Not your father's health care - Next! - the health care industry will likely change as much as Las Vegas has

Physician Executive, Sept-Oct, 1999 by Joe Flower

The gondolier drifts by on the Grand Canal, singing some ancient love song Dusk overtakes the sky, and lights wink on in the palace of the Doges, on the bridges and along the canals, in the shops and restaurants filled with tourists. But here in the great Plaza San Marcos there are no pigeons. Not even one.

There are no pigeons because we are not, in fact, outdoors in Venice, but indoors, in the middle of a great desert, three stories up in a hotel in Las Vegas, in a shopping mall built in cunning imitation of Venice, right down to the gondolier's striped shirt and accent.

The mall was not here six months ago. It's above and behind the casino at the Venetian, which is where the Sands was when I was last in Vegas a decade ago. Of course, then I stayed at the Dunes, but they blew that up and built the Bellagio. And Mandalay Bay. And a hotel that looks like Manhattan, but with a roller coaster wrapped around it. And a hotel in a pyramid. And a hotel where pirates have a battle in the fountain every evening at dusk. And a hotel with live tigers in the back garden. And a tower much like the Seattle Space Needle, but with a roller coaster on top of the spinning restaurant. And a place called Paris, complete with the Eiffel Tower.

The Las Vegas I remember is gone, replaced by a theme park with cleavage.

Wild array of possibilities

Will you recognize health care in ten years? Las Vegas stands as a moving monument to change, to the dance of Shiva, the constant creating and destroying. We in health care are living and working in a world that, for all its technical changes, differs little in its basic assumptions, structures, payment systems, beliefs, expectations, and job titles from the world of health care a generation back, in some ways even two generations back.

How much change can we expect over the coming years?

My guess is: A lot more than we are prepared for.

Look at the array of new technologies headed our way. The genomic sciences have pumped hundreds of new compounds into the FDA approval pipeline, some of them promising actual cures for major diseases. Even more important, the genome sciences and combinatorial chemistry have brought forward new methods for searching for compounds not one at a time but by the scores, hundreds, and thousands. They hold the promise of an entirely new kind of medicine based not on cure and palliation but on individualized genomic profiling, customized vaccines, and lifestyle management.

Advances in organ replacement and hormonal therapies, studies of cell glycosolation and the manipulation of cellular "clocks,' lead major researchers, for the first time, to talk about the possibility of adding decades, or more, to the human life span. The increasing acceptance and study of such "alternative and complementary" regimes as acupuncture, chiropractic, herbs, and meditation place another array of "new" technologies in our medical armamentarium.

Unprecedented new opportunities for change

Digital technologies offer another wild array of possibilities. In a world in which the costs of connection, memory, computational power, and sensing are so trivial, and the methods so profuse that floor tiles have brains, forks have web addresses, and all-day suckers can sense when they are being eaten, both medicine and the management of health care undergo continuous, compounding, interactive transformations. These technologies bring us enormous opportunities for new ways of gathering, storing, and mining information, for new types of communication between medical professionals, for new communications with customers, and new ways of steering large, complex enterprises.

While you are thinking about these new technologies, consider the fact that many of the breakthroughs promise incredible abilities to prevent disease, to profile our proclivities, and to manage our genetic predispositions over long periods of time, rather than merely wait until the disease manifests in an acute phase, then treat the symptoms, as we do now. Yet our current payment structures and business plans, focused as they are on disease in Its acute episodes, offer no way to pay for these long-term prevention and management strategies.

Add that to a stew in which annual health care costs are expected to double to $2 trillion by 2008, antibiotics are widely failing, doctors' incomes continue to fall, and most for-profit HMOs are not only perceived as poor on quality and customer satisfaction, they just flat out are not making any money. In short, no one involved in health care is happy with the system, and the screws just keep getting tighter.

Unprecedented new opportunities for change keep piling in through the door. Vast pressures for change keep building from every side. And the rewards for anyone who can lead the change keep compounding.

What will health care look like?

So what do I think? Anyone who purports to guess what health care will look like in ten, 15, or 20 years is a fool. But so is anyone who assumes that health care will maintain the same basic shape it has held for generations.