Future Now
The IFTF Blog
Interview Summary - Dr. David Lawrence, May 15, 2009
HC2020 Interview Summary: Dr. David Lawrence
Interviewer: Richard * Date: May 15, 2009
1. His/her work
He was trained as an MD, with a specialty in preventive medicine.
He worked internationally, was on the Public Health faculty at the
University of Washington, was head of the Department of Health
for the city of Portland, OR, before joining Kaiser. He became
CEO of Kaiser Foundation Health Plan, Inc. and Kaiser Foundation
Hospitals, Northern California in 2001 and Chairman in 1992;
retired in 2002.
Since then he has been teaching at the Estes Park Institute
(which provides continuing education for hospital execs) and
at the Kennedy School at Harvard. Been studying different aspects
of healthcare – predictive healthcare, consumer health ecosystems.
Has just written a chapter on our current healthcare system for a
book on applying industrial engineering to health care delivery.
TRENDS/CHALLENGES
2. How optimistic about future of health/healthcare in 2020?
He is neither optimistic or pessimistic – but “curious” about
what will happen. What is going on in health care today is
unprecedented – so many different forces at work that it’s
difficult to predict what will happen.
3-4. Biggest trends or challenges & responses
1. The most obvious trend is the challenge to the traditional
physician culture in which the doctor is sovereign. According
to Paul Starr (The Social Transformation of American Medicine,
1984), our current system is the result of the struggle in the
first third of the 20th century that established the “dominant
culture of healthcare” – the physician at the top of the hierarchy,
fee for service payments, etc. In this system, the physician is
autonomous and innately skeptical of the work of anyone else;
diagnosis by “skilled practitioners” is intuitive. Overall, there as
a “strong anti-organization bias.” As a result, there are few
integrated multi-specialty groups (which are based on collaboration);
little development of IT use (which requires transparency and
standardization)
This model of care delivery is now obsolete, but it remains a
powerful “restraining force” on change.
2. The rapidly growing impact of medical science R&D. According
to Ralph Snyderman (former Chancellor for Health Affairs at Duke
University; founder of Proventys Inc), from 1950 to 2000, total
spending on medical R&D was about $1 trillion. He expects
that medical R&D spending from 2000 to 2010 will also equal $1
trillion. The result is a “tsunami of scientific advances” that can
transform health care. We are seeing important advances in
epidemiology, our understanding of the social determinents of
health, biotech, miniaturization, genomics, etc.
The result is a growing conflict between the traditional culture
of autonomy of physicians and the promise of “predictive/empirical
medicine.”
3. Demographic shifts – including:
1) The aging of the population;
2) Overall population growth: the U.S. population is growing
faster than that of any other developed country, projected to
reach 439 million by 2050. We can’t train or import enough
doctors to serve all of these people under the traditional model
of education and practice. Need to improve productivity.
3) Growing diversity of the population: the U.S. now has
the highest percentage of people born outside the country
since 1912. Four states – Texas, New Mexico, California
and Hawaii – now are “minority-majority” states.
More than 50% of all children in the country are minorities.1
According to a linguist at UCLA, there are 224 distinct languages
poken in the LA Basin and news publications in 180 different
languages. How will health care respond to this diversity?
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The impact of these trends will be manifest in a series of
battles over the future shape of the health care system:
1. Conflict inside the traditional healthcare system between
the design imperatives of new scientific medicine and the
cultural bias for autonomy for doctors. This conflict has
already shown up in the efforts to establish “integrated
systems” that have not gained much traction. What gets
integrated are business functions, but not the actual delivery
and coordination of care. It is not possible to fully realize
the benefits of new science in the existing system.
2. Battle between “traditional sick care” and the emerging
consumer-oriented health system. Being driven by technology
that enables diagnoses and treatments to be delivered in new
ways, and by consumer demand for convenience and affordability.
THE TRADITIONAL SICK CARE SYSTEM IS BEING BLOWN APART
BY THE CONSUMER HEALTH ECOSYSTEM.
The fastest growing area of spending is on alternative medical care.
3. Battle over control of the rate and scope of innovation. Everything
that is in the core sick care system is being attacked. Costs of the
traditional system that it has created an ideal environment for
innovation – to provide care more efficiently. There is an open
question about whether current efforts at health care reform will
constrain innovation. Will healthcare go offshore?
