers, funders, insurers, and consumers working in new sorts of organisational relations. Government will become a regulator rather than a provider. Providers will focus on long term relations, and the consumer role will be much greater than now. This integrated and virtual system could operate within more familiar systems, including with a system like an enhanced NHS.
The centrality of consumers is the main characteristic of the sixth scenario–“the informed consumer.” This is a form of health care that might operate within any other system. Consumers will use information technology to access information and control their own health care, consulting professionals much less often. Figure 1 shows how “information age health care” inverts the traditional pyramid of “industrial age medicine.” Instead of being viewed as the apex of a system of care that hardly recognises the large amount of self care that occurs now, professional care will be viewed as the support to a system that emphasises self care. Healthcare providers will progress in this world from managing disease to promoting health, and they will do this through lifetime plans that are built on intimate and detailed knowledge of customers.
Perhaps none of these scenarios will emerge, but some of the developments imagined within them probably will. Doctors think that they have been living through years of uncomfortable change, and they have. But the pace of change is unlikely to slow, and our health systems will probably see more changes in the next 20 years than in the past 20. Most large sectors of developed economies–transport, manufacturing, and telecommunications–have been transformed in the past 20 years. Health care has not but surely will be.
Richard Smith and all the other participants had their expenses for the Singapore trip reimbursed by Andersen Consulting.
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