Complex Adaptive Systems

It will be extremely interesting to watch the new health care system roll out. It will phase in over many years; so, do not expect any quick, meaningful evaluations. Traditional organizational theory (the kind Congress uses) views the health care system as a machine; it has easily interchangeable parts as well as sets of behavior which are predictable and controllable based on prior histories. All the players will line up like good little soldiers; those who resist falling in step can be replaced. Hence, doctors will just accept a 21% Medicare haircut; patients will simply accept the mandate to buy insurance; insurance companies will simply ignore pre-existing conditions; brokers will run efficient exchanges. In your dreams.

Health care does not act like a predictable machine. Complexity theory would describe it as a Complex Adaptive System (CAS). A CAS is an open, dynamic network with incredible plasticity. It is made up of multiple semi-autonomous units which simultaneously compete and cooperate with each other. The social-networking types would call them "frenemies"--friends and enemies at the same time. The plasticity of these systems allows them to adapt to change and to shift allegiances based on ever-evolving behaviors. A CAS adapts to a changing environment incrementally and does NOT respond monolithically to predetermined orders proclaimed from hierarchical or centralized controlling bodies.

Imagine a school board negotiating for a new health care contract. Here are the players: 1) the teachers (the patients), 2) the union reps, 3) the brokers, 4) the school board, 5) the insurance companies, 6) the hospitals, 7) the primary-care physicians, 8) the specialists, 9) the hospital-based physicians, 10) the free-standing centers. I can go on but these are the major forces; their stated ultimate goal may be to provide high quality health care to the patients, but, trust me that their incentives are NOT aligned. Each semi-autonomous group can collaborate with or fight against any other group...but not consistently, depending on what aspect of the contract is being discussed. Actually, within each group, subgroups can align with or fight among themselves simultaneously. Male teachers may want different benefits than female teachers. Primary Care doctors may want different things depending on their comfort with hospitalized patients. Specialists may vary because of the nature of their invasive procedures. Everyone is looking to cherry-pick the low hanging fruit.

Congress, assuming the traditional organizational model, has been clueless in its deliberations. It has assumed that the system is basically stable; that its functions and roles can be carried out by replaceable individuals and that financial incentives, rigid regulations, inflexible protocols and "best practice" initiatives will carry the day. Recall some of the more recent failures spawned by such an autocratic approach: HMO's, gatekeepers, practice guidelines, DRG's, formularies and preferred providers... to name a few.

By recognizing the true nature of Complex Adaptive Systems, it becomes clear why many prior attempts at building sustainable processes (and even consensus) within the health care system have failed and why scientific evidence alone is insufficient to drive the proper adoption of new innovation. In fact, scientific evidence is even slower at weeding out ineffective treatments. Many new innovations (effective or not) spawn cottage industries which are incredibly difficult to eradicate once established.

What to do? The National Institute of Health (NIH) has been studying this problem; they have proposed a counter strategy--the Reflective Adaptive Process. They suggest five main guiding principles:
1) Sharing the same Mission, Vision and Values are fundamental to guiding any changes
to a complex adaptive system.
2) Time and space must be created for learning and reflecting on the process.
3) Tension and Discomfort must be viewed as NORMAL and encouraged as part of the evolutionary process.
4) Improvement teams must include a wide-spectrum of the agents involved--not just the anointed winners and yes- men so common in the hierarchy.
5) Change requires leadership which allows for reflection and for participation by all semi-autonomous groups.

In my view, the first guiding principle is 90% of the battle. Without a shared mission, vision and set of values, the other four will become just wasted effort. So, how do you go about setting up an organization with shared mission, vision and values? Well, you find an organization which has succeeded at just that--then, you buy, copy or steal their model.

