A Zero|Base health system

Photo Antoine Dubout & Guy Vallancien / President, French Federation of Private and Non-Profit Hospitals and Personal Assistance Organizations & President, Convention on Health Analysis and Management / June 10th, 2016

As the world changes, human institutions – beyond the strictly speaking commercial sector – devote a significant part of their resources to make sure they remain in good condition and avoid major structural changes. This conservatism is not only caused by an inclination to preserve their personal circumstances: when a system has proven its ability to function in the long run, any in-depth change represents a leap into the unknown, and a human group is not ready to take such a risk, unless it is forced to do so by competition and markets dynamics, or unless they are in an untenable situation where they have nothing to lose. Change is then initiated in violence and pain: That’s what we call a revolution. The purpose of our Zero|Base series is to imagine what could be, in various areas of non-profit sectors (in whole or in part), an optimal system adapted to today's world and taking especially advantage of technological innovations, while deliberately ignoring the current structures and socio-political constraints. These articles do not have the ambition to propose new solutions to the outstanding problems but rather, to suggest (on paper) rationally coherent, credible and viable systems from scratch, in order to nourish the reflection of all the concerned parties.

In the health field, as in many others, the current structures are, in all countries, inherited from a more or less distant past. The possibilities offered by new technologies were implemented gradually, but without fundamental changes in institutional and human aspects of the structures. Now, saying that it is precisely these structures inherited from the past that can make the most of these new technologies is an understatement. In other words, if today we had to build from scratch an optimal health system, using the best available technologies – which for most of them did not exist only fifty years ago – would we find the same structures current systems are made of?

For this exercise, let us assume that an international organization concerned with completely reorganizing all the health systems structures in the world, resorts to the services of Sirius, an expert from another planet.

Sirius has four characteristics. He is strictly rational and insensitive to any emotional stimulus. He is also insensitive to any political or corporate pressure. He ignores all existing health systems worldwide. He has a full capacity of understanding and immediate learning.

We will provide Sirius with no information on the institutions and infrastructure in the existing health systems. However, we will make available to him all the necessary pieces of information about:
. The men and women who are the users of the health systems, and the companies these citizen-users are affiliated to, all around the world
. The knowledge available on health, the human body and mind, the different memories (human and electronic) where the knowledge is available, the technologies specific to the health sector, and the time required for a human to acquire knowledge and control over such technologies
. Technologies other than those specific to the health sector but which play, or could play, a role in the health system – information technology in the first place, but also housing and transport-related technologies
. The administrative and political borders of the various countries (Government level, local authorities, etc.)

The basic assumptions to found a health system
Sirius will first ask for a definition of health. His interlocutors will provide him with the WHO’s definition of 1946: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” They will add that it is a metastable state and dynamic balance with all environments – family, social, professional, economic and physical – that it is important to maintain or restore even though it is hard to conceptualize, and only perceptible when such balance is lost. Sirius will notice that, while the healthcare sector is very broad – ranging from the environment to mental health, and also includes hygiene, transportation, economy, lifestyles and consumption.

Sirius then first realizes the issues surrounding the value and importance of life, life expectancy, the meaning of death, suffering, disability … He realizes that as it is the weight given to life and death in a human society that leads to very different policies, depending on the company. He presupposes that, depending on the company and its value systems, health policy can have different objectives: for example (A) enable each individual to go through life in the best possible physiological and psychological condition, or (B) to the other extreme, simply ensure the optimal economic return of the population to the national community without worrying about the individual’s quality of life. In order not to complicate his task, Sirius adopts the premise that it is about meeting the conditions necessary to both A and B. He will also start from the consideration that, in a given country, all citizens must be treated equally regardless of their geographical location.

In this sense, Sirius will define health as a public interest service whose execution may be delegated to private or public structures depending on the political models of the country.

Ontological invariants
Beyond these assumptions, Sirius seeks to define “ontological invariants” to confine the question. After discussion with representative philosophers of various human societies, he will identify two invariants that will be required in any health system: individual freedom and respect for the “chance of life.”

