Health care in the 21st century

We are about to complete a century and a millennium. We are at the end of an old era and the beginning of a new one. The old world is coming to an end. A new world is about to appear on the horizon. We live in an in-between period, a zone of rapid transition. The next half decade represents a high leverage window of opportunity. What we do in the next five years will cast a shadow for the next 100 years. What a time to be alive and in health care!

Our five-year zone of transition will be characterized by chaos. The old must fall apart in order to free up the energy needed to build the new. Crisis precedes consciousness on a personal level. Chaos precedes creation on a global level. As old habits, old traditions, and old ways of thinking fail, the way is prepared for the new to assume its rightful place in the evolution of our planet. Health care professionals are challenged to use their collective imagination to pattern chaos and create cosmos. We want the probability wave to collapse in the area of our best-held dreams and visions of a better world and a healthier community.

You hear about the need for welfare reform. Then you are advised of the necessity of health care reform. You read about the crisis in higher education and the need for educational reform. With all of these calls ringing in your ears, someone pleads for reform of our criminal justice system. Soon you have the idea. We must reform everything. We do not have a single human institution that works well enough to take us into the next century. Reform from the top down will never be successful. The only effective reform is from the bottom up. Empowered local communities must assume responsibility for their health, welfare, education, and economic well-being. There are no solutions coming from the federal government or the state governments.

Problems must be solved where they are being generated and that is at the local level. When the hospital board of trustees or the clinic board owns the disease in its community, it can begin to transform it. You can only transform what you own. If you think the problem is someone else's responsibility, you are disempowered to do anything about it. The future is about self-empowered, self-sufficient communities that own their disease, poverty, ignorance, and crime and are therefore empowered to transform these negative qualities into health, economic well-being, insight, and moral citizenship.

The physician plays an increasingly important role in societal transformation. Three stages characterize the natural evolution of a physician's career: (1) physician as clinician, (2) physician as executive, and (3) physician as community developer. Healthy patients, healthy organizations, and healthy communities constitute the basic building blocks of a healthy future society. Now is the time for physicians to become architects of healthy organizations and healthy communities. With experience in patient care, health care delivery organizations, and healthy communities, physicians are logical architects of a healthier America.

As Kevin Kelly points out in Out of Control, we are about to witness the emergence of a neobiological society in America. Have you ever wondered why natural systems work and human systems don't? Animal systems work, plant systems work, planetary systems work, and galactic systems work. But welfare, education, health care, and law enforcement don't work very well. Perhaps the answer is simple. If we structured human systems the same way natural systems are structured, they might work. What would happen if we structured a human community in the same manner the human body is structured? Here the physician has a natural advantage because of professional education. He or she is an expert in the workings of the human organism. How about taking that knowledge and applying it to human communities?

If your brain was connected the same way your community is connected, you could not get up off your chair. A simple rule for the future is "connectivity equals consciousness." Connect your brain cells correctly and you are conscious. Connect organizational members and the organization becomes conscious. Connect community members and the community becomes conscious of itself, its needs, and its current inventory of resources to meet those identified needs. The problem with contemporary American communities is their lack of connectivity. The community-based physician must work with others to connect all the organizations, families, and members of a community in order to become a self-directed, self-conscious, healthy community. We might call this population-based medicine, the key to successful capitated managed care.

One cell meets another cell, and they declare, "Together we could tango," and, behold, the possibility for a multicellular organism is born. One health care organization meets another health care organization, and they agree, "Together we could tango," and the possibility for an integrated delivery network is born. In nature, all forms of life are structured from the bottom up. We have no example of top-down structuring. Structure is developed only as needed, and all higher levels of structure subsume the lower levels of structure. In contemporary health care delivery we do just the opposite. If we want to enter a new market, we send in the corporate staff, build a corporate office building, start buying up physician practices, and throw millions of dollars at the marketplace. This is top-down structuring at its worst.

A bottom-up strategy would ask, "Where is there someone with an unmet health need?" Well, you would have to go out and look. Then the next question, "Where is there someone who could meet that need?" You would have to have a list of potential providers. Then the third and last question, "How do I get these two folks together?" Do you sense the difference between the top-down and bottom-up approaches? Remember, in nature we have no examples of top-down approaches. Perhaps there is a lesson for us here.

In the next five years, we will discover the power of bottom-up reform in empowered communities. In the future, many communities will own their health insurance plans. They will collect the premiums from the enrolled population. They will spend the premiums as needed on various health care providers. A large portion of any remaining profits at year's end will be returned to the community to help those still in need. Dollars will not leave the community and gravitate to Wall Street while children in the community go without basic health services.

Communities, in turn, will network with one another for purposes of shared capital, shared risk, insurance products, computer systems, etc. Profit earned by the network will be returned to the communities on a proportionate share basis. In a network, both the individual and the group are simultaneously maximized. A good regional network is a unity of a diversity, just as with cells in the human body. A group of rural hospitals networking can raise the capital, share the risk, and share the human resources needed to improve well-being in all of their communities.

What will happen to the large investor-owned health providers trying to dominate our current marketplace? When there is little left to buy and profit margins decrease because of managed care and reduced Medicare and Medicaid margins, they will not be able to appease their stockholders and they will ultimately fail. The for-profit (investor-owned or tax-paying) industry is opportunistic. It comes and goes with the fortunes of Wall Street. A lot of communities will be left holding the bag when the for-profits fail. The not-for-profits (community-oriented or tax-exempt) will then have to come in and pick up the pieces.

Although economic failure is the primary reason for the coming demise of the investor-owned health care industry, another factor will also play a strong secondary role as we enter the 21st Century--the emerging spiritual renewal of America with a return to family and community values. We will see the rise of "spiritual politics" and "spiritual economics" within the first decade of the next century. Spiritual politics can be defined as "empowering a community through its value choices." Spiritual economics is best defined as "sharing our abundance." Both will play a major role in reshaping American health care.

When community-oriented hospitals live their values and reach out to serve their communities in a selfless manner, communities will choose them over investor-owned facilities that are designed to serve their shareholders. However, the burden of proof is on community-oriented hospitals to empower their communities to make value choices. Sharing their abundance is best done when the community-oriented hospital tithes its increase and contributes the money to meet unmet community health needs. There is never an isomorphic (same shape) relationship between health needs and reimbursement policies of third-party payers. In fact, most of the things needed to improve the health status of a population are, by explicit policy, not reimbursable by third parties.

The hospital or clinic, therefore, must share its abundance in order to fulfill its charter as a guardian of the community's health. The investor-owned facility is under no such community obligation. It makes its contribution to community well-being in the form of taxes paid to local, state, and federal governments. Much of the money paid does not find its way back into the health system of the community.

America will be the first nation in recorded history to achieve self-consciousness. This will occur by the middle of the 21st Century. Historical nations were unconscious of themselves. Contemporary nations suffer the same limitation. Imagine going back in a time machine to the ancient Aztec empire where a high priest is about to rip the heart out of a sacrificial victim. Imagine saying to the priest, "Do you know you are making up all this stuff? Your civilization and your religion are simply social inventions. They are figments of your imagination. They have no reality except the reality you give them. They are simply shared delusions. And, another thing, while we are having this conversation, the act you are about to perform is not good for the health and well-being of this individual." I doubt the priest would understand what you are talking about. He believes in his system and thinks it comes from the gods. In fact, as a result of your conversation, you might be placed next in the sacrificial line.

With the insights of postmodernism, we are discovering that social reality is a human invention. It is what we say it is. How could it be any other? We are the mythmakers. We are the inventors of our world. We can create a heaven or a hell. We can make the earth blossom forth in all of its beauty or we can destroy the planet. With this understanding of our co-creative abilities comes planetary consciousness.

Planetary consciousness will be greatly aided by the Internet and the new information highways. Here again, it is global connectivity that creates planetary awareness. With our new consciousness we will be able to create intentional people, intentional organizations, and intentional communities. We will assume our rightful place as planetary designers and move the earth toward its status as a designer planet. Our "solution" to most of our social problems occurs too far downstream. It is often too late to "fix it" when it arrives in the emergency department or the divorce court. We must move upstream.

How much ignorance, crime, poverty, and disease can be designed out of a population? We don't have any idea. But we are about to find out. No nation can afford the amount of disease it is generating. Communities no longer want to adapt to the amount of crime they are experiencing. It is time to assume a design ethic and take charge of our communities and our world. Health care should lead this effort. The local hospital, clinic, or insurance company should invite the conversation and invoke the possibility. We are the designers of the planet earth, but design must begin in each of our local communities. It is not possible to be healthy in an unhealthy environment. The future of health care is habitat redesign. Healthy environments produce healthy people. Health is an outcome behavior. It happens when everything else is working in the community. There is a direct relationship between health, education, law enforcement, welfare, transportation, housing, economic development, open space planning, etc.

Our 21st Century health care system will be decentralized throughout the community and will be present in workplaces, churches, schools, and neighborhoods, as well as available in hospitals, clinics, and doctor's offices. An attempt will be made to take services to where the people are rather than expect people to find the services. The hospital without walls will become a reality. The word "hospital" will no longer refer to a place but rather to a geographic area.

Deinstitutionalization and decentralization require electronic integration. Community health information networks will become the norm where there are multiple community health care providers. The electronic medical record will be a necessary feature of all regional integrated delivery systems. Eventually, a single medical record will be required for all U.S. citizens.

Where will the resources come from to redesign society and improve the health and well-being of all Americans? The answer is in the making. The single greatest untapped resource consists of the gift economy, which at present is not even figured into the GNP. America will be transformed by volunteers. We don't have enough paid professionals to do the job, and, even if we had sufficient people, we don't have enough dollars to pay them. Instead we will be calling upon our volunteer sector. We now have millions of retired people with a lifetime of experience and 20-30 years to live after retirement. We will invite these people to "gift" their time and talents for community betterment. In addition, working people will be invited to tithe their time as well.

Every community already has all the people and all the resources needed to improve its health status. All that is required is a change of mind. A change of mind is a change of community. Even now, free clinics throughout the country, staffed by volunteer physicians, dentists, nurses, social workers, and community volunteers, are providing a large amount of health care to underserved populations. With the threatened cutbacks in government-sponsored health programs, the number of needy citizens will increase. Increased taxation cannot meet this challenge. Volunteers can and will provide the solution.

To improve the health status of a population, each household must be visited. This requires a massive community visitation program that is beyond the financial capacity of most of our health care institutions. Hospitals will expand their 55+ clubs to become Centers for Creative Saging (Aging). Prolongevity will be the featured program for senior members of the community. Seniors will come for free health services, educational programs, and life potentiation. Existing and dormant talents will be identified. A lifework plan that is designed to generate high zest and vitality will be the objective of the Center. Although these services are free, all the members will be invited to volunteer their talents and abilities as part of their program for life enhancement. Plumbers, carpenters, and electricians will go to neighborhoods needing rehabilitation and provide their services. Retired physicians, dentists, nurses, and social workers will staff the free clinics. Retired school teachers will assist in the schools. From the pool of volunteers, mentors will be chosen for children experiencing special difficulties in their lives. America will discover it has all the resources it needs to move with confidence into the next century.

As the pressure to reduce costs continues, alternative and complementary medicine will take its place alongside allopathic medicine to create integrated medical clinics and health centers. Complementary medicine will supplement allopathic interventions. In suitable cases, alternative medicine will be used instead of allopathic intervention. Because complementary and alternative medicine have major preventive advantages as well as curative outcomes, they will become therapies of choice unless contraindicated or in cases where the allopathic intervention is clearly the best choice. The cost of insurance premiums will be reduced 15-20 percent as a result of implementing nontraditional therapies.