The Dartmouth Atlas, which I feel is the road-map to improving cost and quality to our health care system, has identified areas of the country where invasive procedures are not overused and where health care costs and quality seem to be relatively controlled. It appears that horizontally and vertically integrated health care systems (like Kaiser, Mayo and Cleveland Clinics) seem to offer the right model for shared vision, mission and values. It is no coincidence that the doctors are all salaried employees and are somewhat less entrepreneurial. (See Blog Off the Tracks below.)

Ironically, this is just what many young doctors want; they think the long hours, little vacation time and dedication of the previous generation are a fool's game. Why not have a successful career AND a life? If Congress had a clue, they would be creating policy which would shepherd all the players into large groups which, by the nature of their organization (horizontal and vertical integration), would foster a shared vision, mission and set of values. As Yogi Berra would say: Half of the battle would be three -quarters over.

Despite being a dinosaur, I would gladly sign up.

And the beat goes on......

There is an old joke about the husband who scolds his wife for buying expensive clothes. Confident that she can defuse this claim, she drags him to the closet and challenges him to pick out the most expensive dress. He picks out a plain, unassuming dress with the tags still attached. "Aha!", she exclaims as she relishes explaining to him that that dress is well below average in cost. He retorts that it is the most expensive because it has hung there, unworn, for six months; the most expensive things we buy are the things that we do not use.

America has the most expensive health care in the world. There are many reasons for this but the most pressing is the fact that so many of our advanced treatments do no good--in fact, many of them do harm. The Dartmouth Atlas, published annually, tracks the variation in use of invasive, high tech therapies across the country. It demonstrates an unbelievably high variation in use; paradoxically, it further demonstrates that the higher the use of these procedures, the worse are the outcomes. In short, excessive use of some procedures can be toxic to your well-being. What happened to the dictum: "First, do no harm."?

The most expensive health care that we provide is the care that does not work...and even more expensive is the care that does harm. We are way too slow in learning this lesson. Why did it take over 30 years to figure out that routine Hormone Replacement Therapy was killing women? How quickly we have forgotten the politically charged issue of bone marrow transplants for metastatic breast cancer from a decade ago. The issue quietly went away when it was conclusively shown that these transplants actually shortened survival.

Coronary Artery Stents are one contemporary example. They are incredibly effective in certain circumstances. However, the indications for their placement have grown so wide as to undercut their rationale. We place about 3 times as many as other developed countries; yet, the long term goals of avoiding heart attack and or death are no different. This is clearly overuse....and,boy, are they expensive. Many other examples abound.

The British have an institute called the National Institute of Clinical Excellence (NICE) which objectively evaluates the utility of procedures, medications and treatments. Based on their findings, they may limit or deny the use of modalities which are not effective. Can you imagine an institute like that here? Not likely as the special interests would have a stroke. Meanwhile, the overuse of dubious treatments threatens to bankrupt our health care system....and the beat goes on. When will we become smarter about the allocation of our resources? Probably, when they are gone. Contrary to what you hear, eliminating treatments which do not work is not rationing. It is time to clean out the closet.

Heavy Lifting

Having passed a health care bill, Congress should be allowed a suitable time for gloating before the real heavy lifting begins. It has been common knowledge that the health care crisis has three main facets: access, quality and cost. The bill just passed addresses access to the system for most Americans; however it simply takes our broken existing system and applies it more widely. The CBO has been able to squeeze out some cost savings in this new plan by cutting reimbursement to Medicare providers by 21%. Office based physicians with a high overhead will find their actual pay reduced by about 50% by these cuts. They will begin opting out of Medicare--hence, making access a problem all over again.

The heavy liftings that I allude to are the quality and cost issues which this bill fails to address. Despite all the claims that we have the best health care system in the world, we do not. Numerous studies demonstrate that we lag significantly behind other developed countries in important quality indicators--yet we spend almost twice what they pay. Fixing the quality/cost (value) problem will look like the Aegean Stables after the relatively simple process (just completed) of securing greater access--a process that is actually in Act I.

