Dealing with the demands of change.

The information appliance will be the most important technology in medical care in the century ahead," according to Marvin Cetron, PhD, Founder and President of Forecasting International, Bethesda, Md. It will contain a computer, a duplicator, a fax, a telephone, and all the other equipment needed to communicate electronically, he said, including a split screen display on the office wall. By the year 2000, he said, 88 percent of American workers will be in the service sector, and 50 percent of them will work from their homes. The information appliance will be needed to maintain contact among these workers, Dr. Cetron said.

The health care system and physicians are apt to face better informed and more discerning patients in the years ahead, according to Dr. Cetron. Both hospitals and doctors will have to become patient-centered, he said. What little absolute authority physicians now have will have disappeared by the next century, and a new hierarchy in the provision of health care services will have evolved, he suggested. "At the first level, where symptoms have just appeared, consumers will consult books or magazines for answers. If answers are not immediately apparent there, they will network with family and friends. Next, they will attempt to find other persons with similar symptoms, probably through Internet. At this stage, they may begin to collect data on specific doctors and hospitals. The consumer's first contact with a physician in this new hierarchy will be in search of an advisor. `Here's what I think; what do you think?' The relationship may then move to a partnership between the patient and physician. Only in the rarest case," Dr. Cetron said, "will the doctor be viewed as an authority."

In Dr. Cetron's view, the biggest growth area in health care will be home care. U.S. occupation rates are the lowest in the world, he said. Older people will fill some of the beds and rates will go up, he said, but cost considerations will force increased attention to home care.

Dr. Cetron called drugs and technology the best investments in health care. "Drugs," he said, "are cheap in terms of the outcomes they produce. Hospitalization and surgery are far more expensive, and generally less productive. If a cost of health care reform is reduction of technology and health research, the cost is too high."

Dr. Cetron expects the concept of "bimodal distribution" to take hold in health care in the 21st Century. Pointing to the airlines and the hotel industry as examples, he said that doctors, hospitals, and large corporations would provide the high-expense, more high-tech health care services on a regional or even national basis. Then nonphysician providers (nurses, physician's assistants, pharmacists, and others) and smaller institutional providers would fill the gaps in less intensive services and at the local and regional level. Overall costs would come down in such an approach, he aid, and all the participants would gain.

Dr. Cetron was not optimistic about the continued need for middle managers. "The computer," he said, "makes it possible for one manager to oversee 21 people instead of the traditional 6." Fewer managers will be needed. Those that survive will be able to monitor and plan the work of larger departments using the power of computers, he said.

No national health care reform will be passed without attending to the needs of the middle class, according to Dr. Cetron. The failure of the Clinton Administration's plan, he said, was that it didn't cover middle class needs. In any plan, he said, the elderly who are able will have to pay a larger portion of their health care costs. The system will "be for the needy, not the greedy," he said.

Middle Class Needs Key to Reform

Ross N. Rubin, JD, Vice President, Legislative Activities, American Medical Association, Chicago, echoed Dr. Cetron's comments about the American middle class and the health care reform debate. He said that the American public was behind the Clinton Administration's health care proposal until it was actually offered. "The highwater point for the plan was September 1993. When the details came out, public support withered. It was too complicated. The public was concerned about a huge bureaucracy and about loss of choice of plans and doctors. They just don't trust the federal government," he said.

Mr. Rubin predicts that the Republican Party's goal in health care reform will be incrementalism. There will be no global budget proposal, and no price controls. But there will be reform in several areas, he said. He expects insurance market reform that provides plan portability for employees. He also expects a return to community-based rating systems for plan premiums. Mr. Rubin also expects adoption of a plan for medical savings accounts that encourages health care coverage and encourages consumers to be prudent buyers of coverage.

The outcome on tort reform is uncertain. The House, for instance, passed a cap on noneconomic awards, but the Senate failed to follow suit. The AMA will push for reform in the conference sessions, but it is not at all clear that anything can be passed. he said that the general aversion to federal intrusion into personal and corporate lives should lead to revision of the Clinical Laboratory Improvement Act, the Occupational Safety and Health Act, and both of the so-called Stark amendments.

With severe budget cuts all but a certainty, and federal health programs high on the target list, the movement toward a managed care approach in Medicare and Medicaid seems likely, Mr. Rubin said. Medicare is likely to be capitated at the national level, he said, and Medicare risk contracting can be expected to expand. he also predicted the implementation of some kind of a voucher system for Medicare beneficiaries. Certainty is tempered in these areas, he said, by the fact that the public is split on the issue - it wants the national debt reduced and the federal budget balanced, but it doesn't want Medicare cut.

