OPINION -- “Doctors aren’t as smart as they used to be,” a financial advisor recently informed me. I thought he was going to tell me a story of bad investments. Instead, he talked about interactions he’d had with his healthcare providers. He noted how distracted they’d become. How they seemed to have a hard time making decisions. How they paid more attention to the computer than to him. That he now sees his physicians as lacking control and focus. He likes them, yes, but he’s losing respect for them and for the profession.
In fact, loss of respect is one major reason physicians and other practitioners are leaving the profession, as described in a physician essay published in the Wall Street Journal on August 29, 2014. It is real. It is undermining what we as healthcare professionals seek to accomplish. And I believe it is happening because of a major misdiagnosis in how the healthcare system is managed.
Healthcare is currently managed using traditional industrial methods. Traditional management is based on established science using the machine as a model. This science depends on reducing systems to understandable units and, from that understanding, making reliable predictions. In contrast, the science of Complexity seeks to understand fundamental properties of nature that are by nature systematically unpredictable.
Complex Systems are self-organizing, as though they had a mind of their own. Self-organization leads to hierarchical structures and from these grow emergent properties. These properties are unpredictable even when every system component is understood.
Healthcare is a Complex “Adaptive” System because it contains independent individuals. The behavior of each person is based on physical, psychological, and social rules. Each individual is intelligent, and as they experiment and gain experience, they learn and change their behaviors accordingly. Each responds to and influences those around them. In this way, overall system behavior inherently changes over time. This is the result of Complexity (self-organization, leading to hierarchical structures, and emergent behavior). There is no single point of control and as a result, the output is unpredictable and uncontrollable.
Most of us who work in healthcare have seen the same recurring story. We start with good intentions and redesign based on what we believe is a good idea. Consequences arise, many being unexpected and others differing in timing or magnitude. Every consequence starts a tree of new consequences, most of which consume our energy and often redirect or derail our efforts.
For example, the Resource Based Relative Value Scale (RBRVS) was developed to create standard pricing for professional services. It is a formula developed by experts in medicine, statistics, economics and measurement. It has been widely adopted as the methodology used in fee-for-service payment. As such, it is an example of a top-down, centrally-planned, system-improvement attempt that is still causing problems.
RBRVS has had multiple unintended consequences. It strongly discouraged price competition, making utilization the path to increase income. In many cases, improved efficiency will lower the cost of medical procedures, but the central committee that controls reformulation is slow and political. This is a windfall for certain specialties and leads to physician overpopulation in those fields and shortages in others. Members will have a hard time finding certain types of care because the remaining providers may not have the capacity to expand their practice.
(We may be tempted to think that RBRVS was just a bad idea, which it was. However, the more important point is that this is what Complex Systems do. Every idea, no matter how noble or well intentioned, if not deployed in a way adapted to Complexity, will waste resources, raise cost, drain the energy from our people, and still not meet the needs of those we serve.)
As costs rose, Dr. Paul Elwood formed the Jackson Hole Group. Their solution was to replace fee- for-service with prepaid comprehensive care operating as “Managed Competition.” This was a major initiative and Health Maintenance Organizations (HMO) sprung up throughout the country. The concept had precedent in existing organizations such as Kaiser Permanente. However, by the start of 2000, the enthusiasm for the HMO model had cooled significantly for commercial health plans and employers; earlier HMO pioneers had grown up with the concept and had the supporting culture to mitigate the effects of Complexity.
Here’s another example: the January 1992 Medicare Physician Fee Schedule contained Coding Standards that established needed documentation to justify payment for each level of office visit. In 2010, audits by the HHS Office of the Inspector General demonstrated a 42 percent error rate, with incorrect payments amounting to $6.7 billion!
Electronic Health Records (EHR), already viewed as necessary infrastructure, would help. EHR had the ability to create self-contained notes that satisfy the standards. Better documentation would result in higher accuracy and savings. However, EHR also has the ability to create notes that justify higher payments independent of services performed. This became a quiet but successful feature for vendors. The increased revenue from higher coding would subsidize the purchase.
As a result, it is likely that we have converted coding errors to administratively justify fraudulent payments. Audits might seem easier due to the electronic format, but finding services that are documented but not performed is not. Vendors were implicitly redirected to coding issues with the effect of decreasing development of interoperability and usability. The result is that cost continues to rise, technology has poor usability, providers are at more risk, and none of this improves the care delivered to members.
