I'll admit it. I'm a "Star Trek" fan. My favorite character in the original series was "Bones" McCoy, the irascible physician to the Starship Enterprise. I was always fascinated by the technology the good doctor employed when examining patients. He had a hand-held device that he would swipe over the patient's body. It would whir, some lights would blink and a readout would tell him exactly what was wrong. Far-fetched? Not really.
When predicting how the state of healthcare in the year 2020 will affect hospitals, we have to begin with the changes technology could bring. McCoy's gadget is totally plausible. Smart people tell us that lots of revolutionary advances are on the way, especially advanced gene therapies, superior pharmaceuticals, new generations of noninvasive diagnostic tools (shades of Dr. McCoy,) robotic surgery and custom-grown tissue.
Those developments will be facilitated by communications technology, which will allow people to have real control over their own health. Ultimately these advances will change healthcare delivery. And they'll also challenge our ethical substructure.
We have already become fully cognizant of the sociological, financial and political impact of an aging population. We know already that the risk to Medicare and Social Security increases exponentially when cohorts of 75-year-olds suddenly become good candidates for a total hip replacement and other high-cost procedures. But as we understand more and more about the genetic causes of aging, it's likely that we will find ways to arrest or postpone it. The possibilities -- and ramifications -- of sharply increasing lifespans, enlarging the productive population and overpopulating the planet become very real.
The world changed tremendously when the printing press was invented and Bibles could be distributed in large numbers, thus changing the dynamics of information flow from the priests to the laity. So, too, the personal computer and the Internet have influenced and will completely change the relationship of physicians and patients. The acquired medical knowledge of the ages, which was presumed to be carried around in physicians' heads, will now be available across a broad spectrum.
The physician's role as the supplier of medication and information will be changed more to one who provides counsel as well as diagnosis. Patients will turn to physicians for information and analysis above all else.
Much of the diagnostics will be miniaturized and available in the consumer market. Well-trained physicians will be faced with a new set of competitors -- less trained, as the snake oil salesmen of the past, but with infinitely more knowledge at their fingertips. And as the sophistication of home diagnostics grows, physicians may be called upon solely to interpret and explain results obtained from do-it-yourself testing. The physicians could begin to see even their patients as competitors.
The opportunity for misuse and misunderstanding of these diagnostic and information tools will become the chief threat to organized medicine. Of course no one is saying that doctors are threatened with extinction. A computer algorithm can never replace the intuition and diagnostic expertise of a physician. But physicians' traditional roles will be changed and in some ways diminished.
Debunking integration myths
What happens to hospitals in this high-tech environment? What will they look like by 2020? Hospitals are already feeling the stresses of organizational change as the myth of being part of a "fully integrated" system is exposed. By integration we mean attempts to combine both the delivery and financing of healthcare. Hospitals already realize that this is not a street on which they can play both sides. To succeed as a managed-care organization, it's essential to keep provider payments as low as possible. To succeed as a provider, the goal is to maximize reimbursement. They are two antithetical concepts. Hybrid networking models are likely to dominate the marketplace in the future.
The cycle of lean reimbursement we are currently seeing will probably end around 2005, to be followed by several other waves, so that by 20 years after the turn of the century most of the marginal operations will be gone and all hospitals will be in regional systems, with a tremendous amount of consolidation.
Most of these systems will be clinically oriented, with caregivers (physicians and/or other clinically trained people) as the administrative heads and chief executive officers. But the future executives also will need to be much more technology-savvy, given the type of healthcare system envisioned. More sophisticated information systems and fewer payers will quickly reduce administrative overhead. There will be fewer positions for the financial types who currently guide the American healthcare system.
With the rapid growth in medical and technological breakthroughs, today's leading causes of death (heart disease, cancer and stroke) will change. Although people will live longer, mortality will remain 100% Therefore, we'll still need hospitals.
But look for hospitals to begin shifting their inpatient capacity from a medical to a surgical focus. Hospitals -- rather than surgery centers -- will be needed for complex procedures, both for trauma and to make other repairs. Hospitals will still be the preferred setting when patients deteriorate at an advanced age and need care due to multisystem failures.
By 2020, remote robotic surgery could be commonplace, giving more facilities around the country access to the nation's top-notch surgeons. The technology already exists that allows a surgeon to manipulate tiny instruments inside the patient and view the results of his or her work on a TV screen. The surgeon stands beside the patient and maneuvers the instruments. Why couldn't the surgeon be in the next town, across the state or even across an ocean, as long as other qualified doctors and support staff are present in the operating room to assist in the procedure?
