PricewaterhouseCoopers

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Trend #3

Workforces Must Adapt to Technology and Empowered Patients

How to retrain tomorrow's healthcare workforce will be one of the most explosive subjects of the next decade as the forces of automation, standardization and consumerism impact the roles of nurses, doctors and administrative workers.

As already discussed in the standardization section, consumers, governments and purchasers of healthcare demand a certain amount of standardization and automation. The challenge for healthcare employers will be to win the confidence and commitment of its professional workforce that clings to traditional professional responsibilities and fears change.

"The most significant rigidities in our present health system, the ones that are most impeding progressive reform relate to the organization of healthcare and the way the work has been compartmentalized among health professions. We have personnel gridlock," notes Steven Lewis, former executive director of Health Services Utilization and Research Commission of Saskatchewan. "Healthcare is an industry in which one category of workers consists of innovators, while the structure and incentives tend to resist innovation."

Manpower Experts Predict New Mix in Healthcare Professionals

Because of projected increases in health spending and aging, most industrialized nations are expected to see an increase in healthcare manpower. However, the types of healthcare workers that will increase will be deeply impacted by technology. For example, the existence of telemonitoring in the home may alter demand for home health aides. The key for healthcare organizations will be using the right mix of different levels of practitioners for the right patients. By using e-health tools or call centers, providers can give care in a more efficient manner. However, the use of such tools must be carefully evaluated because patients are more likely to seek face-to-face intervention for some ailments, such as back pain, than others, such as a sore throat.

Getting the right mix of professionals for patients is even more critical in the hospital setting. "Twenty-five years ago, only doctors and nurses were in the operating room. Now we have anesthetic, cardiopulmonary, nursing and other technicians with us. That is a good trend. Some tasks can be performed by $30,000 technicians who can be trained in a few months," notes Wilbert Keon, chief executive officer of the Ottawa Heart Institute. Yet, it will be difficult at best for some healthcare organizations to overcome the political battles needed to re-engineer processes, such as surgery, to include lower-paid technicians in roles now filled by higher-paid professionals. Healthcare is known for its turf battles, many of which will be difficult to overcome.

Forty-seven percent of healthcare leaders responding to the HealthCast 2010 survey said they believe that hospitals face the biggest restructuring challenge.

Healthcare manpower problems are not monolithic. Each profession has its own traditions and income structure that will have to be realigned for a more automated future. Physicians are a singular example. The hospital of 2010 may be able to draw on the expertise of numerous radiology experts through the Internet, not just the ones inside the hospital walls. That will change the way radiologists are paid and how they work.

The demand for physicians will vary, depending on venue and geography. For example, in the United Kingdom, an extra 1,000 doctors a year need to be trained to meet future demand, according to the Medical Workforce Standing Advisory Committee. This would require the building of one or more medical schools, or a big expansion of existing schools, the committee stated. However, there is no shortage of physicians in other European countries.

In the United States, the overall number of physicians is viewed as adequate, albeit maldistributed. Some specialities may be in oversupply. However, this may be somewhat of an anomaly since physician compensation in the United States is two to three times higher than in other industrialized countries.21 As long as such a disparity exists, the United States will be able to recruit top doctors on the basis of income alone. A recent study from the Canadian Medical Association showed that the majority of Canadians believe there is a physician shortage.22 Experts blamed the aging society and a decrease in the number of medical school graduates. However, Canadian leaders also decry the loss of physicians to the United States, where incomes are substantially higher.

Yet, the supply of physicians isn't easily altered. Doctors typically practice about 40 years, so the supply of physicians in 2010 won't be much different than it is today. In fact, the United States could attract even more physicians because of its higher compensation structure.

Healthcare May Have Difficulty Attracting Talented Young People

The industry could face a shortage of non-physician healthcare workers if it is viewed as too conservative, not innovative and extraordinarily bureaucratic. Already, healthcare organizations have recruiting challenges for information systems and e-business experts. While other parts of the economy are moving at light speed, healthcare's recalcitrance to embrace technology will force it to pay above-market wages in the long run to overcome other drawbacks.

Healthcare organizations must begin to formulate strategies to attract talented professionals. According to the HealthCast 2010 survey, outsourcing will be most popular in the United States, while employee empowerment programs will be favored in Europe. If they fail to attract the people they need, they may have to turn to outsourcing or other means to get the job done.

