The futures of respiratory care are powered by cost pressures, new technologies, and consumer demands

To understand the possible futures of respiratory therapy, as with any future, we have to think systemically. No simple list of trends or predictions can capture the complex tapestry of unfolding reality. To begin to catch the flavor of the future, we have to contemplate the cross-influence of each factor on the others.

Demographics
 The most predictable trend in many countries is the aging of the population, and this shift will affect respiratory care more heavily than it will other areas of health care. For instance, emphysema and other forms of chronic obstructive pulmonary disease (COPD) are strongly age-related.

In the United States, Canada, and Australia, this shift represents the aging of the Baby Boomers. In Western Europe and Japan, it is a more complex phenomenon, but has a similar outcome. In China, it is the result of the long-time “One Child” policy.1 In all these countries, the result is fewer workers to support more elderly frail people. This means two things, which both head in the same direction: 1) With fewer workers paying taxes for social support programs (such as Medicare in the United States), ever-increasing health care costs become unsustainable. 2) At the same time, fewer workers are available to do the necessary health care work. These two factors come together to make it necessary that respiratory therapy be streamlined, networked, and automated as much as possible and the role of the human operator, the therapist, reduced as much as possible to decrease costs and to remove potential sources of error.

In the United States, one other demographic shift is playing out: The non-Hispanic European-American population is growing much more slowly than other groups, particularly Hispanics. In California, non-Hispanic whites are already a minority.2 A number of other countries are experiencing similar increases in diversity. This means that in respiratory therapy, much of which takes place working directly with the patient and even in the home, diversity of background, multilingual capabilities, and cultural sensitivity will increasingly be career assets.

Cost Pressures Lead to a Value Shift
 Simply put, health care costs too much—outlandishly so in the United States, clearly so in all countries. Respiratory therapy is, on the one hand, a complex process that will be amenable to much streamlining, automation, and cost reduction. At the same time, it is often a preventive strategy that reduces costs by keeping COPD patients, for instance, from needing to access much more expensive acute care. So, while the field will grow with an aging population, the relative percentage of the field representing direct intervention by human therapists will shrink, and the relative value of each therapist will grow. Automation will mean that the field will show a large rise in productivity, and that productivity will represent a great increase in the use of respiratory therapy as a preventive and disease management strategy to cut acute care costs.

New Technologies and Networked Automation
It is a simple truism that new technologies will revolutionize the field. It is important, though, to recognize the directions the influence of new technologies will take. They are three, and they are related: complexity, simplicity, and networked automation.

1. Complexity: New and increasingly complex and subtle instruments will allow therapists to measure patients’ respiratory health and capacity more directly than such simple measures as Vo2max and Pao2.

2. Simplicity: These instruments will become increasingly user-friendly, designed to decrease the amount of time and effort the therapist needs to put into each case, to minimize the opportunities for error, and even to relieve the necessity for the therapist at all, turning the responsibility over to the patient or the patient’s family or other caregivers.

3. Networked automation: Increasingly, instruments and therapies will be networked together, with the output of one becoming the direct and automatic input of the next, removing the human therapist from the transaction. Blood oxygenation monitors, for instance, will directly change the settings of ventilators, CPAPs, and other respiratory devices.

Consumer Power
It is likely that the largest change vector of all is the awakening power of the consumer. This force is emerging in different countries for somewhat different reasons and at different speeds. In the United States, the key factor is the introduction of consumer-directed health plans (CDHPs), which make the consumer responsible for more of their health care expenses, but also give the consumer more say in choosing their health care providers. A similar effect will be felt in Singapore and, of vastly greater importance, China, both of which are following the lead of the United States toward CDHPs. In other countries, where insurance of any kind plays a lesser or nonexistent role, consumer power is nonetheless increasing because of widespread dissatisfaction with the effectiveness of health care spending, and the increasing transparency of all health care systems in a digital age.

Three factors are necessary for a market to act like a consumer retail market:

1. Consumer incentive: It must make a difference, in some way (price, amenities, convenience), for the consumer to choose one product or service over another.

2. Provider competition: Consumers must have not only the legal and regulatory ability to make a choice, they must actually have different providers among which to choose, for any given product or service.

3. Full information: The consumer must have multiple sources of reliable, recent, and relevant information on which to base the choice.

All three of these factors are growing, rapidly in the United States, but in most national systems to an appreciable extent. And they need not become the majority pattern for any system to drastically reshape that system: When, in any system, providers actually compete for customers, they will not be able to afford to lose any sizable fraction of the population that has the ability, information, and incentive to make a good choice.

The potential effects of this change are still underappreciated across health care—and they will fall differently in respiratory care than elsewhere, for some fundamental, structural reasons.

The Dimensions of Consumer Power
The effect of consumer power on health care will have three separable dimensions: cost, quality, and the patient experience.

Cost. Nowhere has health care subjected its processes to the kind of rigorous, iterative, and minute cost-benefit and quality analyses that many retail, manufacturing, and service industries now consider routine. Consumer power, whether expressed through buyers’ choices or through political pressure, will combine with increased transparency to force everyone involved in health care to make that level of analysis a regular part of doing business. A number of hospitals in the United States, for instance, have adapted the Toyota Production System to health care, rooting out inefficiencies, redundancies, and waste in the tiniest processes—the placement of a fax machine, the cleaning of an infusion pump filter—and saved tens of millions of dollars in the process.

Quality. Here, too, the new transparency is changing the face of health care. In the United States, Canada, and some other countries, various state, provincial, business, regional, and federal initiatives are forcing health care providers to publish their statistics for particular types of outcomes, infection rates, adverse drug events, and so forth—and some initiatives are basing payment on these outcomes, in “pay-for-performance” (PFP) schemes. This is about cost as well, for lower quality in health care often goes with higher costs—the kind of sloppy system that produces higher costs typically also produces nosocomial infections and adverse drug events, and those in turn generate even more costs.

For instance, in Milwaukee, Minneapolis, and some other areas, business groups have created a tiered payment system that tracks medical care by the case, not by the individual incident, and uses co-payments to steer people through doctors and hospitals, with both better outcomes and lower costs over time. If you carry insurance through one of the employers involved in this effort, you can choose any doctor or hospital you want, but if you choose one that has not shown that they can produce better outcomes at lower cost, you will have to pay more.

In respiratory therapy, this will increase the push both toward networked automation, and to the pervasive use of clinical protocols.

Patient experience. As consumers gain a voice and a sense of choice, we are seeing an increasing focus on the often-abysmal experience of being a patient: the long waiting times, the lack of real information, the feeling of powerlessness, the plain disrespect of the person evinced by many health care institutions.

Health care leaders, especially in the United States, are becoming increasingly aware that they face a future in which every mistake, every lawsuit, as well as complete price lists and outcomes ratings, will be displayed for the world to see on the Internet. This year the federal government’s Centers for Medicare and Medicaid Services (CMS) is rolling out the 26-question Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey3 for use by hospitals across the country, and the results will be posted on the Web at www.hospitalcompare.hhs.gov. The survey will start out as a voluntary program, but as of October hospitals that do not participate will lose 2% of all federal reimbursements. As William Powanda, vice president of Griffin Hospital in Derby, Conn, points out, though, coercion may not be necessary: “Think of a local community hospital with a lay board. Imagine what will happen when their hospital shows up in the lowest quartile. Resources will be reallocated. The message to management will be: ‘Fix this and fix it quick.’ There is going to be a scramble to find solutions.”

Implications for Respiratory Care
Much of the daily work of respiratory care is about education, remediation, monitoring, and hand-holding. Any system that involves an insurance model is skewed toward paying for the definable medical event—the office visit, the x-ray, the intubation—not for the longitudinal measure of health, whether the case (Mrs Smith’s pneumonia) or the person’s increased length and quality of life.

In such a system, the preventive, educational, and monitoring aspect of respiratory care for chronic disease is seen as a cost, twice over. Not only does it cost the system to provide the care, but for the providers, it is an opportunity cost. Institutions and physicians may not consciously deny preventive care because it reduces their patient flow. Across the spectrum of health care, the trend is too obvious, though. Providers will provide the oxygen bottle and the brief home-health visit to hook it up, but they will not provide long-term, preventive care for which no one will pay them, and which reduces the stream of patient visits and admissions for which they are paid.

What do patients want? Clinicians who spend more time with them, listen to them, give them more hands-on care. They would like to not have to go to the doctor so much. They would like their condition to improve; they would like to feel healthier. All of this points to education, remediation, monitoring, and hand-holding, which is often done most easily, cost-effectively, and conveniently by a respiratory care provider.

What do those who pay for health care, whether employers or governments, want? Lower cost and higher quality, happier employees and citizens, less waste, smarter use of the health care dollar. All of this points to education, remediation, monitoring, and hand-holding.

This means that we are likely to see two different and somewhat conflicting trends in the relatively near future. Both trends will show up sooner and in a greater degree in the United States but will spread as well in other countries, especially among the rapidly growing urban middle classes of China and India:

•The tasks of respiratory care will become increasingly automated, networked, or even outsourced. Imagine, in detail, each of the tasks involved in respiratory care. Ask yourself whether that task requires the dexterity of a trained physical body present in the room with the patient, and/or the inquisitive judgment of a trained mind. If it does not, it is likely that that piece of respiratory therapy will be automated, so that a computer can do it. Or it will be made into a home device the patient can use. Or it will be networked, so that a computer somewhere else can do it. Or it may even be outsourced, so that someone in India or the Philippines can do the monitoring, the analysis, and even the phone consultation.

•As consumer-oriented health care takes hold, as people increasingly make their own choices about how to buy the health care that they need, encouraged and guided by governments, employers’ coalitions, and even the financial services industry, we are likely to see a wholesale shift toward recognizing respiratory care as the cost-saving preventive process that it is. Skilled respiratory counseling in the home helps keep people out of the emergency department and the intensive care unit—through education, remediation, monitoring, and hand-holding. We are likely to see this shift first in private-sector pilots and partnerships in the United States, and then see it taken up by government funding bodies.

These trends do conflict, but together they paint a picture of a future for respiratory care in which the parts that can be automated or outsourced will take up less time and funds, while the preventive parts, which largely must be done in person with the patient, will likely grow in importance.

Joe Flower is a health care futurist and founder and chief executive of Imagine What If Inc (http://imaginewhatif.com). Flower has been writing, speaking, and consulting about creating health care changes for more than 2 decades.

References
1. Flower J, Schwartz P, Ogilvy J. China’s futures: scenarios for the world’s fastest growing economy, ecology, and society. Hoboken, NJ: Jossey-Bass; 2000:41-46.

2. US Census Bureau. State and County Quick Facts. Available at: http://quickfacts.census.gov/gfd/. Accessed May 25, 2006.

3. US Department of Health and Human Services. Agency for Healthcare Research and Quality. CAHPS Surveys and Tools to Advance Patient-Centered Care. Available at: www.cahps.ahrq.gov/default.asp. Accessed May 25, 2006.