The U.S. health system is broken. Challenges with insufficient capacity and access, ensuring care quality and timeliness, and curbing costs have persisted for decades, coming to a head during the COVID-19 pandemic. Long wait times for receiving primary and specialty care lead people to emergency departments—often by the time their condition has worsened—where they may wait for hours to be seen and days to get a hospital bed if they require hospitalization.
The current U.S. health system is ill-equipped to respond to the 21st century needs of patients and communities. A health system overhaul is needed to put patients at the center of care, to prioritize health education and disease prevention, to provide care to patients where and when it is most convenient for them, and to leverage technology to do more with less. Reform also should seek to increase access and capacity and curb health care costs.
Health care has become a less appealing profession given the need for costly and lengthy education, the stresses of the job, and often insufficient payment. These barriers cause fewer people to consider going into health care and prompt current health care workers to retire early or leave the field for easier and/or more lucrative careers. On the other hand, patients are largely left to themselves to navigate a highly complex system that does not sufficiently educate them or work to prevent illness and preserve health.
Other challenges include: An older U.S. population with more acute and complex needs, continued rising health care costs and dropping insurance payment, an unpredictable medical supply chain highly sensitive to the world sociopolitical climate, more frequent and intense extreme weather events that increase health services demand and can decrease care access and capacity, uncertainty around the use (and misuse) of emerging technologies (such as AI) in health care, and loss of trust in care providers.
To effectively address these challenges and ensure America’s health, a health system overhaul needs to make care delivery smarter, more efficient, proactive as opposed to reactive, patient-centered, and resilient to current and future threats.
Here are some key considerations for rebuilding the U.S. health system.
Moving Care Delivery from Health Systems into Communities and Homes
Inpatient hospital care accounts for 24 percent of annual health care expenditures in the nation. With home nursing, hospital at home, and technologies such as remote monitoring and telehealth the care of mild to moderately sick patients can be moved to the home setting. This will reduce the risk of hospital-acquired infections and costs related to inpatient care, and keep patients in the setting most prefer—their homes. Hospitals of the future can be limited to emergency departments, operating rooms, and intensive care units to address the needs of the sickest patients while most other current inpatient care can be moved outside hospital walls by leveraging technology.
Many patients have challenges seeking care because of lack of transportation and/or living a long distance from clinics where primary and specialty care are delivered. Expanding the use of mobile clinics—especially in very urban and very rural areas—can help increase patient access to health services.
Incentives for community and home health care programs can facilitate provision of primary and non–primary care in the home setting. Health system redesign should consider the role of community health workers, and financially incentivized family and other “informal” health care providers, with tele-technical assistance (such as video conferencing with a nurse or other primary care provider) in expanding home health care programs.
Designing Care Delivery Models That Make Care Access Easier for Patients
For people who have one or more jobs seeking health care during work hours may not be possible. For that reason, many patients seek care outside of work hours in urgent care or emergency department settings—the only care locations that may be available to them outside of work hours. Some primary care and specialty clinics have late evening and weekend hours to accommodate patients. This practice needs to be widely adopted in outpatient settings. Evening and weekend hours may be appealing to providers if a pay differential is implemented.
To expand 24/7 care access, there could be containerized health pods in everyday locations to facilitate self-administered procedures that require “minimal oversight” such as self-administered blood glucose tests, urinalysis, or collecting samples to test for respiratory or gastrointestinal infections. Secure information transmission systems can be built into the pods to deliver the results of tests to a person’s health care provider. These pods can be stationed in storefronts of businesses that already operate uninterrupted services—for example some restaurants, gas stations, and other hospitality sector businesses.
To increase both care access and timeliness, patients should have the option of opting out of continuity of care altogether so they can be seen by any available clinic provider sooner. Opting out of continuity of care with the same provider may be especially useful for patients who are generally healthy and don’t have complex care needs.
Making Hospitals Energy Resilient
Hospitals are among the most energy-intensive buildings. As they adopt more AI-based technology, their energy needs will only grow. Meeting this rising energy demand will require tough choices. Hospitals need to balance reliance on new technologies with the need to keep energy demand and power bills in check.
Hospitals can try to reduce energy use, whether that be through using more efficient technology to reduce demand (e.g., high efficiency air conditioning), altering use patterns to smooth demand (e.g., wash bedsheets at nighttime when less electricity is needed), or offsetting demand with other fuel sources (e.g., install solar panels and batteries for onsite generation).
Further, there is an urgent need to ensure hospitals have resilient, reliable backup power to keep essential services running in the setting of extreme weather events (such as hurricanes and heat waves) that often result in power outages. Energy resiliency must be a top priority to ensure financially viable hospitals and uninterrupted operations.
Making Hospitals and Care Access Resilient to Extreme Weather Events
During extreme weather events, even if patients can reach the hospital, which is often impossible when floods or fires block roads, hospitals can quickly become overwhelmed. As the population grows and extreme events become more common and destructive, rethinking how hospitals and health systems can maintain continuity of operations must be a priority.