4. [More long term]: Shift from current paradigm of treatment to
new paradigm of personalized/predictive medicine – shifting
from care based on phenotypes (“The observable physical or
biochemical characteristics of an organism”) to diagnosis and
treatment on the molecular level. This is a huge shift.
There is a huge capital investment in “phenotypic health
management” – i.e., diagnosis based on detection of symptoms
of disease. New paradigm will make many current forms of
care obsolete (See 2008 Learning Healthcare System Concepts
v.2008 – report of the IOM Roundtable on Evidence-Based Medicine)
Result is we are developing a more precise understanding of
diseases on a molecular level: We are beginning to link specific
genes and proteins to specific disease states – developing
the ability to identify “proteomic pathways” that develop BEFORE
a disease is manifest. We will have the ability to “watch how
molecules work in the body.”
As this knowledge grows, it turns medicine from intuitive problem
solving to an empirical scientific process. This will lead to prescribing
specific drugs and treatments to patients with a specific combination
of genes. This shift may not lower costs, but it will dramatically
improve outcomes.
Other battle fronts will be:
- Who will control the process? Will it be primary care physicians
or specialists in a “medical home” model – or will the locus of
control shift outside the traditional system to the consumer’s ecosystem?
- Providing “accountable care” – Who will bear accountability? How
Will it be reimbursed? Who will bring the pieces together and
integrate them to benefit the patient?
- Reimbursement – What get included? Who decides? How is
payment made/
5. Have these trends surfaced before?
6. Challenges/responses not on radar now?
FUTURE SCENARIOS
7. Most preferable scenario
The way to “fix” healthcare is to allow the traditional system
to continue to do what it does best – i.e., “sick care” (hospitals
and doctors) – and unbundle other components:
- Health promotion/prevention: this is a fundamentally different
task than taking care of sick people. It is about caring for the
health of COMMUNITIES not individuals. You can’t just apply
prevention to people who go to doctors; you need a public health
approach with different tools and different capabilities.
- “Triage” – deciding if you are really sick enough to need to
see a doctor. This has been “done horribly” by the sick-care
system. If done correctly, it can lower use of the healthcare system,
lower the overall cost of care ( a study of 100,000 patients showed that
proper triage can lower costs by 12-15%). A good example of an
innovative “triage” provider is MedExpert, a Redwood City-based
company that provides “Individual Medical Decision Support (IMDS)”
that gives individual patients access to advice on the most appropriate
treatments and the best sources for that treatment for a range of
health problems.
- Chronic disease management – Different than initial diagnosis and
periodic treatment. Involves professionals plus the patient plus
family members. The sick care system is not good at this. There
are important roles for home-based monitoring and self-care support.
- End of life care – How do we do it? Who should do it? The big problem
is making the transition from active care to support for dying.
Too many people use the sick-care system at the front end (for
triage) and at the final end.
Problem is that “there isn’t the bandwidth in the sick care system to
fix itself” (Don Berwick, CEO, Institute for Healthcare Improvement)
To create a balanced healthcare system that includes all of these
components, we need to experiment with the best ways of doing
each task.
8. Most plausible scenario
Forces for change are uncontrollable. He can’t believe that the
disruptive forces will be thwarted, but how deep and widespread
will be their impact? We need to acknowledge the limits of having
multiple solo operators and the importance of building integrated
systems.
Current reform efforts in Washington won’t have much effect unless
government is willing to do for healthcare what it did with the interstate
highways or the human genome project: make a substantial investment
to accelerate progress. Reform will “solve a few problems” -- e.g.,
increase use of IT, expand efforts at prevention – but won’t bring about
fundamental changes.
Danger is that the same thing will happen as happened when Medicare
was enacted: in order to get legislation passed, agreement was to keep
fee-for-service model.
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FOOTNOTE
1 According to the Pew Research Center, Whites will decline
from 67% of the U.S. population in 2005 to 47% in 2050.
Hispanics will double from 14% to 29% of the population
while Asians will increase from 5% to 9%.
(www.usatoday.com/news/nation/2008-02-11-population-study_N.htm)