Resource Allocation at the Heart of

Health Care Reform

"Will gene therapy go the route of renal dialysis or the polio vaccine? The answer to that question will go a long way in deciding how ell we are able to satisfy unlimited needs with limited means," William L. Kissick, MD, DrPH, George Seckel Pepper Professor of Public Health and Preventive Medicine, University of Pennsylvania, said. If gene therapy is added to the already high costs of caring for the elderly, who consume health care services out of all proportion to their numbers, which are growing at an alarming rate, we simply won't have the resources to care for them and others, he said.

Dr. Kissick offered attendees two laws. "No country in the world has the resources to cover all the health care needs of its population." And, in a play on the writings of Adam Smith, "The invisible hand in the health market is all thumbs." Further, he said, health care reform is a contact sport. And the sport he pointed to is rugby, not football. "The players have no helmets and no protective pads, run around in their underwear, are in a constant state of terror The wounded are removed from the field of play, and the game goes on uninterrupted."

In spite of this, he encouraged physician executives to become involved in developing programs that address the balance between resources and needs. "You have to decide if you want to manage or be managed. You have to decide if you want to be a clerk or own a piece of the Rock."' Dr. Kissick believes that capitation can be an effective way to balance resources and needs, but he cautions physician executives that such systems need to include consumer-provider choice, enrolled populations, weighted capitation formulas, organized medical practices, prospective budgets, and cost-effectiveness measures. To ensure that systems are designed to ensure access, quality, and cost containment, he said, physicians will have to be involved. And, he cautioned, remember that "there is no quick fix in health care."

Dealing with Professional Grief

"Reining in costs is the big issue. Learning to operate in groups for economical reasons and for cost control. And this is hard for many doctors to accept," Mary Frances Lyons, MD, a physician executive recruiter with Witt/Kieffer, Ford, Hadelman & Lloyd, Oak Brook, Ill., said. The medical profession had reached the self-actualization stage of Maslow's hierarchy, she said. Now, the system is bringing many of them back to the physiological stage in its efforts to gain control of health care dollars.

Both physicians and physician executives understand these changes, and it is driving many to seek management positions. "We receive 50-60 resumes for a new position that is being created. Doctors are looking for change. They're going through the classic stages of grief. Right now. many of them are in anger. The problem," she said, "is that the anger is fostering distrust and other destructive behavior, when it is cooperation that is needed." She said that money is critical in our culture. It defines our values to a large degree. The attacks on costs, and thus on the incomes of physicians, are contributing to the distrust, she said.

Some Distrust is Merited

In assessing the worth of management theories, Charles E. Dwyer, Phd, Chairman of the Board, Wharton Center for Applied Research, University of Pennsylvania, Philadelphia, said, a critical faculty must be used. "Valid, practical information is hard to come by." After all the years of organizational theories, most of which have failed, "why aren't we better at organizational behavior than we are? he asked. It is unwise, he said, to simply accept the latest fad. He suggested that the motives of the developer of the management approach should be assessed. "Why are they offering this idea that will change the world and make you rich? If the idea is so personally rewarding, would it be more sensible for the person to keep it secret? he asked.

It isn't that there aren't some good ideas out there, he said. It's just that they have to be viewed from a critical perspective. Dr. Dwyer recommended use of the concept of prior probability: the strength of a hypothesis is inversely proportional to the number of alternative hypotheses available. When other ideas are on the table, he said, the first one begins to look less attractive. The trap, he said, "is in looking for magic solutions."

"Beware," Dr. Dwyer said, "of magic." He cautioned his audience to be especially wary of academic theories. "There is a belief that knowledge is power. It's not. Its implementation may be, but it's not. Ideas don't work. People make them work. Academics try to influence other academics, They won't tell you all plausible theories, only their own. They're mesmerized by theory, but they're short on practice."

Consultants also took a hit from Dr. Dwyer. "They're instant experts," he said. "They go from one consultancy to the next, with the most recent one paying for the next. The consultant," he said, "is equidistant from theory and practice, but doesn't necessarily budge from that position."

Professional colleagues and peers may also be poor sources of information, Dr. Dwyer said. Most such information is anecdotal; practitioners don't know why it works, he said. "And if they do understand the workings of the theory, is it transferable to others? They don't know."

It's no accident, Dr. Dwyer said, that organizational descriptors tend to use behavioral science terminology. It only points to the academic background of much of organizational theory. "The current buzzword is culture, from anthropology. Before that it was personality, from psychology. Organizations don't have personalities or cultures," he said. "They have patterns of personal behavior and acquiescence to power. The members of an organization take care of what is important to them. Loyalty is tranferable," he said.

In short, Dr. Dwyer said, "Don't jump on bandwagons."