A Conversation with William Rowley, MD: What's Past is Prologue? Don't Bet on It
MANAGED CARE April 2004. ©MediMedia USA
Many things that were supposed to happen — like electronic medical records — didn't, this health care futurist reminds us. Tomorrow needs to be shaped.
William Rowley, MD, caught the futurist bug in the 1980s from Joel Barker, who popularized the notion of paradigm shifts. "In his tapes, Barker said, 'I'm a futurist,'" Rowley recalls. "I wondered if there was anybody thinking about what the future of health care might look like."
Twenty years later, Rowley, now a senior futurist at the Institute for Alternative Futures in Alexandria, Va., is still thinking about the future of health care. "We're not interested in being right so much as we're interested in being provocative," he says, "so people think about how can they prepare for different circumstances, what they care about, and what kind of future they want to create." Trained as a vascular surgeon with extensive clinical and medical teaching experience, Rowley went on to be commanding officer of two naval medical centers and CEO of a large managed care organization during a nearly 28-year career in the U.S. Navy Medical Corps.
Rowley, who retired from active duty in 2000 as a rear admiral, chaired the Defense Department's Military Health System 2020 (MHS2020) research project, which included four year-long studies of the future of health care and the implications for military medicine. He earned his undergraduate and medical degrees from the University of Minnesota and completed surgical residencies at the University of California, San Diego, and the Naval Regional Medical Center in Philadelphia. Rowley spoke recently with Senior Contributing Editor Patrick Mullen.
MANAGED CARE: What's the hardest part of your work as a futurist?
ROWLEY: The biggest challenge is trying to guess when our incredibly resistant system will change. We see the possibilities quite far in advance, but assessing how long before the pieces come together is more complicated. An excellent example is computerized medical records. Twenty years ago, people were saying, "This is a no-brainer; we will have it soon." We don't have it yet. We could have a very good computerized medical record now if we wanted it, but the amount of resistance has slowed down progress. To be a good futurist, you need to look at the human side of things. Looking at society is as important as guessing when the next advance in nanotechnology will happen. We try to prepare people to be a little more realistic about when things are likely to come. We believe the future is not pre-ordained. We create it, but we cannot build better futures if we don't have values and visions of what a better future could look like.
MC: Why is health care becoming more unaffordable for more people?
ROWLEY: Many things are driving it. This year in the United States, we will spend $1.79 trillion on health care. That's 15.5 percent of the economy. In 10 years, spending will double to $3.58 trillion, according to conservative projections from the Centers for Medicare & Medicaid Services. That means in 2014, we'll spend 18.7 percent of every dollar on health care. Medicare will double, and we'll spend a trillion dollars a year for Medicare and Medicaid. Clearly, something has to change. Health care is the largest driver of our economy. It's so big that it has the power to feed on itself. You try to make any changes and powerful players say, "Wait a minute, we like it the way it is. Let's hang on to the status quo."
MC: How do we get past that?
ROWLEY: We have to change the focus from spending about 95 percent of every dollar on treating problems to putting a lot more effort in trying to prevent disease in the first place, particularly chronic diseases. Today, incentives are wrong because they encourage maintaining the status quo. We need to change the financial incentives by doing such things as paying for outcomes. Imagine what would happen if we rewarded patients for improving their health status. A few plans and insurance options are beginning to experiment with this. It's not a big trend right now. Medical research will help, because we're not just developing new drugs, we're developing a much better understanding of the things that are truly successful in preventing disease. The challenge, of course, is trying to get society to adopt them.
MC: To what degree is our current public/private hybrid approach to paying for health care an obstacle to the kinds of changes that you feel are needed?
ROWLEY: There are two ways of looking at that. Number one, whatever we do must fit the American psyche and value system. There's a lot to be said for a single-payer universal health care system that covers everybody. It would eliminate a lot of administrative expenses. But America doesn't want to go there. I strongly believe in free enterprise and I think that we have to stick with a free-enterprise-based system. The real question is: What are the motives of the system? We now live under managed care but the motive is not managing care, but managing cost. Managed care was a good idea to start with.
MC: It would be nice to try it sometime.
ROWLEY: That's right. It was a concept for coordinating care of populations over a long term and focusing on treating diseases. That's not the focus right now. Instead, everybody's fascinated with so-called consumer-driven health care and defined contribution health care. Unfortunately, the motive that excites payers is that they can shift costs to patients. If the motive were to empower patients to take better care of their health, to spend their money more wisely, to improve the health of society, and to have patient-centered health care, then we could control costs and create much better health. We can't do that unless we build that motive into the system. We must provide information and management tools for patients, give them coaching, train them how to live this way, and teach the health care system how to provide care this way. Otherwise, consumer-driven health care will be another disaster where everything focuses on shifting the burden and responsibility somewhere else.
MC: As you work with health care organizations and give them that message, what kind of responses do you get?
ROWLEY: One fascinating phenomenon is managerial inertia. Consumer-driven health care is an idea that's been floating around for a few years, but it's not going very far very fast because nobody wants to be the first one to do it. Executives would rather keep the status quo as long as possible because it works for them. What are most insurers and payers thinking about? They say, "Right now I understand how the game is played and I'm fairly successful. I'm either controlling my costs to some degree or I'm making a bunch of money. I realize that health care financing might go to a consumer-driven philosophy. If it goes that way, I can make that work but I'm not going to encourage it." This giant $1.7-trillion-a-year system employs an awful lot of people. People are resistant to changing it unless they see a change that will be significantly better for themselves personally.
MC: The number of uninsured increased by 3.8 million from 2000 to 2002, to 43.6 million people. What's your sense of the political power of this issue?
ROWLEY: It does have political power, but not because of the young kids and poor people who don't have health insurance. It's a political issue because the middle class is feeling uneasy that maybe it will be next. It's moving into the voting population. Large old-line industrial employers like the automobile industry are looking for ways to reduce or eliminate their health care obligations to retirees. Unless you have a strong union, your health care plan is at risk. If we have significant downturn in the economy or if the economy smolders along, as people become unemployed, they're going to lose their health insurance. Even if they are employed, they may lose their health insurance.
MC: What political responses do you anticipate?
ROWLEY: One way to look at this is to say that this is un-American, and every American should be entitled to have access to health care because it's the right thing to do. We spend $1.7 trillion, we're the richest country in the world, so we ought to be able to afford it. That's the moral, principled answer. The other answer is that providing health care to everyone is the smart business thing to do. Maine has launched Dirigo Health [named for the state's motto, Latin for "I lead"]. It's an attempt to make health insurance available for everybody in Maine. They realize that when people don't get good care in a timely manner, we end up paying more for it as a society. A recent study in Texas looked at health costs for the uninsured and who pays for it. They discovered that Texas is paying about $1,000 a person, or $4,000 for a family of four, through various public programs for those who are uninsured. What does it cost for minimal health insurance for a family of four in Texas? About $4,000, so in reality, we're paying it anyway.
MC: How do you make that case in a way that can be embodied in legislation that can actually be enacted into law?
ROWLEY: Devising a way to provide coverage for every American isn't the hard part. The hard part is getting Americans to decide that this is the right thing to do. I would like to see us agree with the premise that every American having access to health care is a good business decision.
MC: I've often heard that, as a nation, we're good at responding to a crisis but not to a lingering, festering problem. Is it going to take something like the Social Security or Medicare trust fund dropping to a crisis point where baby boomers fear that these entitlements won't be there for them? Are there triggers you can envision that would force the country to the consensus that you're seeking?
ROWLEY: If you accept that it's going to take some kind of a catalyst or crisis to wake people up, the question becomes whether the crisis has to be all bad. There's another way of looking at it. One trend we're seeing is that consumers are becoming more empowered, more knowledgeable, and more assertive. Information is becoming more transparent. It's possible that consumers will start demanding some of these things. The conventional wisdom is that change in health care must be incremental, that we'll have to tweak the system here and there and gradually improve it. That doesn't work worth a darn. If we really want a better health care system, it's going to take a dramatic transformation. How do you get something like that to happen? The only way is if an empowered informed public can articulate a vision of what it really wants a health care system to be and pull together enough political pressure to force it to happen.
MC: Do you see any signs of that happening?
ROWLEY: To answer that, you have to ask who has a vision for health care and is actually making a difference right now. The most impressive thing I see is the Institute of Medicine. They've articulated six simple aims for health care. They want a system that's safe, effective, patient-centered, timely, efficient, and equitable. If we could embrace these six simple things, it would fundamentally change our health care system.
MC: How likely is that to happen?
ROWLEY: I believe change is possible because I've seen it as a physician. One thing that's fascinated me is how resistant physicians were to change. When I was a resident in surgery, there was plenty of evidence to show that a modified radical mastectomy for breast cancer is as effective as a radical mastectomy. Surgeons did not want to hear that. They believed in their hearts that the more aggressive surgery got out more cancer and would be more successful. When I was a chief resident, I was forbidden by my department chairman to do a modified radical mastectomy. I left my residency, went to California, and the women in San Diego said, "You don't understand. If you won't do a modified radical mastectomy, I'll find a surgeon who will." When I did vascular surgery, we always gave a lot of transfusions. Vascular surgery is bloody. Then AIDS came along. Patients said, "You don't understand. I don't want a transfusion." We thought that was the dumbest thing we'd ever heard. You can't do surgery without transfusions. But once we realized that that was the new game, we figured out how to do surgery without transfusions. Empowered consumers are our best hope because they see things differently.
MC: Within my children's lifetime, today's technology will be correctly seen as primitive. Over the next 20 or 30 years, what are some of the fundamental changes you foresee in how we use information technology?
ROWLEY: First, I think we've finally reached a tipping point with the electronic medical record. Forces are coming together that will finally make it come about. I wouldn't be surprised that by 2010 most health care systems have a medical record that's effective and can actually communicate with other health care systems. Standards are finally lining up, the technology is robust enough, and physicians are finally getting the hang of how information technology works. I would like to see a world in which patients own their own medical records. Records would be in cyberspace somewhere, would be available anytime, anywhere to whoever the patient gives permission to see it. Bio-sensing devices in hospital rooms would automatically capture information like vital signs and put them into the electronic record. Today, when somebody's hospitalized, we get this awful hundred-page handwritten medical record. With bio-sensing technology, we can do something like what we do with airliners. Let's have a black box monitor collect and store all this stuff. What's it collected for? It's collected in case you get a lawsuit. You know it's available but you don't spend a lot of time with it because it's unnecessary for the care of the patient. The medical record that you look at might be very condensed. It has the critical elements: history, physical examinations, laboratory values, your care plan, and milestones of achieving results.
MC: Do you think that in 10 years we'll still be talking about managed care, or will that have become a historical term?
ROWLEY: It's going to change with regard to how we treat chronic disease. About 125 million Americans have chronic diseases. Half of these people have multiple conditions and roughly one third have five or more chronic conditions. Those individuals use up half of all spending on Medicaid, two thirds of Medicare, three quarters of private insurance spending, and represent 80 percent of health care visits. A patient with five or more chronic diseases sees, on average, 13 doctors a year. Clearly, treating chronic disease is the challenge. The health care system we have now is a nightmare. Doctors are not reimbursed for coordination, they don't work in teams very often, and there is no team leader. What we do now is not designed for the problems that we are taking care of.
MC: Where are we headed?
ROWLEY: We're headed to the practice of medicine in cooperative teams, using evidence-based decision-making where all clinicians are on the same sheet of music. There's got to be continuous healing relationships, with more emphasis on education and coaching. You can't just focus on the current medical problem; you have to focus on all of the risks. People with diabetes don't die of diabetes; they die of heart disease. Information is going to have to flow freely among providers and with the patient. Care will be customized to the disease, to the patient's pharmacogenomics, and to the patient's values and needs. You can say, "That's managed care," but it's a very different managed care from what we're practicing now. Patients must learn how to become active participants in their care. The business side of managed care will be transformed with more focus on eliminating, preventing, and controlling disease.
MC: Thank you.