Introduction
No medical specialty has come so far so fast as hospital-based medicine. In little more than a decade the number of general internists specializing in hospital-based medicine (ie, hospitalists) has grown to include more than 30,000. Hospitalists find themselves at the center of change in healthcare delivery and are key architects of the redesign of acute care to improve quality, safety, and cost-effectiveness. How will the environment of healthcare evolve over the next 10 years, and what will this mean for hospitalists and the patients and institutions they serve?
Although one cannot predict the future, one can think systematically about it. Futurists try to combine analysis and imagination to think through how the future may unfold. A critical tool is to identify the key forces that are, singly and in combination, creating change and shaping the future environment. They are the major trends or directions that can be seen emerging, and their forward progress or lack of it can be analyzed. At the same time, the future can be shifted radically by particular events; for example, 9/11, the economic meltdown of late 2008, the passage of health reform legislation are all events that radically shifted the direction of history. Such event-driven discontinuities are notoriously difficult to predict and are often difficult even to speculate about. Futurists use scenario approaches to describe the range of uncertainty and create plausible stories of how the future unfolds. This chapter describes a series of driving forces that will have direct and indirect effects on the hospitalist field: the quest for value in healthcare, the economic dislocation of the recession, and broader health reform.
Key Driving Forces
There are several key driving forces that will shape the future of healthcare no matter what. Each of these driving forces create strategic issues for hospitalists and the organizations and patients they serve.
Health systems around the world are struggling with the same issues. Aging populations, savvy patients demanding cutting-edge technology, and the need for timely and easy access to services, all of this against a backdrop of payers (whether government, employers, or individual patients) struggling to afford ever rising costs. While cost containment is the permanent ongoing work of many health systems around the world, the focus is increasingly on creating value, not just reducing costs. Health systems around the world, each in their own way, are trying to create as much value as possible. It is a simple equation to write, but it is difficult to optimize:
Where
- Access = access to services enabled through insurance coverage, as well as timely and geographically proximate availability of healthcare services.
- Quality = superior health outcomes enabled by cutting-edge technology, evidence-based care, and responsive customer service.
- Security of benefits = assurance that health insurance benefits (and thus healthcare services) will be available when needed and that benefits cannot be taken away or lost because of change in job status, change in health status, or age.
Every health system around the world is an ugly compromise around this equation. Some systems, like that of the United Kingdom, curtail access to cutting edge technology by slowing the adoption of expensive and marginally effective medical technologies, placing greater emphasis on universal access and encouraging active utilization of primary care and preventive services. The United States, in contrast, has placed much higher emphasis on quality of inputs: high technology, well-trained professionals, modern facilities, and entrepreneurial institutions competing on innovative interventionalist approaches to disease care, rather than emphasizing care coordination, universal access, or primary care approaches.
There is no perfect system. But it is becoming increasingly clear that the United States has struck a very expensive bargain; it has been well documented in a series of studies that the United States spends more than all other health systems, and by many measures gets less health status improvement, than many other systems. This is not the venue in which to explore the reasons for wide differences in comparative performance between countries or within countries; suffice it to say that all health systems will be under increasing pressure to deliver higher performance per dollar, euro, pound, or yen. This places an enormous responsibility on those who design care processes to make the care of patients as efficient, effective, and appropriate as possible.
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Economic Dislocation and the Impact on Hospitals
Recent economic dislocation has changed the economics of healthcare and dramatically affected the financial challenges facing American hospitals. Many believed that healthcare would be immune to the effects of a worldwide economic storm, but there have been major impacts, and they will continue to affect the landscape of hospitals for some time to come. There are a number of key impacts from the recent economic downturn of 2008–09:
