The New Health Age: The Future of Health Care in America

yet.

Introduction

This book is about the future of health care and medicine in America. We have entered a new time, a period that we call The New Health Age. This new age will usher our country into a historically inevitable, transformative process, where the entire landscape of health care delivery and the practice of medicine will change significantly. It will be a time of struggle and exhilaration, as our country will again be called upon to rise up to greatness. The challenge is huge, but the results and probable outcomes are worth the commitment and effort. The returns on this investment and commitment will be staggeringly large and positive for our nation.

As we wrote this book, the debate regarding the future of America’s health care delivery system was politicized and largely driven by fear, uncertainty, and misinformation. No intelligent outcome can result if these limiting dynamics dominate and shape the debate surrounding health care. This book is not about advocating for or against any political platform or about taking a political side. Our greatest hope is that the book that you hold in your hands can provide an understanding of what lies ahead in The New Health Age and why this new age will occur, regardless of which political party may control federal, state, and local governments. The New Health Age will dawn irrespective of the swaying tides in Washington, D.C., and in every state capital city. We believe that the literal health of Americans and our very country are at stake and that it is essential to find a way to not only face but also embrace the inevitable changes rushing toward us.

We have tried to provide a large context for understanding so that all of us can begin with this challenge and opportunity better equipped to succeed as a country. In Part I, we first introduce you to The New Health Age. We then take a quick look back on the histories of medicine and health care delivery from the beginning of recorded history to the present day. Next, we look deeply into American health care as it exists today and look at what works, what doesn’t work, and why the continued success of our very country is at risk if certain systems and practices do not change.

The rest of the book is a look into the future. In Chapter 6, we examine the large contexts of the twenty-first century and the Shift Age,¹ a new age that David introduced to us in his Author’s Note for the present book. We describe the forces and dynamics that have reshaped and are reshaping our professional and personal lives as result of the Shift Age. We look at the medical breakthroughs just around the corner, as they are profound in their potential to alter how we view medicine, health care, and even life itself. Then, in Chapter 8, we point out that nearly 20 percent of America’s economy is connected to health care and that many of the dynamics and changes that Americans have already embraced and accepted in the other 80 percent of our economy will now simply be occurring within health care.

Part II of the book deals with nine dynamic flows—changes and transformational movements—that are historic and forceful and that are driving the major shifts that are occurring, or about to occur, within health care. We believe strongly that the dynamic flows enumerated in Chapters 9 through 12 are the forces that, once explained, can provide the conceptual context for deeper understanding of what will occur in The New Health Age. Many readers, particularly those who work in health care, will already be familiar with some of these dynamic flows, but by gaining a greater understanding of each of the nine flows, we as individuals and we as a nation will be better equipped for the changing landscape of The New Health Age. These dynamic flows became clear to us as we immersed ourselves in research, history, and an analysis of global, national, technological, and economic trends. Understand these flows and you will embrace and feel less threatened by what has begun. It is these flows that, if fully understood, will allow physicians and others in health care to see the pathways to continued, if not greater, economic and personal satisfaction through your daily work.

In Part III, we look forward. The transition that we are entering will be hard and must be considered a short-term investment in a bright, longer term outcome. We provide a detailed analysis of what the future health care delivery landscape will look like. We identify the new structures and institutions that will begin to dominate health care delivery in the years ahead. The understanding of these new shapes and processes will provide those who embrace them with a sense of personal, economic, and social opportunity and growth. We understand that policy, legislation, and education are all critical points to moving the country forward, so we include a chapter suggesting what legislators and educators need to think about and do to help create the opportunity for dramatic success and triumph over out-of-control, ever-escalating costs and a downward spiral of the health of Americans. We point out that it is time for all American citizens to accept greater responsibility for their own health. Not only must we become more knowledgeable about health, but we must also use this knowledge to all become healthier as that will be one of the key ways to lower our health care costs and improve our quality of life. There is even a larger case to be made that the Race to a Healthy America, as we call for in this book, is the national challenge and opportunity of our times. Finally, we look ahead to suggest what the future landscape of health care and medicine in America will look like in 2015, 2020, and 2025.

The road ahead will be difficult. It will be contentious. Yet, don’t despair; it will ultimately be truly transformative and inspirational. The necessary short-term investment of time, money, vision, and willpower can produce a long-term return for America that for many is currently incredibly difficult to see. We fervently hope that reading this book will provide the reader with the tools, thoughts, and understanding to see this future more clearly.

Let us all begin. Welcome to The New Health Age!

Part I

History and Context

1

The New Health Age

We live in a moment of history where change is so speeded up that we begin to see the present only when it is already disappearing.

—R. D. Laing

We live in a transformational time in the history of medicine and health care. The twenty-first century will be a time of dramatic change, incredible breakthroughs, and totally altered thinking about health, medicine, and health care delivery. The years to 2020 will be filled with changes in how Americans think about health, how medicine is practiced, and how health care is delivered. These years will set the stage for a 50-year period that will be viewed as The New Health Age. Future generations will look back and thank those of us alive today for what we accomplished and initiated in this brilliant new age.

Ages are defined by historians because true clarity of human process and social change that can only be documented and seen in hindsight. When looked at through the lens of history, major historical events become clear demarcations of human change.

Biographies are not written about the unborn. Gutenberg was just preoccupied with inventing the moveable type press; he was a printer. Only later was it clear that this invention disintermediated knowledge and launched the Age of Science. In the future, historians will look back upon the simultaneous forces—the new global technological and economic realities and dynamic flows discussed in this book—occurring today as the clear beginning of The New Health Age. We write this book to provide a clear view of this new age that we have entered.

What we now face is an altering of course that will be very difficult, but historically necessary and significant. Centuries of thinking, practices, and morality will be called into question. Legacy thinking and old habits will hold us back. Vested interests, acting out of fear and ignorance, if not greed, will resist change. The unknown can be scary. The different can be resisted simply because it is. Emotion can easily cloud clear thinking.

As this book is being written, the words health care provoke fear and are deeply colored by politics. The conversations around health care are filled with uncertainty, misinformation, and anxiety. In such a climate, it is hard to have intelligent, rational discussions. It is even harder to see the future because all the baggage of legacy thinking from the past and the heated emotions of the present completely cloud any clear view of the future. The purpose of this book is to provide an understanding of the directional flows of the practice of medicine and health care delivery and to present a vision of the probable future of health care and the transformative landscape of medicine that is just around the corner.

In this book, we attempt to explain the larger overarching dynamics and forces that are driving this transformation. We present the nine dynamic flows that are the fundamental underpinnings of all change in health care. Only through a high-level, macro perspective can the direction be seen. The view of the future of medicine and health care is beautiful and breathtaking in its possibilities and potential. Will we achieve perfection in health care? Of course not, but humanity has reached a new time after millennia of trial and error, discovery, death, disease, and the evolution of beliefs that have continually been trumped by subsequent better substantiated beliefs.

Only now can we truly enter into The New Health Age, the age that ancient myths have prepared us for. Living forever? No, but certainly the reality of life expectancy moving to 100 to 125 years old. A life free of disease? Well, closer than we have ever been before. A time when the medical profession gets paid based on the health and wellness it provides? Absolutely! A time when health care providers* embrace technology and innovation to deliver care better? Yes! A time when we can genetically engineer our species to improve health, intelligence, longevity, and performance? Yes! A time when the failure of body parts triggers replacement by superior parts? Yes! A time when all Americans can, will, and must live healthier lives? Yes! Yes! A time when health care providers can continue to thrive economically? Absolutely!

We hope to provide you with an understanding as to the direction we are going, what the benefits will be, why the health costs to society and taxpayers will go down, and how we can all benefit—economically, socially, institutionally, emotionally, physically, and psychologically. We will place the coming transformation of health care delivery within the larger context of the trends and forces that have, are, and will transform human society, economics, and life. It is only through this larger context that the transformation that is now beginning can be understood.

To those who are fearful, we hope to allay your fears. To those who have succeeded economically in the past, we hope to convince you that you can continue with this success. Indeed, a new game with new rules is upon us, but the opportunity to continue to succeed economically will still be a part of this new reality for people and organizations who choose to embrace it. To those who, in moments of private honesty, can admit general ignorance about health care reform, we hope to obliterate that ignorance with information, advice from experts, and explanations that will make you informed and ready to embrace The New Health Age.

In this book, our primary focus is on the United States. It is the richest country with the largest economy, yet many Americans continue to debate and question how the U.S. health care system should be organized and function. The time for unresolved discussion about the topic of health care in America is nearing an end. The time for resolution is now. The future of American health care is becoming clearer. As futurists, it is time for us to bring understanding and perspective to this process that has just begun. America must create a vision of the future that we can attain if we have the fortitude to move toward it.

