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.