Separately, the HITECH Act was passed to promote adoption of electronic health records. It provided a combination of carrots and sticks in three stages to pressure providers to implement certified EHRs. Like Yogi Berra’s “Déjà vu all over again,” the program experienced delays in rule publication while payments, mostly given to vendors, consumed almost all the funding ($28 billion to date), leaving little for the final stage. The rules for the final stage are pending as of this writing.
As of this time, there are inadequate requirements for interoperability, usability, or to measurable outcomes in quality of care delivered to the member. Leaving interoperability out gives a key edge to current vendors who take advantage of existing market share. Existing systems have not been required to improve usability, leaving interfaces ridden with check boxes while the natural human language is narrative. The result is terrible workflow with an even worse disruption of thought flow. Finally, omitting measurable outcomes as a goal puts bureaucracy and control ahead of what practitioners and members want and need.
This and more have diverted providers from their most important work, which is applying their deep and hard-earned knowledge of human pathophysiology to truly help people. That involves listening to each member in order to understand the unique aspects of their ailment, performing an appropriate physical examination, and from there determining the best next step. It should not surprise anyone that reducing this group to the status of a widget in a machine is associated with demoralization and loss of respect. If we are to succeed long term, we must adopt the ways of nature and Complexity.
The late Donella Meadows of the MIT Sloan School of Management noted that “the least obvious part of a system, its function or purpose, is often the most crucial determinate of the system’s behavior.”
This is where we go next: What is the purpose of the healthcare system?
Dr. Rohwer is chief executive officer of Perfomance Health Technology Ltd., and former medical director of Mid-Valley IPA. He also practiced medicine in Salem for 20 years.
Writing into the wind
Thank you for your response. All of us wonder if we are writing into the wind. And what you wrote is true and important.
One concept implicit in your writing I need to clarify. It is one of the many very important distinctions that isn't and won't be covered well in the series.
'Complexity' is not related to complicated. There is no gradient like 'simple->complicated->complex'. 'Complexity' is its own animal so to speak. It is a process of nature that has been poorly named.
It doesn't mean complicated at all. A pile of sand is a simple system of inaniminate objects that will behave as a Complex System. At the same time, our factories are full of computerized robots that are extremely complicated machines that, because they are predictable they do not exhibit 'Complexity'.
The science of 'Complexity' is about the mechanics of things that are predictably unpredictable. And it turns out that these processes exist everywhere we look in the universe. Its rules are strikingly similar whether you are talking about earthquakes or how neurons connect inside our brains.
Much of what you are experiencing comes from a system that is not aligned with this fundamental natural process. If you look at how most human systems work, you will see the same things. Those who study 'Complexity' find it is making lives worse in education, government, large corporations, and certainly not to be left out, the legal system.
This article is #2 in the series. #3 is already on "The Lund Report", and #4 will come out later this week. All over the country, there are experts in 'Complexity' but somehow, despite all that is known, it has been slow to be adopted by traditional managers despite its success in technology, agile engineering and new company 'lean startups'.
Old habits die hard and old beliefs hang on forever. But we can do better! Oregon is well positioned to lead the way as it has many times in the past.
I started this series with some dire statements that I believe are absolutely true. The system is going to collapse. 'Winter is coming' and we need to act soon!
At the same time, I am very optimistic that things can be better. This is nature so we will grow and transform the system, not design it. A very different approach.
Wishing you the best!
Elevating informed consent to a place of honor can and will simplify health systems. We can continue to choose to do this glacially, with much angst and lawsuits, which is where I see us presently.
We can also choose common sense and cooperation, which is where I hope we will go.
I used to work in personal-injury legal offices.
The opposite of contributory negligence is informed consent. We have a system now where almost any player can be accused of negligence, capriciously, at any time, and it can take years to work this out. No wonder it is so tense so many places in the machine.
Oregon has an opportunity to lead with higher expecations of consumers.
As Earl Blumenauer pointed out last night at a forum, we have so many options here with Oregon College of Oriental Medicine, National College of Natural Medicine, Western States, Pacific University, and OHSU.
Respecting individual choice is growing, driven by advantaged cohorts.
Certain cohorts go offshore if they cannot get what they want in the U.S.
Lobbying groups of boomers already brainstorm about how to widen choices for medical tourism.
Young, healthy people, so romanced by current provider/players, can work for companies who contract with insurance companies who allow employees' choices of health homes, without favoring the more-expensive options that many Oregonians do not choose as primary.
One insurance company's lobbyist in Salem appears to be fighting against scope-of-practice lattitude, with support from a committee chairperson, but this is likely to be overcome. Existing law supports consumer choice and full scope of practice for practitioners.
Practitioners discriminated against will likely mount lawsuits against discrimination, with support from patient groups.
When discussing what I want from a supplemental Medicare plan, with a state-trained volunteer, I asserted I want a place like Working Class Acupuncture for my primary- care home.
I take no expensive prescribed pharmaceuticals. I go in to community-supported acupuncture if I pull a muscle. This works for me. I am my own non-randomized clinical trial.
Contributory conscientiousness and informed consent can be validated and encouraged.
I see the present system as working hard to be wasteful, punishingly top-down, and carbon-irresponsible. Why are we doing this? It is lose-lose.
I am one of those persons who will argue the plural of anecdote is data. I understand there are two sides to this, time- and context-based.
Nonetheless, dismissing anecdotes is less common in conventional medicine, currently, than it used to be. Consumers willingly out themselves if they believe they will help others by doing so. I heard two patients discussing their experience with OHSU and recovery just the other day on OPB, as I was driving.
The folks at Working Class have lamented to me in the past that they do not know of suitable conventional medicine practitioners that they trust for referrals. Many of their clients are intimidated and untrusting of conventional medicine.
This is an issue with a number of special populations, notably veterans. This is why The Returning Veterans Project has had volunteers working with veterans, at least in the past that I know of, at no cost and no bureaucracy.
I write as a 65-year old person who has managed to survive some interesting health challenges, e.g., cancer (10-cm tumor) and traumatic brain injury.
I want to be captain of my own float as long as my choices affect only what ends at the end of my skin.
Until I reached 65, I could pay $15 at Working Class for wonderful care that focuses on me as an individual person in my own terms. I explained my issues to a Carer (UK term) in my own 'hood.
I also availed myself of a TCM practitioner for medicinal herbs for a number of years. This was more expensive than Working Class and not in my neighborhood, but it was what I felt I needed at the time, in my own recognizance. I did all this while paying exhorbitant monthly premiums that got me nowhere in the kind of care I would use.
If my chosen Carers were to tell me my issues were beyond their scope of practice, they have a tricky negotiation. They have to vet another practitioner by knowing me well and knowing what I will perceive as safe and trustworthy. I know how to research adverse events.
"Patient" does not describe me well. I think you could ask the neurosurgeon who treated me for TBI, though I have not seen him since 2005, to weigh in on how patient I am. I was not a standard case. I cannot think of a conventional-medicine practitioner who would really want me unless I was knocked out cold, which I was when Dr. Chen first saw me, although I started fading in and out some time after I arrived at the ER.
It would save time, money, and angst for the entire system if I could just choose Working Class to start with and if they had a list of conventional practitioners who play well with them, with a history of good cooperation. I have no objection to going somewhere else to have something checked out if it is a consensus of practitioners I approve of who say this to me.
I have particpated in a number of clinical trials at OHSU. The two most recent ones involved exercise and were great. They have no trouble recruiting for the exercise trials. My neighbor was disappointed not to get in. These protocols need to be Standard of Care. What's up with it that they are not?
I am feisty, but I am not unique--oh well, ok, I am unique (personalized, personal, functional-medicine perpective). I refuse to use the phrase Precision Medicine, as I find it infused with hubris.
Still, I am also part of a special-population cohort, many of whom might prefer the dignity of being considered to have exercised informed consent when we choose neighborhood health care as a medical home and when we do world-wide research before choosing Plans of Healing (POHs). I think I might have made POHs up. I am an exercise instructor. People come in with a baseline, and then can be asked where they want to go. If we came at health from this orientation, we would do so much better in our statistics.
By the way, the state volunteer advisor concerning Medicare asked me to ask Rep. Blumenaer yesterday about Medicare and dental care, because they get that question even more often than my question about wanting my primary-care decision honored. I am asking it here, as this is probably just as good a venue as a meet-and-greet at a cider place was.
U.S. indicator-of-health statistics are shameful. We can do better. Greater honoring of individual values, lived experience, and agency-of-the-person is a place to start.
Thanks for posting this opinion. It gave me a place to vent. Maybe I am just writing into the wind, but I have to say, getting this off my abnormally flat chest is helping my deep-breathing. Lots of carbone dioxide is exiting in a long sigh. My brows were knit as I tried to think where to go with my health aspirations.