Visionary leadership and the future of VA health system.

As the U.S. Department of Veterans Affairs (VA) makes the change over to Veterans Integrated Service Network (VISNs) the need for new and better leadership is warranted if VA wants to not only survive, but thrive in the emerging twenty-first century healthcare system. VA can prepare for the future and meet the challenges facing them by adopting a system of visionary leadership. The use of scenarios and vision techniques are explained as they relate to VA's efforts to move toward their new system of VISNs. The four scenarios provide snapshots of possible futures for the U.S. healthcare system as well as the possible future role and mission of VA--from VA disappearing to its becoming a premier virtual organization.

Scenarios for 21st-century health care in the United States of America: perspectives on time and change.

Scenarios are a powerful way to bound the uncertainty of the future--to sketch the major pathways that the future might take. This article contains five scenarios depicting the United States health care system in the 21st century. These explore: an extrapolation of the current system; a single-payer driven system; a market-oriented system which forces more choice on the individual: a scenario which traces a transformation in health care; and a fifth scenario focuses on the healing role of health care. These scenarios acknowledge certain changes which relevant in all of them, e.g., by the early 21st century health care providers in the United States will have shifted to predicting likely health conditions, preventing what can be prevented and managing optimally those conditions which do arise (optimal in the sense of cost-effective treatment in light of the best practices of the day applied in ways which recognize and take advantage of the biochemically unique nature of each individual. Developed in 1991, these scenarios have been successful as a tool for identifying a range of likely paths which health care might take. The scenarios did not foresee the assertiveness of the President of the United States towards health care reform, although it did identify the difficulty which the President's and any other reform efforts would face. At their base, however, the scenarios trace the fundamental shift taking place in health care in spite of financing reforms. This fundamental shift is being driven largely by outcome measures; a commitment to accountability; better and more accessible health knowledge; enhanced technology; and a greater willingness on the part of some sectors of the health care system to deal with the broader determinants of health (e.g., community and economic factors).

Health care: thinking ahead.

The steps to be taken in order to secure the best possible health care for all people in the coming years will depend not only on what is desired in this field but also on what the wider future is likely to hold. An approach to the exploration of these questions, called "futures thinking", is outlined below.

Health care and AIDS.

The acquired immune deficiency syndrome (AIDS) is a harbinger for change in health care. There are many powerful forces poised to transform the industrialized health care structure of the twentieth century, and AIDS may act as either a catalyst or an amplifier for these forces. AIDS could, for example, swamp local resources and thereby help trigger national reform in a health care system that has already lost public confidence. AIDS can also hasten the paradigm shift that is occurring throughout health care. Many of the choices society will confront when dealing with AIDS carry implications beyond health care. Information about who has the disease, for example, already pits traditional individual rights against group interests. Future information systems could make discrimination based upon medical records a nightmare for a growing number of individuals. Yet these systems also offer the hope of accelerated progress against not only AIDS but other major health threats as well. The policy choices that will define society's response to AIDS can best be made in the context of a clearly articulated vision of a society that reflects our deepest values.