The road-map to the solution of the quality/cost conundrum exists and has existed for some time--but, it has been ignored. The Dartmouth Atlas publishes a yearly study of the variation in use of various medical procedures across the geographical USA. It not only demonstrates a wide variation in the use of invasive procedure to treat common conditions but surprisingly shows that the MORE health care you receive, the WORSE becomes your outcome. In short, the overuse of aggressive high tech medical care can be toxic to your health. Florida, New York, New Jersey and Los Angeles top the list (surprise, surprise).

Correcting this overuse of marginally beneficial medical procedures will take a seismic shift in medical policy. Special interest groups are already digging in their heels. However, we may be approaching a tipping point. Fortune magazine, usually considered a conservative source, published an article last November that outlined the overuse of five common procedures. It recommended that if your doctor has ordered up one of them, to either get a second opinion or run for the hills. Reports concerning excessive radiation exposure from the overuse of CT scans are reaching the lay press. In short, the overuse of medical procedures, medications and therapies are becoming part of the public's consciousness. New diseases (mostly mental) are cropping up faster than we can categorize them. How many of them are real as opposed to just personality quirks?

Correcting this medicalization of everything will be difficult. Key to any frontal assault on the quality/cost issue will be a fundamental overhaul in how statistics are used (misused) to justify the care that we receive. This misuse and misunderstanding of statistical methods has been a dirty little secret of organized science for some time. Yet, the misuse of statistics has made many a career, propelled many a promotion, generated a lot of sales and made a lot of people rich. Forcing a proper use of statistics will be a sea-change that will be difficult to construct.

Let's give our hard working leaders a month to gloat over their shallow victory. Then, we must demand that they attack the other 2/3's of the problem--cost and quality. That is the Heavy Lifting. As health care costs approach 20% of GDP, we had better get it under control before it tanks the entire economy.

Cytokine Storm

The human immune system is one of the seven wonders of nature. It is an incredibly complicated system; when it works well, we are generally unaware that it is even functioning. When it is not working properly, disaster is not far off. It has three major ways of not working: it can be lazy and allow infections (or tumors) to proceed unchecked; it can be wiped out altogether by HIV and leave the victim open to all predators; finally, it can be hyper-vigilant.

When it is hyper-vigilant, its response to some triggering invader goes way beyond what is necessary. One hundred and fifty (or more) chemical agents can be released. Chemicals which increase inflammation compete with chemicals which decrease inflammation. The resulting battle is called a cytokine storm and can be more lethal to its victim that the inciting infection. This exaggerated immune response is caused by the rapid proliferation of highly activated t-cells or natural killer cells.

Bird Flu (the H5N1 influenza), is a classic example. If the patient develops a cytokine storm in reaction to the infection, he develops acute respiratory distress syndrome (ARDS), which is often lethal. Otherwise, Bird Flu is just another self-limited routine respiratory illness.

American Security has parallels to the human immune system. It could be lax and allow unwanted penetration-- such as 9/11. It could be wiped out completely by a nuclear war. Or, it could over-react to penetration by forming a political cytokine storm; such a storm could be more lethal to our well being than the original threat had posed.

In fact, this was exactly what has happened. Our guard was down and twenty determined, well trained terrorists changed our world on 9/11. The situation demanded a measured, well targeted response; what we got was a cytokine storm. The government orchestrated an attack (and war) on one country marginally involved with 9/11 (Afghanistan) and another attack (and war) on a country not involved at all (Iraq). They trampled on Constitutional rights, broke international law by encouraging torture and directed the expansion of aggression via the new "Homeland Security" department. For me, the very name--Homeland Security-- conjures up fascist vapors.

Our security system needs to dial it back and prevent this cytokine storm from destroying who we are. We can enjoy high levels of security with a much smaller bootprint on the throat of the world. Our resources would be more effective and last longer if we showed some moderation. Would not a greater use of drones and special forces accomplish more with less risk than our current role of nation building? Obama promised us a more measured approach during the campaign; let's hold him to his promise. It is not weak to be smart.