Work-Life Issues Will Change the Character of Today's Workforce

"The biggest difference for consumers in 2010 compared to consumers in 1999 will be the role and impact of women," notes Mary Jane England, president of the Washington Business Group on Health." Just as we've seen more and more work/life programs implemented in the workplace, we'll see such important consequences of the role of women in the healthcare system."

In the United States, medical school students have heavily favored the "controllable lifestyle" of specialties like radiology, anesthesiology, dermatology, and pathology. Surgical specialties and others that don't offer such lifestyle advantages will be challenged to do so as more women enter the physician work force.

Women now make up nearly half of all medical students in the United States and more than half in the United Kingdom By 2010, 30% of practicing United States physicians will be women, up from just 8% in 1970.²³

Apart from physicians, healthcare is a female-dominated industry. However, many hospitals are citing shortages of nurses and other technicians that traditionally have been filled by women. "Nurses are no longer interested in doing shift work," said Ron Peterson, president of the Johns Hopkins Hospital and Health System. "The supply is diminishing at a time when the need is increasing."

The shortfall in the supply of nurses worldwide stems from many factors including poor pay, changes in training, lack of power, resource constraints, image problems, inflexibility in working conditions and poor hospital infrastructure. For example, in the United Kingdom, the shortfall is estimated at between 8,000 and 13,000 out of a total NHS nursing, midwifery and health visiting workforce of 330,000.

Entrepreneurial Urges Will Flourish

Studies have shown that women are more likely to gravitate to smaller, more flexible companies. Yet, that is not the profile of many healthcare institutions. Women are already starting new businesses at a record pace and this type of entrepreneurialism will spill into healthcare. With technology, more women will be able to work at home, and more will choose that over punching a clock in a hospital or nursing home.

Physicians and nurses already are starting to form their own businesses that contract with hospitals and other healthcare organizations. Rather than be employees, they're choosing to be partners. Given the move to standard platforms, as discussed in earlier sections, these types of organizations will be able to work in virtual networks that adhere to industry standards.

The empowered consumerate also may force some change, taking power away from one group of healthcare professionals and transferring it to another. "The consumer will seek out low-cost alternatives. The pharmacist will become an alternative provider even acquiring limited authority to prescribe," predicts Glenna Crooks, a former Merck executive. "Doctors will be increasingly in a consultative role."

Philip Davies, who heads the health policy branch for the Ministry of Health in New Zealand, also sees radical changes for healthcare workers. He adds, "We are looking to nurse prescribing where appropriate to improve access and reduce costs. In the longer term, more flexible labor markets in health might offer the possibility of greater responsiveness provided, of course, reasonable safety concerns can be addressed."

E-Medical Education Will Be in Demand

Computer-based and Web-based education will be the foundation of medical education. Already, some medical schools have adapted to this future. For example, the University of Pennsylvania Medical School has uploaded more than 1,200 hours of classroom lectures, in text and audio formats, and more than 100,000 images - everything from pathology slides to MRIs and X-rays - onto its Internet site as part of its Curriculum 2000 project.²⁴

Financing of medical education will require reassessing the need for brick-and-mortar institutions as other venues of higher education adapt to more virtual classrooms. Medical schools will be judged by students on their ability to adapt and prepare students for a future of computerization and standardization.

"Medical schools have not come close to preparing students for the world they are going to face either in terms of the reliance on new technologies or in terms of the expectations of the new consumer," says Richard Alvarez, president and CEO of the Canadian Institute for Health Information. "Electronic service delivery will be the key for treatment of chronic diseases and monitoring treatment compliance. There will be a huge shift to in-home care with the emerging capacity to link monitoring devices to communications devices."

Consumers Will Pay for the Personal Touch

One of the biggest byproducts of an e-connected society is loneliness. As mentioned in the consumerism section, depression is expected to remain a leading cause of disease. Will consumers become even more depressed if human contact is diminished through technology and workplaces are more decentralized?

In banking, the introduction of automatic teller machines has eliminated thousands of jobs, but it hasn't totally eliminated the need for human tellers. Earlier this year, a United States bank laid off 5,800 tellers as it tried to automate the process through ATMs, telecommunications and the Internet. Several months later, the bank decided to hire back 2,000, saying that customers missed human interaction.²⁵

Healthcare businesses that stress a personal touch will find a market of consumers with disposable income. "Patients can find information on the Net, but there will still be a need to provide comfort and support," notes Majorie Beyers, president of the American Organization of Nurse Executives. "This places an interesting challenge on health professionals to find ways to provide that comfort and support."

