Reimaging the present

The World Health Organisation has outlined what it considers the top issues on the health care horizon for the next decade and beyond. As usual with any large consensus organization, the issues outlined are like spent stars – they were shining brightly once but are probably dead already. 

Let’s redesign, rename, revamp and reinvest.

So , rather than attempting to envision a future yet again, let’s have a look at how the current issues could be managed differently. Here is my vision of how to rework healthcare  now:

Let’s redesign the health workforce. Much has changed in the practice of medicine even since the turn of the millennium, but many of the health care settings still function as if they are in the last century. Instead of letting the organizations define our workforce, why not allow workforces to participate defining work conditions, job skills and training requirements, psychosocial resources and demands, environmental conditions, and work arrangements to shape organisations? Rather than top-down hierarchies, healthcare institutions could become more consensus-based, democratic and responsive to all constituents.

Let’s rename the health workforce. Close to two-thirds of occupational titles used in 2018 had not been invented as of 1940. Yet some health care title nomenclature hasn’t changed in centuries. New titles should reflect new realities and might include teledoctor (an expert in virtual consultations) , artificial intelligence diagnostician (an expert in translating complex algorithms in practical healthcare), and real-world treatment synthesizer (an expert in looking at generalized health care data and making it meaningful for the care of the individual patient). 

Let’s revamp disease-based care. Current care focuses on a single organ or system, such as cardiology, dermatology or neurology.  A better way to provide patient care might be to regroup health care service providers under non-traditional themes so that diverse populations can find common ground and co-morbidities can be addressed. This is already happening in geriatric care. Why not, for example,  organise a medical practice around vulnerable populations, such as youth and young adults, recent immigrants, people with disabilities, members of the LGBTQ+ community, indigenous peoples, and those with low socioeconomic status? Or aggregate experts who might work across all spheres where violence is part of everyday life, including the armed forces, gangs, and blood sports.

Let’s reform the fee-for-service model. Present practice in many health care systems including in the US segregates and quarantines the most “expensive” patients in fee-for-service environments. This group of patients accounts for about 68% of total healthcare costs. They have complex social, medical, behavioural, and clinical needs that are poorly met by a fee-for-service scheme that requires additional payment each time the patient is seen, is tested, or has a procedure or hospital stay. These patients fall under three broad scenarios. The first group of patients experiences catastrophic critical events such as acute myocardial infarction or hip/pelvic fracture. These high-cost conditions are usually time-limited by death or recovery and would benefit from global pricing. The second group of patients requires complex, persistent or expensive medications that have a longer trajectory of expense. They might be subject to a different payment model that focuses on drug costs and not clinical visits. The final group of  patients suffers from semi-persistent chronic conditions and high frailty indicators whose expenses are diffused across a range of clinical and non-clinical services. Perhaps a managed care system is best for all of them.

Let’s reinvest in the architecture of health care. Public hospitals and health care facilities are as important as bridges and roads, so infrastructure funds should be allocated to not just maintain but also to upgrade them on a rolling basis. This would include all the non-human components. Then a “soft skills” schedule of fees for providers can be designed to reflect the end user experience.

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