The principle of individual freedom must be, from Sirius’ standpoint, an absolute data. No physical or moral compulsion can force a man to treat or not to treat. But if it is unquestionable dogma, it will be moderated by law for hospitalizations without defined consent requirements and even if, during health crises, such temperance could bring about risks and drifts. Respect for the chance of life forbids Sirius to establish of eugenic policies, therapeutic cloning, sterilization or euthanasia…

The question of genomics deserves to be addressed in this context, since it affects both the individual freedom and the chance of life. Sequencing the genome of individuals brought considerable potential for the detection from childhood of predispositions to certain diseases, for the prescription of “customized” drug therapies and for research, thanks to the availability of highly refined global statistics. However, Sirius, when informed about ethical and economic problems induced by widespread genome sequencing at birth, will resolve not to take a position, for now, on the subject and let another “panel” (philosophers, doctors …) establish themselves a record for a decision.

The components of the health system and their implementation
Starting from the definition of health provided by WHO, Sirius will consider that the health system has three components that meet three fundamental objectives:
. How to keep men and women from a given country in an optimal equilibrium, with physical, mental and social well-being: the Prevention System
. How to restore this equilibrium for those affected by disease, trauma or disability: the Care System
. How to continuously improve both systems – prevention and care: the Research System.

He then defines the technological infrastructures and the institutional structures that form the backbone of these three systems.

network

1. Prevention and its corresponding political system
Manage health, Sirius says, is prevent people from falling ill or get traumas. Prevention focuses not only on health but also – in the strict sense – on all its determinants: diet, lifestyle both at work and outside the workplace, pollution, housing, transportation…

First, to detect and prevent potential diseases that affect the population and make it have a share in the management of their health, Sirius will implement an infants & schools monitoring network.

Then, to ensure the health quality at work (where people spend at least a third of their time), prevention will first be ensured in companies, by a personnel able to detect problems related to work, addiction, poor diet or depression.

In addition to this monitoring in schools and workplaces, ongoing monitoring of individuals’ condition will be provided:
. By periodic check-up in a proximity unit 1 (nursing home) (see below)
. Automatically by means of fixed or implanted sensors, optionally at birth. In this case, the companies attached to the principle of individual’s freedom will impose that the sensor’s implantation is left to the free choice of parents at the child’s birth and be kept under the individual’s control throughout his life. The sensors implantation can be replaced by the wearing of connected outfit.

The choice between these two processes is a political one. It may be decided to focus or not on one of the two processes (management of expenses, possible generalization of sensors). Anyway, in democratic societies, and except in case of epidemic or pandemic, the two options will remain possible and the choice should be left to the individual, who will bear all the consequences, not just financial: the decision of the individual not to undergo testing in case he detects no health problem of his, implies that he accepts the risk that a condition may be detected too late and thus continues or worsen.

However, whether an individual is carrying or not implanted or outfit built-in sensors, Sirius will propose that each person is subject to mandatory periodic check-ups. He will recommend an annual frequency and a reminder in case of absence, with consequences on the insurance premium if absences persist. After two successive and successful check-up, we can reduce the frequency of check-ups.

Sirius insists: in the field of health, it is primarily healthcare and prevention that should concern the State. He discovers, by the way, that in a country like France, prevention expenses amount approximately to 3% of the overall health expenses.

2. The organization of the health system
Sirius draws the ideal chart of a national health network, widely using new technologies. This flowchart will consist of three levels of units: base or proximity units (U1), intermediate units (U2): treatment centers, birthing centers; higher-level units (U3): rare care, research and development facilities.

Proximity units
Proximity units (U1) are engaged both in prevention, care and routine emergencies. They have a dedicated personnel, as we will discuss in “3. Personal Health System”, Sirius proposes to organize the personal health system into three professions that have a common core of training with three skill levels: level 1 therapists with Undergraduate level (TL), Master level 2 therapists (TM) and level 3 PhD therapists (TD). Each U1 unit base will combine three levels of therapists, psychologists, physiotherapists, dentists, pharmacists, speech therapists, social workers, all from health sectors focused on welfare. In each U1 unit a team of forty professionals will collaborate closely. Such structures will operate as real health companies and centers of preventive health, open late into the evening to adapt with people’s working schedules.

Each individual, Sirius recommends, will be given the opportunity to choose the Proximity Unit they are enrolled in, as well as their practitioners. They may change center or physician over time.