Trend #4

The Interaction Between Aging, Technology, and Consumerism Will Force Policy Makers to Make Difficult Choices

The combination of aging societies and the expanding possibilities offered by medical science presents harsh dilemmas for governments, health insurers and individuals. Soon, the issues of how much governments, insurers and individuals should pay to extend life or improve quality of life in old age will be flashpoints.

The United States government recently extended the financial life of Medicare, its 34-year-old health entitlement for senior citizens, to 2015. Yet, funding dilemmas are at the doorstep of many countries whose populations are aging even more quickly. Many nations must soon decide how to fund the pensions and healthcare needs of the elderly on the backs of a smaller working population. As healthcare costs ooze upward, they may subtract from spending for conservation, roads, education and other public needs.

Technology Will Extend Life Spans

By 2010, we may be on the cusp of breakthroughs that could extend life by 20 years or more. Scientists see great advances in bioengineered organs, human growth hormone, organ transplantation, artificial skin and bones, gene therapy, and new vaccines. In the HealthCast 2010 survey, technology was identified as having the most impact on healthcare by 2010. Interestingly, survey respondents were less enthusiastic about genomics and E-business, two forces we focused on in this report. However, interviews with thought leaders led us to concentrate on those forces in 2010.

Will technology or the promise of future developments prompt fewer DNR (do not resuscitate) orders? Will more of the elderly demand organ transplants at later stages of life? In the United States, the elderly consume about 40% of all healthcare spending, yet in 1988, they used only 2% of the organs transplanted. However, that percentage has been growing rapidly and could climb to 16% by 2010. The coming biotech advances could be a well of blessings or a drain of future medical costs.

Still, who will help J. Consumer sort out such choices in light of his or her own moral values? Questions about genetic alterations that affect future generations will certainly raise a need for bioethics counselors who work with practitioners and patients.

Policy makers must look beyond acute and chronic care needs. The "best" healthcare system in 2010 could be the one that provides our empowered consumer with a right mixture or balance between these four factors: physical environment, social environment, lifestyle and genetic profile. Who pays for what?

"Health spending still has to be balanced against other priorities," adds Philip Davies, deputy director general of policy for the Ministry of Health in New Zealand. "For the Ministry, our role is becoming less hands-on management and more policy direction and stimulus to innovation. Innovation in service provision is often difficult to get going. Many private investors are unfamiliar with the sector, and internally, innovation can be hampered by a shortage of entrepreneurial skills and drive."

And governments must explain how it sets guidelines so they aren't misunderstood. "We, the assessment agencies, need to be closer to users, facilitating an easier language to the general population and not only the policy makers," says Alicia Granados, a director of one of the most active technology assessment agencies in Europe, l'Agencia d'Evaluació Tecnológica del Departament de Sanitat Generalitat de Catalunya.

Governments Must Draw the Line

"Clearly medical development is gathering pace but the key question is whether we can react quickly enough to guide and use developments wisely," says John Wyn Owen, who heads the Nuffield Trust, a United Kingdom foundation that does research and policy review in healthcare. "Government will have to face the fact that they can't afford everything."

Many national healthcare systems, including the Netherlands, Norway, New Zealand, the United Kingdom and Germany, are trying to define the core elements that will be covered by tax or social insurance funding. The struggle is making a distinction between basic healthcare needs that are collective and those needs that are an individual's responsibility.

Attempts have been made to introduce citizen juries in the United Kingdom and Norway to review priorities, but by and large the public has not proven ready to accept large limitations on public health services in most European countries. However, certainly in the Netherlands, both the government and health insurers are heading toward a two-tier system: a basic healthcare package and a customized supplementary health insurance system. Sixty-five percent of European health leaders surveyed for HealthCast 2010 believe a two-tiered system will take hold by 2010.

Yet, the subject of two- or multi-tiered health systems inevitably ignites a debate about some citizens receiving a lower quality of care than other citizens, even though all have been assured access to the system. There are other quandaries. If a consumer pays out-of-pocket for services such as laser eye surgery or treatments for baldness, isn't that diverting industry resources from other healthcare needs? By fostering a market economy in which the rich can afford the best healthcare and everyone else gets average care, where will the money in this system shift? To which class of patient will the best researchers, practitioners and capital move?