Even though The New Health Age will be a new age for all humanity, this book addresses America’s health care system and the state of health in the United States. Despite our book’s national focus, make no mistake; the medical breakthroughs ahead have the potential to benefit everyone on the planet. The massive improvements ahead in health care delivery systems and in personal health will, we hope, be utilized by all countries. That said, inventions and breakthroughs take time to migrate across all strata of human society and they move through countries at different speeds. Some move slowly. Electricity was invented more than 100 years ago, but there are millions who live without it in their homes today. Some inventions and breakthroughs move quickly. Cell phones first became widely used in the 1980s. In 1985, there were only 700,000 cell phone subscribers. As this book was being written in 2011, there were an estimated 5 billion subscribers. We hope that all global citizens will be able to take advantage of The New Health Age quickly; however, history shows us that this may not be the case.

We will write to the future. We will write about the trends and forces that even now are moving us into the Shift Age, into the twenty-first century, and into The New Health Age.

First, we need to take a quick look back at the history of medicine and health care, because such knowledge is essential to understanding why we are where we are today and where we are going tomorrow. An understanding of the past is essential to grasp the dynamics of the present and to get a glimpse of the future.

KEY POINTS

We live in a transformational time in the history of medicine and health care.

The conversations around health care are filled with fear, uncertainty, misinformation, and anxiety. In such a climate, it is hard to have intelligent, rational discussions.

In this book, we will explain the larger overarching dynamics and forces that are driving this transformation.

Although perfection can rarely be obtained, the view of the future of medicine and health care is beautiful and breathtaking in its possibilities and potential.

*When we use the phrase health care provider(s) in the book, it is meant to be all inclusive because most of the book is written about the health care delivery system as a whole versus singling out any one group of professionals or organizations. A health care provider for purposes of this book is any individual or institution involved in the delivery of health care services, including physicians, physician assistants, nurses, physical therapists, counselors, hospitals, surgery centers, long-term care providers, hospices, pharmacists, device companies, and others.

2

A Quick Look Back at the History of Medicine

Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.

—Philipus A. Paracelsus

When placed within the hundreds of millennia of human existence on planet Earth, the history of medicine is incredibly brief. Learning about medicine from a historical perspective in a big picture way is extremely informative and offers valuable insights into modern health care as it exists now and as it continues to transform. This chapter walks us down the rapid path of medicine’s progression over the ages. As we examine medicine’s advancement, it becomes apparent that many aspects of medicine and health care today are deeply rooted in the events and traditions of the past.

Those of us alive today manifest the latest iteration of humanity, what anthropologists call Modern Man. Modern Man has been on this planet for approximately 150,000 years. Yet, it has only been in the last 4,500 years, or 3 percent of our time here, that there has been any real history of medicine. The scientific foundations of modern medicine have occurred in even less time, only in the last 150 years.

Much of what we know and experience as medicine and health care has come into being in the last one-tenth of 1 percent (0.1%) of our time on Earth in our current anthropological iteration. Health, wellness, and an ever-extending natural lifespan are very recent developments.

1. The ancient practices of medicine are rich with tradition, some of which continue to influence medicine today.

In ancient cultures, medicine and religion were significantly intertwined.¹ Illness was frequently attributed to demons, witches, astral influences, or the will of the gods.² Although some of these views continue to retain some influence (consider faith-based healing centers), the rise of scientific medicine over the past millennium has altered or replaced most of the historical mystical notions surrounding health care.³

The earliest documented medical care existed in Egyptian religious temples, where leaders provided basic treatments and cures to the sick.⁴ In ancient Greece, temples dedicated to the healer-god Asclepius also opened their sacred doors to the ill.⁵ The ancient Greeks slept and waited patiently in their temples for dreams to reveal diagnoses and treatments.⁶ Dreams were perceived as vehicles for deities to communicate with their followers on earth.⁷

Dating from approximately 1000 BC, the Atharvaveda, a sacred text of Hinduism, is one of the first Indian manuscripts to discuss medicine. Rooted in ancient Eastern cultures, the Atharvaveda contains herbal prescriptions for various ailments.⁸ In the first millennium BC, the literate and scholarly Indian system of medicine known as Ayurveda emerged.⁹ The foundations of Ayurveda are a synthesis of traditional herbal practices, combined with a vast array of theoretical conceptualizations, dating from about 400 BC onward. The Ayurveda was birthed out of communities of Indian thinkers, with heavy influences from Buddhism.¹⁰

Ancient Chinese medical knowledge and practices also contributed heavily to medicine’s evolution.¹¹ Much of Chinese medicine originated from empirical observations of disease and illness by Taoist physicians and reflects the classical Chinese belief that human experiences are an expression of causative principles originating from one’s surrounding environment, at various levels. These causative principles, whether mystical, essential, or material, correlate as the expression of the natural order of the universe.

According to ancient Chinese philosophy, the human body is governed by Chi, or Qi, which can be translated to mean breath, air, energy, spirit or fluid, or life force.¹² The Chi is made up of the Yin and the Yang, two counterbalanced energy forces.¹³ When Yin and Yang are in perfect balance, peace, well-being, and health are the result.¹⁴ An imbalance of the Chi causes disease and poor health.¹⁵

As early as approximately 2700 BC, the intricate and admired practice of Chinese acupuncture had identified pressure points in the human body considered crucial for the healing process.¹⁶ Chinese physicians of the day believed that manipulation of the body’s pressure points could treat most diseases.¹⁷

2. A quick snapshot of the history of medicine demonstrates how far humanity has progressed over the centuries.

The following abbreviated snapshot outlining the history of medicine is by no means exhaustive, but it nonetheless shows how far we have come. Thousands of breakthroughs, inventions, and new practices have occurred just in the last few centuries. The following timeline demonstrates that medicine, as a part of the fabric of human society, is a mostly recent phenomenon.

The most striking aspect of this timeline is the rapid acceleration of medical advancements during the twentieth century and into the twenty-first century. Modern medicine has essentially come into being over the last 150 years. Although each medical advance has been remarkable in its own right, several developments were true game changers for humanity.

The discovery of germs and bacteria radically changed how health care providers treated infections. Nurses would no longer move from soldier to soldier using the same sponges and water to clean patients’ wounds in battlefield hospital tents. The invention of the X-ray gave physicians the ability to diagnose problems within the skeletal system and soft tissues. Vaccines eradicated horrific diseases that had previously killed or handicapped millions. With the invention of antibiotics, bacterial infection, as a cause of death, plummeted. Between 1944 and 1972, human life expectancy increased by eight years.⁴⁵ Such a large increase in life expectancy is largely credited to the introduction of antibiotics.⁴⁶ Humanity is just beginning to grasp the magnitude of the recently concluded Human Genome Project, which resulted in the identification of all human genes. Genes carry the instructions for the production of fundamental proteins that determine, among other things, how we look, how well our bodies metabolize food and fight infections, and sometimes even how we behave. Now that we have identified all human genes, the possible applications of this knowledge are virtually endless.

As we continue into the first part of the twenty-first century, new and exciting medical discoveries are continuously being integrated into our daily lives. It is a fabulous time to be alive as expanded medical knowledge, improved diagnostic capabilities, and enhanced disease treatments bring about a new era of health in the world.

3. Advancements in medical technology accompanied humanity’s rapid growth in medical knowledge.

During the eighteenth century, physicians primarily used manual techniques to diagnose patients and study cadavers. It wasn’t until the nineteenth century that the use of technology expanded and grew within health care and became an integral aspect of practicing medicine.

In the first half of the nineteenth century, certain inventions in medical technology, including the stethoscope, ophthalmoscope, and laryngoscope, transformed health care.⁴⁷ After the development of these devices, physicians were better able to see and hear critical parts of their patients’ bodies, such as the eyes, lungs, and heart. Herisson’s sphygmomanometer, developed in 1835, measured blood pressure.⁴⁸ In 1846, doctors put Hutchinson’s device for measuring the vital capacity of the lungs into use.⁴⁹

Today, the U.S. medical device and equipment market is incredibly innovative and the largest in the world.⁵⁰ The market is highly advanced and very competitive and was estimated at $94.4 billion in 2010.⁵¹ Critical medical devices, implants, and equipment in use today include cardiac defibrillators (external and internal), pacemakers, stents, numerous orthopedic items, ventilators, diagnostic imaging, surgical drills, electronic thermometers, and ultrasonic nebulizers, just to name a few.