The U1 proximity unit occupies adapted architectural spaces built in the heart of the human activity: Dense urban area, in the heart of the urban network; in peri-urban or rural area, they will be located in a traffic crossroads. In providing services, each U1 will maximize the use of new technologies. Consultation and physical examination will be carried out by automated systems. Blood and other bodily fluids samples will be sent to factories, ensuring biological examinations, efficient both in terms of quality and productivity. For the ten to fifteen most common examinations, small automatons will be available to therapists in each U1 base unit. Ultrasound and imaging technology will be available, simple and not oversized: it is useless, Sirius thinks, to resort to expensive imaging techniques and multi-row scanners for basic diagnoses, when screening scanners can do the job. Sirius notes that very soon, ultrasound systems will be embarked in smartphones which will allow everyone to perform basic ultrasound checks at the request of his U1 TD therapist and send the results to him remotely.

Ultrasound, biology and imaging: Sirius considers that these three functions should ensure 97% of diagnoses and 75% of treatments locally.

Such U1 basic unit will form the basis of a relevant health system. It is the first step, a crucial one, having to do with proximity care. The actors are within the community. Therapists will have to share their knowledge both with their peers and with their patients, increasingly connected and informed. In that context, moreover, it is not the TD therapist* (PhD level; see below for personnel training issues) who will be called first, but a TM therapist (master level). The TM will be able to do all the exams and prepare the file for the TD. Only the real expert will practice medicine. The TM will prepare the file along with the patient, who will then feel personally involved in the treatment of his condition, a crucial aspect of the process. The final exchange with the TD will then prove more fruitful.

One TD therapist can monitor and treat from 1000 to 1500 people. With fifteen TD, besides accompanying personnel, a U1 unit will count from 15 000 to 22 500 people. From each U1, mobile teams will visit remote villages and carry out consultations in a dedicated room, or in a mobile office, a U1 extension. Everyone in the village will know in advance the day of his consultation.

If possible, particularly in rural or semi-urban areas, each U1 will have a heliport – cost of 1 hour flight: EUR 2000. Sirus calculated that it is much cheaper to take a patient who needs it to a unit U2 rather than spending budgets on complete units U2 teams installed in secondly populated areas, with on standby therapists.

The U1 Proximity units will be public or private health companies, after a formal consultation by a public service delegation, considering the related obligations.

The investment cost of a U1 unit is estimated by Sirius between one and two million euros for a U1 unit of 750 to 1000 Sqm. Ideally, access to land will be facilitated by local authorities through the creation of health zones. In some areas, real estate investment will be made by a public or private investor who will rent it.

The U2 Intermediate units: treatment centers, birthing centers
At the second level, we find the U2 units with specialist TD therapists. Their implementation will be such that every U1 Proximity Unit will be located within a 30 minutes distance from a U2 unit. It is in the U2 that will be carried out research and treatments that cannot be made in a U1, as well as surgical interventions. The population density will be critical: in France, for example, the population is more concentrated while in Canada a general TD can have patients living 150 km from his center. In addition, the specialist TD devotes much of his time to teleconsultations. Sirius noted, for example, that imaging systems have now reached such a high quality level, that remote diagnoses of skin disease can be carried out by chromatographic analysis.

It is the Unit U1 GP who will decide on sending a patient to a U2, with the patient’s consent.

U2 Care Units will not be specialized but rather be multi-sector. First, the condition the patient is suffering from can be related to several sectors; on the other hand, heavy equipment can be shared.

For baby deliveries, Sirius defined large specialized U2 Units, they are few and reachable within a few tens of minutes. They will be equipped with the most sophisticated equipment to handle the most difficult cases. Each unit will be surrounded by places of accommodation, but private homes will be preferred.

With the generalization of patient transport by helicopter in rural or semi-urban areas, and the development of public transport in urban areas with dedicated traffic lanes, the distance will be measured not in kilometers but in megabits, due to superfast broadband transmission. Medical deserts will then be the areas with too limited bandwidth.

Preference for home care
The core of the policy, says Sirius, will be bring hospital care to the patient as much as possible and not the opposite. To this end, he will recommend a suitable property policy with, for example the creation of an institution able to acquire if necessary the patients’ houses (reverse mortgage) to upgrade them to hospital standards and offering the former owners to rent them. The spread of home hospitalization has important implications not only in the housing development but also in terms of organization of U2 institutions and intervention modes for traveling therapists (mobile equipment, therapists’ mobility).

Installing at home a set of external sensors, different from those the individual carries in his system, can be a complementary or replacement option. External sensors will be connected to the U1 unit. The transmission of the collected data will follow the same rules as for implanted sensors.

At a home hospitalization, specific sensors will temporarily be installed with constant communication (not submitted to the patient’s choice this time) with both the U2 Care Center and the therapist involved.

