The problems in our health care systems include subpar quality and patient safety, a misplaced focus on acute care rather than on prevention and population health, inadequate person centeredness, and unsustainable cost. The next decade will see considerable transformation in how health systems are designed, propelled by opportunities such as digital health, growing consumerism, and mounting financial constraints. The Covid-19 pandemic has also necessitated and accelerated significant transformations. The authors discuss gaps and barriers in the current design of health and health systems, and the needed escalation of transformation including transition from hospital-based systems to primary care, community, and social care–based systems. They also assess the future evolution of payment systems leading toward sustainable health, changes in provider roles, and the entrance of new nontraditional players.

Health care today is often characterized by mediocre quality, poor safety, and high costs.1 Though change usually comes slowly, the Covid-19 pandemic has demonstrated that it is possible to rapidly retool our systems if there is a strong enough stimulus.2 In this article, we examine the future of health care — how it should change over the next 10 years, and the key drivers to enable our systems to become learning health care systems, with improved outcomes.

Challenges and Barriers to Current Design of Health

Despite considerable variation in health system design around the world, most countries suffer from similar gaps and challenges. Patient safety and quality have been a concern since the early days of structured measurements.3-5 Preventable harm to patients is all too common both inside and outside hospitals, and clinical practices are often not evidence based. Although these gaps have been thoroughly studied and many interventions have proven effective in small-scale implementations,6 large-scale progress has been minimal.7
Modern health systems often fail to provide care that is focused on patient and family needs and expectations. Most systems can’t consistently measure outcomes that matter to patients,8 and can’t improve their health-related quality of life and overall function. Furthermore, current health systems often can’t effectively involve patients and their families in the care process or provide empathic care.9
Equitable access to health services is rarely achieved even in countries with universal health coverage.10 The ongoing Covid-19 pandemic has highlighted gaps in accessibility and equity.11
Finally, economic sustainability is elusive, particularly in developed countries. Future health spending is expected to rise even further as new techniques and therapies become available.
These gaps have been present for decades, yet health care systems have failed to close them. Change will require a major redesign.

Drivers of Change

Transformation requires strong drivers. One will be the digital health revolution. We expect digital transformation to change health care as it has changed banking and retailing.
Consumerism is growing, as people become more knowledgeable and active in their care. The health industry will need to become more person-centered, personalized, and more transparent.
Another major driver is unsustainable cost structures across the developed world, creating a “burning platform” for providers, insurers, consumers, and policy makers.
The health care workforce is facing fundamental changes. New specialties will require new health professions. Workforce shortages, seen in many countries, will force adoption of new technologies to stretch the available workers.
Covid-19 has brought about an incredible expansion of digital health, and specifically telemedicine.12,13 It has also meant plunging revenues for providers and a more general global economic downturn. Both factors may make it a watershed moment for health care transformation.2,14
Most systems can’t consistently measure outcomes that matter to patients, and can’t improve their health-related quality of life and overall function.
Change in the U.S. is likely to happen first in regions in which there is a high proportion of accountable care and in organizations, such as Kaiser, that are responsible for the care of populations. In other parts of the world, it will occur in the organizations associated with leading institutions, as in the UK’s Global Digital Exemplars program. The pace of digital transformation in organizations is likely to be limited by the number of people with training in informatics in these institutions. The extent to which organizations emphasis person-centered care may be governed by whether leadership values improvement in this area, and by regional availability of health information exchange allowing systems to take full accountability.

OUR HEALTH SYSTEM TODAY, JANUARY 1, 2020

Silvio thought of himself as generally well. He was 47, and a construction worker. Though he knew he was overweight, ate too much fast food, and avoided all kinds of exercise outside of work, he had never had any serious medical issues that he knew about. But today, his heart was racing, he was sweaty, the room spun, and he felt like he was going to die.
In the emergency room, the medical team diagnosed a dangerously high blood sugar. They delivered normal saline and insulin, and informed Silvio that he had Type 2 diabetes. Over the next few days, Silvio was started on insulin therapy and also diagnosed with high blood pressure. An abdominal CT scan revealed a 4.5 cm abdominal aortic aneurysm. A cardiac MR study confirmed coronary artery disease.
A few weeks later, Silvio had a follow-up visit with a diabetic specialist; he was going to need to radically alter his lifestyle. He had to inject himself with insulin several times daily, take multiple daily blood pressure medications, have periodic monitoring of the aortic aneurysm, and think about the possibility of cardiac intervention if his recently diagnosed coronary artery disease worsened. Silvio asked himself how all this could have happened so suddenly without his knowledge — and in this modern day and age?