There are three key areas to focus on. First, stronger structures, up-to-date safety codes, and green spaces that can serve as safe havens during emergencies are needed to make hospital buildings themselves more resilient. Second, better roads, reliable communication, and backup transportation options are needed to improve the ways people get to hospitals. Third, the need for people to travel to hospitals should be reduced by using tools like drones to deliver supplies and providing care in sites embedded in communities that can keep working even during and in the aftermath of such events.
Prioritizing Patient Education and Disease Prevention
The U.S. health system has historically prioritized treating diseases over preventing them. This is partly due to a longstanding schism between health care and public health where disease education and prevention have been primarily the responsibility of public health and disease treatment has been the focus of health care.
This separation has contributed to inefficient and, often, ineffective disease prevention. The health system of the future needs to bring health care and public health together anywhere and everywhere possible to increase opportunities for patient education and disease prevention and pool resources (including staff and data) around common missions in service to population health.
One approach to bridging health care and public health systems could involve promoting standards for voluntary health data collection at home. This could be combined with health education and facilitate disease prevention and detection. Aggregation of voluntarily-collected data across multiple households can be conducted through peer support groups where individual experiences with chronic health management, for example, could be grouped to understand how variations in environments and other contextual factors can influence outcomes in preventative care and patient compliance. This approach is in line with the Veterans Health Administration’s peer support programs and use of standardized patient-reported outcome measures (PROMs).
Strengthening the Medical Supply Chain
Hospitals in the United States routinely experience shortages in various drugs and other medical supplies. The COVID-19 pandemic showed how vulnerable the U.S. medical supply chain is to disruptions in foreign manufacturing. To combat this vulnerability, both routinely and during emergency conditions, the U.S. health system needs to monitor and analyze potential supply chain shortages to identify, predict, and mitigate them. Health systems within the same region could form compacts that facilitate access to each other’s supply chains when an organization faces shortages. Such compacts can also include multihealth system stockpiling of critical medical supplies and equipment where the risk and benefits of stockpiling can be shared by multiple organizations instead of being restricted to one.
Optimizing the Health Care Workforce
The United States can’t create new pharmacists, nurses, physician assistants, physicians, and respiratory therapists fast enough to keep up with the current and projected health care needs of Americans. The future health system should invest in retaining and optimizing the existing workforce through leveraging technology as a key strategy for doing more with less.
One way to increase staff retention is to ease administrative and basic care duties using AI and robotic technology. AI is already re-shaping health care work by helping to automate electronic health record documentation—as well as risk assessments and care decisions based on that documentation—across a patient’s care team. This is critical to reducing provider burnout.
Additionally, patient care includes a variety of basic care duties that robots can assist with using sensors, cameras, and mapping software under human supervision. As health care demands increase, in tandem with health care workforce shortages, robotic technologies that perform basic physical care duties are likely an important way to optimize the future available health care workforce.
Health care workforce shortages do not occur evenly across the United States. Depending on the health care workforce in question, rural and urban areas or specific states might face greater shortages. Blockchain identity and credential management is key for providing reliable information on current licensing for a more mobile health care workforce, literally and virtually.
Finally, telehealth care across the care continuum can be utilized more, especially when supplementing other technologies. For example, wearable sensors to provide patient vitals and augmented-reality glasses to help a patient perform basic assessments during a virtual “office visit” can help make telehealth more realistic, effective, and informative for both the patient and the provider. In some cases, “telepresence” robots that physically assist a specialist providing remote care to a patient in a hospital or other setting where such specialized care is unavailable can be leveraged to improve care provided remotely.
Revisiting the Health Care Ethics Framework
Central to a health system overhaul is the need to update the current health care ethics framework so it incorporates approaches to 21st century care delivery ethical dilemmas. This is needed to guide care delivery into the future and for enhancing patient trust in health care providers and organizations.
Revisiting the health care ethics framework will require a consideration of if (and how) ethical imperatives in the future might differ from today. Given an aging U.S. population with more acute and complex medical needs health care may inevitably contend with a new range of ethical dilemmas.
In a future defined by rapid bio-tech innovation, AI saturation, and wide adoption of gene therapy, a new spate of ethical concerns will arise, complicating time-honored concerns of autonomy, nonmaleficence, beneficence, and justice. For example, given digitization of health records and increasing use of AI in health data analysis, data privacy and security concerns are likely to increase.
Further, it is critical that AI-based technologies used in health care settings and their algorithms are free of biases that may lead to wrong diagnoses and management plans—so that, above all, they promote treatments that “do no harm.”
America’s health system is in desperate need of reform. These efforts should seek to focus resources and technology on the needs of patients, prioritize education and disease prevention, improve access, and curb costs.
– Mahshid Abir is an emergency physician and senior physician policy researcher at nonprofit, nonpartisan RAND and a professor of policy analysis at the RAND School of Public Policy. Megan Andrew is a social scientist at RAND. Kelly Klima is a senior engineer at RAND. Leslie Payne is a senior political scientist at RAND. Nahom Beyene is a former senior engineer at RAND. Han-Yi Chiu is a Ph.D. student at the RAND School of Public Policy. Published courtesy of RAND.
