The most vivid metaphor I recall from graduate school was one offered by a professor from the school of public health.  It related the story of a village on the side of a river, where people were noticed floating downstream in danger of drowning.  This happened so often, and there were so many such “floaters” being saved by the villagers that it became a “cottage industry”, with families and other groups of people building and mooring boats at the best spots, and making a good living charging those they pulled alive from the river.

While this went on for some time, there eventually came a day when one of the villagers left the crowd of people engaged in this worthwhile and universally appreciated effort.  As he walked away, one of the villagers asked where he was going.  “Upstream, to see who is throwing all these people into the river” was the answer.  One can only imagine the mixed feelings of the villagers in their boats – appreciating the logic of looking upstream to learn why so many were floating in the river, yet realizing that this could easily result in the end of their business and livelihood.

The world is essentially in the same place as the village in this story, except that the movement is clearly “upstream” to keep people from contracting the diseases and injuries that represent the foundation of the “health” care business.  Employers, insurers, and governments alike, often joined by consumers who want to live longer and better, are moving in the upstream direction, and threatening to vastly increase the proportion of healthcare funds spent on “prevention” rather than “treatment”.

With the current proportion generally thought to be 5% or less, there is clearly room for a dramatic increase.  On the other hand, there may not be enough good investments available to increase the proportion to, say, 50% as a truly “balanced” strategy.  On the other hand, at least two sources have predicted that the “wellness” or “healthy living” market, combining payers and consumers, will reach $1 Trillion very soon, compared to the already $2 Trillion size of the sickness care market.

Pilzer, in The Wellness Revolution: How to Make a Fortune in the Next TRILLION DOLLAR Industry New York, NY, John Wiley & Sons 2002, for example, predicted that the “wellness” market will reach $1 trillion by 2010.  A more conservative Haws in “The New ‘Healthy Living’” (Hospitals & Health Networks Online, Jan 25, 2005) estimated that it won’t be until 2020 when the market reaches the $1 Trillion level.  Whichever is the case, this would mean a major redistribution of funds relative to sickness care.

Unfortunately, there is already so much disease and injury that already exists, or is clearly in the “pipeline” of unpreventable (with present expertise) acute and chronic sickness, that the sickness care market is unlikely to decline neatly in a way the will make the shift of resources to wellness care “budget neutral”.  This will create an extremely bothersome period of adjustment for payers and providers.

It seems likely, given the enthusiasm shown by most large employers and others who see their workforces as valuable capital assets, that employers, along with commercial and government insurers will shift their investments as much as possible toward proactive health care in order to reduce their burdens in paying for reactive sickness care.  They are likely to persist in, and probably grind down even further their “generosity” in paying for sickness care, and be joined by an army of consumers whose uninsured, under-insured, or high-deductible/co-pay insurance status will make them perhaps “over-prudent” in seeking sickness care.

Current providers are fortunate in at least two ways.  First, the existence of millions of people who will need their sickness care services for the foreseeable future will create pressures on payers to maintain the present sickness care infrastructure, at least for a while, though perhaps with less generosity than in the past.  And second, even if consumers choose to switch the basis of their choices of providers from emotional to “rational” reasons, the evidence-based best providers will not be able to handle anywhere near as much demand as they arguably deserve, so even lower-ranked and rated providers will still survive for a long time.

The real issue is what the long run future will be like.  Will proactive health management reduce the incidence and prevalence of disease and injury enough to make current providers’ investments high-risk speculations, rather than sure things?  Will a shift to preference for the best providers eventually drive the worst, then the below average, and even the only average out of business – or will the fear of such an eventuality drive every provider to be above average, as in Lake Wobegon?

The real question for sickness care providers may turn out to be that of whether to stick to “downstream” sickness care, as long as the demand and payment for such care enables it – or to join in the “upstream” movement, despite its tendency to “cannibalize” the sickness care business.  Most providers’ missions or professional values would seem to point them toward joining a movement they probably can’t “lick”.  But the extent to which the sickness care market will decline, or, thanks to an aging and recalcitrant population of consumers, not decline but merely grow at a slower rate, is still to be learned.

Whether current sickness care providers join in the proactive health care movement or not, there will surely be plenty of “true” health care providers available to meet proactive health demands.  Huge numbers of nurses, other clinical professionals, along with coaches, peer mentors, etc. are likely to join the proactive health movement, since payers can afford to be far more generous in paying for care that saves them money than they are with care that represents a burdensome cost.

Whether or not a national health policy emerges from current political debates on the future of health care, it seems sure that “natural experiments” by many large employers, insurers, government demonstration projects, and consumers’ own willingness to pay for longer and better lives through prevention will guarantee some amount of shift in that direction.  It remains for sickness care providers to decide whether or not and how much to shift their own efforts in the upstream direction.