Governments also struggle to decide the most effective vehicle for delivering healthcare. "The ability to introduce new technology and expensive new procedures and drugs would depend on the cost effectiveness of primary care in providing effective first-level care, taking care out of expensive hospitals and acting as a gatekeeper for the rest of the system," says Kenneth Scott, M.D., president of the National Association of Primary Care in the United Kingdom.

Either government purchasers of healthcare and providers will be at more frequent loggerheads or they must work more closely together. Look at other industry partnerships. Today, automakers in the United States are working with regional transportation planners to design intelligent transportation systems that benefit drivers. What if government and healthcare providers worked together to design intelligent healthcare systems that benefit patients?

If the system can't be redesigned, the following are alternatives:

• Increasing tax levies to support medical care or other public health systems.
• Paring back of certain health services. For example, governments may increasingly limit what services, drugs and treatments they pay for.
• Passing along more of the costs through higher co-payments and deductibles.
• Limiting coverage for certain conditions or for some individuals who do not take care of themselves.

"People do not necessarily make the connection between taxation and the need to limit health costs," notes Jackie Haynes, chief executive of Buckinghamshire Health Authority, a local agency that buys healthcare services for about 660,000 people in a county northwest of London. Her health authority employs 214 and spends £350 million ($500 million) on health promotion and health services. It is also engaged in moving toward a system of local primary care groups, which are a social form of physician-led HMOs, each serving a population of about 100,000. "NHS Direct (the national medical call system) could also have a major impact on the way people use health services," Haynes adds. " The Health Authority must use this and other channels (such as food co-ops, ethnic groups and interest groups) to engage and enroll people in positive health programs."

The United States Faces Troubling Questions

Healthcare access is not a legislated right in the United States, although HealthCast 2010 survey respondents see that specter on the horizon. "Functionally, we generally have decided that there is a social contract, the objective of which is access to healthcare services for all people," says Dr. William Roper, who formerly headed the United States Health Care Financing Administration. He is now dean of the school of public health at the University of North Carolina. "There will be a movement to prepare for financing long-term-care as the parents of baby-boomers require long-term-care and then as the baby boomers themselves require those services."

Noted Edward Miller, M.D., chief executive officer of Johns Hopkins in Baltimore: "There has to be a national debate. Does an individual have a right to healthcare? The answer is yes. I think you can sell it. You'd have a healthier workforce, a more stable family. If you would allow access to healthcare in a proactive way, some of the other social ills could be solved. You'd have to set up some minimum requirements such as immunizations."

Still, there are questions on how such a system would work in the United States "To establish healthcare as a right would require a radical transformation when there is no mechanism in government to operationalize it," says Glenna Crooks, Ph.D., founder and president of Strategic Health Policy International, a Washington, D.C.-based consulting group, and formerly vice president of worldwide operations for Merck's vaccine business.

Consumerism + Difficult Choices = A Political Voice

The empowered consumer movement raises all sorts of issues about autonomy, spending of personal resources, and the extent of entitlements. How many financial and human resources should be shifted away from other endeavors to pay for five or 10 or 20 more years of life for someone age 65 or 85 or 95?

Can governments simply draw the line at basic benefits and let individuals pay out-of-pocket for the rest? Could they demand a quid pro quo in healthcare - meet these health requirements to gain these health benefits?

"We need to convince the public that there has to be a cap on what the state can afford and then open a debate on where limits should be set," says New Zealand's Davies.

Difficult choices means controversy, which is likely to spur more media coverage of health issues. That will prompt elected representatives to respond. On both sides of the Atlantic, patients' rights are an important theme. In Europe, patients want a greater say in selecting their physician, hospital and course of treatment. They are also becoming more involved in health policy decisions. Legislation to codify patients' rights is in discussion in several countries, including the United States.

By way of precedent, consumerism is pervading other United States institutional structures, such as the publicly funded school system. In several states, legislatures have permitted charter schools where local groups can self-direct their schools. Even though parents don't purchase teaching services like they purchase notebooks, consumers have worked for change and choice, a theme that is resounding in healthcare as well.

As with schools, post-war baby boomer consumers will voice their satisfaction or lack of it because they simply do not have the automatic respect of the healthcare institutions their parents did. Notes John Wyn Owen, a former director of the National Health Service Wales: "Consumers will be more suspicious of government as a provider of services and will demand more information and more choice."

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