Prosthetics and orthotics have also transformed health care over the ages. Prosthetics have been mentioned since circa 440 BC when the Greek historian Herodotus wrote an account of Hegistratus, a Persian soldier, who was reported to have severed his own foot to escape his captors and then replaced it later with a wooden limb.⁵² In recent years, significant advancements have occurred with artificial limbs and prosthetic implants.⁵³ New plastics and other materials, such as carbon steel, have made artificial limbs stronger and lighter, decreasing the amount of extra energy required to operate the limb.⁵⁴ The use of modern materials also means that artificial limbs look much more realistic.⁵⁵ Following major surgeries, such as hip replacements, patients can literally walk out of the hospital and go home, while continuing with some outpatient physical therapy.

4. Over the centuries, the practice of medicine and treatment of health care conditions have become increasingly interconnected and dependent upon pharmaceuticals.

The pharmaceutical industry was born because of the growth in the number of drugs and their increasing importance in the practice of medicine. The earliest pharmacy, or drugstore, dates back to the Middle Ages. Pharmacists in Baghdad opened the first known drugstore in 754 AD.⁵⁶ By the nineteenth century, drugstores had expanded and progressed into the traditional notion of a pharmaceutical company. In fact, many of the major pharmaceutical companies that still exist today, such as Pfizer⁵⁷ and Eli Lilly,⁵⁸ were founded in the late nineteenth century.

By the 1940s, following the discoveries of penicillin and insulin, drug companies manufactured pharmaceuticals in massive quantities and distributed them throughout the world. During the 1950s and 1960s, more drugs were developed, including the first oral contraceptive, known as the Pill, as well as blood-pressure drugs, cortisone, and various psychiatric medications. Valium (diazepam), discovered and marketed in the 1960s, became one of the most prescribed drugs in history.

The pharmaceutical industry experienced explosive growth in the second half of the twentieth century due to the increased understanding of human biology and sophisticated manufacturing techniques. As the concept of managed care spread rapidly during the 1980s, efforts were focused at containing rising medical costs through the development of more medications targeted at disease prevention and maintenance, such as Procardia for angina and hypertension⁵⁹ and Humulin, a form of biosynthetic insulin used to treat diabetes.⁶⁰ Advanced and efficient distribution and supply chains were developed that further promoted the industry’s rapid growth.

The 1990s continued to bring change to the pharma industry, with new marketing outlets such as the Internet and television. The Internet enabled consumers to purchase drugs more easily. Direct-to-consumer advertising proliferated on radio and television. In 1990, pharmaceutical companies spent an estimated $47 million on direct-to-consumer advertising. In 2001, such spending climbed to $2.7 billion,⁶¹ a more than 50-fold increase in a little over 10 years.

In 2011, projected global pharmaceutical sales will likely top $880 billion.⁶² United States’ sales will be in the range of $310 billion, which will represent more than one-third of the total.⁶³ At these sales amounts, America will continue to retain its position as the largest pharma market in the world.⁶⁴ At $310 billion, drugs comprise a major component of America’s spending on health care.⁶⁵

Looking back, pharmaceuticals have cured or treated countless diseases and health conditions and have changed the face of health care across the globe. New drugs are being developed constantly in an effort to chase and discover the next miracle. Today, drugs are an integral component of modern society, which has enabled the pharmaceutical industry to amass great power and influence economically, politically, and socially in America.

Significant medical advancement applicable to the human race is a relatively recent development in humanity’s time on Earth. Modern medicine is less than two centuries old. By looking back at the history of medicine, we see how far we have come and can better appreciate how the pace of inventions, discoveries, and breakthroughs is accelerating.

Next, let’s examine how the health care profession and delivery systems have evolved.

KEY POINTS

The human history of medicine is a recent one.

The world of modern medicine that we live in today started in the Industrial Age some 150 years ago.

Advancements in medical technology accompanied the breakthroughs of modern medicine.

Although pharmaceuticals had humble beginnings, today drugs are an integral component of modern society, which has enabled the pharmaceutical industry to amass great power and influence economically, politically, and socially in America.

The speed of invention, discoveries, and breakthroughs is accelerating.

3

A Quick History of Health Care Delivery and Payment Systems

He’s the best physician that knows the worthlessness of the most medicines.

—Benjamin Franklin

Health care delivery has its own unique history and humble beginnings. Knowledge of the roots of health care delivery is critical to setting the framework for understanding where health care is today and where it is going tomorrow.

Over the centuries, health care professions, delivery systems, and institutions developed and grew as advancements in medicine emerged. To understand how isolated scientific