Wellness centers and self-care play prominently into this same picture. Self-care has the potential to reduce visits to primary care physicians by as much as 50 percent. The full power of self-care will be realized as nurses with well-designed primary care computer programs reach into homes and work with family members. Eventually, case managers will be assigned on a population basis. Each case manager will be assigned a thousand or more families and will track the health status of each family member. As the hospital or clinic continues to move toward the community, half of the employees that were formerly institution-based will become community-based.

Physician executives can benefit from all of these changes. Many physicians will seek additional training in population medicine, community development, operation of wellness centers, alternative and complementary medicine, demand reduction, and self-care. New jobs for physicians will be created as quickly as old jobs disappear. The future is only a threat to physicians attempting to resist change. Society is offering an open invitation to doctors to become the architects of our future health care system. There has never been a better time for imagination and creative challenge. The world will never be the same again. It could be better. It will be better if we fulfill our own visions and prophecies.

Our greatest challenge as we move toward the 21st Century will be reframing American medicine and the associated hospital industry. Health care providers will move from a disease orientation to a health orientation. The new system will be population-driven rather than patient-driven. Physicians will be paid to keep people healthy and will lose money if people become sick. Emphasis in the industry will evolve from treatment, to prevention, to potentiation. A healthy community will be a place where every person has an opportunity to: (1) realize his or her full potential as a physical, emotional, mental, and spiritual being and (2) contribute to community betterment. Senior citizens and students will join together in an effort to design a healthier society. By the end of the century the gift economy will be larger than the money economy. Spiritual values will have replaced monetary values in the marketplace, and people will have learned to assume responsibility for their own soul evolution.

If all of this sounds like a tall order, it isn't. All that is required is "attention shifting." Wherever your attention is focused, that creates your reality. Changing the focus of your attention changes your experienced reality. Too many health professionals hide in their offices, safely insulated from health problems in their communities. When trustees learn you can't govern an institution from the board room, and doctors learn you can't substantially improve a community's health from the exam room, and hospital administrators learn you can't manage the population's health status from the administrative suite, we are nearly there.

What is needed is a "community plunge," where we get on the bus and visit the neighborhoods in our service area and learn about the problems first hand. Then we come back changed, and soon those changes in consciousness are evident in the institution's strategic plan and budget. By beholding, we become changed. Every health care professional needs to spend time going door-to-door talking with families in his or her service area. Many unsolved problems of racism, prejudice, and ill will can be solved through genuine human contacts made in good faith with an invitation to partnering in the effort to improve the neighborhood's health.

Whole system thinking is the paradigm of the future. Everything is connected to everything. In our universe, nothing stands alone. Change one thing, and you change everything. Our challenge in the next five years is to get out of our boxes, cross our boundaries, and remove the lines that have become barriers to community problem solving and understanding. Several exemplary hospitals in this country are constructing "bridge programs" to other community subsystems that influence health. Bridge programs now exist with public health, police departments, churches, schools, recreation districts, housing, transportation, and welfare departments. Medical clinics have been slower to understand their role as community citizens.

Reality is one thing, happening everywhere at once. Different disciplines simply use different words to describe the same thing. Building a healthier community requires skill in learning different language systems. The physician executive functioning as a community-based physician must learn many new languages. General systems theory and quantum physics offer metalanguage capability and should be recommended to all community agencies.

The universe is multidimensional. Therefore, there are alternative realities and parallel futures. The high probability future is what is most likely to happen if we continue going along as we are now. The preferable future is a more desirable future that we could have if we are willing to work for it. Much of what I have discussed in this article is the preferable future. It is one I see when I look into my crystal ball. However, it does not have to happen. Indeed if you look at all the greed and materialism now manifesting in the health care marketplace, you might despair of ever seeing anything better. Take heart, things are about to change. By volunteering yourself, you can make the change happen just a little faster in your part of the health care world.

Leland R. Kaiser, PhD, is President, Kaiser & Associates, Brighton, Colo. He is a long-time member of the American College of Physician Executives faculty and a frequent contributor to Physician Executive and other College publishing initiatives. He can be reached at P.O. Box 339, Brighton, Colo. 80601, 303/659-8814.

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