Also accelerating hospitals' surgical focus will be the fact that transplants will become common, not only for disease but as our organs wear out from advanced age. By 2020 researchers will have conquered the body's rejection of organs from animals, making animal-to-human transplants fairly common.
Expect surgical hospitals to be among the growing line-up of single-competency hospitals, especially in large population centers. A lot of specialty facilities already exist, such as heart, rehabilitation and children's hospitals. But we'll see a wider spectrum, including specific transplant and orthopedic facilities. They will be governmentally sanctioned, based on medical outcomes, service and economic performance standards. They also are likely to be grouped into multistate regional networks to ensure continuous quality improvement, referrals and competency comparison.
Large population centers also will have a single designated quaternary trauma center. Quaternary services -- specialized levels of care beyond tertiary care -- for transplants, neonatal, intensive care and Level-I trauma will all be centralized. These units will be small, not more than 200 beds; the medical staffs will be closed; and the trauma center will be included in all payer networks.
Existing hospitals with fewer than 100 beds, both rural and urban, will be converted to ambulatory-care centers with emergency capabilities. No urban population will be more than 20 minutes away from an ER, short-stay hospital or quaternary center, and no rural population will be more than 40 minutes from such a facility.
Inpatients as we know them today will disappear, except for those who have suffered multisystem failure, have experienced major trauma or have undergone complex surgery. By 2020, our understanding of debilitating senior diseases such as Alzheimer's will be significantly improved. Treatments will be much more plentiful, and the need for chronic long-term-care institutions will sharply decrease.
What kind of leadership will it take to answer the needs of the public in this new technological environment? If we have moved toward a single-payer system and the physicians' role has changed to that of counselor and technocrat, the business planning and strategic thinking skills today's hospital and system CEOs possess will be replaced by leadership that's both technically competent and biased toward clinical skills. For that reason, most CEOs of the future will be physicians or nurses, with physicians dominating in the large quaternary centers, and opportunities for lesser-trained clinicians in the specialty centers. These clinician executives could be nurses or physician assistants with specific specialty training and background.
The year 2020 will have been preceded by decades of consolidation to accumulate the resources to exist in a hostile financial world. Therefore, a few organizations in most areas will control 80% to 90% of the healthcare. My own organization, Integris Health, in order to survive, will have to evolve as well. We are now the leading provider of cardiovascular services in metropolitan Oklahoma City. Certainly, if we believe that gene therapy will vanquish much heart disease, then we will have to adapt our facilities to stay financially viable.
To finance these new healthcare networks, we will probably see the beginnings of a universal payer system. We will see the government mandate performance reviews of practitioners based on continuing education, medical outcomes and cost-effectiveness. On the consumer side, citizens could be required to meet certain fitness and wellness standards, with a penalty for failure. The networks also will encompass not only providers and payers, but schools, factories, offices and homes. Everything will be connected.
Twenty years down the road, technology will have advanced so far that the major issues of the day will no longer be financial, structural or operational but ethical. That will require physicians to take a leadership role. As patients gain more and more information, compounding the ethical conundrum, only the best trained among us, notably the physicians, will have the capability to sort through the many dilemmas.
Those dilemmas will be especially profound as we address issues involving the beginning and end of life. As society is increasingly faced with the capability to genetically engineer certain characteristics, as well as predict the diseases an individual is likely to encounter, access to that information will test our ethical and legal boundaries. To attain the necessary sensitivities, physician education may have to be reworked. Doctors will need new skill sets, not only to help their patients but to help society in general work through the new ethical issues. As patients have more treatment options, many of them highly complicated, the decisionmaking also will become more complex. Doctors can count on spending much more time serving as guidance counselors and ombudsmen.
The hard wiring of communications systems will allow schools, offices, universities and retail outlets to all be places where medicine can be practiced and healing can take place. Our medical histories will be automated. Paper documents will disappear. Medical records will be just a few keystrokes away, no matter what the location.
While technology will profoundly affect the delivery of health services, many moral and ethical roadblocks to progress will be encountered. More than anything else, what threatens to restrain the promise of technology and medical discovery is our unbending focus on the individual over any rights of society, our tradition of retribution through the courts for any human failure and our inability to face death. The issues that will accompany the advances in science and technology into the year 2020 and beyond will grow exponentially. Addressing those issues will probably be the biggest challenge facing our evolving healthcare system in the new millennium.