'Big one' coming for health care. (Next!).

I live on the coast of northern California, among redwoods and vineyards at the edge of the crashing sea. If you moved here, you would have many different experiences, but there is one thing I could guarantee: sooner or later, you will feel the earth move.

Today's health care--what we think of as "business as usual"--is a kind of California. It exists at the grinding margins of vast tectonic plates with names like "technology," "demographics" and "epidemiology." Sooner or later, things will shift and change on a far larger scale and in a far more sudden time frame than we expect.

We are vulnerable. We are muddling through. At some point, muddling will not be enough.

What if?

Consider a few examples:

* How much of your institution's bottom line is derived from cardiovascular care? What would happen to your finances if an inexpensive drug appeared that could reliably prevent atherosclerosis and stabilize and shrink atherosclerotic plaque? Such a drug exists and is in the final stages of human testing. Other drugs also carry promise in the fight against heart disease.

* How much of your bottom line is based on caring for cancer patients? What would happen to your institution if cancer became a pharmaceutically controllable chronic disease? A number of drugs now in human testing show this promise.

* How much of your bottom line depends on complex and repeated diagnostic procedures? What if new procedures, based on advanced imaging and genomic analysis could do the same work better, faster and cheaper without any need for hospital stays or hospital lab work? Some new diagnostic capabilities already functioning in experimental settings may greatly reduce the need for hospital-based tests, laboratory services and exploratory surgery.

* How much of your bottom line is linked to surgery? What if new, more targeted anesthetics and new techniques for measuring anesthesia make it possible for more operations to be performed in the doctor's office, including some major operations? Such devices and techniques are already becoming available to physicians.

On the other hand, how prepared are you for not one, but a series of public health disasters--from natural plagues to bioterrorism?

Considering the roots of terrorism, the possibilities of modern genomics to construct novel pathogens and the socioeconomics of AIDS and other possible epidemics, we may be in store for just such a future.

The speed of change

People say health care doesn't change fast. And it hasn't, at least, in the experience of people who run health care today. But in the past, health care changed repeatedly.

* The discovery of streptomycin wiped out tuberculosis hospitals.

* Germ theory, the discovery of ether and the invention of electric lights drastically re-shaped surgery.

* The discovery of antibiotics made many more types of surgery possible and cleared hospital beds of thousands of people struggling against bacterial infections.

* The Salk and Sabin vaccines eventually closed polio wards.

* Even regulation and bureaucracy had sudden and massive effects. In the two decades after the publication of the Flexner Report in 1910, half of all the medical schools in the United States closed their doors and the survivors were reformed almost beyond recognition.

Our experience in the last few decades, in contrast, is quite different. The largest changes are legislative and regulatory such as:

* New funding mechanisms

* Arrival of DRGs (diagnostic-related groupings) in the U.S.

* Advent of accountability for costs in the 1980s

* Proliferation of HMOs in the 1990s

* Restructurings and experiments with compensation formulas in Canada in the 1990s

* The continuing battles over privatization in the U.K.

* Battles over funding in Australia

Technology, on the other hand, seemed to change incrementally. New procedures and drugs were added to the old ones, rarely supplanting them. New diagnostics added information and improved the odds, but few proved so definitive and predictive as to wipe out their predecessors.

We traditionally make planning decisions based on incremental assumptions.

We may hire a consultant to look at demographic projections such as the aging of baby boomers or shifting immigration patterns. We may look at growth patterns. Perhaps the city is expanding to the north or a new highway is being built that will shift population centers. Or we may try to guess how the political and economic landscape will effect our funding over the coming years.

In recent decades, we look at new technologies when physicians demand them. But this means that we only consider new technologies that are already on the market or about to be introduced. The unspoken assumption is that nothing is about to show up that will make the earth move under our feet.

The danger zone of the future is two to 10 years out. If something will not affect us for more than a decade, it is too unpredictable to act on yet. But something that will show up in full force in three to five years is something we need to prepare for today.

Predicting the future

Every decision is a bet on the future--every hiring decision, every new program, every capital plan. These bets are based on assumptions about the shape of the future.

How many people are going to come through those doors every day in five years, in 10 years? What diseases will they have? What traumas will they suffer? What will we need to do to treat them? What sort of equipment will we need? What sort of spaces will we need? How long will people stay?

When I speak to hospital executives across North America and Europe and lay out the possibilities for large-scale discontinuities in health care, I hear a refrain of questions that start with, "How can we know whether these possibilities are real?" And go on to: "How can we know when they will show up? How can we tell how big their effect will be?"

As a CEO of a hospital chain in Maryland asked me recently, "These are bet-the-organization questions. They call for bet-your-career decisions. How can we get a better handle on them?" This is precisely the problem.

When we combine the range of new technologies with the possibilities offered by new digital media, it is possible to imagine a health care environment quite different from today, with the hospital stripped of many of its functions, with other functions dispersed.

Perhaps only a birthing and well-baby facility, a trauma facility and greatly reduced surgery and intensive care unit, will be at the hospital. And the hospital will be networked with dispersed clinics.

It is also possible to imagine a different scenario, in which the community hospital maintains its place as the center of health while drastically changing its shape and many of its functions, dropping types of care that are no longer needed while adding, for instance, genomic screening and lifelong health planning, health "coaching," widespread digital home self-care, hospice care, nutritional management and other longitudinal wellness programs.

The questions

Whichever scenario turns out to be correct, how will we know ahead of time? How soon will we know? What part will come true first? How do we need to build today to anticipate such a future? Whom should we hire?

We cannot know the answers. What we can do is begin to ask the questions. We must begin to ask them in ways that are at once continual, disciplined, global and local.

We must continually ask questions.

Listening to a futurist once a year or doing a study every five years is insufficient. Futurism is like navigation. If you are heading into unknown territory, the need for navigation is constant over the entire journey. While a consultant may be helpful, you and others in your organization must become personally involved in the search for the future or it will not enter your thinking with the gravity that it deserves.

We must ask disciplined questions.

Idle speculation is worse than ignorance. Real decisions about the future must be based on real future work, careful work with scenarios and other techniques for evaluating the probabilities, relevance and impact of any possible future.

The questions must be global.

It is insufficient to just search for new medical research or diagnostic advances. The fields that could affect the future of health care include materials science, nanotechnology, systems biology, computers, communications, or even accounting.

The questions must be local.

Health care deals in human bodies and physical interactions. Much of it is ineluctably local. So any future scenarios must be tailored to the local population, its relationship to major teaching centers, its socioeconomic situation, as well as the history and personality of the institution.

We must ask these questions as an industry, as regions and networks, as individual organizations--and as individuals. When things threaten to change this massively, futurism is part of everyone's job.

Joe Flower is an internationally recognized health care futurist. You may contact the author by calling 415/924-5036 or via email at [e-mail].