Saturday, July 18, 2015
The U.S. (Complex) Health Care System and Implications for Population Health Management
And when a policy maker, speaker, expert or consultant sagely points out that the U.S. doesn't really have a health care "system," what does that mean?
According to Lewis Lipsitz writing in JAMA, "complex" means that the system is made of multiple components that interact non-linearly (for example, they can be self-reinforcing) and over multiple scales (such as patient, family, hospital and government) that can lead to unpredictable results. The good news is that this complexity can lead to outcomes that are greater than the sum of its parts. Unfortunately, the bad news is simple payment levers or single disease protocols can lead to unintended consequences.
Dr. Lipsitz's insight for Disease Management Care Blog readers is that complex systems can engage in emergent self-organized behaviors with the guidance of a "master plan" that harmonizes aims, limits and resources. For example, U.S. agriculture evolved from a highly inefficient enterprise into a very efficient farming system. All it took was some multi-stakeholder experimenting, measuring, learning and feedback. Think the flocking of birds, the synchronized flashing of fireflies or the DMCB spouse, her sister and mother-in-law ganging up in criticizing the DMCB's admiration for vampire vixen movies.
That's why, when the Affordable Care Act is viewed through the prism of complex systems theory, the author optimistically believes we may be on the verge of a transformation of U.S. health care. By promoting aims, imposing some limits and using some incentives through the use of a variety of risk sharing mechanisms (for example, episodes of care, upside risk sharing), it's possible that self-organized behaviors will emerge and "move the needle" in the right direction.
What doesn't work are specific and narrow single-purpose interventions. Dr. Lipsitz points to the infamous "three day rule," which prohibits admission of a Medicare beneficiary to a skilled nursing facility (i.e. a nursing home) unless the patient has first spent at least 72 hours in a hospital. While intended to reserve nursing home admissions for patients who really need it, what happened in the complex system was an increase in unnecessary inpatient admissions just so patients can achieve criteria for coverage of a nursing home stay. DMCB readers are familiar with other examples, including tight diabetes control (leading to the apparent death of some persons with diabetes) and the timely administration of antibiotics to ER patients with pneumonia (that resulted, it turns out, unnecessary antibiotics in persons who turned out to not have pneumonia)
Which suggests that the U.S. does have a health care system, it's just that its complexity defies the narrow, parochial and linear expectations of all those experts, speakers and consultants (except one, by the way).
The lesson for the population health management community is that we need to be aware of this notion of complexity and include "self-organizing behaviors" as an additional dimension as interventions are developed.
Image from Wikipedia