Moving forward from the current system

Any consideration of a change in the status quo needs to consider the tradeoff among three competing objectives in the healthcare system. This is fundamentally the tradeoff among coverage for basic services, ethical consideration of the guaranteed benefits at each stage of life, and national interest, limiting universal coverage to basic services while providing the opportunity for private enterprise to innovate new value added services beyond basic coverage, such as into incentivized wellness programs to combat costly chronic diseases of aging rather than goverment coercion to achieve this, reported recently in Japan for metabolic disease.

The current system has evolved from the post-World War II integration of civilian and military medical technologies, preserving secrecy in those areas which are in the national interest. So while delivery of care by individual doctors is fairly standardized by practice guidelines, the institutional structure such as hospitals are a combination of market driven procedures that can be competitively priced and government run services which constitute an overhead burden.

This places some limits on how flexible the overall system is to a change in business models. Business model innovation will be an important factor in driving down costs and adding more value in outcomes per dollar spent, but can only be applied in certain areas of the healthcare system that are unconstrained by national policy. The idea that any change leads in the direction of socialized medicine and a single payer model is a fallacy. There are several possible trajectories that this can take depending on which constituencies are more highly valued. For example, in a scenario planning exercise we can imagine different future outcomes based on the primary and secondary forces influencing the environment, such as the federal and state budget upsides or downsides, federalism versus state or local control, and corporatism versus cooperative or non-profit delivery structure. What we need is a 10 to 15 year roadmap with sensitivity analysis based on these different environmental factors.

We are assuming that the major improvements we are seeking are increased coverage, lower cost per capita, and regional quality benchmarks within the constraints of the financial impact that can be tolerated in the budgets over the period of re-engineering of the system. We want a "seamless system" enabled by information technology, while maintaining individual privacy and choice. Our model should explicitly include the redistribution of revenues that could be shifted from one sector to another if we successfully address the major cost barriers anticipated by prevalence of disease and demographics. Government's role is to force the parties to the table to negotiate these redistributions so that resources reallocations are not blocked by vested interests.

The least desirable outcome is for immediate adoption or expansion of a government run program that limits the possible trajectories the system evolution could take given introduction of new technologies and business models. Interests that already have a substantial amount of control such as corporations, could easily railroad the process to gain more control over the system, to the detriment of the both the richness of service offerings and the freedom of individuals to control their own destiny within the system. What began as a military-industrial complex, could either become more centralized or more responsive to individual health issues. The dream of personalized medicine centered around the individual and enabled by new technologies with highly leveraged outcomes can only take place if we make choices as a society around the financial constraints imposed by the aging process itself and what measures are the minimal safety net for a particular stage of life.