In the curative phase, devices implanted in the human body, operated either by the patient or by predefined protocols or remotely by care centers, will adjust and cure.

U2 units will be managed by public or private companies chosen for a period of time and according to precise specifications, following competitive procedures.

The units of higher level U3: centers of heavy or rare care, of research and development
Sirius brings together several functions in the units of the upper level, which are the brain of the system: exceptional care (transplants, rare diseases, resuscitation complex, for instance), as well as research on and development of new therapies.

For exceptional care, U3s will have outstanding facilities and highly specialized personnel and experts.

The research will be fueled by information provided by U1s. This information, collected from all over the world, will constitute a mass of data (big data) of great value, which will track both the evolution of conventional ailments and the complications encountered.

The development of new therapies will take place in start-ups hosted by U3s. As soon as the product developed by the startup will be available and has obtained marketing authorization, it will be sent to U1 or U2 units for tests on large samples of populations, in order for the tests results to be meaningful.

This feedback loop (research, development, application, return of results), will “academicize” U1s. A patient’s feedback will be needed (“patient’s outcome”) for any prescription, so that such data may be input and that computers may be in a position to detect if, in some human groups, the total impact of a disease on the patient and his entourage is properly measured. In this regard, Sirius noted that a sick person does not say the same thing in a consultation and on questionnaire. The tele-medical relationship changes everything. This is not a deteriorated personal relationship: it is different but very strong, since the screen weakens inhibitions.

U3s will have full autonomy and will be managed by private or public companies with a public service delegation. The leaders of U1, U2 and U3 units will be appointed by the Board of Directors for a fixed term (4-5 years). They will have the freedom to undertake, enough latitude to promote the best, and to get rid of the mediocre.

Overall, everything will be done, Sirius recommends, to spare the patient reaching U2 or a fortiori U3: the goal is 90% of consultations and 75% of care in U1, 10-15% of care at level U2. U3 units will be dedicated to very serious and rare injuries, and devote most of their resources to research and development, in association with industrial players.

Emergencies
Common emergencies will be handled by U1 units. For exceptional emergencies, U2 units will have a specialized department that can be moved to homes or on-site. This service will determine the action to be taken, to stay in U2 or possibly move to U3.

The analytical and radiology centers
With the widespread use of electronic bandwidth transmission, and faster transport and delivery services for material elements (especially for samples), Sirius recommends the creation of a small number of large centers of analysis, which would operate as real plants, operating 24/day. Similarly, he will propose a distribution of sophisticated investigative materials and of their operators between U2 and U3; TD radiologists will perform remote scans.

The grouping & pooling patients worldwide
With big data and genomics, we will have very detailed statistics. Sirius recommends that patients’ communities be organized worldwide. They may decide to pay for their own risks. For example, Sirius says, there are 300 million diabetics in the world. Raising one euro per month (in purchasing power parity) per patient in crowdfunding, that makes 3.6 billion euros per year for diabetes research. Similarly, with one billion hypertensive, we can raise 10 billion a year for research on hypertension. This will be financed within the U3 research laboratories and in the U2 treatment centers by selecting the world’s best researchers and practitioners.

Transport and information networks, health records
A transportation network consisting of the current public transportation, plus dedicated transport (including helicopter), provides access to emergency centers and U2 or U3 home and with a maximum travel time set by the community (eg. 3 hours for no emergency, 10 min in emergency situations). Helicopter use will be generalized as much as possible (rural, semi-urban), to ensure the equality of citizens regarding care, regardless of their geographical location. Sirius recommends that this transport option be entrusted to companies after bidding.

An information network will connect people to U1s (via implanted sensors) and homes (for non-implanted sensors). The information will be referred to U2 units when a unit U1 general therapist deems necessary, for specialist recommendation or preparation for hospitalization.

A second information network, bandwidth, will connect the basic U1 units to U2 and U3 units.

A digital health record will be owned by the patient or by the U1 unit to which he is linked (depending on the country’s choice in terms of policy). The communication of this file will determine whether the treatment of a patient will be carried out by a U2 or U3 unit. These “patients’ records” will also allow to assess the level of care and the quality of services and of medical practices needed.

Research policy
Research policy must involve, according to Sirius, not only the diseases themselves or the investigative techniques and care, but also the determinants of health: health, consumption, energy, transport, etc.

It will in all cases require a collective regulation concerning both the control and authorization of research results’ implementation, but also on the ontological limits of such research.

