First we see the health care problem as having four elements. They are shown below; demand modulation, cost reduction, genetic development and finally organization, namely how do you pay for it.
These four steps we will detail more in a short while.
Yet to develop a good health care policy we must understand that we must be wary of assuming that the past is what the future will be . We know that looking solely at the past as prologue to the future to be patently false. The chart below is descriptive of three major changes in the 20th century. There are of course many more.
Consider two past examples; infectious diseases and psychiatry. In the early part of the 20th century health care was dominated by the management of infectious diseases. New York City had its own Tuberculosis hospital, Sea View Hospital, which was filled with TB cases which the City cared for. This is no longer the case. The psychiatric centers such as Willow Brook Hospital on Staten Island in New York City were filled with psychiatric patients until the early 1970s. With the advent of drugs such as haloperidol and the like they closed in just a few years. The Commonwealth of Massachusetts had in 1965 a total of 45,000 hospital beds occupied every day. 25,000 of those were for psychiatric patients. By 1975, the psychiatric beds were reduced to 6,000 and today they are less than 1,000. This would mean that if we planned health care in 1965 for twenty years into the future using the past and not recognizing the impact of the new "technologies" then we would have been grossly in error! This is a clear warning as the Government approaches this task.
Looking to the future we must be careful to understand how we assemble the pieces or elements of the health care system.The chart below depicts the approach of Kuhn in his work on scientific revolutions. We believe it applies directly to health care as well.
The elements are the bits and pieces which make up health care. The paradigms are those examples which we hold as the basis of our beliefs. The world view is the almost religious understanding of how things should work. When the paradigm shifts, due often to new technology, the assembly of the pieces moves all over the board.
Now look at the elements as shown below. The question we pose is that if we see in genetic medicine the changes we anticipate in the next twenty years, this change will create a new paradigm, namely core example, and this paradigm will change the world view and in turn the architecture. Government should not address how to manage the past but ow to promote the future. By targeting genetic screening, staging, treatment and prevention we change the field of medicine. By rearranging the deck chairs we spend money and wast time and delay the future.
These thoughts will be provided in a new paper shortly. The understanding of how to approach the problem is critical. One needs a framework, a philosophy, so as to assemble a broad picture. As I have been reading the current collection of health care policy types they see to totally ignore these factors. Kuhn was brilliant in his articulation. He applied it to science but as I have looked at many other fields his approach stands the test of time in all areas and policy makers must take this into account. Antibiotics, psychiatric drugs, protease inhibitors, imaging systems, all of these changed the way we view medicine and changed the way it is architected. We truly believe that gene therapy will do the same. We also truly believe it will do so in a shorter time than most anticipate. Hopefully our Government leaders do not set it back because of their lack of understanding and that the policy makers do not just rest in their ignorance.
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