It should go without saying that as the health system changes over the next decade, it will produce considerable conflict. At the macro level, the broad sweep of the change means doing more with less. Such a change is always a prescription for tension. And if this process involves changing the ways we organize and deliver health care to get a better, less expensive process, rather than just cutting budgets, then it will involve adapting and adjusting to a new paradigm for health care. Any time you stomp around on someone’s long held revealed truth, conflict is always a byproduct. So if your leadership is hitting the mark of significance, you will know because you will notice the steam around you.

At a recent talk on health care’s future I carefully laid out what I believe to be the five most significant drivers of health care change: 1) cost of care, 2) uneven patterns of use, quality and safety, 3) aging population, 4) shifting disease trends from acute to chronic, and 5) dramatic changes in consumer understanding and demand for care. I then pointed to the opportunity these trends created as the enormous $2.5 trillion US health care system searched for new ways to meet these shifting demands. Moreover, though not perfect, the market and policy drivers were more aligned than ever across health care, presenting even more opportunity for individuals, organizations and professions to realign themselves to meet the emerging needs. One of the best questions following the talk went something like this: This all sounds right, but who, specifically, will actually do this work to remake the system? It is a good question because it focuses us all on the next step and hard work that lies ahead.

As health institutions position themselves to respond to the policy and market driven demands of the emerging health care system, leaders in every setting are challenged to create new visions to help shape the future. We commonly think of a vision as that bright and shiny future state in which every problem has been addressed and everyone is happy. Leaders should get over such messianic impulses.

For the past half century, the US has assembled a remarkable set of cultures, institutions, and practices to organize, deliver and finance health care. Each year, tens of thousands of the best and brightest of each generation accept the demanding challenge to enter one of the pathways to become the next generation of leaders within these amazing arrangements for health. In large American cities, the aggregation of these health centers takes up multiple city blocks, and they are often the largest employer, and a place where world class research, patient care and education come together in the service of society. There is no less pride in small town America, where the local hospital, staffed with graduates from the big city health center, is often the tallest building on the horizon; and parents take pride that their sons and daughters have found a good job in the helping business. These citadels of health, large and small, have come to represent many of the good things of life: helping others, growing and applying knowledge, having a career, being responsible. The truth is that in the walls of these shining cities on the hill miracles do happen and lives are saved. In gratitude and hope we have left behind larger and larger financial gifts as recompense at their doors.

There are four big things that are done to produce heath: prevention, diagnosis, treatment and management. Prevention has great leveraging ability to bring about enormous change in health status, but its impact is felt over a long time horizon and we do not have a complete set of tools to drive changes in individual behavior -- which is key to effective prevention. Moreover, the public policies needed to fully engage all effective preventive strategies can intrude on individual freedom and choice, raising an array of political issues. Of course, most of the focus of the current US health care system is on the diagnosis and treatment of disease, including training and payment. Finally, management of disease, particularly chronic disease, is an effective, but underutilized component of the overall health landscape in our country. Switching from managing the nation's large and growing chronic disease burden from our expensive acute care practice models to new management modalities in the community has been demonstrated to lower costs significantly, improve the quality and safety of the care and, when fully understood, enhance the patient's experience as a consumer.

The Center for the Health Professions sponsors a large number of leadership development programs in health care. An essential part of these programs is to help participants understand the changing environment, and to assist them in developing responses so that their organizations can be strategically successful. I am frequently asked by my colleagues if there was a single, short document that summarizes that changing environment facing all of health care. There isn't, so I'm taking this opportunity to try to remedy that situation. What follows is my list of some of the most critical issues, developments, and concerns in the health care environment now and in the future. Grasping them from the perspective of your practice, hospital, clinic, group, school, company or agency will be an essential first step in being a transformational leader.

The creaking sound that you are hearing is the ice beginning to break up in the overly ossified structures of what has for many years passed as a “system” of health care in the US. While the policies and regulations are yet to be fully in place and a few courts and a majority in the House of Representatives are calling for its demise, the organizations, institutions, professions, practices, companies and agencies that form our crazy quilt arrangements for care are beginning to imagine what a more integrated, more consumer responsive, more value added approach to health care might look like.

Most of us cannot resist the temptation of new year's resolutions this time of year but, in health care, the needed change will be tricky. The opportunities we have been presented by the crisis in health care costs and the framework of reform do not need new commitments to work harder, longer or even better. The major challenge we face today and for the next few years is how to work differently.

Across the nation different parts of the health care system are scrambling to figure out how they will respond and fit into a reformed approach to health care. Hospitals, professional practices, clinics, safety net institutions, health plans, schools and colleges see the parameters of the policy change, feel the movement of the market and are beginning to realize that they need to reposition their vision and strategic business objectives to align with these forces. While these institutional and organizational responses are to be expected and are needed to give shape and definition to the broad principles set out in the legislation, they generally fail to rise to another level of consideration for integration and improvement.

The concept of American exceptionalism, the notion that a distinctive set of values and practices have served the nation well for over 200 hundred years, is a powerful part of our success as a nation and a people, is a deep-seated part of our culture and curiously has appeal to both sides of the political aisle. However, the parties’ ideologues do see the pathway to enhancing that exceptionalism in very different ways. This broad cultural characteristic is a composite of many different and sometimes even conflicting qualities. It includes individual responsibility, entrepreneurship, community action, innovation, pragmaticism, compromise, diversity, and a trust in the wisdom of the common citizen. There is not much in our cultural past, the rhetoric of current politics or our aspirations for the future that do not play on the belief set that makes up American exceptionalism. And these values and abilities are essential to making the health care reform come to meaningful life over the next decade.