Finally, in each of the health-impacting sectors (consumer, energy, transport, etc.), research policy and activity should include a “health” component.

3. Health system personnel and training

Staff training
Sirius will offer a classic training course: Undergraduate, Post-Graduate, PhD (similar to the European “Licence, Master, Doctorat” system) as in many other specialties in the world. The Undergraduate cursus will be general one. The art of medical examination, computers and genomics will be taught. Those who stop there will be first level therapists, TLs. In master (TM), students will specialize. Holders of a master degree will be level 2 therapists. Level therapists 3 (TD) will be those who keep studying until PhD. For each of these levels, training will include an important part of knowledge and use of technical tools and machines.

Within U1 Unit, the TL will be in charge of first aid and basic investigations. TM will conduct human querying according to a predetermined questionnaire, as well as a first diagnosis. He will prepare a file for the TD before the interview with the concerned patient.

In this three-level health system, two components of the Sirius health system play a major role: the unit U1 TD general practitioner, and the machinery.

By being in regular contact with the patient, the TD general practitioner is the first contact with both the prevention and the care system. It is also him who, within the research system, feeds the U3-level data.

The machines play the second central role. The diagnosis, for example, will be assisted by artificial intelligence systems to compare a particular case given in extremely rare cases, since a therapist will never be able to store all unique cases in his memory.

Thus, the machine will guide the therapist using assumptions, as the latter will choose between different hypotheses. Diseases will be detected through the computer, even before symptoms appear. The therapist will have a limited scope, both in terms of technical diagnostics and therapy. The in-house general health TD will act as a data integrator. The residual value of the therapist will be low quantitatively, but qualitatively essential. In special cases, when the personal choices of the patient, his religion, his phobias, only individualized treatment will be possible. The machine not be able to process such considerations. As technology and the Big-data constantly upgrade in power, the more the patient will demand such irreplaceable human relationship.

Sirius does not promote any distinction between medical and paramedical personnel. All trades that have access to the human body are, tells Sirius, medical professions with variable responsibility. TDs will delegate a maximum tasks to dedicated personnel, such as TMs. With technology, robotics and remote handling, surgery may also be delegated. TD surgeon will not provide, in general, surgical procedures; it will be done by trained engineer operators who will work on a given anatomical area with robots and manipulators. The TD surgeon will be present at the patient’s side during the operation, and will be fully responsible. He will be able to take over “manually” at any time, as an airline pilot with an autopilot.

Continuing training
For each occupation, Sirius will define a continuous and compulsory education system. Sine qua non of the exercise of the profession, it may be “delivered” under all existing forms (MOOCs, residential …).

The evaluation of diagnoses and medical actions, their relevance and efficiency through patient records will inform about the kind of training to be undertaken. 

4. Economy and implementation of health system
The health system economy will be based on the principle of debt impossibility excepted to finance depreciable assets (infrastructure, research …)

For the rest and whatever the political model of the different human societies, the health economy will be based on an insurance business model rather than on banking.

Various types of financing are possible, adapted to the choice of political and social systems of the various human societies: “merely” individual financing, insurance – and individual-based, collectively mandatory and insurance-based, public or even mixed.

This prevention network being based on an economy such that no “profit” is really accessible to annual financial results, Sirius proposes to implement a or collective and insurance-based public financing. Since the success of the prevention policy allows to maximize the expected insurance-based profits, Sirius may propose, depending on the type of company, to combined or delegate the management of the prevention policy to specialized players.

As for the care network, it will be funded individually or collectively depending on society’s model chosen. The impact on the concerned individuals will obviously not be the same.

However, the social and political, financial and economic issues of a “healthy” population, as well as the progressive awareness that “health is a marker of the living together” will make that Sirius will favor a system based on a common foundation, complemented by mandatory, collective and guaranteed insurance, then by an individual funding (merely individual or insurance-based), the boundary between the three levels, and the relative importance (or lack) of levels, depending on the choice of the company.

*

Sirius noted that there will be a great deal of machines and relatively few human actors in the health system. Among the human actors, U1 Units’ general therapists TD, engineers, machine operators and researchers from U3, will play the leading role.

Contacted by governments of various countries, Sirius finally calculated that the implementation of the system from scratch, that is: the training of health professionals including TD therapists trained for collaborative work, the building of U1 Proximity Units, the setting up of telemedicine elements as well as of data and transport networks – in particular to organize the fleet of rapid intervention vehicles – could be achieved in ten years.

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