Nurse Leader Future Scan: The Unknown Unknowns with Health Reform

By Rose O. Sherman, EdD, RN, FAAN

“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know.” Donald Rumsfeld

This past month has been interesting as the websites for health insurance exchanges have been introduced nationwide with varying success. This is only the first step in the health reform process. We can already see that this will be a rocky road as move forward. The only certainty at this point is that the future of health care will be much different than the system that we have today. I have taught health policy for a number of years and have learned through my work that with any major policy change there are usually unintended consequences. These usually don’t surface until the implementation stage. This makes planning very challenging for nurse leaders today. Depending on your viewpoint, utilization of hospital services will either dramatically increase when the uninsured become insured OR dramatically decrease because services will be more tightly managed and pushed into community settings.

It is the unknown unknowns – or the things that we don’t yet know we don’t know that could impact the current health system in ways that we don’t yet understand. What we do know about health reform is that there will be significant shift from volume-based care to value-based care. We already see examples of this with changes in reimbursement such as reduced payment on 30 day readmissions for certain conditions. New payment structures will move to episode-based funding that will encourage hospitals, providers and community-based care agencies to work together to improve care continuity. More care will occur in the community. There will be a greater focus on preventative care and chronic disease management as access to the system for these services will be available to a larger number of people.

We are also moving into the era of “BIG DATA” in health care which will be transformative. The first step was the implementation of the electronic health record. Ultimately, it is the rich data bank in these records that will be mined on a national level to determine what treatments and medications work and on what populations. There could be a significant reduction in treatment because we will be better able to personalize it for the patient and eliminate treatments that don’t work.

It is difficult to anticipate what the unknown unknowns could be but the following are several that I have thought about:

Some Unknown Unknowns

Consumer Behavior – Reducing costs in health care will require a “less is more” approach to care. There is uncertainty about how consumers, with a history of being able to request and get treatments and drugs whether indicated or not, will respond to these changes. The public has been educated that health reform will reduce costs but much less is said about the need to totally restructure care delivery and what this could mean.
Slow Medicine at the End of Life – Changes in reimbursement will reverse some of the perverse incentives that have led to 25% of all Medicare dollars being spent in the last six months of the patient’s life. More than a quarter of the elderly today die in intensive care units. Will we be able to embrace a different approach such as slow medicine than we have used for the past 50 years?
The Health care Workforce – One of the biggest unknowns in health care reform is whether we have a workforce with the right skills for a totally different health system. We have moved over the past 3 decades to high tech, specialty focused care. The new system is likely to be lower tech, in the community and focused on prevention and chronic disease management. Primary care is a weakness in our current system and is poised to become the cornerstone of health reform but is the healthcare workforce ready for this?
Impact on the Economy – The biggest unintended but necessary consequence of health reform may be the negative financial impact on some corporations who provide health related products and services. With a “less is more” approach to care – there will be decreased utilization and possibly price controls on imaging equipment, implantable devices, durable medical equipment and pharmaceuticals.

The next five years will be tumultuous ones in the health care system. There will be radical changes – some of which we anticipate and others which catch us by surprise. We plan today with the best knowledge that we have available to us but embracing the reality that there will be unknown unknowns is important.